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Gynecology_Novak. between the sexual assault and the initiation of therapy, and the patient’s desire to be treated. All survivors of unprotected vaginal or anal sexual assault presenting within 72 hours should be offered HIV prophylaxis unless the assailant is known and tests negative with rapid HIV testing (169). Treatment should be initiated as soon as possible. The usual regimen is Combivir or its equivalent (300 mg zidovudine [AZT] and 150 mg lamivudine [3TC]) administered twice daily for 4 weeks). Administration of a protease inhibitor (nelfinavir, five 250 mg tablets twice a day for 28 days) should be considered for high-risk exposures, such as when the assailant is known to be HIV infected. Providers should also consider consulting an HIV specialist or calling the National Clinicians’ Post-Exposure Prophylaxis Hotline. Side effects of HIV prophylaxis include nausea, malaise, headache, and anorexia. About 33% of survivors who elect to take antiviral medication discontinue therapy prematurely


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Gynecology_Novak. Prophylaxis Hotline. Side effects of HIV prophylaxis include nausea, malaise, headache, and anorexia. About 33% of survivors who elect to take antiviral medication discontinue therapy prematurely (168). Patients should be aware that the efficacy of prophylactic treatment for HIV after sexual assault is unknown, and they will have to be carefully monitored if they initiate treatment with antiretroviral medication.


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Gynecology_Novak. 5. Bite wounds can be treated with amoxicillin/clavulanate (Augmentin) 875 mg twice a day for 3 days. 6. If prophylactic treatment for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis is not given, the survivor should return in 2 weeks for repeat testing for STDs and pregnancy. If the initial serologic test results were negative, repeat serologic tests for syphilis, hepatitis B, and HIV should be performed at 6, 12, and 24 weeks after the assault. 7.


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Gynecology_Novak. 7. Ongoing supportive counseling for the patient should be arranged, and the patient should be referred to a sexual assault center or a therapist who specializes in the treatment of sexual assault survivors. A number of excellent resources are available for providers caring for women who were sexually assaulted (170). These include a policy statement on treatment of sexual assault survivors from the American Academy of Family Physicians and a national protocol for sexual assault medical forensic evaluations from the U.S. Department of Justice. 1. Hayes RD. Assessing female sexual dysfunction in epidemiological studies: why is it necessary to measure both low sexual function and sexually related distress? Sex Health 2008;5:215–218. 2. Fugl-Meyer AR, Sj¨ogren Fugl-Meyer K. Sexual disabilities, problems and satisfaction in 18–74 year old Swedes. Scand J Sexology 1999;2:79–105. 3.


Gynecology_Novak

Gynecology_Novak. 2. Fugl-Meyer AR, Sj¨ogren Fugl-Meyer K. Sexual disabilities, problems and satisfaction in 18–74 year old Swedes. Scand J Sexology 1999;2:79–105. 3. Cain VS, Johannes CB, Avis NE. Sexual functioning and practices in a multi-ethnic study of mid-life women: baseline results from SWAN. J Sex Res 2003;40:266–276. 4. Lutfey KE, Link CL, Rosen RC, et al. Prevalence and correlates of sexual activity and function in women: results from the Boston Area Community Health (BACH) Survey. Arch Sex Behav 2009;38: 514–527. 5. Yucel S, de Souza A, Baskin LS. Neuroanatomy of the human female lower urogenital tract. JUrol 2004;172:191–195. 6. Graham CA, Sanders SA, Milhausen RR. The sexual excitation/sexual inhibition inventory for women: psychometric properties. Arch Sex Behav 2006;35:397–409. 7. Meston CM, Buss DM. Why humans have sex. Arch Sex Behav 2007;36:477–507. 8.


Gynecology_Novak

Gynecology_Novak. 7. Meston CM, Buss DM. Why humans have sex. Arch Sex Behav 2007;36:477–507. 8. McCall K, Meson C. Differences between pre-and postmenopausal women in cues for sexual desire. J Sex Med 2007;4(2):364–371. 9. Pfaus JG. Pathways of sexual desire. J Sex Med 2009;6:1506– 1533. 10. Blaustein JD. Progestin receptors: neuronal integrators of hormonal and environmental stimulation. Ann N Y Acad Sci 2003;1007:1–13. 11. Basson R. Women’s sexual function and dysfunction: current uncertainties, future directions. Int J Impot Res 2008;20:466–478. 12. Segraves RT. Bupropion sustained release for the treatment of hypoactive sexual desire disorder in premenopausal women. J Clin Psychopharmacol 2004;25:339–342. 13. Dennerstein L, Lehert P. Modeling mid-aged women’s sexual functioning: a prospective, population-based study. J Sex Marital Ther 2004;30:173–183. 14. Pfaus JG, Kippin TE, Centeno S. Conditioning and sexual behaviour: a review. Horm Behav 2001;40:291–321. 15.


Gynecology_Novak

Gynecology_Novak. 14. Pfaus JG, Kippin TE, Centeno S. Conditioning and sexual behaviour: a review. Horm Behav 2001;40:291–321. 15. ter Kuile MM, Both S, van Uden J. The effects of experimentally-induced sad and happy mood on sexual arousal in sexually healthy women. J Sex Med 2010;7:1177–1184. 16. Carvalho J, Nobre P. Sexual desire in women: an integrative approach regarding psychological, medical and relationship dimensions. J Sex Med 2010;7:1807–1815. 17. Bancroft J, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003;32:193–211. 18. HartmannU,HeiserK,R¨uffer-HesseC,etal. Female sexual desire disorders: subtypes, classification, personality factors, a new direction for treatment. World J Urol 2002;20:79–88. 19. Basson R. Sexual function of women with chronic illness and cancer. Women’s Health 2010;6:407–430. 20. Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet 2007; 369:409–424. 21.


Gynecology_Novak

Gynecology_Novak. 20. Basson R, Schultz WW. Sexual sequelae of general medical disorders. Lancet 2007; 369:409–424. 21. Rees PM, Fowler CJ, Maas CP. Sexual function men and women with neurological disorders. Lancet 2007;369:512–525. 22. Archer JS, Love-Geffen TE, Herbst-Damm KL, et al. Effect of estradiol versus estradiol and testosterone on brain activation patterns in postmenopausal women. Menopause 2006;13:528–537. 23. van Lunsen RHW, Laan E. Genital vascular responsive and sexual feelings in midlife women: psychophysiologic, brain and genital imaging studies. Menopause 2004;11:741–748. 24. Ottesen B, Pedersen B, Neilsen J, et al. Vasoactive intestinal polypeptide (VIP) provokes vaginal lubrication in normal women. Peptides 1987;8:797–800. 25. Creighton SM, Crouch NS, Foxwell NA, et al. Functional evidence for nitrergic neurotransmission in human clitoral corpus cavernosum: a case study. Int J Impot Res 2004;16:319–324. 26.


Gynecology_Novak

Gynecology_Novak. 25. Creighton SM, Crouch NS, Foxwell NA, et al. Functional evidence for nitrergic neurotransmission in human clitoral corpus cavernosum: a case study. Int J Impot Res 2004;16:319–324. 26. Chivers ML, Seto MC, Lalumi`ere ML, et al. Agreement of self-reported and genital measures of sexual arousal in men and women: a meta-analysis. Arch Sex Behav 2010;39:5–56. 27. Shafik A. Cervico motor reﬂex: description of the reﬂex and role in sexual acts. J Sex Res 1996;33:153–157. 28. Shafik A, El-Sibai O, Mostafa R, et al. Response of the internal reproductive organs to clitoral stimulation: the clitoro-uterine reﬂex. Int J Impot Res 2005;17:121–126. 29. van Netten JJ, Georgiadis JR, Nieuwenburg A, et al. 8-13 Hz ﬂuctuations in rectal pressure are a objective marker of clitorally-induced orgasm in women. Arch Sex Behav 2008;37:279–285. 30.


Gynecology_Novak

Gynecology_Novak. 29. van Netten JJ, Georgiadis JR, Nieuwenburg A, et al. 8-13 Hz ﬂuctuations in rectal pressure are a objective marker of clitorally-induced orgasm in women. Arch Sex Behav 2008;37:279–285. 30. Georgiadis JR, Reinders AATS, Paans AMJ, et al. Men versus women on sexual brain function: prominent differences during tactile genital stimulation but not during orgasm. Human Brain Mapping 2008;30:3089–3101. 31. Mah K, Binik YM. Do all orgasms feel alike? Evaluating a two-dimensional model of the orgasmic experience across genders and sexual contexts. J Sex Res 2002;39:104–113. 32. McCabe M, Althof SE, Assalian P, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med 2010;7:327–348. 33. Basson R. Clinical practice. Sexual desire and arousal disorders in women. N Engl J Med 2006;354:1467–1506. 34. Klusmann D. Sexual motivation and the duration of partnership. Arch Sex Behav 2002;31:275–287. 35.


Gynecology_Novak

Gynecology_Novak. 34. Klusmann D. Sexual motivation and the duration of partnership. Arch Sex Behav 2002;31:275–287. 35. Kennedy SH, Dickens SE, Eisfeld BS, et al. Sexual dysfunction before antidepressant therapy in major depression. J Affect Disord 1999;56:201–208. 36. Avis NE, Zhao X, Johannes CB, et al. Correlates of sexual function among multi ethnic middle aged women: Results from the study of women’s health across the nation (SWAN). Menopause 2005;12:385–398. 37. Davison SL, Bell RJ, LaChina M, et al. The relationship between self-reported sexual satisfaction and general well-being in women. J Sex Med 2009;6:2690–2697. 38. Frohlich P, Meston C. Sexual functioning and self-reported depressive symptoms among college women. J Sex Res 2002;39:321–325. 39. Laumann EL, Paik A, Rosen RC. Sexual dysfunction in United States: prevalence and predictors. JAMA 1999;10:537–545. 40.


Gynecology_Novak

Gynecology_Novak. 39. Laumann EL, Paik A, Rosen RC. Sexual dysfunction in United States: prevalence and predictors. JAMA 1999;10:537–545. 40. Mansfield PK, Koch PB. Qualities midlife women desire in their sexual relationship and their changing sexual response. Psychol Women Q 1998;22:282–303. 41. Leiblum SR, Koochaki PE, Rodenberg CA, et al. Hypoactive sexual desire disorder in postmenopausal women: US results from the Women’s International Study of Health and Sexuality (WISHeS). Menopause 2006;13:46–56. 42. Dennerstein L, Lehert P, Burger H, et al. Factors affecting sexual functioning of women in the midlife years. Climacteric 1999;2:254– 262. 43. Berra M, De Musso F, Matteucci C, et al. The impairment of sexual function is less distressing for menopausal than for premenopausal women. J Sex Med 2010;7:1209–1215. 44. Sj¨ogrenFugl-MeyerK,Fugl-MeyerAR. Sexual disabilities are not singularities. Int J Impot Res 2002;14:487–493. 45.


