Abstract
Psychological disorders are commonly associated with gynecological conditions, but are frequently undetected and untreated, and may influence the presentation and treatment outcomes of the physical condition. A literature search was conducted in order to provide a narrative review of psychological aspects of menopause, premenstrual syndrome, premenstrual dysphoric disorder, chronic pelvic pain, incontinence and polycystic ovarian syndrome. All the conditions that have been addressed in this review can be associated with an increased risk of psychological symptoms and disorders. Anxiety and depression are common and are associated with significant morbidity. Gynecological conditions, by their nature, are likely to be accompanied by impairments in social, occupational and personal functioning. Greater emphasis should be placed on the mental health aspects of gynecological conditions.
Keywords
Background
Women present to gynecological clinics with a wide variety of physical conditions, ranging from bothersome premenstrual and menopausal symptoms, to incontinence and pelvic pain. It is well established that depression and anxiety occur more commonly in those with physical illness compared with healthy populations [1]. Moreover, many gynecological conditions, by their nature, affect personal and intimate relationships, as well as social and professional roles [2,3], thus giving rise to a range of psychological issues, which, may in turn influence the presentation and outcomes of coexisting physical conditions. These relationships are complex, and involve the interplay of hormonal, social, cultural and individual psychological factors. The gynecological setting provides an important opportunity for the detection and treatment of psychological issues. These can range from transient concerns to more serious symptoms of depression and anxiety, and depressive and anxiety disorders that meet specific diagnostic criteria. Yet, the psychological aspects of conditions presenting in the gynecological setting are somewhat neglected, resulting in relatively few studies that have examined the consequent mental health care needs of women attending gynecological clinics [4].
Much of the literature relevant to mental health in the gynecological setting is located in studies of individual gynecological conditions. It is beyond the scope of this paper to conduct systematic reviews of all of these conditions; rather, the objective of this paper is to provide a clinically relevant up-to-date synthesis of the psychological and psychiatric aspects of the problems presenting most commonly in the gynecological setting. The focus is on depression and anxiety, as these are the most prevalent, and most widely studied conditions. Therefore, this narrative review will focus on psychological dysfunction, in particular depression and anxiety associated with menstruation, the menopausal transition (MT) and chronic pelvic pain. Psychological aspects of incontinence and polycystic ovarian syndrome (PCOS) will also be addressed. This review will examine both the prevalence and nature of the identified problems, and aspects of their psychological and pharmacological treatment, and seek to highlight the complex interrelationships between the physical and psychological aspects of mental health care in the gynecological setting. This sits alongside a broader aim of raising awareness of the mental health implications of gynecolgical conditions, which tend to be somewhat neglected.
Methods
Search strategy
A literature search was conducted in the CINAHL, PsychInfo, Medline and PubMed databases using a combination of the following keywords: gyn(a)ecolgy, gyn(a)ecolgical clinics, menopause, premenstrual syndrome, premenstrual dysphoric disorder, chronic pelvic pain, incontinence, polycystic ovarian syndrome, anxiety, depression, psychological adjustment. These keywords were chosen to reflect the most common presentations to gynaecology clinics [4], and we chose to focus on broad conditions, rather than their specific causes, such as endometriosis, as this reflects the ways in which services are organized (e.g., clinics for pelvic pain, rather than clinics for endometriosis). Abstracts of identified articles were checked for their relevance. The majority of articles included were published in a peer-reviewed journal between 1990 and 2013 in order to ensure that the review is focused on current knowledge.
Analytic approach
As some studies identified in the review used qualitative research methods, a narrative approach was used to review the literature. This approach has the advantage of allowing studies using both qualitative and quantitative methodologies to be included and enabled the review to encompass a heterogeneous range of studies from diverse disciplines. In addition, the narrative approach is consistent with the goal of this article to provide a synthesis, rather than an exhaustive review of individual papers.
