Gynecology_Novak

Gynecology_Novak. Social phobia causes the patient to fear and avoid situations in which the patient anticipates, without rational cause, that she will be perceived in a humiliating light. Such situations include giving a business-related presentation, making an announcement at a meeting, and having a casual dinner with friends. Patients may alter their lives to avoid these anxieties, interfering with their interpersonal relationships and their ability to carry out their responsibilities, or they may manage to carry on despite considerable psychological pain (150).


Gynecology_Novak

Gynecology_Novak. Obsessive-compulsive disorder (OCD) is characterized by obsessions: recurrent impulses, images, or thoughts that the patient recognizes as her own, but dislikes and cannot control; or compulsions: intrusive, repetitive behaviors that the patient feels she must perform to prevent some dire consequence (155–157). The disorder can be mild or totally crippling; in half of the cases, it becomes chronic. This disorder is classified as an anxiety disorder because the obsessions are anxiety provoking, and the compulsions are performed to avoid overwhelming anxiety. The term OCD has made its way into popular parlance to describe people who focus on petty details and have trouble making up their minds. This is an incorrect use of the term.


Gynecology_Novak

Gynecology_Novak. Posttraumatic stress disorder (PTSD) is the result of exposure to an event that threatens the life or bodily integrity of the patient or others. At the time of the trauma, the patient experiences horror, terror, or a sense of helplessness. Afterward, the patient may lose conscious memory of all or part of the event, avoid situations reminiscent of it, and become acutely distressed when she cannot avoid them. She feels numb and detached, without a sense of the future. She is hyperarousable and irritable and has difficulty sleeping and concentrating. She re-experiences the event in nightmares, ﬂashbacks, and intrusive thoughts (149).


Gynecology_Novak

Gynecology_Novak. Epidemiology Panic disorder without agoraphobia is twice as common in women as it is in men; panic disorder with agoraphobia is three times more common in women (149). Onset is generally in young adulthood, often following a stressful event. The lifetime prevalence is 1.5% to 3.5%; the 1-year prevalence is 1% to 2%. A substantial percentage of patients experience depressive episodes as well. Phobias are somewhat more common in women, depending on the object of the phobia. The 1-year prevalence is 9%, and the lifetime prevalence is 10% to 11%. Obsessive-compulsive disorder is equally common in women and men, with evidence of familial transmission. Prevalence is 2.5% for lifetime and 1.5% to 2.1% for 1 year. Posttraumatic stress disorder has a lifetime prevalence of 1% to 14%; victims of violence (including child abuse and wife battering) and war are at increased risk. Men and women differ in the types of violence to which they tend to be exposed. Rape, for example, poses a similarly


Gynecology_Novak

Gynecology_Novak. violence (including child abuse and wife battering) and war are at increased risk. Men and women differ in the types of violence to which they tend to be exposed. Rape, for example, poses a similarly high risk of PTSD in both men and women, but women are more often the victims of rape (149).


Gynecology_Novak

Gynecology_Novak. Assessment Given the relationship between anxiety disorders and traumatic experiences, the presence of signs and symptoms of anxiety disorders should trigger inquiries about abuse (146,147). Before making attempts to treat these disorders, it is important to know how long the patient has suffered from the disorder, what previous attempts were made to diagnose and treat it, and the effect it had on her psychological development, life choices, lifestyle, and relationships. In some cases, the entire family will have organized their schedules and activities around the patient’s symptoms and limitations; they may not volunteer this information.


Gynecology_Novak

Gynecology_Novak. Management Treatment should not be limited to antianxiety medications. Managing, even tolerating, patient anxiety is an anxiety-provoking process; anxiety is contagious and raises the specter of unlimited demands on the gynecologist’s time and energy. Prescribing medication is a familiar and comfortable, if not optimal, way to end a medical interview. Overprescribing benzodiazepines is a cause for medical and media concern. It is useful to defer the administration of anxiolytic medications until the impact of the physician’s support and interest can be assessed (150). Treatment should address the effects on the patient’s life and family and the signs and symptoms of the specific disease (151).


Gynecology_Novak

Gynecology_Novak. Benzodiazepines are most useful in acute situations (150). Use can quickly become chronic, with escalating dosages, diminishing therapeutic effects, and increasing demands on the physician. Women taking benzodiazepines may forget to include them in their medical history. When admitted to the hospital, they may suffer unrecognized withdrawal symptoms, complicating their treatment, or may continue to take medications from a personal supply without informing the medical staff (150).


Gynecology_Novak

Gynecology_Novak. There are many patients who could benefit from anxiolytics but who are inordinately worried about becoming dependent or addicted. A patient with no history of addictive behaviors is unlikely to get into trouble with a standard dose of medication (156,157). It is important to ascertain the source of anxiety or obsessive behavior. Many patients and their families are anxious because of misinformation or misunderstanding about a medical problem or treatment. Few patients can absorb all the information about significant gynecologic conditions at a single visit, but many feel that asking questions will burden the physician or make the patient appear stupid. Patients suffer anxiety when there is disagreement among family members or medical staff about the diagnosis or recommended treatment. Many patients dread certain aspects of care, sometimes on the basis of past experience or outdated information (157). A simple explanation or alteration in procedure can alleviate the anxiety. For


Gynecology_Novak

Gynecology_Novak. Many patients dread certain aspects of care, sometimes on the basis of past experience or outdated information (157). A simple explanation or alteration in procedure can alleviate the anxiety. For example, a reassuring family member or friend can be allowed to stay with the patient during a diagnostic test, sedation can be administered orally or by inhalation before an intravenous line is inserted, or the patient can be allowed control over her own analgesia.


Gynecology_Novak

Gynecology_Novak. Behavioral interventions are extremely useful in managing anxiety disorders without problematic side effects. They include hypnosis, desensitization, and relaxation techniques (152– 163). These techniques provide a patient with tools to cope with her own anxiety. Specialists in behavioral medicine, usually psychologists, are expert in these techniques. A local medical school department of psychiatry or behavioral medicine is a good source for referrals. Interested gynecologists can master some of the techniques.


Gynecology_Novak

Gynecology_Novak. It is easy to be trapped into a cat-and-mouse game with an anxious and needy patient who has an anxiety or personality disorder (153). Faced with an obsessive or anxious, talkative, and needy patient in the midst of bedside rounds, clinic, or office hours, the clinician can develop a pattern of avoidance, sometimes alternating with overindulgence stemming from feelings of guilt. This kind of behavior results in sporadic, unpredictable reinforcement of the patient’s symptoms and demands for attention and is very likely to increase them. Attempting to escape by appearing distracted or harassed or yielding with despair to the destruction of the day’s schedule and the care of other patients simply heightens the patient’s anxiety (154–160).


Gynecology_Novak

Gynecology_Novak. It is preferable to develop a prospective approach (153,162,163). Gynecologists tend to underrate the power of their personal interactions with patients and their own ability to structure and limit those interactions appropriately. A patient with a long list of symptoms can be informed at the beginning of the visit how much time is available and asked to focus on her most important problem, with other problems to be discussed at future, scheduled appointments (162). Instead of scheduling appointments and returning telephone calls grudgingly in response to patient demands, the gynecologist should inform the patient that her condition requires brief regular scheduled visits. If she is contacting the office more often than visits can reasonably be scheduled, she should be asked to call between visits, at prearranged times, to advise the staff of her progress. There are useful self-help groups for patients with various psychiatric conditions and their families. Although groups focused


Gynecology_Novak

Gynecology_Novak. visits, at prearranged times, to advise the staff of her progress. There are useful self-help groups for patients with various psychiatric conditions and their families. Although groups focused only on victimization can validate patients’ experiences and pain and help them build new lives, they may interfere with their motivation to find other ways to identify themselves and obtain gratification (159). The gynecologist can monitor the patient’s responses to the self-help group interaction.


