Gynecological Health Research Paper

1. Menstrually Related Distress

A comprehensive review (Klebanov and Ruble 1994) indicated no relationship between subjective distress and any hormonal measure; there is no consensus on its definition, symptoms, prevalence, effects, or indeed the component of the menstrual cycle (premenstrual, menstrual, or intermenstrual) with which the distress is associated.

Although mood, physical symptoms, and coping with life are claimed to demonstrate menstrually related cyclicity, the empirical evidence is mixed and inconclusive. Decades of research provide evidence for no cyclic variation in any aspect of cognitive functioning, memory, or motor performance (Richardson 1992). Women’s reports of symptoms and mood swings are no different from those experienced by men (McFarlane and Williams 1994), and menstruallyrelated fluctuations in mood are considerably less than those associated with days of the week.

Prevalence estimates of menstrually related distress range from 95 to 5 percent, illustrating a complete lack of definitional consensus. The main standardized self-report survey, the Moos Menstrual Distress Questionnaire, obtains prevalence rates between 55 and 70 percent for physical discomfort, and between 23 and 70 percent for negative affect, with the majority of symptoms extremely mild and causing negligible distress (Logue and Moos 1986).

The American Psychiatric Association included a preliminary definition of premenstrual dysphoric disorder (PDD) in DSM-IV. PDD involves ‘symptoms such as markedly depressed mood, marked anxiety, marked affective lability, and decreased interest in activity … during the last week of the luteal phase in most menstrual cycles during the last year. The symptoms begin to remit within a few days of the onset of menses and are always absent in the week following menses.’ PDD is diagnosed if the condition is comparable in severity to a major depressive episode, involving marked impairment in either social or occupational functioning. PDD must be confirmed with prospective daily ratings over at least two cycles, since retrospective reports are unreliable and there is little consistency across consecutive cycles. Rivera Tovar and Frank (1990), using a prospective, blind, study over 90 days, found that 5 percent of US students met criteria for PDD. This suggests that some women experience menstrually related distress, but that it is not the norm, and it should be noted that experiencing distress on a cyclic basis does not necessarily mean that it is hormonally mediated.

2. Postnatal Distress

It is often assumed that negative psychological outcomes of childbirth result from hormonal changes, but three main categories of childbirth-related psychological distress with different causes and prognoses need to be distinguished.

2.1 Baby Blues

Postpartum dysphoria, or ‘baby blues,’ tearfulness, mood swings, and irritability, occurs in a high proportion of mothers in the few days following childbirth, and normally resolves itself within 10 days. It is not related to any environmental, social, or cultural factor (Kumar 1994), and may be related to changes in estrogen levels, although individuals undergoing surgery experience similar symptoms, suggesting it may be a reaction to physical stress. Prevalence estimates vary from 26 to 85 percent of all mothers. The condition is distressing, especially if women are not expecting it, but resolves quickly and has little long-term impact.

2.2 Postpartum Psychosis

Postpartum psychosis, characterized by hallucinations, delusions, and other schizophrenia-like symptoms, occurs in all societies, at a relatively consistent rate of 0.01 to 0.02 percent of all births (Kumar 1994), and can result in suicide or infanticide. Previous psychotic illness is the strongest risk factor for postpartum psychosis; there is no link with life events, stress, or relationship difficulties, supporting the view that it arises, like other psychotic states, in biologically susceptible individuals as a reaction to substantial life change.

2.3 Postpartum Depression

Nonpsychotic postpartum depression is mainly influenced by psychosocial factors, and there is no convincing evidence for hormonal causation (Kumar 1994). Postpartum depression is predicted by relation- ship difficulties, low social support, previous depression, and stress. It is identical in presentation to other major depression, and while DSM-IV allows the specifier ‘with postpartum onset’ to be applied to depression which occurs within four weeks of the delivery of a child, it has no separate diagnostic category for postpartum depression.