Results
Psychological dysfunction during the menstrual cycle: premenstrual syndrome Prevalence & mental health aspects of premenstrual syndrome
One of the stages of the reproductive cycle that has received particular attention in research as a source of both mental and physical complaints is menstruation [5]. Typically, such symptoms appear during the final premenstrual phase, and subside a few days after menses begins. This phenomenon has been conceptualized as the premenstrual syndrome (PMS). A mild form of PMS is common, occurring in approximately 75% of women of reproductive age [6]. The severe form of PMS, termed premenstrual dysphoric disorder (PMDD; [7]), is considered to affect at least 3–8% of women of reproductive age [8].
The defining characteristics of both PMS and PMDD are the cyclic pattern of physical symptoms (e.g., breast tenderness, sensation of bloating, weight gain), affective or other mental symptoms (e.g. depressed mood, anxiety/tension, affective lability, or anger/irritability, difficulty in concentrating, lethargy, change in appetite), which has to be confirmed by prospective daily self-ratings of symptoms over two consecutive menstrual cycles. In addition, the symptom severity level must be high enough in order for it to interfere with functioning in work, family or social relationships [9]. The primary difference between PMS and PMDD lies in the number, severity, duration and the quality of symptoms.
The etiology of premenstrual symptoms is still unclear, but it is best understood as a bio-psychosocial phenomenon that is based on the interaction of physical and psychological factors. Multidimensional approaches that include psychological, environmental and social aspects along with biological factors are needed. For example, Blake and colleagues proposed a model that concentrates on the appraisal of premenstrual symptoms resulting in a series of different idiosyncratic vicious circles, which are driven by anxious and depressive reactions, owing to directing attention on the physical and emotional correlates of hormonal changes in addition to an increased striving for control [10].
Treatment of premenstrual syndrome
The treatment of PMS primarily includes three different approaches: pharmacotherapy, nutritional supplements or herbal products, and psychological treatments. A Cochrane review of pharmacotherapy with selective serotonin uptake inhibitors (SSRIs) [11] identified moderate effect sizes regarding physical and psychological symptoms. However these findings should be interpreted cautiously because of several critical issues, such as the rather low response rates of 40% [12], high placebo rates (30–40%) in women with PMS [13,14], and high rates of side effects [11]. Combined oral contraceptives containing drospirenone provide another frequently used pharmacological treatment for PMS. The authors of a Cochrane review that included only five trials concluded that such contraceptives may help reducing severe premenstrual symptoms [15]; however, their efficacy has to be discussed in the context of high placebo rates.
Nutritional supplements such as vitamin B6 [16], calcium [17] or magnesium [18,19] are also often recommended in the treatment of PMS. However, efficacy in reducing premenstrual symptoms has only been demonstrated for calcium [17]. Additionally, herbal products are also used for treating PMS. Vitex agnus castus extract for example, has been shown to be beneficial for breast tenderness [20]. A randomized controlled trial of hypericum perforatum (or St John's Wort) demonstrated a superior effect in contrast to a placebo in regard to physical and behavioral symptoms, but not affective or pain symptoms [21].
Against the background of severe side effects and high placebo rates of prescribed and over the counter preparations, psychological approaches play a very important role in the treatment of women with PMS. These diverse approaches can include a range of concepts, such as changing lifestyle as well as cognitive behavioral interventions. Lifestyle changes in regard to both dietary changes as well as graded activity seem to have beneficial effects for women with PMS. Freeman and colleagues, for example, demonstrated that the regular consumption of a carbohydrate-rich beverage in the premenstrual phase reduced mood symptoms for approximately one-third of women, in comparison to only 5% of those consuming placebo [22]. Similar results were found by Sayegh et al. [23]. Typical recommendations for dietary changes for women with PMS include the consumption of complex carbohydrates; regular, more frequent and smaller meals; and a reduced consumption of refined sugar, sweeteners and caffeine [24]. Furthermore graded activity, especially aerobic exercise and fitness training, seem to have a beneficial effect on premenstrual symptoms [25,26]. Two controlled trials demonstrated a significant decrease inpremenstrual symptoms in a group of women with PMS who had received an educational program combining psychoeducation about basic menstrual cycle physiology and a session of training in self-care behaviors [27,28].