Gynecology_Novak

Gynecology_Novak. 44. Sj¨ogrenFugl-MeyerK,Fugl-MeyerAR. Sexual disabilities are not singularities. Int J Impot Res 2002;14:487–493. 45. Cayan S, Bozlu M, Canpolat B, et al. The assessment of sexual functions in women with male partners complaining of erectile dysfunction: Does treatment of male sexual dysfunction improve female partner’s sexual functions? J Sex Marital Ther 2004;30:333–341. 46. Hajjar RR, Kamel HK. Sex in the nursing home. Clin Geriatr Med 2003;19:575–586. 47. Santoro N, Komi J. Prevalence and impact of vaginal symptoms among postmenopausal women. JSexMed 2009;6:2133–2142. 48. Santoro N, Torrens J, Crawford S, et al. Correlates of circulating androgens in midlife women: the study of women’s health across the nation. J Clin Endocrinol Metab 2005;90:4836–4845. 49. Davis SR, Davison SL, Donath S, et al. Circulating androgen levels in self-reported sexual function in women. JAMA 2005;294:91–96. 50.


Gynecology_Novak

Gynecology_Novak. 49. Davis SR, Davison SL, Donath S, et al. Circulating androgen levels in self-reported sexual function in women. JAMA 2005;294:91–96. 50. Basson R, Brotto LA, Petkau J, et al. Role of androgens in women’s sexual dysfunction. Menopause 2010;17:962–971. 51. Peng YS, Chiang CK, Kao TW, et al. Sexual dysfunction in female hemodialysis patients: a multicenter study. Kidney Int 2005;68:760– 765. 52. Zivadinov R, Zorzon M, Bosco A, et al. Sexual dysfunction in multiple sclerosis: correlation analysis. Mult Scler 1999;5:428– 431. 53. Bhasin S, Enzlin P, Caviello A, et al. Sexual dysfunction in men and women with endocrine disorders. Lancet 2007;369:597–611. 54. van Lankveld JJDM, Granot M, Weijmar Schultz WCM, et al. Women’s sexual pain disorders. JSexMed 2010;7:615–631. 55. Avis NE, Stellato R, Crawford S, et al. Is there an association between menopause status and sexual functioning? Menopause 2000;7:297–309.


Gynecology_Novak

Gynecology_Novak. Women’s sexual pain disorders. JSexMed 2010;7:615–631. 55. Avis NE, Stellato R, Crawford S, et al. Is there an association between menopause status and sexual functioning? Menopause 2000;7:297–309. 56. Oberg K, Sj¨ogern Fugl Myer K. On Swedish women’s distressing sexual dysfunctions: some concomitant conditions and life satisfaction. J Sex Med 2005;2:169–180. 57. Benyamini Y, Gozlan M, Kokia E. Variability in the difficulties experienced by women undergoing infertility treatments. Fertil Steril 2005;83:275–283. 58. Wischmann TH. Sexual disorders in infertile couples. J Sex Med 2010;7:1868–1876. 59. Clayton AH, Warnock JK, Kornstein SG, et al. A placebo-controlled trial of bupropion SR as an antidote for selective serotonin reuptake inhibitor-induced sexual dysfunction. J Clin Psychiatry 2004;65:62–67. 60. Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. JAMA 2008;300:395–404. 61.


Gynecology_Novak

Gynecology_Novak. 60. Nurnberg HG, Hensley PL, Heiman JR, et al. Sildenafil treatment of women with antidepressant-associated sexual dysfunction. JAMA 2008;300:395–404. 61. Conaglen HM, Conaglen JV. Sexual desire in women presenting for antiandrogen therapy. J Sex Marital Ther 2003;29:255–267. 62. Hahn S, Benson S, Elsenbruch S, et al. Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality. Hum. Reprod 2006;21:1925–1934. 63. Ganz PA, Desmond KA, Leedham B, et al. Quality of life in longterm, disease-free survivors of breast cancer: a follow-up study. J Natl Cancer Inst 2002;94:39–49. 64. Ganz PA, Desmond KA, Belin TR, et al. Predictors of sexual health in women after a breast cancer diagnosis. J Clin Oncol 1999;17:2371–2380. 65. Adler J, Zanetti R, Wight E, et al. Sexual dysfunction after premenopausal stage I and II breast cancer: do androgens play a role? J Sex Med 2008;5:1898–1906. 66.


Gynecology_Novak

Gynecology_Novak. 65. Adler J, Zanetti R, Wight E, et al. Sexual dysfunction after premenopausal stage I and II breast cancer: do androgens play a role? J Sex Med 2008;5:1898–1906. 66. Berglund G, Nystedt M, Bolund C, et al. Effect of endocrine treatment on sexuality in premenopausal breast cancer patient: a prospective randomized study. J Clin Oncol 2001;19:2788–2796. 67. Ganz PA, Rowland JH, Desmond K, et al. Life after breast cancer: understanding women’s health related quality of life and sexual functioning. J Clin Oncol 1998;16:501–514. 68. Fallowfield L, Cella D, Cuzick J, et al. Quality of life of post-menopausal women in the Arimidex, Tamoxifen, Alone or in Combination (ATAC) Adjuvant Breast Cancer Trial. J Clin Oncol 2004;22:4261–4271. 69. Enzlin P, Rosen R, Wiegl M. Sexual dysfunction in women with type-I diabetes: long-term findings from the DCCT/EDIC study cohort. Diabetes Care 2009;32:780–783. 70.


Gynecology_Novak

Gynecology_Novak. 69. Enzlin P, Rosen R, Wiegl M. Sexual dysfunction in women with type-I diabetes: long-term findings from the DCCT/EDIC study cohort. Diabetes Care 2009;32:780–783. 70. Wierman ME, Nappi RE, Avis N, et al. Endocrine aspects of women’s sexual function. J Sex Med 2010;7:561–585. 71. Gimbel H, Zobbe V, Andersen BM, et al. Randomized controlled trial of total compared with subtotal hysterectomy with 1-year follow-up results. Br J Obstet Gynaecol 2003;110:1088–1098. 72. Roovers JPWR, van der Bom JG, Huub van der Vaart C, et al. Hysterectomy and sexual well being: prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ 2003;327:774–779. 73. Kim DH, Lee YS, Lee ES. Alteration of sexual function after classic intrafascial supracervical hysterectomy and total hysterectomy. JAm Assoc Gynecol Laparosc 2003;10:60–64. 74.


Gynecology_Novak

Gynecology_Novak. 73. Kim DH, Lee YS, Lee ES. Alteration of sexual function after classic intrafascial supracervical hysterectomy and total hysterectomy. JAm Assoc Gynecol Laparosc 2003;10:60–64. 74. Long CY, Fang JH, Chen WC, et al. Comparison of total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy. Gynecol Obstet Invest 2002;53:214–219. 75. Pieterse QD, Ter Kuile MM, Deruiter MC, et al. Vaginal blood ﬂow after radical hysterectomy with and without nerve sparing: a preliminary report. Int J Gynecol Cancer 2008;18:576–583. 76. Jongpipan J, Charoenkwan K. Sexual function after radical hysterectomy for early-stage cervical cancer. J Sex Med 2007;4:1659– 1665. 77. Serati M, Salvatore S, Uccella S, et al. Sexual function after hysterectomy early-stage cervical cancer: Is there a difference between laparoscopy and laparotomy? J Sex Med 2009;6:2516–2522. 78. Bukovi´c D, Strini´c T, Habek M, et al. Sexual life after cervical carcinoma. Coll Antropol 2003;27:173–180.


Gynecology_Novak

Gynecology_Novak. 78. Bukovi´c D, Strini´c T, Habek M, et al. Sexual life after cervical carcinoma. Coll Antropol 2003;27:173–180. 79. Bergmark K, Avall-Lundqvist E, Dickman PW, et al. Vaginal changes and sexuality in women with a history of cervical cancer. N Engl J Med 1999;340:1383–1389. 80. Pauleta JR, Pereira NM, Graca LM. Sexuality during pregnancy. J Sex Med 2010;7:136–142. 81. Asalan G, Asalan D, Kizilyar A, et al. Prospective analysis of sexual functions during pregnancy. Int J Impot Res 2005;17:154–157. 82. Benedetto C, Marozio L, Prandi G, et al. Short-term maternal and neonatal outcomes by mood of delivery. A case-controlled study. Eur J Obstet Gynecol Reprod Biol 2007;135:35–40. 83. Safarinejad MR, Kolahi AA, Hosseini L. The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primeparous women and their husbands. J Sex Med 2009;6:1645– 1667. 84.


Gynecology_Novak

Gynecology_Novak. 84. Marwick C. Surveys say patients expect little physician help on sex. JAMA 1999;281:2173–2174. 85. Nazareth I, Boynton P, King M. Problems with sexual function and people attending London general practitioners: Cross-sectional study. Brit Med J 327:2003;423-428. 86. Basson R, Leiblum S, Brotto L, et al. Revised definitions of women’s sexual dysfunction. J Sex Med 2004;1:40–48. 87. Basson R, Leiblum S, Brotto L, et al. Definitions of women’s sexual dysfunctions reconsidered: advocating expansion and revision. J Psychosom Obstet Gynaecol 2003;24:221–229. 88. Brotto LA. The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Arch Sex Behav 2010;39:221–239. 89. Graham CA. The DSM diagnostic criteria for female sexual arousal disorder. Arch Sex Behav 2010;39:240–255. 90.


Gynecology_Novak

Gynecology_Novak. 89. Graham CA. The DSM diagnostic criteria for female sexual arousal disorder. Arch Sex Behav 2010;39:240–255. 90. West SL, D’Aloisio AA, Agans RP, et al. Prevalence of low sexual desire and hypoactive sexual desire disorder in a nationally representative sample of US women. Arch Intern Med 2008;168:1441–1449. 91. Graziotiin A, Koochaki PE, Rodenberg CA, et al. The prevalence of hypoactive sexual desire disorder in surgically menopausal women: an epidemiological study of women in four European countries. J Sex Med 2009;6:2143–2153. 92. Leiblum SR, Hayes RD, Wanser RA, et al. Vaginal dryness: a comparison of prevalence and interventions in 11 countries. J Sex Med 2009;6:2425–2433. 93. Harlow BL, Wise LA, Stewart EG. Prevalence and predictors of chronic lower genital tract discomfort. Am J Obset Gynecol 2001;185:545–550. 94. Brotto LA, Bitzer J, Laan E, et al. Women’s sexual desire and arousal disorders. J Sex Med 2010;7(Pt 2):586–614. 95.


Gynecology_Novak

Gynecology_Novak. 94. Brotto LA, Bitzer J, Laan E, et al. Women’s sexual desire and arousal disorders. J Sex Med 2010;7(Pt 2):586–614. 95. Braunstein G, Sundwall DA, Katz M, et al. Safety and efficacy of a testosterone patch for the treatment of hypoactive sexual disorder in surgically menopausal women: a randomized, placebo-controlled trial. Arch Intern Med 2005;165:1582–1589. 96. Buster JE, Kingsberg SA, Aguirre O, et al. Testosterone patch for low sexual desire in surgically menopausal women: a randomized trial. Obstet Gynecol 2005;105:944–952. 97. Simon J, Braunstein G, Nachtigall L, et al. Testosterone patch increases sexual activity and desire in surgically menopausal women with hypoactive sexual desire disorder. J Clin Endocrinol Metab 2005;90:5226–5233. 98.