Gynecology_Novak

Gynecology_Novak. Medication does have a place in the management of anxiety disorders (164–166). Table 12.5 describes many of these agents. SSRIs are effective for a variety of anxiety disorders, sometimes Table 12.5 Compounds Used for Anxiety aLong ≥2 hours; Intermediate = 1–2 hours; Short ≤1 hour. bLong >20 hours; Intermediate = 6–20 hours; Short <6 hours. From Gilman AG, Rall TW, Nies AS, et al. The pharmacological basis of therapeutics. 8th ed. New York: McGraw-Hill, 1990; Stotland NL. Psychiatric and psychosocial issues in primary care for women. In: Seltzer VL, Pearse WH, eds. Women’s primary health care: office practice and procedures. New York: McGraw-Hill, 1995.


Gynecology_Novak

Gynecology_Novak. in different dosage regimens than those used for depression. Benzodiazepines are effective when taken for acute anxiety or during relatively brief, time-limited (several days) stressful situations. The specific agent should be chosen on the basis of onset of action and half-life. The patient must be admonished to avoid concomitant use of alcohol and to exercise extreme care about driving or engaging in other activities requiring attention, concentration, and coordination. Patients who fail to respond to a trial of office counseling or medication, who are unable to fulfill their responsibilities, who exhaust the patience and resources of significant others, who pose a diagnostic dilemma, who consume inordinate quantities of medical resources, or whose symptoms are becoming increasingly worse should be evaluated by a psychiatrist (166).


Gynecology_Novak

Gynecology_Novak. by the patient, and appears to be related to psychological stress or conﬂict. The prognosis is directly related to the length of time from onset to diagnosis and treatment (169–172).


Gynecology_Novak

Gynecology_Novak. Epidemiology Somatization is believed to be among the most common and most difficult psychological conditions in office practice. It is estimated that 60% to 80% of the general population experiences one or more somatic symptoms in a given week, providing an ample substrate for the patient preoccupied with her health (167). Somatization disorder occurs almost exclusively in women; menstrual symptoms may be an early sign. Lifetime prevalence in women is 0.2% to 2.0%. Conversion disorder occurs 2 to 10 times more frequently in women than in men (there is no difference for gender in children), and it is more common in rural and disadvantaged populations with little medical sophistication (167). Cases have become relatively rare. Conversion disorder may develop into somatization disorder. Reported rates of somatization disorder range from 11 to 300 per 100,000. Pain disorder is extremely common in both genders. Hypochondriasis is equally distributed between men and women; prevalence in


Gynecology_Novak

Gynecology_Novak. rates of somatization disorder range from 11 to 300 per 100,000. Pain disorder is extremely common in both genders. Hypochondriasis is equally distributed between men and women; prevalence in general medical practice is estimated to be 4% to 9%. There are few statistics about body dysmorphic disorder, but it seems to be equally distributed between men and women, with an average age of onset of about 30 years (167).


Gynecology_Novak

Gynecology_Novak. Assessment Most somatizing disorders are chronic. The goal of treatment in primary care is not to eliminate all the somatic symptoms but to help the patient cope with them and minimize their effect on her relationships and responsibilities (167). Because patients often seek care simultaneously or sequentially from several physicians, it is crucial to ask about all past and current diagnostic procedures, diagnoses, treatments, and responses. Patients’ level of function over the years is important; prognosis is inversely related to chronicity. Chronicity should not be an excuse for a failure to treat the patient. The impact on the lives of patients and their families can be mitigated even if the condition is not entirely eliminated. For these and most other patients, the gynecologist needs to know what the patient believes is wrong with her and what she believes she needs in the way of diagnostic and therapeutic interventions. When the patient does not receive what she expects or


Gynecology_Novak

Gynecology_Novak. needs to know what the patient believes is wrong with her and what she believes she needs in the way of diagnostic and therapeutic interventions. When the patient does not receive what she expects or desires, she is unlikely to comply with the recommended course of action, although she may accept it and pretend to be following it so as to avoid criticism from the physician. This behavior is actually very common among patients in general (167).


Gynecology_Novak

Gynecology_Novak. Management The management of somatizing disorders is focused on the avoidance of unnecessary medical interventions, iatrogenic medical or psychological complications, and disability. It is never possible to rule out all potential medical causes of a symptom. The literature is full of case presentations of patients with multiple sclerosis, brain tumors, and intermittently ﬂaring infections that for years were mislabeled as psychosomatic until a correct diagnosis of the condition was made (167,173). Organic pathology can befall patients with somatizing disorders. Patients who have benign gastrointestinal symptoms for extended periods can get appendicitis. Often a difficult differentiation must be made in each specific case and presentation.


Gynecology_Novak

Gynecology_Novak. Patients who have a somatizing disorder often approach each new clinician as the one who, “unlike the incompetent and insensitive physicians consulted in the past,” will finally get to the bottom of her troubles and cure her symptoms. The gynecologist must not get caught up in these expectations, but rather remind the patient that symptoms that have resisted diagnosis and treatment for many years are likely to be challenging ones. As with anxious patients, it is important to structure the doctor–patient relationship to avoid giving the patient attention inconsistently and only in response to escalating symptoms and demands (173). It is best to schedule frequent, brief office visits during which the clinician allots a small amount of time to listen to and sympathize with the patient’s somatic symptoms and spends the bulk of the time reinforcing the patient’s efforts to function despite her symptoms. Family members should be encouraged to facilitate functionality rather than invalidism.


Gynecology_Novak

Gynecology_Novak. Unmasking patently psychologically based symptoms by tricking the patient (shouting “Fire!” in the vicinity of a “paralyzed” patient), or documenting the patient’s behavior when she does not realize she is being observed, is momentarily gratifying for medical staff but humiliating for the patient. It may force her to relinquish a symptom, at least temporarily, but she will seek care elsewhere, exacerbating her dysfunction, distrust, and demands on the health care system (173).


Gynecology_Novak

Gynecology_Novak. Patients with conversion, somatization, and hypochondriacal disorders often benefit from prescriptive behavioral regimens aimed at saving face and improving function (174). It was once believed that a patient relieved of one symptom would soon substitute another, but this assumption is not confirmed by empirical evidence. The behavioral regimen should consist of health-promoting activities relevant to the target symptoms, planned in a stepwise progression, and recommended with reasonable medical conviction and authority. For example, the patient with psychogenic difficulty swallowing could be advised to drink only clear liquids, at specified intervals, for a specified number of days, and then go on similarly to full liquids, purees, soft foods, and finally a regular diet. The patient with difficulties in the extremities can undertake an exercise regimen. The patient’s preoccupation with her symptoms can be channeled into documentation of her progress in a log that she brings to her


Gynecology_Novak

Gynecology_Novak. difficulties in the extremities can undertake an exercise regimen. The patient’s preoccupation with her symptoms can be channeled into documentation of her progress in a log that she brings to her medical appointments. The physician is not bound to peruse the entire document at each visit. If it is too long, the patient can be asked to prepare a summary. This process may enlighten both her and the physician to the relationships between her symptoms and her diet, relationships, or activities. She should be advised not to dwell on her symptoms apart from this important notation (174).


