Maltreatment during childhood: a risk factor for the development of endometriosis?

STUDY QUESTION: Is maltreatment during childhood (MC), e.g. sexual abuse, physical abuse, emotional abuse and neglect, associated with diagnosis of endometriosis? SUMMARY ANSWER: Childhood sexual abuse, emotional abuse/neglect and inconsistency experiences were associated with the diagnosis of endometriosis while no such association was found for physical abuse/neglect and other forms of maltreatment. WHAT IS KNOWN ALREADY: Symptoms of endometriosis such as chronic pelvic pain, fatigue and depression, are correlated with MC, as are immune reactions linked to endometriosis. These factors support a case for a potential role of MC in the development of endometriosis. STUDY DESIGN, SIZE, DURATION: The study was designed as a multicentre retrospective case-control study. Women with a diagnosis of endometriosis were matched to control women from the same clinic/doctor's office with regard to age (±3 years) and ethnic background. A total of 421 matched pairs were included in the study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women with endometriosis and control women were recruited in university hospitals, district hospitals, and doctors' offices in Germany, Switzerland and Austria. A German-language version of the Childhood Trauma Questionnaire (CTQ) was used to evaluate MC. Diagnosis of endometriosis was confirmed histologically and classified according to ASRM criteria. MAIN RESULTS AND THE ROLE OF CHANCE: Women with endometriosis reported significantly more often than control women a history of sexual abuse (20%/14%, P = 0.0197), emotional abuse (44%/28%, P < 0.0001), emotional neglect (50%/42%, P = 0.0123) and inconsistency experiences (53%/41%, P = 0.0007). No statistically significant differences could be demonstrated for physical abuse/neglect (31%/26%, P = 0.1738). Combinations of different abuse/neglect experiences were described significantly more often in women with endometriosis. Frequencies of other MC, i.e. violence against the mother (8%/7%, P = 0.8222), drug abuse in the family (5%/3%, P = 0.0943), mentally handicapped family members (1%/1%, P = 0.7271), suicidal intentions in the family (6%/4%, P = 0.2879) and family members in prison (1%/1%, P = 0.1597) were not statistically different in women with endometriosis and control women. LIMITATIONS, REASONS FOR CAUTION: Some control women might present asymptomatic endometriosis, which would lead to underestimation of our findings. The exclusion of pregnant women may have biased the results. Statistical power for sub-analyses of physical abuse/neglect and sexual abuse was limited. WIDER IMPLICATIONS OF THE FINDINGS: A link to MC needs to be considered in women with endometriosis. As there are effective strategies to avoid long-term consequences of MC, healthcare professionals should inquire about such experiences in order to be able to provide treatment for the consequences as early as possible. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: Endo_QoL NCT02511626.

[Assessment of subjective physical well-being in heart failure : Validation of the FEW16 questionnaire]. / Erfassung des subjektiven körperlichen Wohlbefindens bei Herzinsuffizienz : Validierung des FEW16-Fragebogens.

INTRODUCTION: Improvement in the quality of life (QoL) is a major goal of therapy for heart failure (HF) patients. Physical well-being as an important component of QoL has not yet been sufficiently covered by disease-specific assessment instruments. The aim of the study was to validate the questionnaire for assessing subjective physical well-being (FEW16) in HF patients with preserved ejection fraction (HFpEF) from the exercise training in diastolic heart failure (Ex-DHF­P) trial. METHOD: A total of 64 HFpEF patients (65 years, 56 % female) were randomized to usual routine treatment with (n = 44) or without training (n = 20). At baseline and 3 months, patients were clinically evaluated and assessed using appropriate questionnaires on the QoL (SF36), physical well-being (FEW16) and depression (PHQ-D). RESULTS: The FEW16 showed good values for Cronbachs' alpha coefficients (0.85-0.93). The cross-validity with SF36 and PHQ-D was highly significant but more so for psychological aspects. At baseline, the FEW16 score correlated with age, the subscale resilience with age and the 6 min walking distance test. At follow-up, the total and resilience scores had improved in the training group. In contrast to the SF36, the FEW16 did not detect differences between the groups in Ex-DHF­P. DISCUSSION: The FEW16 questionnaire showed good internal consistency and correlation with SF36, its total score and resilience had improved after training; however, it did not reflect different changes between the study groups. The FEW16 is therefore more suited to assess general/mental well-being than the subjective physical well-being.

Validation of the FEW16 questionnaire for the assessment of physical well-being in patients with heart failure with reduced ejection fraction: results from the CIBIS-ELD study.