Gynecology_Novak

Gynecology_Novak. 98. Davis SR, van der Mooren MJ, van Lunsen RHW, et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized, placebo controlled trial. Menopause 2006;13:387–396. 99. Shifren JL, Davis SR, Moreau M, et al. Testosterone patch for the treatment of hypoactive sexual desire disorder in naturally menopausal women: results from the INTIMATE NM1 STUDY. Menopause 2006;13:770–779. 100. Davis S, Moreau M, Kroll R, et al. Testosterone for low libido in postmenopausal women not taking estrogen. N Engl J Med 2008;359:2005–2017. 101. Panay N, Al-Azzawi F, Bouchard C, et al. Testosterone treatment of HSDD in naturally menopausal women: the ADORE study. Climacteric 2010;13:121–131. 102.


Gynecology_Novak

Gynecology_Novak. 101. Panay N, Al-Azzawi F, Bouchard C, et al. Testosterone treatment of HSDD in naturally menopausal women: the ADORE study. Climacteric 2010;13:121–131. 102. Barton DL, Wender DB, Sloan JA, et al. Randomized controlled trial to evaluate transdermal testosterone in female cancer survivors with decreased libido: North Central Cancer Treatment Group Protocol N02C3. J Nat Cancer Inst 2007;99:672–679. 103. Davis S, Papalia MA, Norman RJ, et al. Safety and efficacy of a testosterone metered-dose transdermal spray for treatment of decreased sexual satisfaction in premenopausal women: a placebo-controlled randomized, dose ranging study. Ann Intern Med 2008;148:569–577. 104. Wild RA. Endogenous androgens and cardiovascular risk. Menopause 2007;14:609–610. 105. Barbach L. For yourself: the fulfillment of female sexuality.New York: Signet, 2000. 106.


Gynecology_Novak

Gynecology_Novak. 104. Wild RA. Endogenous androgens and cardiovascular risk. Menopause 2007;14:609–610. 105. Barbach L. For yourself: the fulfillment of female sexuality.New York: Signet, 2000. 106. Fortney L, Taylor M. Meditation in medical practices: a review of the evidence and practice. Prim Care Clin Office Pract 2010;37:81– 90. 107. Long CY, Liu CM, Hsu SC, et al. A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause 2006;13;737–743. 108. Labrie F, Archer D, Bouchard C, et al. Effect on intravaginal dehydroepiandrosterone (Prasterone) on libido and sexual dysfunction in postmenopausal women. Menopause 2010;16:923–931. 109. Obermeyer CM. The consequences of female circumcision for health and sexuality: an update on the evidence. Cult Health Sex 2005;7:443–461. 110.


Gynecology_Novak

Gynecology_Novak. 109. Obermeyer CM. The consequences of female circumcision for health and sexuality: an update on the evidence. Cult Health Sex 2005;7:443–461. 110. Elnashar A, Abelhady R. The impact of female genital cutting on health of newly married women. Int J Gynaecol Obstet 2007;97:238– 244. 111. Johnson C, Nour NM. Surgical techniques: defibulation of type III female genital cutting. J Sex Med 2007;4:1544–1547. 112. Dunn SFM, Gilchrist VJ. Sexual assault. Prim Care 1993;20:359– 373. 113. Sorenson SB, Stein JA, Siegel JM, et al. The prevalence of adult sexual assault. Am J Epidemiol 1987;126:1154–1164. 114. American College of Obstetricians and Gynecologists. Sexual assault. Technical bulletin no. 242. Washington, DC: ACOG, 1997. 115. McGrath ME, Hogan JW, Peipert JF. A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynecol 1998;91:511–514. 116.


Gynecology_Novak

Gynecology_Novak. 115. McGrath ME, Hogan JW, Peipert JF. A prevalence survey of abuse and screening for abuse in urgent care patients. Obstet Gynecol 1998;91:511–514. 116. McFarlane J, Malecha A, Watson K, et al. Intimate partner assault against women: frequency, health consequences, and treatment outcomes. Obstet Gyncol 2005;105:99–108. 117. Walch AG, Broadhead WE. Prevalence of lifetime sexual victimization among female patients. J Fam Pract 1992;35:511–516. 118. DeLahunta EA, Baram DA. Sexual assault. Clin Obstet Gynecol 1997;40:648–660. 119. Bachman GA, Moeller TP, Bennet J. Childhood sexual abuse and the consequences in adult women. Obstet Gynecol 1988;71:631–642. 120. Campbell R. The psychological impact of rape victims. Am Psychol 2008;63:702–717. 121. Springs FE, Friedrich WN. Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clin Proc 1992;67:527– 532. 122.


Gynecology_Novak

Gynecology_Novak. 121. Springs FE, Friedrich WN. Health risk behaviors and medical sequelae of childhood sexual abuse. Mayo Clin Proc 1992;67:527– 532. 122. Lang AJ, Rodgers CS, Laffaye C, et al. Sexual trauma, posttraumatic stress disorder, and health behavior. Behav Med 2003;28:150– 158. 123. Weitlauf JC, Finney JW, Ruzek JI, et al. Distress and pain during pelvic examinations: effect of sexual violence. Obstet Gynecol 2008;112:1343–1350. 124. Council on Scientific Affairs, American Medical Association. Violence against women: relevance for medical practitioners. JAMA 1992;267:3184–3189. 125. Wyatt GE, Guthrie D, Notgrass CM. Differential effects of women’s child sexual abuse and subsequent sexual revictimization. J Consult Clin Psychol 1992;60:167–173. 126. Polit DF, White CM, Morton TD. Child sexual abuse and premarital intercourse among high-risk adolescents. J Adolesc Health 1990;11:231–234. 127.


Gynecology_Novak

Gynecology_Novak. 126. Polit DF, White CM, Morton TD. Child sexual abuse and premarital intercourse among high-risk adolescents. J Adolesc Health 1990;11:231–234. 127. McCauley J, Kern DE, Kolodner K, et al. Clinical characteristics of women with a history of childhood abuse: unhealed wounds. JAMA 1997;277:1362–1368. 128. Mackey TF, Hacker SS, Weissfeld LA, et al. Comparative effects of sexual assault on sexual functioning of child sexual abuse survivors and others. Issues Ment Health Nurs 1991;12:89–112. 129. Laws A. Does a history of sexual abuse in childhood play a role in women’s medical problems? A review. J Womens Health 1993;2:165–172. 130. American College of Obstetricians and Gynecologists. Adult manifestations of childhood sexual abuse. Technical Bulletin No. 259. Washington, DC: ACOG, 2000. 131. Danielson CK, Holmes MM. Adolescent sexual assault: an update of the literature. Curr Opin Obstet Gynecol 2004;16:383–388. 132.


Gynecology_Novak

Gynecology_Novak. 131. Danielson CK, Holmes MM. Adolescent sexual assault: an update of the literature. Curr Opin Obstet Gynecol 2004;16:383–388. 132. Kilpatrick DG, Edmunds CN, Seymour AK. Rape in America. New York: National Victim Center, 1992. 133. Ellis E, Atkeson B, Calhoun K. An assessment of long term reaction to rape. J Abnorm Psychol 1981;90:263–266. 134. Walling MK, Reiter RC, O’Hara MW, et al. Abuse history and chronic pain in women. 1. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994;84:193–199. 135. Golding JM, Wilsnack SC, Learman LA. Prevalence of sexual assault history among women with common gynecologic symptoms. Am J Obstet Gynecol 1998;179:1013–1019. 136. Hendricks-Matthews MK. Survivors of abuse. Prim Care 1993;20:391–406. 137. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328–331. 138.


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Gynecology_Novak. 136. Hendricks-Matthews MK. Survivors of abuse. Prim Care 1993;20:391–406. 137. Felitti VJ. Long-term medical consequences of incest, rape, and molestation. South Med J 1991;84:328–331. 138. Jones JS, Rossman L, Wynn BN, et al. Comparative analysis of adult versus adolescent sexual assault: epidemiology and patterns of anogenital injury. Acad Emerg Med 2003;10:872–877. 139. Mein JK, Palmer CM, Shand MC, et al. Management of acute adult sexual assault. Med J Aust 2003;178:226–230. 140. Eckert LO, Sugar NF. Older victims of sexual assault: an unrecognized population. Am J Obstet Gynecol 2008;198:688.e1–688.e7. 141. Sugar NF, Fine DN, Eckert LO. Physical injury after sexual assault: findings of a large case series. Am J Obstet Gynecol 2004;190:71–76. 142. Hampton HL. Care of the women who has been raped. N Engl J Med 1995;332:234–237. 143. Linden JA. Sexual assault. Emerg Med Clin North Am 1999;17:685– 697. 144.


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Gynecology_Novak. 142. Hampton HL. Care of the women who has been raped. N Engl J Med 1995;332:234–237. 143. Linden JA. Sexual assault. Emerg Med Clin North Am 1999;17:685– 697. 144. Groth AN. Men who rape: the psychology of the offender. New York: Plenum, 1979. 145. Bechtel K, Podrazik M. Evaluation of the adolescent rape victim. Pediatr Clin North Am 1999;46:809–822. 146. Wiley J, Sugar N, Fine D, Eckert LO. Legal outcomes of sexual assault. Am J Obstet Gynecol 2003;188:1638–1641. 147. McGregor MJ, Du Mont J, Myhr TL. Sexual assault forensic medical examination: is evidence related to successful prosecution? Ann Emerg Med 2002;39:639–647. 148. Williams A. Managing adult sexual assault. Aust Fam Physician 2004;33:825–828. 149. Millar G, Stermac L, Addison M. Immediate and delayed treatment seeking among adult sexual assault victims. Women Health 2002;35:53–64. 150. Burgess A, Holmstrom L. Rape trauma syndrome. Am J Psychol 1974;131:981–986. 151.


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Gynecology_Novak. 150. Burgess A, Holmstrom L. Rape trauma syndrome. Am J Psychol 1974;131:981–986. 151. Holmes MM, Resnick HS, Frampton D. Follow-up of sexual assault victims. Am J Obstet Gynecol 1998;179:336–342. 152. Patel M, Minshall L. Management of sexual assault. Emerg Med Clin North Am 2001;19:817–831. 153. Geist F. Sexually related trauma. Emerg Med Clin North Am 1988;6:439–466. 154. Dupre AR, Hampton HL, Morrison H, et al. Sexual assault. Obstet Gynecol Surv 1993;48:640–647. 155. Maguire W, Goodall E, Moore T. Injury in adult female sexual assault complainants and related factors. Eur J Obstet Gynecol Reprod Biol 2009;142:149–153. 156. Jones JS, Dunnuck C, Rossman L, et al. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med 2004;22:201–203. 157. Beckmann CR, Groetzinger LL. Treating sexual assault victims: a protocol for health professionals. Female Patient 1989;14:78–83. 158.