Besides such educational programs cognitive-behavioral treatments adapted for PMS play an important role in the treatment of premenstrual complaints [10,29–34]. Techniques that are typically included in such approaches are depicted in Table 1.
Typical components of psychological treatments for women with premenstrual syndrome and studies in which they are reported.
PMDD: Premenstrual dysphoric disorder; PMS: Premenstrual syndrome.
The central aim of cognitive-behavioral treatments for PMS is not primarily curing premenstrual physical symptoms but coping with them more effectively, and reducing the affective premenstrual complaints as well as the functional impairment in everyday life. One systematic review [38] as well as two meta-analyses [39,40] have examined the efficacy of cognitive-behavioral therapy for PMS. Busse et al. aggregated nine randomized-controlled trials of different psychological treatments, including cognitive-behavioral programs, for PMS and a total of 420 patients [39]. Moderate effect sizes were identified in regard to anxiety (g = 0.58; 95% CI: 0.01–1.15), depressive symptoms (g = 0.55; 95% CI: 0.05–1.05), and behavioral symptoms (g = 0.70; 95% CI: 1.29–0.10). In regard to functional impairment a large effect (g = 1.10; 95% CI: 0.39–1.81) was demonstrated. In the second meta-analysis [40] six partly randomized controlled trials of cognitive-behavioral treatments and a total of 173 patients were included. Additionally this meta-analysis included 15 randomized controlled trials (with a total of 1656 patients) examining the efficacy of psychopharmacotherapy. In regard to cognitive-behavioral therapies, the results reported by Kleinstäuber et al. [40] were comparable to those of Busse [39]. Furthermore, for all outcomes (mood, behavioral symptoms, physical symptoms and functional impairment) small to moderate effect sizes were found for both cognitive-behavioral therapy (0.24 < g < 0.70) as well as SSRIs (0.29 < g < 0.58). In summary both meta-analyses demonstrate that psychosocial interventions – especially cognitive-behavioral therapies – seem to be beneficial for patients suffering from PMS. However, the effect sizes are small to moderate and have to be interpreted very carefully owing to the rather small number of aggregated studies in these meta-analyses and their methodical constraints. These findings are in accordance with the conclusions drawn by Lustyk and colleagues [38] in their systematic review about the efficacy of cognitive-behavioral therapy for PMS. The authors highlighted that there is still a dearth of evidence providing statistically significant cognitive-behavioral therapy intervention effects for patients with PMS. They furthermore suggest that psychotherapies for PMS should perhaps have less emphasis on thought and behavior modification but more emphasis on acceptance, mindfulness and values. They suggest that the unique characteristics of PMS or PMDD, such as the diversity and inconsistency of its presenting symptoms, the origin of the symptoms in the natural and healthy process of menstruation and its predictable cyclic nature, need to be given greater consideration in the conceptualization of psychological PMS treatments.
In summary, serotonergic drugs and psychological treatments seem to be the best evidenced approaches in the treatment of PMS to date. However their efficacy is not optimal. The recommendations of experts of the American College of Obstetricians and Gynecologists [41] for administering pharmacotherapy as a first-line intervention for premenstrual symptoms, especially SSRIs and other serotonergic antidepressants, should therefore be reconsidered. Maybe a multidisciplinary and individually tailored treatment concept for PMS, where pharmacological and psychotherapeutic treatments are combined in a reciprocally supporting way, could be a valuable option.
Depression & anxiety during the MT
Depression during the MT
Depression is a highly prevalent condition, associated with significant morbidity and mortality. Midlife (from age 45–55 years) and, more specifically, the menopausal transition (MT), has been regarded by some authors as a ‘high-risk’ time for the development of depression [42]. The MT, one of the key hormonal changes in a women's life, has a highly variable duration, but the perimenopause commences with the onset of menstrual irregularity, and ends with the final menstrual period, when menopause is said to have occurred [43]. Menopause, however, is not merely a hormonal event, but involves complex personal, social and cultural meanings. For example, women with more negative attitudes towards the menopause in general report more symptoms during the MT [44,45].
