Gynecology 1.

EMOTIONAL ASPECTS OF GYNECOLOGY

OUTLINE

I. Introduction
II. Threats to Emotional Development
in Childhood
A. Parental Loss/Death
B. Separation or Divorce
III. Problems in Adolescence or
Adulthood
A. Anorexia Nervosa
B. Bulimia Nervosa
C. Treatment of Anorexia and
Bulimia Nervosa

D. Obesity
IV. Sexual Function and Dysfunction
A. Phases of Sexual Response
B. Sexual Response and Menopause
C. Sexual Dysfunction
V. Depression
VI. Loss and Grief
VII. Counseling the Dying
VIII. Hospice Care

Everything is from the Powerpoint unless otherwise specified.

References:
1. Recording
2. Comprehensive Gynecology, 6e, Chapter 9

INTRODUCTION
Choices in life are dependent on how well our personalities are developed
from childhood to adolescence.
Development of self-esteem and self-perception begins in early childhood
and is reinforced by nurturing factors:
o Love and care of parents brings an emotional impact in childhood
o Good environment
However, any attack against the childs mental and physical well-being
(i.e., physical or sexual abuse) will tear down the building of self-esteem
and can have serious consequences unless help is sought out.
As a result, negative factors will make the child unable to cope with
certain life difficulties.
In general, positive reinforcement of the childs worth as an individual,
mixed with appropriate warmth and love, tends to build self-esteem,
whereas negative statements or actions tend to tear it down.2
We, as gynecologists, may have the chance to take care of young
adolescents and old patients with such inability. It is our duty as health
care providers to provide or obtain counseling for our patients to help
them get through their problems.

THREATS TO EMOTIONAL DEVELOPMENT IN CHILDHOOD

PARENTAL LOSS/DEATH
Loss of a parent during childhood is an important factor predisposing to
later depression2
The earlier the separation or death the greater is the maladjustment
The risk of developing a psychiatric disorder is greatest when the child
loses a parent
o At 5 y/o
o At adolescence
o Of the same sex
Often associated with antisocial disorders commonly delinquency
Management
o Counseling helps in the grief period
o Establishment of a parent substitute of the same sex (e.g., relative,
social worker, stepmother/father)

SEPARATION OR DIVORCE
Marital discord more detrimental than permanent absence of a parent
o If marital conflict is always present producing an upheaval, it is better
for the parents to separate. Permanent loss of the one parent while the
other stays to serve the needs of the child. This is better a better
situation for the child.1
Parental illness and marital discord are associated with development of
psychiatric disorders such as substance abuse or dependency, conduct
and mood behavior

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DR. AIDA SALUD

NOV. 6, 2014

PROBLEMS IN ADOLESCENCE AND ADULTHOOD

Eating Disorders:
1. Anorexia Nervosa
2. Bulimia Nervosa
3. Obesity
Most women are seen by gynecologists because of menstrual
abnormalities.
Girls or women presenting with amenorrhea, menstrual dysfunction, low
bone density, sexual dysfunction, infertility, anxiety, depression, or
hyperemesis gravidarum should be screened for eating disorders. [2]
ANOREXIA NERVOSA
Common in adolescent girls
Cause is multifactorial
More common in women especially in ballet dancers
Diagnostic Criteria
o Food aversion
o Ideal weight <85%
o Fear of weight gain or obesity
o Distorted body image
Pag mas payat, mas maganda [1]
o At least 3 months of amenorrhea
*See appendix for complete diagnostic criteria of anorexia nervosa and
bulimia nervosa
Differential Diagnosis
o Medical or Psychiatric
Two Types (DSM-IV)
o Primary Restriction of Food Intake
o Binge Eating with Purging Behavior
50% of anorexia patients use binge eating and self-induced purging
Binge eating uncontrollable appetite, opposite of food aversion,
you eat and eat [1]
Purging after eating, you feel guilty, so you compensate through
other behaviors like self-induced vomiting or through frequent use of
laxatives [1]

BULIMIA NERVOSA
Episodes of binge eating with inappropriate compensatory behaviors
(examples: self-induced vomiting and abuse of laxatives)
More psychological problems
More difficult to treat
More extroverted, more depression, anxiety and sleep disturbances
As in anorexia nervosa, cause may be organic or familial
Increase in neurotransmitters, like norepinephrine and serotonin, may be
involved in its causation
MANAGEMENT OF ANOREXIA NERVOSA AND BULIMIA NERVOSA
In-patient therapy
o Nutritional support
o Medications (anti-depressant, SSRI)
o Cognitive behavior therapy
Prognosis
o 70% good outcome
o 18% death (starvation and suicide)
OBESITY
Major contributor to worldwide chronic disease and disability
WHO Definition
o BMI 30-39: Obese
o BMI 40: Extreme Obesity
Complications
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GYNECOLOGY 1.2
o Medical: Hypertension, diabetes mellitus, hyperlipidemia, arthritis,
compromised pulmonary function
o OB-GYN: Spontaneous abortion, endometrial hyperplasia, endometrial
and breast Cancer
12x increase in mortality compared to normal population
Obesity in adolescence is a more powerful predictor of morbidity from
CVD
MANAGEMENT OF OBESITY
A. Mild Obesity
Diet, exercise, and behavior modification under lay supervision
B. Moderate Obesity
Diet, exercise, and behavior modification under medical supervision
o 400-700 calories/day
o Associated with more depression
o Maintenance of weight loss is difficult
o Orlistat, Sibutramine may be given to maintain weight loss
Orlistat inhibits dietary fat absorption and is considered first-line
treatment because of its better safety profile than other
medications.[2]
Sibutramine inhibits reuptake of neurotransmitters and affects
satiation.[2]