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Gynecology_Novak. 157. Beckmann CR, Groetzinger LL. Treating sexual assault victims: a protocol for health professionals. Female Patient 1989;14:78–83. 158. Glasier A. Emergency postcoital contraception. N Engl J Med 1997;337:1058–1064. 159. Von Hertzen H, Piaggio G, King J, et al. Low dose mifepristone and two regimens of levonorgestrel for emergency contraception: a WHO multicentre randomised trial. Lancet 2002;360:1803–1810. 160. American College of Obstetricians and Gynecologists. Emergency contraception. Practice Bulletin No 112. Washington, DC: ACOG, 2010. 161. Hamoda H, Ashok PW, Stalder C, et al. A randomized trial of mifepristone (10 mg) and levonorgestrel for emergency contraception. Obstet Gynecol 2004;104:1307–1313. 162. Ellertson C, Evans M, Ferden S, et al. Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Am J Obstet Gynecol 2003;101:1168–1171. 163.


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Gynecology_Novak. 162. Ellertson C, Evans M, Ferden S, et al. Extending the time limit for starting the Yuzpe regimen of emergency contraception to 120 hours. Am J Obstet Gynecol 2003;101:1168–1171. 163. Beebe DK. Emergency management of the adult female rape victim. Am Fam Physician 1991;43:2041–2046. 164. Jenny C, Hooton TM, Bowers A, et al. Sexually transmitted diseases in victims of rape. N Engl J Med 1990;322:713–716. 165. Reynolds MW, Peipert JF, Collins B. Epidemiologic issues of sexually transmitted diseases in sexual assault victims. Obstet Gynecol Surv 2000;55:51–57. 166. Kawsar M, Anfield A, Walters E, et al. Prevalence of sexually transmitted infections and mental health needs of female child and adolescent survivors of rape and sexual assault attending a specialist clinic. Sex Transm Infect 2004;80:138–141. 167. Centers for Disease Control and Prevention. 2006 guidelines for sexually transmitted diseases. MMWR 2006;55(RR11):1–94 168.


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Gynecology_Novak. 167. Centers for Disease Control and Prevention. 2006 guidelines for sexually transmitted diseases. MMWR 2006;55(RR11):1–94 168. Weinberg GA. Postexposure prophylaxis against human immunodeficiency virus infections after sexual assault. Pediatr Infect Dis J 2002;21:959–960. 169. Merchant RC, Keshavarz R, Low C. HIV post-exposure prophylaxis provided at an urban paediatric emergency department to female adolescents after sexual assault. Emerg Med J 2004;21:449– 451. 170. Luce H, Schrager S. Sexual assault of women. Am Fam Phys 2010;81:489–495. Major depression, anxiety disorders, and other specific disorders are common and therefore are seen in general gynecologic practice. Appropriate referral to mental health specialists must be made in a sensitive manner. Suicidal and homicidal behaviors are absolute indications for referral. Alcohol and other substance abuse needs prompt recognition and intervention.


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Gynecology_Novak. Suicidal and homicidal behaviors are absolute indications for referral. Alcohol and other substance abuse needs prompt recognition and intervention. Some women are vulnerable to mood symptoms at times of hormonal change. However, menopausal hormone levels are not correlated with depression, and premenstrual syndrome should not be diagnosed without 2 months of prospective daily ratings. Personality disorders and somatizing disorders rarely can be cured, but informed management can greatly decrease the suffering of the patient Withdrawal of successful psychotropic treatment is very likely to lead to relapse. Psychotic disorders should nearly always be managed by psychiatrists.


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Gynecology_Novak. Withdrawal of successful psychotropic treatment is very likely to lead to relapse. Psychotic disorders should nearly always be managed by psychiatrists. Psychiatric problems are a central or complicating factor for many patients who seek care on an outpatient basis (1,2). Psychiatric diagnoses are extremely common and account for considerable morbidity and mortality in the general population (3). Despite their prevalence, psychiatric disorders are often undiagnosed or misdiagnosed (4–7). Clinical depression affects up to one-fourth of women during their lives, but probably more than half of those women are neither diagnosed nor treated (8–11). More than half of the patients who commit suicide have seen a nonpsychiatric physician during the previous 3 months (12). Psychiatry in the Gynecology Office


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Gynecology_Novak. Psychiatry in the Gynecology Office Many gynecologists feel uncomfortable diagnosing and treating psychiatric illnesses. The practice of gynecology is demanding, and patients with psychological problems can evoke a variety of negative reactions in physicians (Table 12.1). Some physicians, and some members of the public, have the misconception that psychiatric diagnoses are vague and ill-defined. Current diagnostic criteria and categories of psychiatric disorders are supported by empirical evidence Table 12.1 Practitioners’ Negative Reactions Toward Patients with Psychiatric Problems 1. Social stigma attached to psychiatric diagnoses, patients, and practitioners. 2. Belief that individuals with psychiatric disorders are weak, unmotivated, manipulative, or defective. 3. Belief that the criteria for psychiatric diagnoses are intuitive rather than empirical. 4. Belief that psychiatric treatments are ineffective and unsupported by medical evidence. 5.


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Gynecology_Novak. 3. Belief that the criteria for psychiatric diagnoses are intuitive rather than empirical. 4. Belief that psychiatric treatments are ineffective and unsupported by medical evidence. 5. Fear that patients with psychiatric problems will demand and consume inordinate and limitless time from a medical practice. 6. Precipitation in others, including doctors, of feelings that are complementary to the strong and unpleasant emotions experienced by patients with psychiatric disorders. 7. Gynecologists’ own uncertainty about their skills at psychiatric diagnosis, referral, and treatment. 8. Failure to acknowledge psychiatric problems as legitimate grounds for medical attention.


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Gynecology_Novak. 7. Gynecologists’ own uncertainty about their skills at psychiatric diagnosis, referral, and treatment. 8. Failure to acknowledge psychiatric problems as legitimate grounds for medical attention. that is as reliable and valid as those used in most medical treatment. Physicians are naturally reluctant to uncover problems for which there seems to be no solutions. There are effective treatments for psychiatric disorders, and they are straightforward to use in clinical practice. Although the newly enacted parity laws forbid discrimination by insurers against mental health care, gynecologists and their patients may have difficulty accessing mental health services. It is sometimes necessary for the physician and family to advocate strongly for necessary care. By incorporating the management strategies in this chapter into their practice, gynecologists can reduce clinical frustration and play a major role in improving the health and well-being of their patients.


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Gynecology_Novak. Psychiatric Assessment In the past, the diagnosis of psychiatric disorders was based partially on hypotheses about a patient’s unconscious psychological conﬂicts, which cannot be verified (13). Current psychiatric diagnosis, as codified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), produced and published by the American Psychiatric Association, is based on empirical, valid, and reliable evidence (9). The DSM-IV yields reliability comparable to that of diagnostic systems used in other areas of medicine, and its diagnoses strongly correlate with response to treatment. The criteria in DSM-IV are the basis for the diagnostic entities described in this chapter. The new edition, DSM-IV-TR, differs only in the explanations of some of the diagnoses and not in the diagnostic criteria themselves. The DSM-IV-PC is a special edition designed for the primary care provider. This volume is organized by initial signs and symptoms rather than


Gynecology_Novak

Gynecology_Novak. diagnoses and not in the diagnostic criteria themselves. The DSM-IV-PC is a special edition designed for the primary care provider. This volume is organized by initial signs and symptoms rather than psychiatric categories and uses algorithms and decision trees to facilitate the diagnostic process (9). The fifth edition of the DSM is scheduled for publication in 2013, and it might not contain changes of major importance for gynecology practice. Accurate diagnosis is absolutely critical to successful management, whether care is provided by a gynecologist or through referral to a mental health expert.


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Gynecology_Novak. Approach to the Patient Although diagnostic criteria list signs and symptoms, the interaction with a patient should not be reduced to a series of rapid-fire questions and answers. A wealth of valuable information can be obtained from the patient’s spontaneous description of her concerns and from her responses to the physician’s open-ended questions (14). A patient who is encouraged to speak for several minutes before being asked to respond to specific questions will reveal information that is useful, even vital, to her care: a thought disorder, a predominant mood, abnormally high anxiety, a personality style or disorder, and attitudes toward her diagnosis and treatment. Such information may emerge only much later, or not at all, in a question-and-answer format (15,16). It is critical that the gynecologist neither jumps to diagnostic conclusions nor proceeds directly to therapeutic interventions. One study revealed that many primary care physicians, feeling that they have too little


Gynecology_Novak

Gynecology_Novak. the gynecologist neither jumps to diagnostic conclusions nor proceeds directly to therapeutic interventions. One study revealed that many primary care physicians, feeling that they have too little time or training to assess psychological symptoms, tend to minimize verbal interactions with patients and to rely on the prescription of psychotropic medications (17). Allowing a few moments for open-ended discussion does not mean that the physician and the other patients awaiting care are to be held hostage by an overly talkative patient. The clinician can tell the patient with multiple, detailed symptoms how much time is available for the current appointment, invite her to focus on her most pressing problem, and offer a future appointment to continue the account.


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Gynecology_Novak. Psychiatric Referral Many gynecologists consider referral to a mental health professional, particularly a psychiatrist, to be a delicate matter. The first question is when to refer, followed by how to refer and to whom. Most mild psychiatric disorders are treated by nonpsychiatric physicians, who often prescribe antidepressants and anxiolytic medications (18). Psychiatric disorders often are overlooked, misdiagnosed, or mistreated in primary care practice. The factors that determine the decision to refer are the: Nature and severity of the patient’s disorder Expertise of the gynecologist Time available in the gynecologic practice Gynecologist’s degree of comfort with the patient and the disorder Availability of mental health professionals


Gynecology_Novak

Gynecology_Novak. Expertise of the gynecologist Time available in the gynecologic practice Gynecologist’s degree of comfort with the patient and the disorder Availability of mental health professionals Patients who are suicidal, homicidal, or acutely psychotic should be referred immediately to a psychiatrist, and often are accompanied to the appointment (19). The primary provider should refer patients for psychiatric evaluation when the diagnosis is not clear or when the patient fails to respond to initial treatment. The gynecologist can resume responsibility for ongoing care of many patients after their initial or periodic assessment by a psychiatrist.


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Gynecology_Novak. How to Refer Some clinicians fear that patients will be insulted or alarmed by a psychiatric referral. Following are techniques that decrease the discomfort of both the gynecologist and the patient and enhance the likelihood of success (19). The referral should be explained on the basis of the patient’s own signs, symptoms, and level of distress. For a patient suffering from clinical depression, for example, this might be difficulty sleeping, loss of appetite, and lack of energy. For a patient with an anxiety disorder, it might be palpitations, shortness of breath, and nervousness. For a patient with mild Alzheimer’s disease, it might be forgetfulness or frightening episodes in which she finds herself in a neighborhood she does not recognize. With the advent of treatments that may slow dementia, these referrals are easier and more meaningful because there is now some hope for effective intervention.