Depressive symptoms are reported by one in four women at this time [46]. Studies by Freeman and colleagues have reported that women in the perimenopausal period are 1.5-times more likely to report high scores on the Centre for Epidemiological Studies Depression Scale (CES-D; Radloff et al. [47]), and those in the late MT are three-times more likely to report clinically significant levels of depressive symptoms than premenopausal women [48]. These findings are comparable with those of Bromberger and colleagues who found that the late perimenopausal period was the time of highest risk for depressive symptoms [49].
One of the few studies of depressive disorder (as distinct from depressive symptoms) to use a diagnostic interview was a subsequent study by Bromberger and colleagues [50]. In this study, trained interviewers used the Structured Clinical Interview for DSM-IV Disorders (SCID [51]), annually for 7 years. No association was found between first episode depressive illness and menopausal status. On the other hand, psychosocial factors were more likely to predict first onset depressive illness during the MT; these included difficulties in role functioning due to physical health, stressful life events, and a history of an anxiety disorder. Perception of the effect of physical health on role functioning nearly doubled the risk of first onset of depression.
A recent review by Judd and colleagues [46] highlighted the difficulties in making comparisons between studies because of differences in design, measures of depression, and in adjustment for important confounders. It appears that menopausal stage is only one of a range of factors that increases the risk of depressive symptoms in menopausal women. Notably, Bromberger and colleagues found that the risk of depressive symptoms was doubled in those with a history of depression [50]. Other significant predictors of depressive symptoms include severe PMS or premenstrual mood disturbance [52], postpartum mood disorders [53], severe and prolonged vasomotor symptoms (VMS) [54] and physical health problems [53,54]. Broader psychosocial risk factors include financial difficulties, negative attitudes to aging and/or menopause and stressful life events [53]. Taken together, these studies demonstrate that although a significant number of mid-age women do report depressive symptoms, perhaps particularly in the late perimenopausal period, the majority of women do not develop depression during the MT, and longitudinal studies are conflicting regarding the MT as a hormonal event per se as a risk factor for depressed mood [46,54]. Midlife commonly coincides with other major changes, including incipient physical health problems, changes in family and professional roles, changes in relationships and sexual functioning, or new care giving roles in relation to aging parents or ill partners [55–59]. Some of these changes, stressors and even opportunities at midlife may be risk factors for depression in midlife, just as they would be at other times of life [58].
Anxiety during the MT
Anxiety symptoms such as feeling on edge, worrying, specific fears and physiological arousal, are highly prevalent in the general population [60]. Anxiety disorders, such as generalized anxiety or panic disorder, as defined by reference to specific criteria have much lower prevalence than anxiety symptoms [60]. There has been far less research on anxiety than depression in midlife, and the prevalence of anxiety during the MT is not well established. The published literature is limited in both quantity and quality, and comparisons are limited by the methodological shortcomings of the studies [61]. For example, of the nine studies reviewed by Bryant and colleagues, five used brief self-report measures of anxiety, rather than diagnostic interview [61].
Anxiety symptoms may be increased during the MT, but the prospective relationship between anxiety symptoms and menopause stage is poorly understood. Some authors report that levels of anxiety symptoms rise during the menopause transition, and then fall [62]. Others report that anxiety is not related to menopausal stage [63,64], but rather to other lifestyle factors, such as being overweight, high levels of alcohol consumption and low participation in exercise [65]. A common source of anxiety during midlife is concern about memory performance [66], which can give rise to fears of incipient neurocognitive disorders, such as Alzheimer's disease. The balance of evidence at the moment appears to suggest that any objective declines in memory performance in midlife are mild and subtle [67], but women's subjective concerns about memory can nevertheless cause considerable distress [68]. Thus, these concerns should be taken seriously and may be suitable targets for psychological intervention.
