Heribert Kentenich

ORIGINAL ARTICLE: Immune Status, Psychosocial Distress and Reduced Quality of Life in Infertile Patients with Endometriosis

Problem  The aim of the study was to identify if (i) psychosocial factors differ in endometriosis; (ii) related psychosocial aspects alter immune markers of depression/sickness behaviour; and (iii) serum immune marker may be indicative for endometriosis.

Emotional impact and acceptability of medical abortion with mifepristone: A German experience

In Germany, four years of experience with mifepristone as an alternative procedure to surgical abortion have revealed a still reluctant use of the new method. In the public discussion, the more participatory role of the women in the abortion procedure is often feared to have negative consequences for the emotional processing of the event. This study compares the womens criteria for selecting a method and the psychological responses before and four weeks after medical or surgical abortion. Two hundred and nineteen women answered questions regarding demographic data, motivation, medical details and social support. Additionally, the women completed the Hospital Anxiety and Depression Scale (HADS) and the Impact of Event Scale (IES). There were no differences regarding sociodemographic and reproductive characteristics among both groups. Comparing data before and a month after the abortion, our study showed a significant decline of both anxiety and depression for both abortion methods. The medical group had significantly lower entrance levels of anxiety than the surgical group. The medical regimen caused significantly more sequelae such as prolonged bleeding, pain and other side effects. However, this did not have a negative influence on the coping process. A vast majority of women in both groups evaluated choosing between different abortion methods as being highly important to them. Our study supports the consensus view that termination of an unwanted pregnancy is a positive first solution to the conflict, regardless of the chosen method. The positive outcome and high satisfaction levels among the participants illustrate the importance of an ongoing and improved accessibility of medical abortion for women in Germany.

Neuroendocrine circuitry and endometriosis: progesterone derivative dampens corticotropin-releasing hormone-induced inflammation by peritoneal cells in vitro

Clinical symptoms of endometriosis, such as pain and infertility, can be described as persistent stressors. Such continuous exposure to stress may severely affect the equilibrium and bidirectional communication of the endocrine and immune system, hereby further aggravating the progression of endometriosis. In the present study, we aimed to tease apart mediators that are involved in the stress response as well as in the progression of endometriosis. Women undergoing diagnostic laparoscopy due to infertility were recruited (n = 69). Within this cohort, early stage of endometriosis were diagnosed in n = 30 and advanced stage of endometriosis in n = 8. Levels of progesterone in serum were determined. Frequency of progesterone receptor (PR) expression on CD56+ and CD8+ peritoneal lymphocytes was analysed by flow cytometry. The production of tumour necrosis factor (TNF) and interleukin (IL)-10 by peritoneal leukocytes upon stimulation with the potent stress mediator corticotropin-releasing hormone (CRH) and the progesterone derivative dydrogesterone, or both, were evaluated. Furthermore, the production of progesterone-induced blocking factor (PIBF) by peritoneal leukocytes and the expression of PR in endometriotic tissue were investigated. Levels of progesterone in serum were decreased in women with endometriosis and inversely correlated to pain scores. Furthermore, an increased frequency of CD56+PR+ and CD8+PR+ peritoneal lymphocytes was present in advanced endometriosis. The TNF/IL-10 ratio, reflecting cytokine secretion by peritoneal cells, was higher in cells derived from endometriosis patients and could be further heightened by CRH stimulation, whereas stimulation with dydrogesterone abrogated the CRH-mediated inflammation. Finally, the expression of PIBF by peritoneal leukocytes was increased in endometriosis. Low levels of progesterone in the follicular phase could be responsible for the progression of endometriosis and related pain. Peripheral CRH, increasing upon high psychological stress, might contribute to the peritoneal inflammation present in endometriosis. The therapeutic application of progesterone derivatives, CRH blocking agents as well as improvement of stress coping may disrupt the vicious circle between the chronic peritoneal inflammation and high perception of psychological stress in endometriosis.