AIMS: Patients with heart failure (HF) commonly suffer from severe impairment of quality of life (QoL). One main goal of HF treatment is improvement of QoL. Physical well-being is an essential component of QoL. To enable assessment of physical well-being in HF patients, we validated the FEW16 questionnaire in a prospective study with patients from the Cardiac Insufficiency Bisoprolol Study in ELDerly. METHODS AND RESULTS: In 127 HF patients (age 73 ± 5.5 years, 72% male, 60% New York Heart Association class II, left ventricular ejection fraction 37 ± 8.5%), we measured physical well-being (FEW16), QoL [36-Item Short-Form Health Survey (SF36)], and depressive symptoms [PRIME MD Patient Health Questionnaire German short version for depression (PHQ-D)] at baseline and two follow-up visits, and correlated FEW16 scores with QoL data and clinical parameters. FEW16 mean scores are 3.04 ± 1.04 at baseline, 3.19 ± 0.94 after 3 months, and 2.77 ± 0.94 after 2-4 years. We assessed data quality, scale assumptions, and construct validity and reliability. Cronbach's alpha for subscales resilience: 0.84; ability to enjoy: 0.80; vitality: 0.88; inner peace: 0.87; total score: 0.95. Intraclass correlation coefficient (ICC) is 0.87 (95% CI 0.84-0.89, ICC (1.4). Pearson's correlations of FEW16 with SF36 and PHQ-D were significant. Six minutes walking distance and heart rate correlated significantly with the FEW16 total score. CONCLUSIONS: The FEW16 showed good reliability, internal consistency, and intraclass correlation. FEW16 scores correlated well with psychological and physical well-being (SF36) and clinical markers of exercise tolerance (6 min walk test and heart rate). Our results indicate a strong correlation of self-reported physical well-being with psychological factors. FEW16 values at baseline predicted the development of several aspects of QoL during beta-blocker up-titration.

Psychosomatic Primary Care in Gynecology-Assessment and Acceptance by Residents for Obstetrics and Gynecology in Germany.

Background: The course "Psychosomatic Primary Care" has been part of the training curriculum of obstetrics and gynecology in Germany since 2003. The aim of the course is to train up physicians, whose prior training primarily focussed on somatic care, to enable them to offer care also taking into account biopsychosocial aspects. Taking the guidelines for psychotherapy as a template, the aim of psychosomatic primary care is to recognize the etiological links between psychological and somatic factors which contribute to diseases. The necessity for a compulsory course as part of training in gynecology was recently critically discussed. Major points discussed included the question whether the current forms of teaching, consisting of courses, are outdated and whether the required skills should be part of regular daily training. Method: A 3-part online questionnaire consisting of 30 items was developed and sent to 2431 residents in the period from September to December 2012 through the online mailing list of the DGGG. Results: The 540 residents who responded to the questionnaire were predominantly female (83.3 %) with an average age of 30 years; 50.3 % were in their 1st to their 4th year of training. Over the longer term, the majority of respondents (56.1 %) hoped to continue working in a hospital and regularly (84.6 %) attended teaching courses voluntarily. 70.9 % of them had already attended the course "Psychosomatic Primary Care". Of the group who had completed the course, 29.4 % were satisfied with the offer. The main criticism directed against the course was its scope which 24.1 % considered completely inadequate. 24.5 % considered the course to be an important part of training, while 16.5 % would have preferred that the course be abolished. 18 % of respondents reported that psychosomatic medicine did not feature regularly in their daily clinical routine. Perspective: Because of the huge gap between what is currently offered and the experiences reported by the respondents, the Young Forum of the DGGG and the DGPFG have expanded the program of courses offered by the DGPFG, which will offer practice-oriented courses to future gynecologists across Germany in cooperation with the DAGG. The first courses are held in Heidelberg and Erlangen in 2014.

Influence of so far neglected psychosomatic factors, BMI and smoking on pregnancy-induced hypertension (PIH).

OBJECTIVE: Correlation of descriptive psychosomatic factors and birth parameters for pregnancy-induced hypertension (PIH). STUDY DESIGN: For this prospective study 508 pregnant (singleton) women from 16th-22nd gestational week (GW) were investigated by means of a semi-standardized questionnaire. Complete data concerning delivery were obtained from medical records. In addition to medical and sociodemographic risk factors, so far neglected parameters such as biographical information, personality factors, social environment, stress coping strategies and pregnancy-related anxieties were examined. A factor analysis was performed using a principal component method with subsequent varimax rotation. MAIN OUTCOME MEASURES: Main outcome measures were imminent preterm delivery, PIH, factual preterm delivery before 37GW and birth weight <10th percentile. RESULTS: Four hundred and eighty-eight qualified for evaluation and got included in the univariate logistic regression - 12.6% of them had PIH. The development of PIH showed a significant correlation with age (OR, 95% CI). Very young and older women were more likely to develop PIH. Development of PIH is significantly more frequent in women, whose parents adhered to an authoritarian educational style, had no emotional support of female friends, and a higher BMI. Women who always had been non-smokers and women who did not give up smoking during pregnancy, but only reduced the amount of cigarettes had the least probability of developing PIH, whereas total abandoning of smoking before and especially during pregnancy was associated with a significantly increased risk for the development of PIH. CONCLUSIONS: This study suggests psychosomatic factors, BMI and smoking behavior to be relevant for the development of PIH.