Another area of interest is the relationship between anxiety and hot flushes. There are notable similarities between hot flushes and symptoms of anxiety, particularly of panic [69]. Both are characterized by sudden, intense physical sensations, including palpitations, sweating and increased metabolic rate. Some studies have reported that women who are anxious are more likely to report having hot flushes [70], but these findings are based on self-reported hot flushes, which may be less reliable in women who are anxious. Other studies using skin-conductance measures of hot flushes found no relationship between trait anxiety, daily stress and hot flushes during sleep [71]. In a large community-based sample (n = 3369; postmenopausal women aged 51–83 years) using a retrospective questionnaire, Smoller and colleagues reported a 10% prevalence of panic attacks in postmenopausal women and found that women with panic attacks had an increased risk of coronary heart disease and stroke [72]. These were postmenopausal women, which may have underestimated the prevalence of anxiety, which may be higher in women during the MT [62].
Treatment of depression & anxiety during the MT
With respect to the treatment of depression and anxiety during the MT, clinicians should firstly be alert to the possibility of these disorders and their potentially complex etiology. At times it can be difficult to distinguish symptoms of anxiety and depression from those of menopause. For example, symptoms of fatigue, concentration and memory problems, sleep disturbance, weight changes and sexual dysfunction are common to depression and menopause [46]. Some measures of anxiety, such as the Zung Anxiety Index [73], have a strong somatic focus, making them less suitable for use in women with VMS [61]. A number of authors have developed psychological models for understanding the relationship between VMS and anxiety [44,69,74]. These emphasize the importance of symptom perception, cognitive appraisals and thinking styles. These are all potential targets for intervention, and have, indeed been developed by Hunter and colleagues into effective cognitive-behavioral treatments for hot flushes [75]. Further details are given in Table 2.
Typical components of psychological treatments for anxiety and depression in menopausal women and studies in which they are reported.
CBT: Cognitive-behavioral therapy; VMS: Vasomotor symptoms.
If an affective disorder is diagnosed, treatment should follow the broad principles applied at other life stages. The approach should be bio-psychosocial, with specific treatments varying according to the nature of the disorder [55,83]. For example, while hormone replacement therapy is not an antidepressant, it may improve depressive symptoms in women with hot flushes, and should be considered after careful consideration of the risks in those with mild depressive symptoms accompanying vasomotor disturbance, provided there are no other contraindications [84]. Lifestyle interventions such as exercise may improve psychosocial functioning and also health-related quality of life [85]. Depression of greater than moderate severity requires treatment with an antidepressant. Some SSRI and serotonin–norepinephrine reuptake inhibitor antidepressants may also improve VMS, and these should be considered in women with both affective disorder and VMS [86]. There has been interest in the efficacy of herbal preparations for the treatment of anxiety and depression during the menopause. One randomized controlled trial of Black cohosh (Cimifuga racemosa) found no reduction in anxiety scores (albeit in a very a small sample of 28 women [87]), while a larger study of 109 women who were allocated to placebo or treatment with isoflavones extracted from red clover reported reductions in anxiety and depression symptoms in the treatment group [88]. The authors noted that women in the intervention group also reported reductions in VMS, and suggested that this mediated the improvement in mood.
Chronic pelvic pain
Prevalence & psychological aspects of chronic pelvic pain
Chronic pelvic pain (CPP) is defined as the occurrence of pain in the lower abdomen that has persisted for at least 6 months and is unrelated to periods, intercourse or pregnancy [89]. Epidemiologic studies report a high prevalence of CPP in community settings with rates between 14.7 and 25% [90–92]. Chronic pelvic pain can originate from several organ systems or diseases; including, endometriosis, pelvic inflammatory disease or pelvic adhesions [93]. It is also associated with a history of childhood sexual abuse and assault [94]. However, in approximately one-third of cases, no underlying organic pathology can be identified, making CPP a perplexing and frustrating condition for patients and medical professionals alike [95,96]. The pain associated with CPP can be debilitating, affecting a woman's social relationships, employment opportunities, sexual functioning and self-esteem [97–99].