Ethnic Turkish fathers in birth support roles in a Berlin labour and delivery room – motives, preparation and incidence in a 10-year comparison

Purpose. Have there been changes among German (G) or ethnic Turkish (T) fathers with respect to birth preparation or motivation to participate in a birth support role? In a 10-year comparison is it possible to identify an increase among ethnic Turkish fathers in birth support roles in Germany? Methods. (1) In 1995/96 and 2003, structured interviews were conducted with German and ethnic Turkish fathers on the second or third post-natal day, focusing on the following topics: birth preparation, motives for participating in the birth, anxieties experienced by the father in the labour and delivery room, the fathers assessment of his role in the birth, information deficits. (2) In 1995 and 2006, the birth support roles of family members (partners, sisters, mothers-in-law etc.) were documented per 1000 consecutive hospital births and analysed according to parity and ethnicity. Results. (1) Structured interviews based on guidelines: In comparing 1995/96 (G/T n = 100, in each case) to 2003 (G/ n = 54, T/ n = 42) there is a significant increase among both Germans and ethnic Turks in the number of fathers participating in courses preparing for birth; ethnic Turkish men attended birthing courses noticeably less often (1995/96 and 2003: 8%; G approx. 40%, respectively). During both interview cycles the most common motivation given for providing birth support was ‘to solidify the relationship with the partner’. (2) Data on birth support roles: In the comparison between 1995/96 and 2006, more German fathers, as well as more ethnic Turkish fathers, were by the side of their wives/partners in the labour and delivery room; however, in contrast to the Germans, ethnic Turkish men more commonly tended to participate in a birth support role together with female family members, either simultaneously or by turns. Conclusions. The birth support role of the father has gained significant ground in the last 10 years, and is now also accepted among ethnic Turkish couples despite cultural differences. This is possibly the result of an acculturation process, in which a phenomenon within the host culture (fathers in the labour and delivery room) mixes with ancestral tradition (the birth support role of women).

The Investigation and Treatment of Female Pelvic Floor Dysfunction

BACKGROUND 25% of all women report involuntary loss of urine, and 7% may require treatment. METHODS This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews. RESULTS The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patients behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered. CONCLUSION Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

New challenges in medical education. The psychosomatic training program for gynecologists in Germany.

The unity of psyche, soma and social living conditions is especially evident in gynecology and obstetrics. Gynecological disorders often coincide with emotional or marital problems. These concomitant problems predict clinic attendance more than organic factors [1]. Women themselves perceive health and sickness within the context of their particular situation in life. They like for their gynecologist to take notice of personal and family conditions and to initiate communication about these subjects [2]. Concerning a wide range of obstetric and gynecological disorders, psychosocial factors are considered to be wholly or partially responsible for their appearance. For example several psychosocial factors predict pre term delivery. Furthermore, there is a broad spectrum of obstetric and gynecological disturbances affecting the quality of life and psychosocial interventions are urgently advised to achieve a more positive development in treatment and rehabilitation. These psychosocial issues are rarely discussed in gynecological practice [3]. Fallowfield et al. pointed out that doctors need communication skills training to elicit problems during consultations [4]. In addition, there are indications that insufficiently trained consultants are more frequently confronted with burnout syndrome [5]. Scientific studies on the psychosomatic aspects of obstetric and gynecological diseases and their epidemiology are relatively rare, especially in Germanspeaking countries. Within the framework of the Mannheim cohort project, a population-related prevalence of psychogenic disorders of 26% was determined. The frequency amounted to 18% for men and 34% for women. At 11.6%, functional and psychosomaticdisordersoccurredmost frequently [6]. In view of the above-mentioned factors, we can readily assume that the gynecologist, both in the outpatient and inpatient sectors, will be faced with a wide range of psychosomatic disorders. In the field of outpatient practice, doctors have long been aware of the relevance of psychosomatic care. In spite of this, a large part of the membership of the German Association of Psychosomatic Gynecology and Obstetrics are in outpatient practice. The DGPFG, with its 1200 members, is the largest psychosomatic association all over the world. However, of the 14,000 German gynecologists, not even one in ten is a member of our association. Since their foundation, the main aim of our association, besides the scientific compilation and propagation of psychosomatic findings over the whole field of specialization, has lain in the qualification of gynecologists and in maintaining quality in psychosomatic work throughout the whole sector.

ISPOG European Consensus Statement – chronic pelvic pain in women (short version)

Abstract To date there is no international guideline on chronic pelvic pain available that focuses on medical, psychosomatic and psychological diagnostics and treatment of this complicated disease pattern. In this paper, a European working group, which was established in October 2010, aims to bridge this gap. The working group decided to use the current German guideline as source text and to transform it into a European consensus statement by deleting parts that apply only to the conditions of the German health system. The literature search included papers published up to and including December 2010, using Medline search and by adding some new search terms. This manuscript reports the essential facts of the above-mentioned consensus statement. Within this article we use the term “psychosomatic” as the integrated concept of medical and psychosocial aspects of a disease.