Gynecology_Novak

Gynecology_Novak. It is critical to remember that patients whose somatic symptoms result from depression, posttraumatic stress disorder and other anxiety disorders, and domestic violence frequently seek care from gynecologists. In the case of domestic violence, the gynecologist is often the only human contact the abuser allows the patient outside the domestic situation (175– 177). These possibilities must be ruled out before care is directed to symptom management. Several medical associations have drawn attention to the need to screen women for domestic violence and the infrequency with which this is actually done. It appears that screening alone does not significantly change outcomes. Acknowledging domestic violence and finding and accessing resources are part of an often prolonged and incremental process—of which screening can be an important first step (178).


Gynecology_Novak

Gynecology_Novak. There is considerable cross-cultural variation in the extent to which feelings and psychological conﬂicts are somatized. In many Asian cultures, for example, presenting problems with feelings, behaviors, and interpersonal relationships are almost unheard of; these problems are expressed, diagnosed, and treated somatically. Conversely, some very sophisticated and psychologically informed patients in Western society may dismiss serious somatic signs and symptoms as indications of psychological conﬂict (177).


Gynecology_Novak

Gynecology_Novak. Referral Patients with somatizing disorders may resist mental health referral more adamantly than any other single class of patients (167). Focused as they are on physical symptoms, these patients can regard referral as a message that their symptoms are not being taken seriously and as a sign of contempt and rejection by the gynecologist. It is particularly useful with these patients to emphasize that distinctions between mind and body are artificial. The brain is part of the body. Our language expresses this synthesis; anxiety causes “butterﬂies in the stomach,” aggravation “gives us a headache,” and unwelcome news “gives us a heart attack.”


Gynecology_Novak

Gynecology_Novak. The referral should be framed as support for the patient’s suffering rather than as a statement that her problems are “all in her head” (168). The mental health professional should be introduced as a member of the medical team. Some medical institutions have dedicated psychiatric consultation, medical psychiatry, or behavioral medicine services offering expertise in the psychological complications of disease and in somatization disorders. Because so-called somatic and psychological symptoms often coexist and interact, the gynecologist should work in collaboration with the mental health professional. Patients should be given a return appointment with the primary physician, or a request for a telephone contact, at the time of the original mental health referral to reassure them that they are not being dismissed and to inform the primary physician of the results of the consultation (168).


Gynecology_Novak

Gynecology_Novak. Personality disorders are pervasive, lifelong, maladaptive patterns of perception and behavior (177–179). Patients with personality disorders believe that whatever unpleasant feelings they have are caused by the behavior of others. They view their own behaviors, which can wreak havoc in the health care setting as well as in patients’ lives, as normal, expectable, inevitable reactions to these perceived circumstances. To make matters worse, their behaviors tend to provoke in others the very responses that confirm their expectations; for example, a patient who is convinced that people always abandon her will cling desperately to others, eventually driving them away. Diagnosis Personality disorders are organized into clusters in DSM-IV (9). Patients often manifest characteristics of several disorders within a cluster and between clusters.


Gynecology_Novak

Gynecology_Novak. Individuals with Cluster A disorders are isolated, suspicious, detached, and odd. Narcissistic patients are grandiose, arrogant, envious, and entitled. Histrionic individuals are ﬂamboyant and provocative. Antisocial patients disregard laws and rules of common decency toward others. Borderline personality disorder causes patients to have difficulty controlling their impulses and maintaining stable moods and relationships (177). They engage in self-destructive behaviors. They ﬂuctuate between overvaluation and castigation of the same person or direct these feelings alternately between one person and another. When this happens on a gynecology service or in the office, it can precipitate significant tensions among the staff. There is one caveat: research reveals that many women who were abused are diagnosed as borderline when posttraumatic stress disorder more accurately fits their symptoms (175– 178). Posttraumatic stress disorder is a less stigmatizing and more treatable condition than


Gynecology_Novak

Gynecology_Novak. are diagnosed as borderline when posttraumatic stress disorder more accurately fits their symptoms (175– 178). Posttraumatic stress disorder is a less stigmatizing and more treatable condition than borderline personality disorder.


Gynecology_Novak

Gynecology_Novak. Epidemiology Lifetime prevalence of personality disorders as a group is 2.5% (177–179). Cluster A disorders are more common in men. Within Cluster B disorders, 75% of cases are women; the prevalence in the general population is 2%. Personality disorders such as narcissistic personality are more common in the clinical population than in the general population. Among Cluster C disorders, dependent personality is one of the most frequently diagnosed. Obsessive-compulsive personality is twice as common in men as in women. It is important to distinguish the personality disorder from the symptomatic obsessive-compulsive disorder. There is a strong association between personality disorders and a history of childhood abuse. The possibility of an ongoing abusive situation should be considered. There is so much overlap among the clusters that the diagnostic structure may well change in the forthcoming DSM revision (179).


Gynecology_Novak

Gynecology_Novak. Assessment The impact of personality disorders ranges widely (177–179). At one end of the spectrum, the disorder is an exaggerated personality style. At the other end of the spectrum, the individual suffers terrible emotional pain and is unable to function in work roles or relationships, spending significant periods of time in psychiatric hospitals. She characterizes her symptoms of despair as inevitable responses to abandonment or other mistreatment. As the definition implies, the patient will not seek treatment for the signs and symptoms listed in the diagnostic criteria but instead will have complaints about her treatment by others, their responses to her, and the unfairness and difficulties of life in general. Taking the history, the clinician should frame questions in those same terms: How long have these troubles gone on, and how much do they interfere with her ability to work and relate to others? Personality disorders do not bring patients to gynecologists’ offices directly,


Gynecology_Novak

Gynecology_Novak. How long have these troubles gone on, and how much do they interfere with her ability to work and relate to others? Personality disorders do not bring patients to gynecologists’ offices directly, but they greatly complicate things when patients arrive.


Gynecology_Novak

Gynecology_Novak. Management Intense and lengthy psychotherapy is required to effect significant improvement in patients who have personality disorders (177). There is increasing evidence that expert, targeted therapeutic interventions can be successful and that the long-term prognosis is more hopeful than previously believed. The challenge in the gynecology setting is to minimize contention and drain on medical staff while maximizing the likelihood of effective diagnosis and treatment of the patient’s medical problems. The most helpful single step is the identification of the personality disorder. Diagnosis enables the gynecologist to recognize the reasons for a patient’s problem behaviors, to avoid becoming entangled in fruitless interactions with the patient, and to set appropriate limits.