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Gynecology_Novak. When a somatizing (psychosomatic) disorder is suspected, the gynecologist should emphasize the difficulty of living with symptoms in the absence of a definitive diagnosis and treatment rather than the hypothesis that the symptoms have a psychological basis (19): 1. “It is very stressful to be suffering while we can’t pinpoint the problem. I would like you to see one of our staff who specializes in helping people cope with these difficult situations.” 2. “It must be difficult to function when you have been so sickly all your life, have seen so many doctors, have had so many diagnostic tests and medical treatments, and still don’t have an answer or feel well.” It is counterproductive to convey the idea that because the diagnostic process has not revealed a specific disorder, the problem must be “in the patient’s head.” It alienates the patient. It is never possible to rule out an organic cause with absolute certainty; and diseases “in the head” are real diseases (19).


Gynecology_Novak

Gynecology_Novak. Although suicidal and homicidal behaviors are absolute indications for referral, many physicians fear that questioning patients about these behaviors will provoke them. That is not the case (12). An open discussion of impulses to hurt oneself or someone else helps the patient to regain control, recognize the need for mental health care, or agree to emergency interventions such as psychiatric hospitalization, whereas avoiding the subject intensifies the patient’s feelings of isolation. The management of suicidal behavior is addressed later in this chapter in the section on mood disorders.


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Gynecology_Novak. Likewise, the possibility of psychosis need not be avoided. Most patients with psychotic disorders have had previous experience with psychiatric referral. Their psychotic symptoms are often distressing, so treatment is an appealing option (19). They can discuss hallucinations and delusions quite matter-of-factly. The rare patient who comes to a gynecologist in the midst of a first episode of psychosis is likely to be frightened by her symptoms and willing to accept expert consultation.


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Gynecology_Novak. Despite increasing public sophistication about mental illnesses and psychiatric care, some patients believe that any mention of mental health intervention implies that they are either “crazy” or that the referring physician is convinced that their physical symptoms are imaginary or feigned. It is helpful to state explicitly that this is not the case. Making the real reason for the referral clear and founded in signs and symptoms obvious to the patient will nearly always allay anxiety over a psychiatric referral (19).


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Gynecology_Novak. It is not acceptable to refer a patient to a psychiatrist without informing her in advance and obtaining her consent, unless she is acutely psychotic, functionally incompetent, or in the throes of a suicidal or homicidal emergency. Even under those circumstances, it is highly preferable to be straightforward. A referral that begins with an unexpected clinical encounter with a psychiatrist is unfair to both the psychiatrist and the patient and is unlikely to result in a satisfactory outcome (17–19).


Gynecology_Novak

Gynecology_Novak. To allay any concern a patient may have that a mental health referral is an indication of the gynecologist’s disdain or disinterest, and to promote good patient care in general, the referring gynecologist should make it clear to the patient that he or she will remain involved in the patient’s care. The mental health professional should be introduced as a member of the health care team, and the gynecologist should ask the patient to call after the mental health appointment to report on how it went. The patient should be given a follow-up appointment with the gynecologist at the time of the referral (19).


Gynecology_Novak

Gynecology_Novak. Mental disorders are treated by social workers, psychologists, members of the clergy (often the first to be consulted), and various kinds of counselors as well as by psychiatrists (17–19). The lay public or even some medical professionals may not understand the distinctions between types of mental health professionals. The criteria for membership in each profession can vary by region and institution. Social workers and psychologists can receive degrees at the bachelor, master, or doctoral level. In some states, licensure is required. Social workers require a master’s degree and psychologists receive a doctoral degree, in addition to supervised clinical experience to qualify for licensure. The category of counselor includes a wide variety of practitioners, such as marriage counselors, pastoral counselors, school counselors, and family counselors. The training of social workers may focus on social policy, institutional care, psychosocial aspects of medical illness, or individual


Gynecology_Novak

Gynecology_Novak. pastoral counselors, school counselors, and family counselors. The training of social workers may focus on social policy, institutional care, psychosocial aspects of medical illness, or individual treatment (17–19).


Gynecology_Novak

Gynecology_Novak. Practitioners of all these disciplines may or may not be trained in psychotherapy. For a patient whose symptoms do not meet criteria for a major psychiatric disorder and who is able to eat, sleep, and carry out her regular duties, supportive psychotherapy provided by a trained mental health professional may suffice. Supportive psychotherapy calls on a patient’s existing coping mechanisms to combat a stressful situation. Doctoral-level psychologists and neuropsychologists can perform testing that can be helpful in establishing a diagnosis. Such testing is especially useful in identifying and localizing brain pathology and in defining intelligence levels. Undiagnosed cognitive deficits may contribute to noncompliance with gynecologic care as well as other problems (17–19).


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Gynecology_Novak. Trained social workers are often knowledgeable about community resources for patients and their families and about the impact of gynecologic diseases and treatments on the patients. Self-help or professionally led therapy groups can be helpful for patients reacting to gynecologic problems such as infertility or malignancy. Participation in a supportive group was said to lengthen the survival time and improve the quality of life for some patients with cancer, although this assertion is controversial (20–26). Psychiatrists are the only medically trained mental health professionals. They play a particularly important role in resolving diagnostic dilemmas, especially when questions arise about the psychological or behavioral manifestations of medical illness and pharmacologic treatment; when a medical understanding of the gynecologic condition and treatment is essential to the care of the patient; and when such issues as drug–drug interactions must be considered (19).


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Gynecology_Novak. Psychiatrists are the only mental health professionals trained to prescribe psychoactive medications and other biologic interventions and provide psychotherapy. The legislatures of New Mexico and Louisiana have conferred prescribing rights on doctoral-level psychologists with additional training but have not defined the limits of the prescribing authority. It is highly likely that psychiatrists will continue to treat the most seriously ill patients and take ultimate responsibility for psychiatric emergencies (19).


Gynecology_Novak

Gynecology_Novak. Because psychiatric problems frequently present in gynecologic practice, it is worthwhile for the gynecologist to develop an ongoing relationship with one or more local mental health professionals. The state psychiatric society may have a list of subspecialists in “consultation liaison” psychiatry; this is an official subspecialty of the American Board of Psychiatry and Neurology. Many psychiatrists without specific fellowship training offer consultative services. The availability of familiar and trusted resources enhances the likelihood that problems will be identified and addressed. An ongoing relationship with a mental health professional allows the gynecologist to familiarize that professional with relevant developments in gynecology. It is important to keep up-to-date information on local suicide prevention hotlines and other kinds of resources for battered women and for mothers who may pose a danger to their children. Local laws may require that physicians report to the


Gynecology_Novak

Gynecology_Novak. on local suicide prevention hotlines and other kinds of resources for battered women and for mothers who may pose a danger to their children. Local laws may require that physicians report to the authorities their knowledge of mothers in this situation (19).


Gynecology_Novak

Gynecology_Novak. Whenever a patient’s thinking, emotions, or behaviors cause concern, the gynecologist should first consider a nonpsychiatric medical disorder or a reaction to prescribed or illicit drugs. Psychiatric disorders frequently coexist with these conditions (19). HIV/AIDS infection, some malignancies, hypothyroidism, and other diseases can present with psychiatric symptoms. Psychiatric conditions are extremely common in gynecologic practice. Some are primary and some are related to reproductive events. All patients should be screened for depression, anxiety, domestic violence, and substance abuse, each of which can be diagnosed and treated, either by the gynecologist or by referral to a social resource or a mental health specialist (16–19).


Gynecology_Novak

Gynecology_Novak. Mood is the emotional coloration of a person’s experience. Mood may be pathologically elevated (mania) or lowered (depression) or may alternate between the two (bipolar or manic-depressive disorder) (26). Mood disorders are different from, but frequently confused with, the inevitable ups and downs of everyday life, such as the reactions to difficult situations, including gynecologic conditions. In the English language, depression is used to describe both a transient mood and a psychiatric disorder. Because of this confusion, both patients and their loved ones become frustrated when well-meaning attempts to reason with them, distract them, or do thoughtful things for them in a manner that would affect a self-limited reaction to a difficult situation, fail to inﬂuence their protractedly disturbed moods. Mania is characterized by the following behavior (26): 1. Elevated mood, with euphoria or without irritability 2. 3. Pressured, accelerated speech and physical activity 4. 5. 6.


Gynecology_Novak

Gynecology_Novak. Mania is characterized by the following behavior (26): 1. Elevated mood, with euphoria or without irritability 2. 3. Pressured, accelerated speech and physical activity 4. 5. 6. Reckless and potentially damaging behaviors, such as wild expenditures and promiscuity Mania can be acute or subacute (hypomania). Hypomania can produce self-confidence, ebullience, energy, and productivity that are the envy of others, making the patient reluctant to relinquish this mood by undergoing treatment. It can be particularly difficult to arrest the condition before it progresses to full-blown mania. Acute mania is a life-threatening condition; without treatment, patients fail to maintain essential sleep and nutrition levels and literally exhaust themselves with frantic activity. Patients with bipolar illness must be taught and encouraged, and often learn from bitter experience, to recognize the early signs of disturbed mood so that treatment or treatment changes can be initiated (16).


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Gynecology_Novak. The overall lifetime prevalence of affective disorders is 8.3%; the 6-month prevalence is 5.8%. During the reproductive years, depression is two to three times more common in women than in men (26–32). The highest incidence of depression is in the age group of 25 to 44 years, but depression occurs in every age group, from toddlers to the aged. Women have a lifetime risk of 10% to 25% and a point prevalence of 5% to 9% (33–36). Although public understanding and acceptance of mental illnesses has significantly increased, patients may have difficulty accepting, and telling others, that they are suffering from depression. Depression is the single most common reason for psychiatric hospitalization in the United States.


Gynecology_Novak

Gynecology_Novak. Depression is the single most common reason for psychiatric hospitalization in the United States. As many as 15% of individuals with severe depressive disorders eventually commit suicide (37). Depression is a significant risk factor for cardiovascular disease and for noncompliance with essential treatments for other diseases, including diabetes. Depression is a recurrent disorder; of those who experience a major depressive episode, 50% have a second one. Of these, 70% have a third, and the incidence continues to increase with each subsequent episode. In the past diagnostic criteria were not standardized, so it is difficult to know whether the incidence of depression has increased over recent years, as has been asserted in the popular press. Because women’s roles in society changed a great deal over the past few decades, there is a temptation to postulate a higher rate of depression attributable to women’s work outside the home.