C. Severe Obesity
Surgery: found to be more effective in weight loss
o Bariatric procedure
o Gastric bypass
o Banded gastroscopy
o Biliopancreatic diversion
Less depression in patients
Weight loss is easily maintained
SEXUAL FUNCTION AND DYSFUNCTION
50% of all married couples experience some sexual dysfunction
Sexual response though physiologic is also influenced by many
emotional or psychological factors.
As gynecologists, knowing when to counsel or refer patients with such
complaint is important.
SEXUAL RESPONSE: 4 PHASES

Orgasm

Plateau

Multiple
orgasms

Resolution

Excitement -

Time
1. EXCITEMENT PHASE OR SEDUCTION PHASE
Initiated by internal or external stimuli
Prolonged stimulation leads to a more pronounced orgasmic activity
Under the influence of parasympathetic portion of the autonomic nervous
system
Anticholinergic drugs may interfere with full response
CHARACTERISTICS OF EXCITEMENT PHASE OF SEXUAL RESPONSE CYCLE IN
FEMALES:
Deep breathing
Increased pulse
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Increased blood pressure

Warmth and erotic feelings
Increased tension
Generalized congestion
Skin flush
Breast engorgement
Nipple erection
Engorgement of labia and clitoris
Vaginal transudation
Uterine tenting

2. PLATEAU STAGE
Marked degree of vasocongestion
Lower third of vagina decrease in diameter by 50% orgasmic platform
o Physiologic response in preparation for penetration as it increases
friction increasing pleasure for the male partner[1]
o At the same time, the upper 2/3 of the vaginal canal dilates which in
effect prepares the vagina for orgasm[1]

3. ORGASM
Release of sexual tension
Myotonic contractions
Contraction of perivaginal muscles
Uterine contractions
Sympathetic control
Can be affected by anti-hypertensive and antidepressants

RESOLUTION PHASE
Return of a womans physiologic state to pre-excitement level
Woman feels satisfaction and well-being
No refractory period in women (only in males)
*Clitoris as the center of sexual satisfaction
SEXUAL RESPONSE AND MENOPAUSE
Slowing of sexual response due to decrease in estrogen
o Decrease in intensity of response
o Slower arousal and fewer orgasms
Caused by hormonal changes
o Atrophy of vaginal epithelium
o Decrease in vaginal secretion
o Decrease in circulation in the vagina and uterus
o Pelvic relaxation
HRT prolongs postmenopausal womans ability to demonstrate a more
normal sexual response
o Thickening of vaginal epithelium
o Increase in vaginal secretion
SEXUAL DYSFUNCTION
Exists in 50% of marriages
Sexual response problems may be due to:
o Previous negative experiences
o Emotional or physical illness
o Difficulties in current relationship
o Alcohol or drug addiction
o Medication (ex. Anti-hypertensive drugs)
o Distractions like family or job concerns
KINDS OF SEXUAL DYSFUNCTION
Decreased sexual desire
o Most common sexual dysfunction
o Management
Set aside appropriate time for intimacy
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GYNECOLOGY 1.2
Encourage satisfactory foreplay mutually enjoyable to the couple
Approved medications: estrogen (for pain during intercourse),
bupropion (for sexual urge)
Improve sexual education/knowledge
Check for vaginismus (involuntary spasm of introital and levatorani
muscles causing painful penetration) and manage with self-dilatation
techniques
Orgasmic Dysfunction
o 10-15% of woman have never experienced orgasm
o Sexual contacts without orgasms are normal but at least 60% of sexual
contacts should be orgasmic otherwise, may lead to congestion[1,2]
o Some are non-orgasmic during intercourse but may be orgasmic in oral
sex or self-stimulation
o Communicate to partner orgasmic techniques which may be applied
during coitus
o Clitoris - most erotic part of the female genitalia [2]
o Management counseling
Dyspareunia
o Dysfunction where genital pain occurs before, during, or after
intercourse
o Caused by organic problems like poor lubrication, painful bladder
disorder, poorly healed lacerations or episiotomy, PID or endometriosis
o Management should include:
Treatment of underlying cause
Pelvic floor physical therapy
Change in coital position
DEPRESSION
Common symptom arising from patients suffering from loss or grief
The second most frequent cause of disability
More common in women during reproductive years (25-44 years)
Depressed patients are more prone to suicide
Symptomatology:
o Chronic fatigue
o Anxiety and irritability
o Anhedonia
o Decreased interest in usual pursuits
o Poor concentration and lack of decisiveness
o Loss of recent memory
o Insomnia
o Change in bowel habits
o Suicidal thoughts and delusions in its late stages
Management:
o Assess degree of depression
o Determine reason for depression whether appropriate or not
It is expected for you to be depressed if you lose someone but
should be within a certain period only [2]
Therapy:
o Psychotherapy can singly be effective in 50% of mild to moderate
depression
o Medications:
SSRI a lot of side effects including serotonin syndrome (can be fatal)
Serotonin + Norepinephrine Reuptake Inhibitors (NERIs) less sexual
dysfunction
MAOIs not considered as 1st line treatment because it is difficult to
give
Lithium Salts best for bipolar disease
Heterocyclic and Tricyclic Antidepressants significant
anticholinergic side effects and possible cardiac arrhythmia
Complementary and alternative medications (CAMs) St Johns Wort
benefits mild depression