Patients’ beliefs about the causes of myomas: a pilot study from a large European city

Abstract Introduction: Patients usually develop subjective concepts about their illness, which then influences their further health behaviors and treatment decisions. This study aimed to evaluate several possible patient beliefs about the causal factors of illness, in a large sample of women seeking treatment for myomas. Methods: From November 2011 to October 2013, all patients at a specialized myoma clinic in a large European city were surveyed about their beliefs about the causes of myomas. We used a modified version of the Patient Theory Questionnaire from Zenz et al., which presented 16 of the most common possible beliefs about the causes of myomas, and asked patients to rate them on a five-point scale of likelihood. Retrospectively, statistical analysis was performed on their answers and sociodemographic data. Results: Data from 482 patients was included (return rate of 91.5%). The most frequent answers for possible causes were “inherited susceptibility for myomas” (67.3%), “reorganization in the body during a particular phase of life” (63.5%), “stress at work or home” (49.3%) and “an in-born tendency to react to emotional agitation with physical disorders” (41.8%). Significant differences were found for the factors of age, immigration background and self-rated knowledge about myomas. Conclusions: It is curious that two of the four most common explanations for myomas were stress and somatization, and were endorsed by nearly half of all patients. Physicians seeing women for myomas should consider that many such patients may have further hidden reasons for seeking medical care.

Data not correctly calculated.

Stang et al have provided an important impulse for further discussion with their much-welcomed article on hysterectomy in Germany. All crucial statements in the article relate to hysterectomy undertaken for benign indications. The data on hysterectomy given in the first sentences of the results and discussion sections are contradictory: the hysterectomy rate in benign diseases of the female genital organs in Germany was not 3.6 per 1000 person-years; this is obviously the total hysterectomy rate for the whole of Germany. A more detailed explanation of the hysterectomy rate per 100 000 person-years, which was mentioned several times, would have been desirable. One critical comment: the authors obviously used the entire female population on their selected date of 2005 in their calculations. However, it does seem sensible to exclude at least girls younger than 10 years and women older than 80 years. The statement relating to the use of MRI-guided focused ultrasonographic ablation and uterine artery embolization for women wishing to keep their uterus requires a correction: these treatments for fibroids have been routinely used for many years. An alternative to hysterectomy in menorrhagia is hysteroscopy, a minimally invasive procedure, which was not mentioned in the discussion section (2). The hysterectomy rate, but also the way in which hysterectomies are performed in benign indications, gives a clue about the respective surgeons school of thought, the apparatus and other options available in the respective hospital, and flows—sometimes extending beyond state boundaries. A self-critical look at the hysterectomy rate in Germany on the part of the gynecological community is urgently required. This relates to defining indications in case of benign disease, the surgical modus operandi, and the question of whether the cervix should be spared. In conclusion, a large, nationwide, prospective health services research study is more than overdue in Germany.

Anmerkungen zur Geschichte der psychosomatischen Frauenheilkunde in Deutschland im 19. und 20. Jahrhundert

Psychosomatische Medizin in der Frauenheilkunde, wie wir sie heute verstehen und wie sie sich auf den Kongressen der Deutschen Gesellschaft fur Gynakologie und Geburtshilfe (DGGG) oder der Deutschen Gesellschaft fur Psychosomatische Frauenheilkunde und Geburtshilfe (DGPFG), in wissenschaftlichen Vortragen und auf Fortbildungsveranstaltungen prasentiert, blickt auf eine Traditionslinie zuruck, die etwa bis in das letzte Viertel des 19. Jahrhundert zuruckreicht. Drei Quellen lassen sich im Wesentlichen identifizieren, aus denen die Entwicklungen mehr oder weniger stark, bis hin zum Profil der heutigen Psychoso-matik in Deutschland gespeist wurden, bis schlieslich Mitte der 60er-, Anfang der 70er-Jahre des 20. Jahrhunderts die gesellschaftlichen, fachpolitischen und wissenschaftlichen Prozesse soweit gereift waren, dass die durch die Studenten- und Frauenbewegung induzierten Veranderungen auch der Etablierung der Psychosomatik sowohl in der damaligen Bundesrepublik Deutschland als auch in der DDR einen entscheidenden Schub gaben.