PSYCHOLOGICAL A-WPS Office

PSYCHOSOCIAL
ASPECTS OF
GYNAECOLOGY
Prof Chigbu B
OVER VIEW
• Women experience a variety of

changes to their body
throughout life. These include
• Pubertal changes
• Menstrual cycle
• Pregnancy
• Transition to Parenthood
• Ability to adapt to these changes
is important
Other issues that affect women
include
• Infertility
• Fertility choice and control
• Premenstrual syndrome
• Chronic pelvic pain without
pathology
• Sexual problems
Puberty
• Changing body shape

• Menstruation
• Awareness of sexuality
• Risk taking behaviour and
relationships
• Separation from family.
• Not all adolescents complete
Transition to Parenthood
• Loss of freedom
• Depression
• Sexual difficulties following
childbirth
• Expression of perceived
inadequacy
Menopause
• Emotional upset
• Physical discomfort
• Loss of youthful vigor
• Children leave home
Menstrual problems
• Emotional problems affect cycle

eg anorexia nervosa, anxiety
about exams
• Anxious or depressed women
may be bothered more about
their menses
Chronically anxious or depressed
women
• Frequent complaint of
menorrhagia, dysmenorrhea or
scanty menses to obtain medical
attention or to avoid sexual
intimacy or pregnancy
• Psychosomatic
Emotional disturbances underlying
complaint of menstrual problems include
• Relationship problems
• Divorce
• Bereavement
• Dysfunctional family background
• Alcohol abuse or eating disorders
• Chronic anxiety or depression
Evaluation
• History taking may reveal above

precipitating factors
• Physical examination may be
normal
• Investigations may be normal
Treatment
• Referral to a Counselor or
Clinical psychologist where there
is no identified organic
pathology.
• Some women will not accept
presence of a psychological
component to their complaint
Menopause
• Attitude may be that of relief or

acute dread
• Anxiety may manifest as physical
symptoms or as excessive
emotional reaction to ordinary
situations
Stressful life events that coincide
with menopause
• Retirement
• Divorce
• Bereavement
• Elderly parents
• Teenage children
• Etc
Remedy
• Counseling
• long-term hormone
replacement therapy
• Inability to adjust to aging may
lead to depression when HRT is
withdrawn
INFERTILITY
• Very stressful
• Cycles of continual hope and
disappointment
• Life centered around having a
baby.
• Nothing else seems important
• Partners blame each other,
become frustrated and guilty
• The more advanced technology
becomes the more difficult it is
to accept infertility
• Paradoxically, the woman who
originally did not want children
may become more desperate,
depressed and unable to face
life without a child.
Unconscious reasons why some
women do not want a child
• Mother's life was dull hence motherhood
should be avoided
• Hatred of younger siblings displacing them
• Successful career valued more than
motherhood
• Avoidance of having a child of hated
gender
• Desire to have been born a boy
Insight from reaction to issue of
adoption
• A woman who realistically wants
a baby will consider adoption
• Those hating adoption may be
unconsciously wanting a child to
prove a point.
Chronic pelvic pain without
pathology
• Common symptom in
gynaecology
• No pathology in two-thirds of
women at laparoscopy
• May be a somatic expression of
a psychic pain
Sexual Problems
• Studies have shown that

• Coitarche is now at a younger
age amongst women
• Vaginal intercourse is performed
more than anal intercourse,
fellatio and cunnilingus
• Homosexual activity is reported
by a minority of women
• Eight-five percent of women have
masturbated
• Younger women tend to have
more partners than older women
Sexual response cycle
1.Desire
2.Arousal (Subdivided into
excitement and plateau)
3. Orgasm
4. Resolution
DSMIV Classification of sexual
disorders
• Sexual desire disorders:
Excessive sexual desire,
hypoactive sexual desire, sexual
aversion disorder
• Arousal disorder
• Orgasmic disorder
• Sexual pain disorder :
• DMSIV refers to Diagnostic and
Statistical Manual of Mental
Disorders fourth edition.
PREVALENCE
• Unknown
• About 60% of women will have a
sexual problem at some time in
their life
ASSESSMENT
• Common complaints are
• 1. Decreased frequency either due
to low desire or avoidance
• 2. Problems with penetration
• 3. Problems with orgasm
• 4. Painful intercourse
TAKING A SEXUAL HISTORY
• History taking is important to
determine if the problem is
emotional or physical or both.
• Open non judgemental style when
asking about sensitive matters
(sexual orientation, masturbation,
affairs, fantasies)
SEXUAL HISTORY
• Childhood and adolescent

experiences
• Adult experiences
• Current experiences
• PMH/PSH
• Past Gynae and Obs history
• Drug history
EXAMINATION
• Examining a patient with a sexual
problem requires tact. Ensure
privacy and ensure patient is in
control and fully informed of what
steps you have to take.
INVESTIGATIONS
• Depends on the possible underlying
causes for the sexual problem.
INVESTIGATIONS
• Loss of desire (anemia, renal dx, liver
dx, heart failure,
hyperprolactinaemia, hypothyroidism
etc)
• Superficial dyspareunia (STI,
Dermatological condition)
• Deep dyspareunia (UTI,
Endometriosis, PID)
DYSPAREUNIA
• Either Superficial or deep

• There can be organic component
• Therefore full medical history, and
examination is needed
• About 70% women have no obvious
disease process
• Emotional pain can be expressed as real
physical pain
NON ORGANIC
DYSPAREUNIA
• Can be divided into
• Type 1: Intrapersonal
• Type 2: Interpersonal
• In type 1 the presentation involves
guilt, misinformation, previous
traumatic experiences or previous
physical factors such as episiotomy.
• Type 2 is where relationship
problems exist and dyspareunia is
an expression of unconscious fear
or anger in the relationship
providing an excuse to avoid sex.
CASE HISTORY
• Mrs. BC a 30 year old married
teacher presents with superficial
dyspareunia leading to loss of
interest in sex since the difficult
assisted vaginal delivery of her first
child a year previously. She has
been married for 3 years to a busy
medical doctor.
• Sex prior to the pregnancy was
satisfactory. Six months after the
birth of her child she resumed
work. Her husband's practice seems
to have gotten busier and he spends
long hours at work. There
relationship is under stress.
DISCUSSION
• 1.What is the most likely diagnosis?
• Is dyspareunia leading to sexual avoidance
or sexual avoidance leading to dyspareunia?
• 2. What organic factors may be present in
Mrs BC?
• 3.What psychosocial problems may exist?
• 4.What management options would you
recommend?
ANSWER
• 1. It could be either or both.
• 2. There may have been organic
factors such as initial high prolactin
and low Oestrogen levels if she was
breastfeeding, or a painful
episiotomy scar
• 3. Alternatively, it could be psychosocial
with her symptoms secondary to fear of
a further pregnancy and delivery, or
coming to terms with her new role as a
mother, or a relationship problem if she
is resenting the time her husband
spends at work or is suspicious he is
having an affair.
MANAGEMENT OPTIONS
• 1. Brief individual or couple

counseling to give information and
improve communication between
the partners (general and sexual
communication)
• 2. Attention should also be paid to
any identified organic factors and
adequate management given.
THANK YOU
WITH ALL MY LOVE

PSYCHOLOGICAL A-WPS Office

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PSYCHOSOCIAL

• Women experience a variety of

• Changing body shape

• Emotional problems affect cycle

• History taking may reveal above

• Attitude may be that of relief or

• Studies have shown that

• Childhood and adolescent

• Either Superficial or deep

• 1. Brief individual or couple

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