[Experience of pregnancy for women with pregnancy-induced hypertension]. / Schwangerschaftserleben von Frauen mit schwangerschaftsinduzierter Hypertonie.

BACKGROUND AND OBJECTIVE: The experience of pregnancy for women with pregnancy-induced hypertension (PIH) is compared to the experience of women with a normal pregnancy course in order to gain insights into the development of PIH and possible strategies for prevention and care. PATIENTS AND METHODS: This study was performed as a retrospective investigation of 21 women - 10 with PIH and as control group 11 with uncomplicated pregnancies - between 5 and 13 months after delivery by means of an interview relating to their experience of pregnancy. The interviews were evaluated by qualitative text analysis with categorisation. The specific categories "planning of pregnancy", "affective complaints", "significant others", "work" and "out-patient care" were compared between cases. RESULTS: The interviews with women with PIH revealed a significantly more conflict-shaken pregnancy, often unplanned and undesired. Also during pregnancy there were severe conflicts with relevant third persons. A weak expression of their emotions was observed. Additionally, the majority of women reported a rather disturbed relationship with their physicians. DISCUSSION: Stress and PIH are intertwined. This is presented in the literature available about this subject. Qualitative research produces only contextual and subjective evidence, nevertheless this is the most concrete base that one can obtain. Only a readiness to deal with conflicts developing during pregnancy and the expression of also negative emotions towards relevant third persons would be helpful to cope with one's own negative feelings. CONCLUSIONS: The practical impact on care for women with PIH is awareness for their underlying conflicts, weak emotional expressivity and provision of an adequate supply of psychological support.

Gynaecological symptoms associated with physical and sexual violence.

OBJECTIVE: The study aims to describe the prevalence of violent physical and sexual experiences in female outpatients and to identify specific gynaecological symptoms that are associated with a history of abuse. STUDY DESIGN: We performed a cross-sectional study among native German women. The confidential self-administered questionnaire included items on physical and sexual abuse and on the patient's medical history. Of a total of 1941 eligible women, 730 (37.6%) participated in the survey. We calculated prevalence rates of physical and sexual abuse and compared victims and non-victims of violence with respect to specific symptoms and complaints. We developed multivariate models for pelvic pain and vaginal infection. RESULTS: The lifetime prevalence of severe physical violence by any kind of perpetrator was 35.5%. 13.5% of participants reported a completed rape. The lifetime prevalence of physical and/or sexual intimate partner violence (IPV) was 28.3%. Physical and sexual abuse is significantly associated with irregular menstrual cycle, urinary tract infections and pelvic pain independent of menses. CONCLUSIONS: Physical and sexual violence are associated with many gynecological symptoms. Especially gynecologists and general practitioners have to be aware that their patients might be victims of violence. This is important for adequate diagnosis and therapy and to avoid retraumatization in affected women.

Psychopharmacotherapy in eating disorders: a systematic analysis.

The most common and serious eating disorders, which are particularly prevalent in young women, are anorexia nervosa (AN), bulimia nervosa (BN), and binge-eating disorders (BED). Further, the prevalence of unspecific hyperphagous eating disorders frequently causing obesity is substantially increasing. All of these eating disorders tend to be chronic and comorbid to psychiatric diagnoses. Because of the multifactorial etiology, these disorders require a multimodal treatment. Among different treatment options, symptomatic psychopharmacotherapy has been an important component, and especially in recent decades, it has been subject to many trials. This article gives an overview of the current literature, summarizing diagnostic criteria, epidemiology, and critically discussing psychopharmacotherapy of those eating disorders. Based on the literature and our clinical experience, the psychopharmacological recommendations for patients with AN, BN, and BED are suggested.

[Biopsychosocial predictors of preterm labor and preterm delivery? Results of a prospective study]. / Vorzeitige Wehen und Frühgeburt--eine psychosomatische Störung? Ergebnisse einer prospektiven Studie.