Gynecology_Novak

Gynecology_Novak. There is increasing evidence that psychotropic medications are useful adjuncts in the treatment of personality disorders (179). Treatment should be provided in consultation with a psychiatrist. The patient’s ability to use the medication can be compromised by impulsivity, self-destructive tendencies, and unstable relationships. Low doses of major tranquilizers are sometimes helpful, especially when the patient has brief psychotic episodes. Minor tranquilizers or anxiolytics pose significant risk of overdose and physical and psychological habituation (179). They can be prescribed for temporary stresses, but only in a quantity sufficient for several days and with no refill allowed. Some patients’ anxiety, demands, and power struggles are eased when they are given control over their own use of medication. Such an approach requires enough familiarity with the patient to ensure her safety and should be managed by an expert. Because the patient with a personality disorder attributes her


Gynecology_Novak

Gynecology_Novak. of medication. Such an approach requires enough familiarity with the patient to ensure her safety and should be managed by an expert. Because the patient with a personality disorder attributes her problems to others, her symptoms cannot be adduced as reasons for psychiatric referral, but her suffering can be. If a diagnosis of a personality disorder absolutely must be noted in the patient’s chart or on insurance forms, it is essential that she be so informed. It is useful to review the DSM-IV-TR criteria with her so that she understands the basis for the diagnosis (9). All psychiatric diagnoses, but particularly personality disorders, carry a significant stigma.


Gynecology_Novak

Gynecology_Novak. Diagnosis Adjustment disorders are temporary, self-limited responses to life stressors that are part of the normative range of human experience (unlike those that precipitate posttraumatic stress disorder) (180). The patient has mood or anxiety symptoms that are sufficient to lead her to seek medical care but that do not meet criteria of sufficient quantity or quality to qualify for psychiatric diagnosis. The diagnosis requires an identifiable stressor, onset within 3 months after the stress begins, and spontaneous resolution within 6 months after the stressor ends. Obviously the latter cannot be determined until the symptoms resolve—but they do rule out the disorder if the symptoms persist beyond that time (180,181).


Gynecology_Novak

Gynecology_Novak. Adjustment disorders can be distinguished from normal grieving (180,181). Grieving produces symptoms similar to those of depression, although depression is more likely to cause guilt. Interference with function should not persist beyond several months, but some degree of sadness and preoccupation with the lost loved one often goes on for years. Patients with persistently disabling grief should be referred to a mental health professional. Epidemiology Adjustment disorders affect men and women equally. An estimated 5% to 20% of patients undergoing outpatient mental health treatment suffer from adjustment disorders. There is little literature on the subject; one study reported a prevalence of 2.3% among a sample of patients receiving care in a walk-in general health clinic (180).


Gynecology_Novak

Gynecology_Novak. Management Patients with adjustment disorders can be treated effectively with brief counseling in the primary care setting (180). The counseling can be provided by the gynecologist or by a nurse clinician, social worker, or psychologist, preferably a member of the office or hospital staff who is familiar with the gynecologist and the practice. The medical setting is sometimes the only place where the patient can vent her feelings and think through her situation. Counseling is aimed at facilitating the patient’s own coping skills and helping her to make thoughtful decisions about her situation. The gynecologist should follow the patient’s progress and facilitate referral to a psychiatrist if symptoms do not resolve.


Gynecology_Novak

Gynecology_Novak. The etiology of eating disorders is neurobiological as well as psychosocial (182). Preoccupation with thinness, sometimes to the point of pathology, is a major problem for women in North America (183). Only a small number of women profess to be satisfied with their weights and body shapes. Nearly all admit to current or recent attempts to limit food intake. Physicians often share social prejudices against overweight patients and can easily exacerbate patients’ concerns by making chance comments. In some cases, such comments by the physician or others can precipitate, if not cause, an eating disorder.


Gynecology_Novak

Gynecology_Novak. Diagnosis Anorexia nervosa is characterized by severe restrictions on food intake, often accompanied by excessive physical exercise and the use of diuretics or laxatives. Clinical features include menstrual irregularities or amenorrhea, intense and irrational fear of becoming fat, preoccupation with body weight as an indicator of self-worth, and inability to acknowledge the realities and dangers of the condition. Some patients approach gynecologists for treatment of infertility (184). Bulimia is characterized by eating binges followed by self-induced vomiting or purging. Patients’ weights may be normal or somewhat higher than normal. Patients have drastically low self-esteem, and the condition frequently coexists with depression (185).


Gynecology_Novak

Gynecology_Novak. Patients’ weights may be normal or somewhat higher than normal. Patients have drastically low self-esteem, and the condition frequently coexists with depression (185). Obesity is an increasingly frequent health problem, and there is little evidence that any nonsurgical approach is effective over time. Sensible eating should be encouraged, and fad or crash diets, which are rampant, are medically and psychologically counterproductive (186). Given the stigma against being overweight in our society, patients may avoid the doctor’s office just because they will be weighed there. The best approach with overweight patients is to acknowledge that being overweight is detrimental to health but that changing one’s diet and lifestyle, and losing weight, is very difficult. Primary care physicians should indicate that they are not going to judge the patient, but are available to provide support and information at the patient’s request.


Gynecology_Novak

Gynecology_Novak. Epidemiology More than 90% of cases of anorexia and bulimia occur in female patients. The prevalence is 0.5% to 1.0% in late adolescence and 1% to 3% in early adulthood. There is some evidence of familial transmission (182–185). Assessment The clinician treating the anorexic patient needs to know how much insight she has into her problem and to assess her mood, relationships, and general level of function. Anorexia poses significant risks of severe metabolic complications and death, often from cardiac consequences of electrolyte abnormalities. Thorough physical and laboratory examination is critical; immediate hospitalization may be necessary (182–185).


Gynecology_Novak

Gynecology_Novak. Management Patients with anorexia or bulimia should be treated by mental health professionals, preferably those with subspecialization in this area. The conditions are highly refractory to treatment; patients can resort to elaborate subterfuges to conceal their failure to eat and gain weight (185–187). There are Web sites dedicated to anorexia, with information about the minimum calories necessary to sustain life, and photographs of individuals who seem pleased with their skeletal appearance. Up to 50% of cases will become chronic, and approximately 10% of those will ultimately die of the disease. Antidepressant medication is sometimes helpful. Amenorrheic patients should not be treated with ovulation induction. Evaluation for osteopenia and osteoporosis is necessary (187).


Gynecology_Novak

Gynecology_Novak. Schizophrenia affects approximately 1% of persons worldwide (188). Since the deinstitutionalization of persons with severe and persistent mental illnesses several decades ago, most affected individuals live in the community. Often health care and other services are inadequate, leaving these women vulnerable to sexual abuse and involuntary impregnation. Overall, the fertility of women with schizophrenia approximates that of matched populations. Schizophrenia is not an absolute contraindication to successful parenting, but there is considerable stigma against psychotic disorders, and patients may avoid prenatal care because they fear loss of custody (189,190).


Gynecology_Novak

Gynecology_Novak. Diagnosis Psychotic disorders are characterized by major distortions of thinking and behavior. They include schizophrenia, schizophreniform disorders, schizoaffective disorders, delusional disorders, and brief psychotic disorders. General medical and toxic conditions must be ruled out in determining the diagnosis. Distinctions between the disorders are based on symptoms, time course, severity, and associated affective symptoms. The hallmark of psychosis is the presence of delusions or hallucinations. Hallucinations are sensory perceptions in the absence of external sensory stimuli. Delusions are bizarre beliefs about the nature of motivation of external events (188). Because there is no reliable definition of “bizarre,” a physician working with a patient from an unfamiliar culture must determine whether a given belief is normal in that culture. Delusions and hallucinations are the positive symptoms of schizophrenia. The negative symptoms include apathy and loss of connection to others


Gynecology_Novak

Gynecology_Novak. whether a given belief is normal in that culture. Delusions and hallucinations are the positive symptoms of schizophrenia. The negative symptoms include apathy and loss of connection to others and to interests. The negative symptoms may be more disabling than the positive. There is increasing evidence that schizophrenia is associated with cognitive deficits (191).