Gynecology_Novak

Gynecology_Novak. Because women’s roles in society changed a great deal over the past few decades, there is a temptation to postulate a higher rate of depression attributable to women’s work outside the home. There is no evidence that employment outside the home increases women’s vulnerability to depression. Multiple life roles actually contribute to life satisfaction, although the need to carry out multiple roles in the absence of adequate social support, as is all too common in women’s lives, is stressful (38–40). Depression is characterized by the following (9,19): 1. 2. 3. 4. Decreased ability to concentrate 5. 6. Interference with sleep, generally with early awakening, inability to return to sleep, and failure to feel rested; atypically, with increased sleep 7. Decreased appetite and weight; atypically, increased food intake 8. 9. Inability to enjoy previously gratifying activities 10. Loss of libido 11. 12. 13. Thoughts of death or suicide


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Gynecology_Novak. Decreased appetite and weight; atypically, increased food intake 8. 9. Inability to enjoy previously gratifying activities 10. Loss of libido 11. 12. 13. Thoughts of death or suicide The patient who has five or more of the signs and symptoms of depression for most of each day for 2 weeks or more fulfills the criteria for the diagnosis of clinical depression (36–38). Depression may be acute or chronic (dysthymic disorder). Like many diseases, it is caused by genetic, neurophysiologic, and environmental factors. Trauma in early life plays a role. Serotonin is a major mediator of mood. Treatment, whether pharmacologic or psychotherapeutic, is effective for depression. The average duration of a major depressive episode is approximately 9 months (36). Patients must be cautioned to continue treatment at least that long, even if symptoms remit; relapse is common.


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Gynecology_Novak. Depression may be precipitated by an adverse life event such as an interpersonal loss, economic reversal, or serious illness (41,42). When there is an identifiable precipitant, there is a danger that the depression will be written off as the inevitable reaction to the event rather than considered properly as a complication that requires active treatment, similar to infection or pneumonia complicating a surgical procedure. When a patient’s symptoms meet criteria for the diagnosis, treating the depression will relieve symptoms and will enable her to cope more successfully with the precipitating situation (43). Paradoxically, patients in happy life situations, and their loved ones, may have resistance to the idea that they are depressed. They need to understand that depression is not a sign of ingratitude or lack of appreciation for their life advantages, but a disease, like any other, that can strike even otherwise fortunate people.


Gynecology_Novak

Gynecology_Novak. Concomitant gynecologic or other medical illness can cause signs and symptoms similar to those of depression—loss of energy, sleep, and appetite—but does not cause guilt, hopelessness, or helplessness (44). These observations are helpful in differentiating depression from the malaise associated with other disease states.


Gynecology_Novak

Gynecology_Novak. Gynecologic Issues The incidence of depression peaks, and the gender difference prevails, during the reproductive years (45). Connections between female reproductive functions and mood changes have been posited for centuries. When it first became possible to determine circulating hormone levels, researchers expected to find specific relationships between psychological and physiological changes. These expectations were uniformly discounted. There is no serum hormone level associated with premenstrual dysphoria, postpartum depression, or depression at menopause (46). There is a subgroup of women who are vulnerable, not to absolute circulating hormone levels, but to hormonal changes (47–50). There is a correlation between the degree of hormonal change, pre-and postpartum, and the incidence of postpartum mood disorder. Women who are vulnerable to hormonal changes may experience severe premenstrual mood symptoms, postpartum depression, and, possibly, depression in association with hormonal


Gynecology_Novak

Gynecology_Novak. postpartum mood disorder. Women who are vulnerable to hormonal changes may experience severe premenstrual mood symptoms, postpartum depression, and, possibly, depression in association with hormonal inﬂuences such as hormonal contraceptive methods, menopause, and hormone treatments (51).


Gynecology_Novak

Gynecology_Novak. Premenstrual Syndrome Depending on the methodology used to gather the data, most women report mood and behavioral changes associated with the menstrual cycle. Although there are both ups and downs associated with the cycle, it is the more problematic parts of the cycle that are characterized, as premenstrual syndrome, or PMS. An estimated 3% to 5% of ovulating women appear to suffer from symptoms so marked that they qualify for a diagnosis of premenstrual dysphoric disorder (PMDD) (52–54). PMDD is included in DSM-IV-TR as an example of a depressive disorder, not otherwise specified, and as a category requiring additional research (9). Provisional diagnostic criteria are provided to standardize this research. In most cycles over the past year, the patient had at least five of the following symptoms for most of the time during the premenstrual week, with symptoms remitting completely in the postmenstrual week (54):


Gynecology_Novak

Gynecology_Novak. Depressed mood, hopelessness, self-deprecation Anxiety, tension Affective lability Anger, irritability, interpersonal conﬂict Decreased interest in usual activities Difficulty concentrating Decreased energy Appetite changes or cravings Changes in sleep Feeling overwhelmed or out of control Physical symptoms such as breast tenderness, headache, bloating The symptoms markedly interfere with work, family, or academic responsibilities; are not exacerbations of another existing disorder; and are corroborated by at least 2 months of prospective daily ratings (54).


Gynecology_Novak

Gynecology_Novak. Premenstrual syndrome, as differentiated from premenstrual dysphoric disorder, has been characterized by more than 100 different physical and psychological signs and symptoms, making it difficult to define scientifically. Methodological problems further complicate the situation; in the United States, the prevalence of attitudes linking the menstrual cycle to adverse mood and behavioral changes is so high that it skews women’s perceptions, the way they report symptoms to researchers, and the factors to which they attribute negative feelings. No specific circulating hormone levels or markers are associated with premenstrual symptoms (55). When prospective daily ratings are obtained systematically, the symptoms of most women who seek care for PMS are not related to the menstrual cycle (56,57). Therefore, careful assessment is essential. Before the diagnosis of PMS or PMDD can be established, a woman must record symptom ratings daily for at least two full cycles. Records of emotions and


Gynecology_Novak

Gynecology_Novak. Therefore, careful assessment is essential. Before the diagnosis of PMS or PMDD can be established, a woman must record symptom ratings daily for at least two full cycles. Records of emotions and behaviors should be kept separate from menstrual records to avoid confounding patients’ perceptions. At the same time, the patient must be screened for other psychiatric disorders, including depression and personality disorders, and for domestic abuse and other life circumstances that may contribute to her psychological state (58).


Gynecology_Novak

Gynecology_Novak. No treatment for PMS has been validated by empirical studies (59). Studies of St. John’s wort, possibly the most popular alternative treatment, are contradictory (60). A number of lifestyle changes and other benign interventions alleviate symptoms for some patients with PMS (61): Elimination of caffeine from the diet Stress reduction can be accomplished by reducing or delegating responsibilities, insofar as that is possible, and devoting part of every day to relaxation techniques such as meditation and yoga. Many women experience stress factors over which they have no control (59).


Gynecology_Novak

Gynecology_Novak. For premenstrual dysphoric disorder, several selective serotonin reuptake inhibitors (SSRIs) proved effective in clinical trials (62–65). Although SSRIs and all other antidepressants require about 2 weeks of daily administration to achieve therapeutic effect for other depressive disorders, it appears that ﬂuoxetine is effective for PMDD when taken in the usual daily doses for the 1 to 2 weeks preceding menstruation. The medication is packaged for this specific indication and dosage. It is thought that the mode of action of SSRIs when used in this fashion differs from that which alleviates major depression (65). Other medications for the treatment of PMS and PMDD are shown in Table 12.2. There is some interest in the role of oral contraceptives in management of PMDD, and for patients interested in contraception, trials of oral contraceptives are a reasonable approach (66). Symptoms must be carefully monitored to determine whether the hormonal intervention improves or exacerbates the


Gynecology_Novak

Gynecology_Novak. in contraception, trials of oral contraceptives are a reasonable approach (66). Symptoms must be carefully monitored to determine whether the hormonal intervention improves or exacerbates the problem mood changes.


Gynecology_Novak

Gynecology_Novak. Infertility is described by most women who undergo treatment for it as the most stressful event of their lives. Each unsuccessful treatment episode is experienced as the loss of a hoped-for pregnancy (67). The loss of a fetus or newborn induces grief, with some of the same symptoms as depression. Depression is associated with guilt, whereas bereavement is not. However, women who lose pregnancies or infants often do feel guilty, regardless of whether these feelings are logically justified. Patients should not be pressed to “put the loss behind them” or expected to be “over it” within several months. Some feelings of sadness may persist for years. However, their sleep, appetite, and other vital functions and behaviors should begin to improve after a few weeks (68). Grief that persists and interferes with normal function is characterized as pathologic. Depression can complicate grief and should be treated (69).


Gynecology_Novak

Gynecology_Novak. Table 12.2 Scientific Basis of Selected Medications Used to Treat Premenstrual Syndrome Alprazolam Several double-blind, placebo-controlled, randomized crossover studies. Results were mixed. Placebo was as effective as alprazolam in some studies. Oral medication Potential for The studies involved appears to be more dependence; requires highly selective groups of effective in alleviating tapering; drowsiness women. There was a high depression and anxiety reported by many dropout rate in one of the symptoms than subjects; long-term positive studies. In one physical symptoms. effects unknown; safety study that found during pregnancy alprazolam effective, unknown. 87% of the women had a history of major depression or an anxiety disorder. Different doses were used in the studies (0.75–2.25 mg); the standard effective dosage is unknown. Several double-blind, randomized, placebo-controlled, crossover trials. All found ﬂuoxetine effective.


Gynecology_Novak

Gynecology_Novak. Several double-blind, randomized, placebo-controlled, crossover trials. All found ﬂuoxetine effective. Well tolerated; single daily oral dose. Significant decrease in psychic and behavioral symptoms. Long-term effects unknown. Safety during pregnancy unknown. Appears less effective in controlling physical symptoms. Trials involved very small, highly select groups of women. Duration of treatment did not exceed 3 months. All trials used 20 mg orally daily. Several small, double-blind, randomized, placebo-controlled, crossover trials. Most patients experienced improvement. Rapidly reversible; many patients report being virtually symptom-free during therapy. Produces pseudomenopause; expensive; risk for osteoporosis, hypoestrogenic symptoms. Usually given for only short periods of time.


Gynecology_Novak

Gynecology_Novak. Produces pseudomenopause; expensive; risk for osteoporosis, hypoestrogenic symptoms. Usually given for only short periods of time. An add-back regimen of estrogen-progestin in addition to gonadotropin-releasing hormone agonist has been reported. If replicated, it may have potential for an effective, long-term treatment for premenstrual syndrome. From The American College of Obstetricians and Gynecologists. Committee opinion. Washington, DC: ACOG, 1995, with permission. There is no convincing evidence that induced abortion causes clinical depression or any other negative psychiatric sequelae. Studies purporting to demonstrate negative sequelae fail to take into account the circumstances under which women conceive unintended pregnancies and elect to terminate them—abuse, abandonment, poverty, rape, and incest—or the circumstances in which they occur—familial pressure or disapproval, the presence of clinic demonstrators (70).