RESEARCH QUESTION: In addition to medical, job related, sociodemographic risk factors, and health related behavior, topics that traditionally have been less in the focus of attention in this context, such as biographic data, coping with stress, personality variables, pregnancy related attitudes, fears, and the social network were examined. PATIENTS AND METHODS: 589 women between 16(th) and 22(nd) week of pregnancy were examined using a questionnaire that was designed for the study. This resulted in 508 women pregnant with a single child, whose pregnancy and delivery were examined based on their medical records. Factor analysis and main component analysis with subsequent varimax rotation resulted in factors that were subject to a proof of reliability. Statistical analysis was based on logistic regression. RESULTS: 129 (27.7%) of women displayed signs/indices of an imminent preterm delivery, 29% (5.8%) of whom later actually had a preterm delivery before the end of the 37(th) week of pregnancy. Pregnant women who were in treatment for an imminent preterm delivery appear to have been subject to higher social stress as compared to those, who later later actually gave birth before completing the 37(th) week of pregnancy. Lack of a female network and lack of emotional understanding from the partner are correlated to both of these complications. Specifically, actual preterm delivery appears to be significantly influenced by partner relationship. Another significant predicting variable for imminent and actual preterm delivery appears to be a history of gynecological problems. A distinct risk factor for delivery before completion of the 37(th) week of pregnancy was a history of colpitis. In addition, pronounced anxieties in respect to the pregnancy, and low general anxiety were significant predicting variables for delivery before completion of the 37(th) week of pregnancy. CONCLUSIONS: Partner relationship, female networks, psychosomatic reactivity in terms of diseases/disorders of the reproductive organs, and anxieties appear to be worthwhile targets in the prevention of preterm delivery.

[Unplanned pregnancies in a developed society--a study on a maternity ward in Berlin]. / Zum Problem der ungeplanten Schwangerschaften in einer hoch entwickelten Gesellschaft - Modellstudie auf einer Wochenstation in Berlin.

OBJECTIVE: Unplanned pregnancies are still common in developed societies. Although the medical-technical methods are mainly in use for family planning, other methods - not provided by the medical care system - have an important impact on the occurrence of unplanned pregnancies. Moreover the frequency of their use is not accurately recorded in usual study-protocols. The spread of methods based on the knowledge of physiologic infertility in woman's cycle (further: fertility awareness) and their relation to unplanned pregnancies is to be investigated. METHODS: A survey by way of self-administered questionnaire was conducted between September 1997 and March 1998 on women in a maternity ward in a hospital in Berlin (former East-Berlin, n = 220). The use of family planning methods (with a special focus on fertility awareness) and the planning state of pregnancies were recorded. RESULTS: 33 % of delivered pregnancies were unplanned. In the last year before conception occurred the part of the use of fertility awareness grew from 12 % to 30 % and correspondingly 25 % to 32 % of unplanned pregnancies were connected with these methods. CONCLUSIONS: The blanking-out of fertility awareness in the framework of medical care system leads to a constellation where a considerable part of unplanned pregnancies occurs beyond its range. The adequate solution for this problem should be an incorporation of fertility awareness into the mainstream of family planning.

Risk perception and psychological strain in women with a family history of breast cancer.

BACKGROUND: The thinking in health psychology is that patients' willingness to adopt preventive health behavior is contingent on their perceiving an increased risk of disease and is influenced by accompanying psychological stress. In counseling women with a family history of breast cancer, physicians focus on encouraging the patient to undergo early detection examinations as recommended. Therefore, it is essential to examine how women in this risk group perceive their own chances of developing breast cancer and to assess the psychological effects of their situation. MATERIAL AND METHODS: 129 women with at least one first or second degree relative who had developed breast cancer were enrolled in a questionnaire study. The object was to ascertain the extent to which these women may be expected to realistically estimate their own probability of contracting the disease and what influence risk perception and psychological strain have on their willingness to make use of diagnostic opportunities for early detection. Additionally, the effects on their physical and mental well-being were analyzed. RESULTS: Among the women of the study group, a family history of breast cancer did not always correlate with the subject's perception of an increased risk of contracting the disease compared. On the whole, the majority of the women overestimated their personal risk despite prior genetic counseling. Only slightly less than one quarter of the study group correctly estimated their risk; another quarter underestimated it. The majority of those women who exhibited an increased risk perception were also those who overestimated their probability of personally contracting the disease. They underwent recommended screening examinations significantly less often than women with a low risk perception. However, women subjected to intense psychological strain showed above-average participation in screening programs. CONCLUSIONS: Women with a family history of breast cancer often find it difficult to realistically estimate their own risk of contracting the disease. Increased risk perception had a negative effect on participation in recommended breast cancer screening. Therefore, an effort should be made to correct the patient's overestimation of her personal risk. Integrating psychological counseling in screening programs is essential considering that women from high-risk groups are subjected to increased psychological strain. Further studies are required to more precisely evaluate other psychosocial factors in the behavior of women in risk group toward screening.