Rates of depression in new mothers, assessed by the Edinburgh Postnatal Depression Scale (Cox et al. 1987), are between 6 and 10 percent. Symptoms may begin at any time up to 12 months after the birth of the baby and may be preceded by normal adaptation. High rates of depression persist as long as the mother has young children at home, and fathers also experience postnatal depression. Looking after a baby is stressful and anxiety provoking, and fatigue and disturbed sleep add to the difficulty. Depression in the postpartum period is best treated as reactive depression, reflecting a need for social and practical support, rather than as unique to childbirth.

3. Fertility-Related Problems

3.1 Infertility

Infertility is generally defined as the failure to achieve a pregnancy after 12 months of unprotected sexual intercourse. Research on failure to conceive focuses on women, even though the cause is equally likely to be a characteristic of the male partner (Rowland 1992). The main causes are biological, although stress and anxiety can exacerbate physical problems.

Infertility and its treatment are distressing, but neither is associated with major psychological disturbance. The long-term outcomes of successful in vitro fertilization for children and their families are positive, but most outcomes are less benign. Involvement in in vitro fertilization is disruptive, expensive, and stressful. The probability of bearing a living child is around 10 percent per treatment cycle, and the risk of gynecological and obstetric complications, malformations, and multiple births is significantly increased. Repeated cycles of treatment are associated with increasing levels of depression (Rowland 1992).

3.2 Fertility Control

Access to adequate contraception and to abortion is important to women’s physical and psychological well being. Where abortions are legal, around 2 percent of women aged between 15 and 44 have an abortion in any year. The worldwide annual death rate from illegal abortions has been estimated at 100 000, while the death rate from legal abortions is 0.05 per 10 000, 25 times lower than the rate for childbirth. Provision of safe abortions and adequate contraception would have a major impact on the well being of women and children in developing countries.

Women may need support in deciding whether to choose abortion, but the majority experience no significant psychological distress. Psychological distress following abortion is considerably lower than that associated with childbirth. Distress is highest during decision making before the abortion, and the most common postabortion reaction is a sense of relief.

Women who cope best with abortion are characterized by optimism, high self-esteem, and a sense of personal control. Social, cultural, and partner support, and confidence in the decision, assist in coping, while women with a history of psychiatric disorder are likely to react negatively (Adler et al. 1992).

3.3 Miscarriage

Miscarriages are relatively common; over 30 percent of 50-year-old women have had at least one miscarriage. Reactions to spontaneous abortion of a wanted pregnancy are generally characterized by short-term grief, anxiety, and depression, normally resolved successfully within a few months (Slade 1994). Reactions to medical abortions follow a similar pattern, with short-term distress which may be severe but which resolves rapidly. Serious negative consequences are rare, and associated with previous psychiatric illness or lack of social support.

4. Menopause

Menopause is a natural physiological process resulting from aging of the ovaries, leading to cessation of ovulation and of estrogen production. Natural menopause occurs over several years. During the perimenopause, estrogen levels decrease and menstruation becomes irregular and ceases. The postmenopause, defined after 12 months without menstruation, is reached at an average age of 50.4 years.

Menopausal symptoms are categorized as: vasomotor (e.g., hot flushes, night sweats), psychosomatic (e.g., headaches, dizziness), and psychological (e.g., tiredness, irritability). The most common symptoms, reported across most cultures, are hot flushes and night sweats, clearly the result of changes in estrogen. However, prevalence of symptoms varies between countries, suggesting that sociocultural factors play a role (Hunt 1994).

Hormone replacement therapy relieves hot flushes and night sweats, but does not influence psychological well being in mid-aged women. Stress, life events, history of depression, and expectations are the strongest predictors of psychological well being during menopause. Women in their middle years often experience major life events (McKinlay et al. 1987). Once life changes are accounted for, there is little evidence to suggest that menopausal women are particularly prone to negative psychological states.

5. Conclusion

Distress associated with gynecological events is better explained by poor social support and by negative expectations than by endocrine function. Future research might usefully examine the experiences of women in a wider range of situations, including women in same-sex relationships, women who choose childlessness, and women with disabilities. An exploration of the experiences of women in different ethnic groups would also provide a broader perspective on psychosocial aspects of gynecological health.

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