Gynecology_Novak

Gynecology_Novak. The incidence of depression in women during their reproductive years is approximately 10%. The incidence of depression does not decrease during pregnancy; most postpartum depression is a continuation of antepartum depression (71–73). Although there are some cross-cultural variations under study, postpartum depression is found around the globe (74). Risk factors include social isolation, lack of social supports, history of depression, and past or present victimization (75). It is important to remember that women without risk factors may become depressed. Postpartum depression must be distinguished from the transitory, self-limited, and very common “baby blues,” which are associated with changes in hormone levels and are better characterized as mood intensity and lability rather than depression. Mild depression can be managed with psychotherapy (76). Moderate to severe cases often require antidepressant medications (77). Electroconvulsive treatment acts rapidly and effectively, appears


Gynecology_Novak

Gynecology_Novak. Mild depression can be managed with psychotherapy (76). Moderate to severe cases often require antidepressant medications (77). Electroconvulsive treatment acts rapidly and effectively, appears to be safe during and after pregnancy, and can be a life-saving option for the most severe cases (78). Treatment with artificial light may alleviate milder symptoms (79). Although no agent can be declared perfectly safe for use during pregnancy and lactation, older SSRI agents are well studied, yielding little or no evidence of adverse effects on the fetus or nursing infant (80–82). These agents are used in the treatment of obsessive-compulsive disorder (83).


Gynecology_Novak

Gynecology_Novak. Medication should not be stopped arbitrarily, nor should breastfeeding be prohibited. The withdrawal of antidepressant medication during pregnancy is very likely to result in postpartum depression; both antenatal and postnatal depression have demonstrable, long-term ill effects for mother and child (84–91). There is concern about withdrawal syndromes in neonates whose mothers took SSRIs (92). These concerns arise from anecdotal reports and do not include data about the number of births from which the reports emerged, nor about confounding variables. Some observers recommended that pregnant women be withdrawn from SSRIs some days or weeks before delivery. However, delivery dates are often uncertain; maternal withdrawal might subject the fetus, rather than the newborn, to withdrawal symptoms; and the likelihood of postpartum depression, with its effects on both mother and infant, would be greatly increased. Researchers are exploring ways to prevent postpartum depression, but thus far


Gynecology_Novak

Gynecology_Novak. and the likelihood of postpartum depression, with its effects on both mother and infant, would be greatly increased. Researchers are exploring ways to prevent postpartum depression, but thus far nothing has proved effective (93,94).


Gynecology_Novak

Gynecology_Novak. Sertraline appears to be the safest medication for pregnant and lactating women, and paroxetine is the cause of most concern. If treatment is begun during pregnancy or lactation sertraline is the reasonable choice. Switching a patient successfully treated with another antidepressant to sertraline is not indicated. The fetus would be exposed to a second medication, and the patient may not respond as well to sertraline as to the currently effective antidepressant (80–82). Hysterectomy Studies of the relationship between hysterectomy and mental illnesses are contradictory (95,96). Probably the determining factors in psychiatric outcomes are the reason for the procedure and the context, whether the patient loses valued fertility as a result, including the reactions of significant others and cultural beliefs about the importance of an intact uterus (97).


Gynecology_Novak

Gynecology_Novak. Menopause Although menopause was assumed for many years to be associated with an increased incidence of depression, empirical studies led to conﬂicting results and controversy. Menopause appears to have mood effects in some women that can be differentiated from the secondary effects, such as hot ﬂashes interfering with sleep. Psychosocial studies indicate that some patients are upset by their loss of fertility or the departure of grown children from the home (empty nest syndrome), but many women find menopause liberating (98,99). For some women the return of adult children to the maternal home, or responsibilities for the care of grandchildren, seems to be a precipitating factor for depression. Patients who suffered PMS or postpartum depression may be vulnerable to a recurrence of depression at this new time of hormonal change. Patients with depression at the time of menopause should be assessed for psychosocial precipitants and domestic abuse. There are conﬂicting reports on the


Gynecology_Novak

Gynecology_Novak. at this new time of hormonal change. Patients with depression at the time of menopause should be assessed for psychosocial precipitants and domestic abuse. There are conﬂicting reports on the effectiveness of hormones for treatment of mood symptoms during menopause (100–105). Treatment with SSRIs may ameliorate hot ﬂashes (106).


Gynecology_Novak

Gynecology_Novak. Depression in elderly patients can cause a pseudodementia, characterized by decreased activity and interest and what appears to be forgetfulness. Unlike patients with genuine dementia, these patients report memory loss rather than trying to compensate and cover up for it. The early stages of dementia can precipitate depression as patients react to the loss of cognitive abilities (107).


Gynecology_Novak

Gynecology_Novak. Approach to the Patient The severity of depression is determined by the patient’s emotional pain and the degree of interference with her normal functioning. Depression is an agonizingly painful and disabling, but readily diagnosable and treatable, disease (108). Nevertheless, it shares the stigma of all psychiatric disorders. Patients and their families often attribute the signs and symptoms of depression to life circumstances or to a medical condition, either diagnosed or undiagnosed. The persistence of symptoms in the face of a pleasant life situation or the failure of the patient to respond to attempts at cheering, such as changes of scene, often exacerbate suffering by provoking guilt in the patient and frustration in her significant others. Some patients report low energy and general malaise rather than depressed mood. Physical symptoms are especially common in Asian and some other cultures and in the elderly (107). Some patients with severe depression continue to function and


Gynecology_Novak

Gynecology_Novak. malaise rather than depressed mood. Physical symptoms are especially common in Asian and some other cultures and in the elderly (107). Some patients with severe depression continue to function and can appear normal and cheerful. The only way to rule out depression is by asking about symptoms and using the diagnostic criteria (108).


Gynecology_Novak

Gynecology_Novak. Management Both antidepressant medication and psychotherapy are effective treatments for depression. There is evidence that a combination of the two produces the best outcomes (109–111). Reports about the efficacy of alternative treatments, the most common of which is St. John’s wort, are conﬂicting, but mostly negative (112). Patients should be specifically questioned about their use of herbal and other preparations and encouraged to use those whose components are standardized. Transcranial magnetic stimulation is a promising research intervention (113,114).


Gynecology_Novak

Gynecology_Novak. There are many forms of psychotherapy. Those that were specifically studied for efficacy in the treatment of depression are cognitive-behavioral therapy and interpersonal therapy. These forms of therapy are focused on present thoughts, feelings, relationships, and behaviors. Therapy continues for a set number of sessions, usually no more than 16 weekly sessions, in a prescribed, predetermined progression (115). There is increasing evidence that supportive and psychodynamic psychotherapy is effective.


Gynecology_Novak

Gynecology_Novak. It is especially important for the patient to have the opportunity to work out her feelings about having a psychiatric disorder, understand how it has affected her life, and feel comfortable taking medication or undergoing psychotherapy (115). Patients often attribute depression to weakness, laziness, or immorality, and they often confuse antidepressants with stimulants, tranquilizers, and other psychoactive drugs. Although written materials cannot substitute entirely for verbal instruction, it is useful to provide the patient with written material about depression so that she can review it at her leisure and with her family and friends if they have difficulty understanding her condition. There is widespread difficulty understanding written information, especially about medicine. Many or most antidepressant prescriptions are either not filled or not taken as prescribed (116).


Gynecology_Novak

Gynecology_Novak. Depression in one individual has a powerful effect on other members of the family, particularly children. This can be a motivating factor for patients who are reluctant to accept treatment. The types and characteristics of antidepressants are presented in Table 12.3. All antidepressants have comparable therapeutic efficacy, and all require up to 2 to 4 weeks to take full effect. It is not yet possible to identify those patients who will respond best to certain medications, but there is early evidence that depression may be related to specific neurotransmitters and respond differentially to medications affecting a given neurotransmitter. The response to treatment may differ with gender, but the data are not sufficient to drive clinical decisions (117).


Gynecology_Novak

Gynecology_Novak. It is sensible to use a more activating agent (ﬂuoxetine) in a lethargic patient and a more sedating agent (paroxetine) in an agitated patient (118). Nonetheless, responses vary on an individual basis, even within the same class of medications. The choice of antidepressant is based on side effects, dosage, cost, and the physician’s clinical experience (Table 12.4). Patients tend to respond to medications that worked for them in the past and to those that worked for depressed family members. Many patients require successive trials of two or more antidepressants before the one that is effective for them is identified. It is essential to continue active management through the usual duration of a depressive episode—9 to 12 months for major depression, Table 12.3 Pharmacology of Antidepressant Medications


Gynecology_Novak

Gynecology_Novak. Table 12.3 Pharmacology of Antidepressant Medications MAO, monoamine oxidase; bid, two times a day. aHalf-lives are affected by age, gender, race, concurrent medications, and length of drug exposure. bIncludes both ﬂuoxetine and norﬂuoxetine. cBy extrapolation from ﬂuoxetine data. dMAO inhibition lasts longer (7 days) than drug half-life. eIncluding pseudoephedrine, phenylephrine, phenylpropanolamine, epinephrine, norepinephrine, and others. Modified From Depression Guideline Panel. Depression in primary care: detection, diagnosis, and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993:15; AHCPR pub. no. 93-0552, with permission.


Gynecology_Novak

Gynecology_Novak. Table 12.4 Side-Effect Profiles of Antidepressant Medications aNumerals indicate the likelihood of side effect occurring ranging from 0 (for absent or rare) to 4+ (for relatively common). bDry mouth, blurred vision, urinary hesitancy, constipation. From Depression Guideline Panel. Depression in primary care: detection, diagnosis, and treatment. Quick reference guide for clinicians, no. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993:14;AHCPR pub. no. 93-0553, with permission. until the patient has responded sufficiently that she has returned to her previous level of mood and function. If the patient does not recover completely, she should be referred to a psychiatrist (118).


Gynecology_Novak

Gynecology_Novak. Tricyclic Antidepressants Tricyclic antidepressants are the oldest antidepressants still in use and are available in generic preparations (118–122). They all have significant anticholinergic side effects that may be problematic in medically ill and elderly patients. They are associated with some slowing of intracardiac conduction; this side effect can be tolerated and managed in all but a few patients, and it can be therapeutic for those with hyperconductibility. Tricyclic antidepressants should be taken in divided doses through the day, although bedtime dosing may help patients who have difficulty sleeping. Some tricyclic agents, such as nortriptyline, have “therapeutic windows”—blood levels above or below which they are not effective—that must be monitored. The average dose for tricyclic agents is 225 mg per day in divided doses (122). The most important drawback of tricyclic medications is their lethality in overdose, which is especially important because they are used with


Gynecology_Novak

Gynecology_Novak. agents is 225 mg per day in divided doses (122). The most important drawback of tricyclic medications is their lethality in overdose, which is especially important because they are used with depressed patients who are already at risk for suicide. In the rare event that they must be used by a potentially suicidal patient, the patient must be given only a few pills at a time (121). Some medication plans, private or public, require that treatment begin with the least expensive generic medication, and that the patient first fail with that medication before a newer compound will be provided. The clinician may have to serve as advocate for the patient when this is not a clinically acceptable approach.


Gynecology_Novak

Gynecology_Novak. Monoamine Oxidase Monoamine oxidase (MAO) inhibitors are especially effective for atypical depression, which is Inhibitors associated with abnormally increased, rather than decreased, sleep and appetite. They require dietary restrictions and can be used only in patients who are able to understand and comply with those restrictions to avoid hypertensive crises (117).