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LOSS AND GRIEF

UNCOMPLICATED GRIEF
Grief is usually used to refer to the emotional, behavioral, and functional
response to the death of a loved one[2]
Gynecologists are likely to see women at times of uncomplicated grief,
complicated grief, or grief-related major depression.[2]
Stages of Uncomplicated or Normal Grief [2]:
o Initial numbness or shock
o Sadness and depression
o Reorganization
o Recovery
Normal grief reaction takes 6-18 months
Lose of a child, a spouse, a body organ or a pet will often precipitate an
acute grief reaction[1]
Acute grief is a definite syndrome with both psychological and somatic
components [1]
o May be immediate or delayed
o Occurs early after the loss
o Intensely painful, includes sadness, crying, preoccupation with thoughts
of the deceased or of the loss disturbed sleep and appetite, trouble
concentrating, and separation from and lack of interest in other people
and usual activities. [2]
After a few months acute grief becomes Integrated Grief [2]
o A state in which the deceased or what has been lost is thought of often
with sadness
o But the woman is not preoccupied and can once more participate in
pleasurable and meaningful activities
o Triggers, including birthdays, anniversaries, or situations that remind
her of the loss, may precipitate waves of grief, which gradually become
less intense and less frequent over time.
Symptomatology of Normal Grief[1]:
o Tightness in throat and chest
o Chocking sensation
o Shortness of breath
o Frequent sighing

COMPLICATED GRIEF [2]

Failure to move from acute to integrated grief, and is associated with
significant difficulty functioning
Requires treatment to avoid becoming chronic and unremitting
Treatment should include psychotherapy and often also antidepressant
medication.
Symptoms of Complicated Grief[2]
o Intense pain and longing
o Difficulty accepting the loss
o Anger
o Intrusive thoughts
o Guilt
o Feelings of estrangement from other people
o Suicidal thoughts
Risk Factors[2]
o History of mood and anxiety disorders
o Multiple losses
o Adverse life events
o Other stressors reducing the womans ability to cope
Women with a past history of depression, or severe depressive symptoms
as part of grief, should probably be treated aggressively, even in the first
month or two after the loss, with antidepressant medication and
psychotherapy, whereas those with milder depression can be monitored
or referred for psychotherapy alone.[2]
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GYNECOLOGY 1.2
Four variants of Abnormal Grief Reaction[1]
o Delay of Reaction
o Distorted Reaction
o Development of psychosomatic conditions
o Development of pathologic relationships

APPENDIX

Loss of a body organ or body part like hysterectomy is one OB-GYN

problem that can bring about grief reaction [1]
o Depression is a strong component
o Incorporation is important to resolve the grieving process
o Four Stages of Incorporation[1]
Impact of knowing that you will lose something that you have
Retreat desire for second opinion occurs
Acknowledgementto fully submit to the procedure
Reconstructionto adjust to the results of the operation
Women suffering losses as a result of miscarriage, perinatal loss,
unplanned pregnancy, or infertility benefit from support, counseling, and
screening for depression and posttraumatic stress disorder.[2]
COUNSELING OF THE DYING
Women with terminal illness benefit from:[2]
o Engaged, genuine relationship with physicians and other health care
providers
o Treatment of depression and anxiety states
o Psychological interventions and psychotherapy
o Early integration of palliative care into treatment
Five Stages in the Acceptance of the Inevitability of Death:[1]
o Denial
o Anger most difficult to cope with
o Bargaining postpone the inevitable
o Depression monetary family concerns
o Acceptance accepting her faith
HOSPICE CARE [1]
Innovative way of caring for the terminally ill and their families
Involves a medical team, volunteers, social workers, psychologists,
psychiatrists that can help the patient and the family
Offers psychosocial support and post death follow-up
Services may be as in-patients, community based home programs or
hospital based
Contributes to:
o An improved family function
o Greater individual well-being
o Ability of family member to cope with the situation

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