Gynecology_Novak

Gynecology_Novak. Epidemiology Onset of schizophrenia is in the late teens to mid-30s. Women succumb later in life and have more prominent mood symptoms and a better prognosis than men (191,192). The risk is 10 times greater for first-degree biologic relatives and for individuals of low socioeconomic status (192). It is unclear whether indigent status is a precipitating stress or a result of psychotic illness, but, especially as extremely few individuals have private or public coverage for adequate treatment, most people with schizophrenia are indigent.


Gynecology_Novak

Gynecology_Novak. Assessment There is wide variability in the functional impact of psychotic disorders. Patients must not be assumed to be incompetent to make medical decisions or lead independent lives, especially if they comply with treatment. Patients must be asked specifically about their living situations and coping skills. When psychotic women have responsibility for the care of children, their ability to do so should be assessed in consultation with a mental health expert. Motherhood and child custody are exceedingly sensitive matters for these vulnerable patients (191).


Gynecology_Novak

Gynecology_Novak. A relentlessly downhill course is not inevitable; remissions and recovery can occur (192). Therefore, the patient’s mental status must be examined carefully. Under the pressures of a busy medical setting, psychotic illnesses can be overlooked, only to erupt in the labor room, operating room, or recovery room. Patients who believe that conspiracies or aliens are responsible for their symptoms can answer yes-or-no medical questions without revealing their delusions. Open-ended questions (“Tell me about your symptoms”) are more useful (191). Sensationalized media accounts of violent crimes committed by psychotic patients exacerbate public misconceptions about these diseases. Statistically, individuals with psychoses are more likely to be victims than perpetrators of crime. Untreated patients, especially when under the inﬂuence of alcohol or other substances, are at somewhat increased risk of violent behavior; treated patients are no more violent than the general public (192).


Gynecology_Novak

Gynecology_Novak. Management Psychotic illnesses are usually managed by psychiatrists. A primary care practitioner can assume responsibility, in consultation with a psychiatrist, for a stable patient who complies with treatment. When a patient expresses delusions, the clinician may indicate that he or she does not share these delusions, but should not debate with the patient (193–195). It is important to concentrate on the patient’s strengths. She can be humiliated easily by thoughtless epithets or behaviors that betray the expectation of violence or incompetence. Patients with severe cases must be treated with an integrated system of social services, family support, rehabilitation, general medical care, psychotherapy, and psychopharmacology. In the process of referral to a mental health professional, the primary clinician should be clear, matter-of-fact, open, and confident of the possibility of successful treatment (192). 1.


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Gynecology_Novak. 170. Ljundberg L. Hysteria: clinical, prognostic, and genetic study. Acta Psychol Scand 1957;32:1–162. 171. Stefansson JH, Messina JA, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand 1976;59:119–138. 172. Toone BK. Disorders of hysterical conversion. In: Bass C, ed. Physical symptoms and psychological illness. London, Engl.: Blackwell Science, 1990:207–234. 173. Strassnig M, Stowell KR, First MB, et al. General medical and psychiatric perspectives on somatoform disorders: separated by an uncommon language. Curr Opin Psychiatry 2006;19:194–200. 174. Ruddy R, House A. Psychosocial interventions for conversion disorder. Cochrane Database Syst Rev 2005;19:CD005331. 175. Koss MP. The women’s mental health research agenda: violence against women. Am Psychol 1990;45:257–263. 176.


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Gynecology_Novak. 175. Koss MP. The women’s mental health research agenda: violence against women. Am Psychol 1990;45:257–263. 176. Bryer JB, Nelson BA, Miller JB, et al. Childhood sexual and physical abuse as factors in adult psychiatric illness. Am J Psychol 1987;114:1426–1430. 177. Warshaw C. Women and violence. In: Stotland NL, Stewart DE, eds. Psychological aspects of women’s health care, 2nd ed. Washington, DC: American Psychiatric Press, 2001:477–548. 178. MacMillan HL, Wathen CN, Jamieson E, et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA 2009;302:493–501. 179. Clark LA. Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization. Ann Rev Psychol 2007;58:227–257. 180. Andreasen NC, Wasek P. Adjustment disorders in adolescents and adults. Arch Gen Psychiatry 1980;37:1166–1170. 181.


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Gynecology_Novak. 180. Andreasen NC, Wasek P. Adjustment disorders in adolescents and adults. Arch Gen Psychiatry 1980;37:1166–1170. 181. Fabrega H Jr, Mezzich JE, Mezzich AC. Adjustment disorder as a marginal or transitional illness category in DSM-III. Arch Gen Psychol 1987;44:567–572. 182. Kaye W, Strober M, Jimerson D. The neurobiology of eating disorders. In: Charney DS, Nestler EJ, eds. The neurobiology of mental illness. New York: Oxford University Press, 2004:1112–1128. 183. Mickley D. Are you overlooking eating disorders among your patients? Womens Health in Primary Care 2000;3:40–52. 184. Strober M, Morell W, Burroughs J, et al. A controlled family study of anorexia nervosa. J Psych Res 1985;19:329–346. 185. Stewart DE, Robinson GE. Eating disorders and reproduction. In: Stotland NL, Stewart DE, eds. Psychological aspects of women’s health care, 2nd ed. Washington, DC: American Psychiatric Press, 2001:411–456. 186.


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Gynecology_Novak. 186. VanItallie TB. Health implications of overweight and obesity in the United States. Ann Intern Med 1985;103:983–1038. 187. Bulik CM, Berkman ND, Brownley KA, et al. Anorexia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Discord 200740:310–320. 188. Von Korff M, Nestadt G, Romanoski A, et al. Prevalence of treated and untreated DSM-III schizophrenia: results of a two-stage community survey. J Nerv Ment Dis 1985;173:577–581. 189. Nilsson E, Lichtenstein P, Cnattinguis S, et al. Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res 2002;58:221–229. 190. Jablensky AV, Morgan V, Zubrick SR, et al. Pregnancy, delivery and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. Am J Psychiatry 2005;162:79–91. 191.