Gynecology_Novak

Gynecology_Novak. SSRIs pose few risks of medical complications. Side effects include anxiety, tremor, headache, and gastrointestinal upset (either diarrhea or constipation), and usually abate within a few days of the onset of treatment. A more serious side effect is loss of libido and interference with orgasm (119). Patients may be reluctant to report sexual side effects, but they may discontinue treatment because of them. Some women are willing to accept the sexual side effects of SSRIs as an acceptable price to pay for recovery, especially considering that depression already interferes with their sexual functioning. Female patients are frequently concerned about weight gain. In one study, it appeared that a weight gain of 5 to 7 pounds might be attributed to an SSRI; the return of normal appetite may lead to weight gain. Concerned patients should be advised to watch their diets carefully while taking the medication. There is some evidence that bupropion causes less weight gain than SSRIs. SSRIs


Gynecology_Novak

Gynecology_Novak. lead to weight gain. Concerned patients should be advised to watch their diets carefully while taking the medication. There is some evidence that bupropion causes less weight gain than SSRIs. SSRIs appear to interfere with the efficacy of tamoxifen, resulting in excess mortality from breast cancer (120).


Gynecology_Novak

Gynecology_Novak. SSRIs are administered in a once-a-day regimen, with little need for dosage adjustments in most cases. SSRIs have long half-lives, so occasional late or missed doses do not constitute a problem. Withdrawal, especially sudden withdrawal, from SSRIs causes ﬂulike symptoms and sleep problems in a small proportion of patients (121). Patients should be cautioned not to discontinue their medications without consulting the physician, and only then by gradually decreasing the dose. As with most medications, antidepressants were not initially tested in older women, but several are under consideration by the U.S. Food and Drug Administration (FDA) for use in this age group (122). The FDA mandated so-called black box warnings on SSRIs when used in adolescents and young adults. This decision is highly controversial. The studies upon which the decision was based included no subject who had committed suicide. Suicidal thoughts, which are extremely common, were conﬂated with serious attempts, all


Gynecology_Novak

Gynecology_Novak. controversial. The studies upon which the decision was based included no subject who had committed suicide. Suicidal thoughts, which are extremely common, were conﬂated with serious attempts, all lumped together as suicidality. SSRI prescriptions decreased after the warning was imposed, and there is some evidence that suicides have gone up as a result (123–125).


Gynecology_Novak

Gynecology_Novak. Atypical Agents Medications considered atypical include venlafaxine, lithium salts, and anticonvulsants, which are effective mood stabilizers used for bipolar disorders (126–130). Bupropion is available in a once-a-day preparation. It lowers the seizure threshold slightly more than other antidepressants and should be avoided or used with caution in patients who have a history of head trauma. It is used, under a separate trade name, for smoking cessation, and is particularly useful for smokers who are depressed. Bupropion seems to cause fewer sexual side effects than the SSRIs and may decrease these side effects when added to an SSRI regimen. Suicide The most acute issue in the assessment and referral of depressed patients is the possibility of suicide (131). Following are the risk factors for suicide: Previous suicide attempts, even if seemingly not serious Family history of suicide A plan to commit suicide Access to the means to carry out the plan


Gynecology_Novak

Gynecology_Novak. Women attempt suicide more frequently than men, but men complete the act more frequently than women (131,132). This is probably because men use more drastic or irreversible means, such as firearms, whereas women tend to overdose, which can be treated if discovered. It might seem that someone who repeatedly makes suicidal gestures is more interested in the responses of others than in ending her life. However, past attempts or gestures increase the risk of completed suicide. Patients who made a suicide attempt should be queried about the following risk factors: the intent to die (rather than escape, sleep, or make people understand her distress); increasing numbers or doses of drugs taken in a progression of attempts; and drug or alcohol misuse, especially if it, too, is increasing. Inquiry about suicidal ideation and behavior is an inherent part of every mental status examination and is mandatory for every patient with past or current depression or evidence of self-destructive


Gynecology_Novak

Gynecology_Novak. Inquiry about suicidal ideation and behavior is an inherent part of every mental status examination and is mandatory for every patient with past or current depression or evidence of self-destructive behavior. The inquiry can follow from discussion of difficulties in the patient’s life or mood or be introduced with a comment that almost everyone has thoughts of death at one time or another. Nonsuicidal patients will immediately volunteer that they have had such thoughts and that they have no intention of acting on them. They will often add reasons: they have too much to look forward to, it is against their religion, or it would hurt their family.


Gynecology_Novak

Gynecology_Novak. It is important to distinguish among thoughts of death, the wish to be dead, and the intention to kill oneself (132). A patient in a painful life situation—a chronic, painful, or terminal medical condition, the birth of a severely damaged child, or a grievous loss—may express a wish to die, and even refuse recommended medical care but emphatically and honestly disavow any intention of actively harming herself. The patient must be directly asked (132).


Gynecology_Novak

Gynecology_Novak. If the patient previously engaged in impulsive self-destructive behavior, without a plan or warning, it is wise to consult a psychiatrist. If a patient is actively contemplating suicide, she must see a psychiatrist immediately (132,133). Other mental health professionals may be helpful but are less likely to have dealt extensively with and assumed responsibility for suicidal patients, to be able to determine whether the patient should be hospitalized, and to have admitting privileges. Until she is in the physical presence of a psychiatrist, or in a safe environment such as a hospital emergency room, a suicidal patient should be observed and protected at all times— every second—whether she is in the consulting room or the bathroom. The staff member assigned to remain with her may not leave to make a telephone call, go to the bathroom, or get a cup of coffee. Family members may offer to monitor the patient and can sometimes be effective, but the health care professional is responsible


Gynecology_Novak

Gynecology_Novak. to make a telephone call, go to the bathroom, or get a cup of coffee. Family members may offer to monitor the patient and can sometimes be effective, but the health care professional is responsible for ensuring that they understand and implement this level of supervision. It is better to risk inconvenience and possible embarrassment to both the gynecologist and the patient than to risk a fatal outcome. When suicide is an immediate consideration, only a psychiatrist can make the decision that a patient is safe (133). Psychiatric referral can be useful in less dramatic cases: when the gynecologist lacks experience or is overloaded with patients, when a first trial of treatment is unsuccessful or there is uncertainty about the diagnosis, when domestic violence or substance abuse may be present, and when the depression is recurrent.


Gynecology_Novak

Gynecology_Novak. Many people are not aware that approximately half of suicides are not associated with depression. Suicide can occur in the context of an anxiety disorder, personality disorder, psychotic illnesses, or as an impulsive response to an adverse life event (133). Suicide is not an inevitable consequence of any of these conditions, including depression. Most people rescued from potentially lethal suicide attempts do not ultimately commit suicide. That is why barriers on bridges and other devices to prevent impulsive suicides are necessary. Alcohol and substance abuse are major causes of morbidity and mortality (134). The essential feature of substance dependence, or addiction, is the continued use of the substance despite serious resulting problems. Alcohol and substance abuse are among the most common—and most frequently overlooked—conditions in medical practice. In the DSM-IV-TR, the term “substance” can mean a medication, a toxin, or a drug of abuse.


Gynecology_Novak

Gynecology_Novak. In the DSM-IV-TR, the term “substance” can mean a medication, a toxin, or a drug of abuse. Nicotine is included among “substances,” and women appear to be more susceptible to nicotine addiction than men, but smoking cessation is more a topic for general medicine than for psychiatry (9,135). Substance abuse leads to major complications, including intoxication and withdrawal. Withdrawal is major problem because, as mentioned in this chapter in the section on benzodiazepines, patients often fail to inform clinicians of their alcohol and substance use before being hospitalized or undergoing procedures, when they may experience unanticipated undiagnosed withdrawal (136–138).


Gynecology_Novak

Gynecology_Novak. Significant problems caused by continued use of the substance may include symptoms of withdrawal, interference with family and work obligations, and the depletion of, or criminal activity to obtain, resources to obtain the substance. Other features include tolerance, or the need to consume more of the substance to obtain the same effect, and compulsive use (139). Patients frequently use alcohol along with other substances of abuse. The abuse of prescription medication, especially in younger populations, has increased (140). Patients should be advised to take care that their medications are not accessible to others.


Gynecology_Novak

Gynecology_Novak. Alcohol is the most frequent substance of abuse. Legal and accepted by society, it nevertheless causes a high proportion of morbidity, mortality, and life complications. Women’s alcohol abuse is more likely to take place in private than is men’s; society frowns more on women who are drunk or create disturbances in public than on men who do the same. Women are more likely than men to use a substance because an intimate partner uses or abuses that substance, and to trade sexual favors for access to the substance (141). There is strong evidence for a genetic link for alcoholism, but not for the other substances of abuse.


Gynecology_Novak

Gynecology_Novak. The most successful treatment for substance abuse disorders is a so-called 12-step program such as Alcoholics Anonymous. Most of the programs for the treatment of substance abuse were developed for men. Women are less responsive to the usual confrontational approach (142,143). Many women with substance abuse issues have children. Such women, and women who are pregnant, are often reluctant to enter treatment for fear of prosecution or losing custody.


Gynecology_Novak

Gynecology_Novak. Treatment programs for women with primary responsibility for children must include arrangements for child care. Recidivism after treatment is very common, but that does not mean that treatment is useless. On average, patients require three episodes of treatment before achieving sobriety (139). The essential obligation of the primary physician is to ask each patient about substance consumption and any problems arising from it (141). Buprenorphine is a useful adjunct medication; physicians are required to undergo specific training in order to prescribe buprenorphine (144). Anxiety is a sense of dread without objective cause for fear, accompanied by the usual physical concomitants of fear. Although every human being has anxious feelings from time to time, anxiety disorders are diagnosed when anxiety becomes disabling or so painful as to interfere with an individual’s quality of life. Anxiety disorders place patients at risk for suicide (145).


Gynecology_Novak

Gynecology_Novak. Panic Disorder Panic disorder is characterized by panic attacks: acute periods, generally lasting about 15 minutes, with intense fear and at least four of the following symptoms (146–152): Diaphoresis Trembling Shortness of breath A sense of unreality Fear of going crazy or dying Chills or hot ﬂashes The attacks can recur with or without specific precipitating events (148). The patient is preoccupied with them and makes behavioral changes she hopes will avert future attacks: avoiding specific situations, assuring herself there is an escape route from certain situations, or refusing to be alone. The symptoms of panic attacks are often confused with the symptoms of cardiac or pulmonary disease. They lead to many fruitless trips to the emergency department and to costly, even invasive, medical investigations. A careful history can establish the correct diagnosis in most cases (153–155).


Gynecology_Novak

Gynecology_Novak. Agoraphobia Agoraphobia is the avoidance of situations in which the patient fears she may be trapped, such as the center of a row in the theater or driving over a bridge. She fears that such a situation will trigger anxiety or a panic attack and therefore tends more and more to stay at home or limit her sphere of activity to an increasingly short list of venues. Agoraphobia and panic disorder can occur separately or together (150–154). Specific Phobias Specific phobias are irrational fears of certain objects or situations, although the patient recognizes that the object or situation poses no real danger. Of particular concern in gynecology are fear of needles and fear of vomiting (150).