[Child or career? Desire for a child in East and West Berlin]. / Kind oder Karriere? Kinderwunschmotivation in Ost und West am Beispiel von zwei Berliner Stadtbezirken.

OBJECTIVE: In the Federal Republic of Germany the rate of the childless women rises. While the topic of unwanted childlessness among gynecologists receives broad attention among gynecologists, the question of (temporaryly?) intended renouncement of pregnancy and birth is of little interest. For the former GDR a low age with the firstborn and a high mother rate were typically. After the "turn" serious modifications of the birth rate in East Germany happened. MATERIAL AND METHODS: The available study examined 1996 motives for and against a child with 554 up-to-date wanted childless women in East- and West-Berlin (population-referred sample). In the questionnaire, besides sociodemographic data, information was raised to own childhood, partnership, occupation, satisfaction with life and for child desire motivation. RESULTS: Apart from the school and vocational termination conceptions on the age with the firstborn, disadvantages for a life with child and value hierarchies for partnership and family were important for the description of the dilemma of compatibility of occupation and family. Eastsocialized women consider a compatibility rather possible. CONCLUSIONS: Targets for vocational development and responsible parenthood for young women come into conflict. Temporal delaying of the child desire leads to an increase of intended and unwanted childlessness with various (psychosomatic) effects on obstetrics and gynecology.

[Resource oriented interventions in pregnancy]. / Ressourcenorientierte Interventionen in der Schwangerschaft.

Premature labour and premature birth keep on being an unsolved problem in spite of diverse medical measures in the obstetrics. The system of risk catalogues did not meet the expectations and can lead even for the disconcertion from pregnant women. If one places the risks performed in the German mother passport as a basis, approximately 50% of all pregnant women would be risk cases. In current publications stress finds strong attention as a psychophysiological declaration model of premature birth. Own results refer to psychosomatic connections at premature birth. Social relief and here particularly the one through the babies father seems to be a preventive factor with regard to some premature birth. Under a resource-oriented visual angle the salutogenetic-model of Antonovsky is employed for care concepts of the primary and second prevention in the pregnancy as a basis. Specific target group offers for pregnant woman that focus also on the stabilization of their competence feeling, particularly next to knowledge transfer, relaxation training and learning of coping strategies, the activation of social nets and, where appropriate, early inclusion of the partner and offer of communication training for pregnant couples are described as a good complement to traditional prenatal care. A bearing away of the risk-model opens the resources-model for prenatal care new ways and is a challenge also for science.

[Counseling in prenatal diagnosis and possible handicap: medical viewpoint]. / Beratung zu Pränataldiagnostik und eventueller Behinderung: medizinische Sicht.

The possibility and the application of prenatal diagnostics (PND) has fundamentally changed the psychological experience of pregnancy for the pregnant woman, the expectant father, and society. When dealing with PND a balance between the positive effects for a large number of people and the risks and strains for an also considerable number of affected people must be strived for. This affects the decisions for and against examinations or interventions and coping with these, suitable strategies of care, and also possibilities of cooperation of different professions and institutions. Due to the growing number of possibilities of non-invasive methods a population-based PND is developing from the primarily individual PND. This means that the requirement for informed consent should affect all pregnant women. Informed consent is oriented on the situation, i.e. the more an examination is invasive/risky or the more serious the consequences are, the more extensive the information has to be. This requires a qualified caring person who must have well-founded somatic and psychosomatic knowledge, must also be able to conduct communicative counselling and create relationships, and be cooperative and be able to work in a team.

[Program and effectiveness of psychologically-oriented preparation for childbirth. 1. Behavior therapeutic program for childbirth preparation]. / Programm und Effizienz psychologisch orientierter Geburtsvorbereitung. 1. Mitteilung: Verhaltenstherapeutisches Geburtsvorbereitungsprogramm.

A program of preparation for childbirth tested at present by the author is demonstrated, and some results of an investigation about anxieties for labour are pointed out. The program of preparation for childbirth is oriented on behavioural and learning-theoretical principles and contains the following elements: information on pregnancy and labour, functions and effects of pains in labour and the influence of anxiety to muscle tension, vasoconstriction and pain as well as a good knowledge of hospital; relaxation training, breathing exercises and anxiety management techniques as well as self-control strategies.