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Gynecology_Novak. 191. Goff DC, Manschreck TC, Groves JE. Psychotic patients. In: Cassem NH, ed. Massachusetts General Hospital handbook of general hospital psychiatry. St. Louis, MO: Mosby Year Book, 1991:217–236. 192. Black DW, Andreasen NC. Schizophrenia, schizophreniform disorder, and delusional (paranoid) disorder. In: Hales RE, Yudofsky SC, Talbott JA, eds. Textbook of psychiatry, 2nd ed. Washington, DC: American Psychiatric Press, 1994:411–463. 193. Beiser M, Iacono WG. Update on the epidemiology of schizophrenia. Can J Psychiatry 1990;35:657–668. 194. Michels R, Marzuk PM. Progress in psychiatry. N Engl J Med 1993;329:552–560. 195. Stotland NL. Psychiatric and psychosocial issues in primary care for women. In: Seltzer VL, Pearse WH, eds. Women’s primary health care: office practice and procedures. New York: McGraw-Hill, 1995. Tracy W. Gaudet


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Gynecology_Novak. Tracy W. Gaudet The spectrum of complementary and alternative approaches is broad and includes methods worthy of integration into our current practice, and ineffective or fraudulent practices that should be avoided. A complete history should include the patient’s use of complementary and alternative medicine (CAM), particularly botanicals and supplements, as these can have actions ranging from estrogenic to anticoagulant. The U.S. Food and Drug Administration does not currently regulate botanicals and supplements, so extra steps must be taken to ensure the quality of such products. The management of many women’s health issues can be enhanced by the integration of selected CAM approaches. Perceived congruency of values around life and health with CAM providers was predictive of use of these approaches; dissatisfaction with conventional medicine is not a predictor of use of CAM.


Gynecology_Novak

Gynecology_Novak. Perceived congruency of values around life and health with CAM providers was predictive of use of these approaches; dissatisfaction with conventional medicine is not a predictor of use of CAM. Acupuncture is of benefit in a variety of conditions, including pain, nausea and vomiting of pregnancy, and secondary to chemotherapy. Mind–body approaches such as stress reduction, visualization, and hypnosis are gaining evidence as valuable adjuncts in a spectrum of women’s health concerns, from surgery to fertility.


Gynecology_Novak

Gynecology_Novak. The use of complementary and alternative medicine (CAM) for health maintenance and disease management is on a steady rise in the United States, and for nearly 15 years, the number of visits to alternative care providers exceeded the number of visits to primary care providers. Although evidence exists to support many of these approaches, some approaches are used in the absence of any documented benefit and can be potentially dangerous and fraudulent (1). The primary users are women, who are frequently making decisions regarding treatment options without the advice of their physicians. Obstetrician–gynecologists are in an excellent position to help guide patients in their treatment choices, counseling them about potentially dangerous alternative treatments and supporting their use of potentially beneficial ones. The most significant challenge is the lack of training that most obstetrician–gynecologists have in this area; thus, this chapter reviews the domains of CAM as they apply to the


Gynecology_Novak

Gynecology_Novak. beneficial ones. The most significant challenge is the lack of training that most obstetrician–gynecologists have in this area; thus, this chapter reviews the domains of CAM as they apply to the practice of gynecology.


Gynecology_Novak

Gynecology_Novak. Table 13.1 The Five Domains of Complementary and Alternative Medicine Adapted from National Institutes of Health. National Center for Complementary and Alternative Medicine. What is complementary and alternative medicine? Available online at: http://nccam.nih.gov/ The concept of complementary and alternative medicine is by definition a relative one. In a landmark publication, CAM was defined as “medical interventions not taught widely at U.S. medical schools or generally available at U.S. hospitals” (2). As practices or therapies move in or out of the mainstream in this country, the definition of CAM will change. The spectrum of therapies, practitioners, and products that fall into this category are extremely broad and include everything from botanical medicine to “crystal gazing.” The five domains of CAM are listed in Table 13.1.


Gynecology_Novak

Gynecology_Novak. The amount of evidence on the use of these approaches varies widely. A significant number of randomized controlled trials, including those with sufficient quantity and quality to allow meta-analyses in some areas, were done to assess the efficacy of acupuncture, botanical medicine, nutritional approaches, manual therapies, and mind–body medicine. Research in the other domains is much more limited. Many culturally based practices such as shamanism and curanderismo have virtually no research basis. A growing number of randomized controlled trials are being done in spiritual healing and homeopathy, but these techniques remain controversial based on the lack of understood biophysical mechanisms to justify their efficacy.


Gynecology_Novak

Gynecology_Novak. Integrative medicine is a distinct entity separate from the practice of CAM. Integrative medicine neither blindly advocates CAM nor rejects conventional medicine. Integrative medicine is healing oriented and patient centered and adopts a whole-person approach to the treatment of disease and the maintenance of health. It draws on the best practices of medicine, regardless of system of origin. Typically, integrative medicine would include, in addition to conventional medicine, CAM techniques that may be of benefit, including nutrition, movement and exercise, mind–body approaches, and spirituality. As the paradigm of conventional medicine broadens to include other therapeutic modalities that previously were considered “alternative,” and the focus of our system becomes more accepting of health optimization and disease management, we will see greater integration of these philosophies, approaches, and providers. The distinction of “complementary and alternative therapies” may ultimately no


Gynecology_Novak

Gynecology_Novak. optimization and disease management, we will see greater integration of these philosophies, approaches, and providers. The distinction of “complementary and alternative therapies” may ultimately no longer be useful, nor will integrative medicine. This approach, which is inclusive of effective philosophies and approaches that can improve the health and healing of women, will simply become the standard for U.S. health care.


Gynecology_Novak

Gynecology_Novak. The first national survey assessing the use of CAM in the United States was done in 1990. This study revealed that 34% of the 1,539 individuals who responded to the survey had used CAM in the previous 12 months and that most of these users were women. When extrapolated, these results suggested 425 million visits to alternative care providers occurred that year, which exceeded the number of visits to primary care providers in the same year (388 million visits). An estimated $13.7 million was spent, $10.3 million of which was spent out of pocket. This expenditure is comparable to the $12.8 billion spent out of pocket for all hospitalizations in the United States that same year. Only 28.5% of individuals disclosed this usage to their physician. Of note to conventional health care providers, 71.5% of individuals using these approaches did not inform their physicians of their use (2).


Gynecology_Novak

Gynecology_Novak. This national survey was repeated 7 years later and established the use of CAM in the United States as a significant and growing trend (N = 2,055). When compared with use in 1990, the use of CAM increased from 33.8% to 42.1%. Extrapolations suggest a 47.3% increase in total visits to alternative medicine providers, from 427 million in 1990 to 629 million visits in 1997, again exceeding visits to primary care providers. Most of these users again were women, with 48.9% of women having used CAM that year, compared with 37.8% of men (1). There was no significant improvement in disclosure, with only 39.8% of users disclosing this information to their physicians. Most users were again found to be paying entirely out of pocket, with no significant change between 1990 (64%) and 1997 (58.3%). Estimated expenditures for alternative medicine services increased 45.2%, and total 1997 out-of-pocket expenditures related to alternative therapies were conservatively estimated at $27 billion, which is


Gynecology_Novak

Gynecology_Novak. expenditures for alternative medicine services increased 45.2%, and total 1997 out-of-pocket expenditures related to alternative therapies were conservatively estimated at $27 billion, which is comparable to the out-of-pocket expenditures for all physician services that year. More recently, the CDC reported that in 2002, 75% of adult Americans reported having used CAM approaches, and 62% had used them in the past year (3). A study of gynecologic oncology patients revealed that 56% were using CAM, and surveys of menopausal women showed that 80% were using “nonprescriptive therapies” (4). The Study of Women’s Health Across the Nation (SWAN) found that approximately one-half of women were actively using herbal, spiritual, or manipulative therapies (4). A study examining the use of CAM by women suffering from nausea and vomiting during pregnancy found that 61% reported using CAM therapies, with the most popular being ginger, vitamin B6, and acupressure (5). A study evaluating the use of


Gynecology_Novak

Gynecology_Novak. suffering from nausea and vomiting during pregnancy found that 61% reported using CAM therapies, with the most popular being ginger, vitamin B6, and acupressure (5). A study evaluating the use of CAM therapies by women with advanced-stage breast cancer revealed that 73% of patients used CAM, with relaxation or meditation techniques and botanicals being used most often (6). The reason most often given for the use of CAM was immune support, followed by the second treatment of cancer. A survey in Washington state exploring use of alternative therapies for menopause revealed that 76% of women were using alternative approaches, with 43% of these women using stress-reduction techniques, 37% using over-thecounter alternative approaches, 32% using chiropractic medicine, 30% massage therapy, 23% dietary soy, 10% acupuncture, 9% naturopathy or homeopathy, and 5% herbalists (7). Of these women, 89% to 100% found these approaches to be somewhat or very helpful. Current users of hormone therapy


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Gynecology_Novak. dietary soy, 10% acupuncture, 9% naturopathy or homeopathy, and 5% herbalists (7). Of these women, 89% to 100% found these approaches to be somewhat or very helpful. Current users of hormone therapy were 50% more likely to use CAM than those who never used hormone therapy.


Gynecology_Novak

Gynecology_Novak. Following the results of the Women’s Health Initiative indicating the risks associated with hormone therapy, interest in the use of CAM for management of menopausal symptoms increased. The Attraction A national survey published in 1998 was the first to explore the very intriguing question of why so many patients were turning to CAM (8). Three hypotheses were proposed: 1. Dissatisfaction with conventional medicine. 2. Personal control in their health care. 3. Philosophical congruence of values around life, health, and wellness.


Gynecology_Novak

Gynecology_Novak. Surprisingly, dissatisfaction with conventional medicine was not predictive of use of CAM. Patients turn to CAM because they are seeking greater congruency of values regarding life, health, and wellness (8). The message is, that people are happy to use conventional medicine when they have a diseased or injured body part, but when their goal is to improve their health or manage a chronic condition or lifestyle issue, they turn to alternative care providers. Establishing a partnership with patients can help them explore all of the options for maximizing their health. The Centers for Disease Control and Prevention (CDC) reported that the majority (55%) of people stated that their reason for using CAM therapies was that they thought combining these approaches with conventional ones would help them. It is interesting to note that 26% reported they tried these approaches because medical professionals had recommended them (3).


Gynecology_Novak

Gynecology_Novak. The reluctance of patients to inform their physicians of their use of CAM creates barriers to the best practice of medicine. Included in the realm of CAM are potentially harmful practices and products and potential interactions between effective CAM and conventional approaches. In a 5-year prospective cohort study following women in San Francisco with newly diagnosed breast cancer, 72% were using at least one form of CAM in the management or treatment of their breast cancer. Of these women, 54% disclosed their use to their physician (much higher than the national average), whereas 94% discussed their conventional treatment with their CAM provider (9). Three reasons were given for the patients’ lack of disclosure: 1. Women anticipated physician disinterest, negative response, or unwillingness or inability to contribute useful information 2. Women believed their use of CAM to be irrelevant to their biomedical treatment 3.


Gynecology_Novak

Gynecology_Novak. Women believed their use of CAM to be irrelevant to their biomedical treatment 3. Women did not view disclosure as appropriate coordination of disparate healing strategies This study highlighted the fact that the use of conventional approaches is well integrated into CAM patient visits, whereas the history of use of CAM is poorly integrated into the conventional medical encounter. Overall, patients’ disclosure to their physicians is very cautious, even when the physicians involved would welcome the discussion.


Gynecology_Novak

Gynecology_Novak. The Challenge The demographics and trends associated with CAM use create challenges for physicians and dangers for patients. A huge market demand exists, and with it comes an opportunity for products and therapies that may be ineffective, dangerous, or fraudulently marketed. The development of the patient demand preceded the incorporation of education regarding CAM for medical students, residents, and practicing physicians. As a result, patients make decisions regarding their care without the benefit of medical advice or the coordination of their care by one provider. The best practice of medicine necessitates the integration of all therapies that can benefit the patient and the exclusion of those that can cause harm. Integration of these techniques will require the collaborative, concerted effort of physicians, CAM providers, and patients. Biologically Based Therapies: Botanical Medicine


Gynecology_Novak

Gynecology_Novak. Biologically Based Therapies: Botanical Medicine The many types of CAM techniques can be organized by categories as outlined by the National Institutes of Health (NIH). Each type is associated with some risk or complication. Licensing and certification requirements vary widely from state to state, but most techniques have a formal structure for training and accreditation (Table 13.2). Botanical or herbal therapies use botanicals singly or in combination for therapeutic value. A botanical is a plant or plant part that contains chemical substances that act on the body. Botanical or herbal medicines were studied extensively in Europe, and large multicenter trials are beginning to provide more robust evidence in this country.


Gynecology_Novak

Gynecology_Novak. Botanical medicine is the area of CAM most conceptually accessible to patients. Botanicals are the source of the active agents in approximately 25% of prescription drugs and 60% of overthe-counter drugs. In the United States these products are often not perceived as active and are regulated as “dietary supplements,” that are not under the direction of the U.S. Food and Drug Administration (FDA). The most popular botanicals used in the United States are listed in Table 13.3. Complications and Risks Botanical medicines are being used by an increasing number of patients, and they often do not advise their clinicians of this use. Certain patients are at risk for drug– botanical interactions or adverse reactions, and patients should be questioned about them (Tables 13.4 and 13.5). Mega doses of vitamins and supplements have associated risks and complications, and their use is increasing. Because botanicals are regulated as dietary supplements, quality control is challenging.


Gynecology_Novak

Gynecology_Novak. Because botanicals are regulated as dietary supplements, quality control is challenging. In 1994, the Dietary Supplement Health and Education Act (DSHEA) was enacted (10). This act makes it legal to refer to the supplement’s effect on the body’s structure or function or to Table 13.2 Training and Licensure in Complementary and Alternative Medicine Hypnotherapy The International Medical and Dental Hypnotherapy Association will certify hypnotherapists if they meet the minimum eligibility requirements and provide referrals. Clinical hypnosis Basic certification requires a minimum of 40 hours of ASCH approved workshop training, 20 hours of individualized training, and a minimum of 2 years of independent practice using clinical hypnosis. The advanced level, called approved consultant, requires a minimum of 60 additional hours of ASCH-approved workshop training and 5 years of independent practice using clinical hypnosis.


Gynecology_Novak

Gynecology_Novak. American Society of Clinical Hypnosis (ASCH) Certification in clinical hypnosis ensures that the certified individual is a bona fide health care professional who is licensed in that state to provide medical, dental, or psychotherapeutic services. Acupuncture Schools provide 3-or 4-year training programs in oriental In most states, the practitioner must provide medicine that consist of about 2,500 to 3,200 hours. proof that he/she has attended and graduated from an accredited school or from a school that is in the process of being accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Forty states either license or register acupuncturists as Doctors of Oriental Medicine or Acupuncture Physicians, and about two-thirds of these states grant licenses. Table 13.3 Top-Selling Herbal Dietary Supplements in the Food, Drug, and Mass Market Retail Channels in 2009 (for 52 Weeks Ending December 27, 2009)


Gynecology_Novak

Gynecology_Novak. Table 13.3 Top-Selling Herbal Dietary Supplements in the Food, Drug, and Mass Market Retail Channels in 2009 (for 52 Weeks Ending December 27, 2009) From Cavaliere C, Rea P, Lynch ME, et al. Herbal supplement sales rise in all channels in 2009. American Botanical Council. Herbalgram 2010;86:62. Available online at: http://cms.herbalgram.org/ herbalgram/issue86/article3530.html?Issue=86. a person’s well-being. Products within the jurisdiction of DSHEA are easily recognized by the following statement on their labels: “This product is not intended to diagnose, treat, cure, or prevent any disease.” Because the FDA does not regulate these products, the potential for lack of standardization of products, as well as adulteration or mislabeling, exists. Pharmacokinetic evaluation is lacking.


Gynecology_Novak

Gynecology_Novak. Botanicals can cause toxicity in one of three ways: (i) the products can be adulterated; (ii) the labels can recommend dosages that exceed appropriate use and cause toxicity even when the product is safe in appropriate dosages; and (iii) even when they are of good quality and taken in the correct dosage, these products can interact with other supplements and pharmaceutical agents. The Institute of Medicine recommended the following measures: seed-to-shelf quality control, accuracy and comprehensiveness in labeling and other disclosure, enforcement against inaccurate and misleading claims, research into consumer use, incentives for privately funded research, and consumer protection against all potential hazards.


Gynecology_Novak

Gynecology_Novak. There is no national licensure for botanical or herbal medicine, and there is no national or professional organization that regulates or accredits Western and Ayurvedic herbal medicine education. In 1996, the National Certification Commission for Acupuncture and Oriental Medicine developed a national certification written examination, which tests for entry-level capabilities in oriental herbal medicine. Passage of this examination allows practitioners to call themselves Table 13.4 Botanicals: Potential for Interactions with Drugs Anticoagulants Bilberry Chamomile Coenzyme Q-10 Danshen Dong quai Feverfew Garlic Ginger Ginkgo Ginseng Kava St. John’s wort Increased risk of bleeding (high dose) Increased risk of bleeding Decreased effectiveness Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Increased risk of bleeding Decreased effectiveness


Gynecology_Novak

Gynecology_Novak. Anticonvulsants Borage Decreased seizure threshold Comfrey Increased risk of phenobarbital toxicity Evening primrose oil Decreased seizure threshold Valerian Increased effects of barbiturates St. John’s wort Yohimbine Increased effect of monoamine oxidase inhibitors Increased risk of monoamine oxidase inhibitors Hypertension Monoamine oxidase inhibitors; increased blood pressure level Tricyclics—hypertension; selective serotonin reuptake inhibitors; increased serotonin levels Data from O’Mathuna DP. Herb-drug interactions. Altern Med Alert 2003;6:37–43. Table 13.5 Selected Risk Factors for Adverse Reactions or Drug Interactions with Botanicals Radiation with or without chemotherapy Taking sedatives/anxiolytics/central nervous system depressants, oral contraceptives, diuretics, monoamine oxidase inhibitors, antiretroviral drugs Diplomats of Chinese Herbology (Dipl CH). The Commission’s website contains a searchable directory of certified practitioners (11).


Gynecology_Novak

Gynecology_Novak. Diplomats of Chinese Herbology (Dipl CH). The Commission’s website contains a searchable directory of certified practitioners (11). Chiropractic Medicine Chiropractic medicine focuses on the relationship between structure (primarily the spine) and function, and how that relationship affects the preservation and restoration of health. It uses manipulative therapy as an integral tool. Chiropractors can legally do more than manipulate and align the spine, including taking a medical history, performing a physical examination, and ordering lab tests and x-rays to determine a diagnosis. The spectrum of chiropractors varies in terms of the conditions treated with manipulation. Although some practitioners limit their practice primarily to musculoskeletal problems, others claim to offer effective treatment for virtually any medical condition. They are referred to as doctors, which can be misleading to patients.


Gynecology_Novak

Gynecology_Novak. The most significant risk associated with chiropractic medicine is stroke. Vertebrobasilar accidents occur mainly after a cervical manipulation with a rotatory component. The average age of patients with a vertebrobasilar accident is 38 years. The frequency of serious adverse events varied from 1 stroke per 20,000 manipulations to 1.46 serious adverse events per 10 million manipulations and 2.68 deaths per 10 million manipulations (12). The true incidence of these risks is not known and more data are needed. There is a national process for licensure for chiropractic medicine to which all 50 states adhere. Chiropractors must complete a 4-year chiropractic college program of study accredited by the Council on Chiropractic Education (CCE).


Gynecology_Novak

Gynecology_Novak. Massage therapy involves manipulation of the soft tissues of the body to normalize those tissues. A wide variety of approaches are available that include deep-tissue massage, Swedish massage, reﬂexology, Rolfing, and many others. A number of randomized controlled trials documented the value of massage therapy, particularly in pediatric conditions such as childhood asthma. Some studies show an increase in dopamine and serotonin, and an increase in natural killer cells and lymphocytes with regular massage therapy.


Gynecology_Novak

Gynecology_Novak. Massage therapy and bodywork are used by a wide array of people seeking the benefits of massage, which include physical relaxation, reduced anxiety, increased circulation, and pain relief. Specific indications for massage include treatment of acute low-back pain and lymphatic massage for patients with lymphedema from conditions such as postmastectomy extremity edema. Massage is used by various practitioners, including physicians, physical therapists, osteopathic physicians, chiropractors, acupuncturists, nurses, and massage therapists.


Gynecology_Novak

Gynecology_Novak. Massage should not be used in the presence of bleeding disorders, phlebitis and thrombophlebitis, edema that is caused by heart or kidney failure, fever or infections that can be spread by blood or lymph circulation, and leukemia or lymphoma. Massage should not be performed on or near malignant tumors and bone metastases; over bruises, unhealed scars, or open wounds; on or near recent fracture sites; or over joints or other tissues that are acutely inﬂamed.


Gynecology_Novak

Gynecology_Novak. There is no national licensure in massage therapy, but licensure is offered in 40 states. One-fourth of the massage training schools are accredited by the American Massage Therapy Association (AMTA). The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) administers a certification examination, and 35 states use it for licensure. The NCBTMB is an independent, private, nonprofit organization, founded in 1992, that fosters high standards for therapeutic massage and bodywork professionals. There are more than 90,000 nationally certified massage therapists and bodyworkers in the United States. Certification by NCBTMB requires successful completion of the examination and the completion of a minimum of 500 in-class hours of formal education and training (13). Hypnosis involves the induction of trance states and the use of therapeutic suggestions. Hypnosis has documented value for a variety of psychological conditions and pain control and recovery from surgery.


Gynecology_Novak

Gynecology_Novak. Hypnotized persons occasionally report unanticipated negative effects during and after hypnosis. The spectrum of reported effects encompassed minor transient symptoms such as headaches, dizziness, or nausea in experimental situations to less frequent symptoms of anxiety or panic, unexpected reactions to an inadvertently given suggestion, and difficulties in awakening from hypnosis. More serious reactions following hypnosis are attributed to the misapplication of hypnotic techniques, failure to prepare the participant, and preexisting psychopathology or personality factors. There are no known deaths attributed to the use of hypnosis.