It is not surprising, then, that CPP is associated with very high rates of depression and anxiety. One study found that depression was present in 86% of women with chronic pelvic pain compared to 38% of pain-free, gynecological controls [100]. Although depression and CPP frequently co-occur, the link between these two factors is an inherently complicated one [101]. Traditional conceptualizations of chronic pelvic pain have often been characterized by a ‘mind-body dualism’ in which, if no organic pathology is found, a patient is classified as having ‘psychogenic’ pain [102]. This view of pain is potentially stigmatizing for women, and unhelpful for the treatment of their condition [103,104]. Indeed, qualitative studies reveal that many women with CPP believe their medical practitioner did not understand the extent or seriousness of their pain, and gave them the impression that they were hysteric, neurotic and the pain was ‘all in my head’ [97,98]. It has therefore, also been proposed that women can develop significant feelings of depression as a consequence of living with a chronic pain condition [105–107]. It is likely that the relationship between pain and psychological distress is, in fact, bidirectional [108]. Depressive symptoms that arise in reaction to pain can in turn exacerbate the severity of the pain and impair a person's ability to successfully adapt to living with a chronic pain condition [109]. It has been found that women experiencing comorbid chronic pelvic pain and depression have higher levels of anxiety, substance abuse and role dysfunction than women who had CPP without depression [110]. Moreover, the co-occurrence of pain and depression is associated with greater functional impairments (limited mobility and activity levels), increased pain intensity and poorer treatment outcomes [105,111].
Treatment of CPP
Often, women undergo extensive physical investigations, including internal examination and laparoscopy, in order to establish the extent – if any – of organic pathology before referral to a multidisciplinary team [112]. At this point, physical and psychological assessment will probably take place. The Consensus Guidelines for the Management of Chronic Pelvic Pain [103] suggest that the first step in effective treatment is to take a detailed history of the pain, including gaining a sense of the patient's own understanding of her pain, which should be validated and respected. Psychological assessment should address the functional impact of the pain, including on personal and intimate relationships, as well as the presence of anxiety or depression and life stresses [103]. Similar suggestions have been made by several authors, who emphasize the value of a cognitive-behavioral evaluation of the pain and living with its impact [112] and a multidisciplinary team that includes the skills of the gynecologist, physiotherapist, anaesthetist and psychologist [93,113,114].
Treatment of pelvic pain needs to take account of its complex etiology, and the potential for misunderstanding between clinician and client. A recent Cochrane review of interventions for treating CPP [115] identified 14 studies of adequate quality and reported some benefit for hormonal treatment (progestogen and goserelin), but not for adhesiolysis. The review found that multidisciplinary treatment was the preferred approach, and was beneficial for improvements in daily functioning scores but not in pain (but this was based on only one study). There are few studies of specific psychological interventions, but one study of writing as a form of emotional self-disclosure showed a small positive effect on pain scores in the intervention group [116]. The Cochrane review concluded by stating that treatment options for CPP continue to be limited, and that randomized controlled trials of both physical and psychological treatments are urgently needed.
PCOS
Prevalence & psychological aspects of PCOS
PCOS is one of the most common endocrine disorders, affecting between 6–10% of women [116,117]. It includes gynecological and endocrine symptoms, notably chronic anovulation, hyperandrogenism (manifested in acne and hirsutism) and insulin resistance [117]. As a chronic disease that poses complex physical and body-image challenges, PCOS is known to reduce health-related quality of life, and increase the risk of depression and anxiety in affected women [118].
There are relatively few studies of the mental health aspects of this condition. With regard to the prevalence of depression in women with PCOS, Rasgon and colleagues reported that 50% of their sample (a small group of 32 attending a specialist clinic) had a score greater than 16 on CES-D [47] and were considered depressed [119]. Further analyses revealed an association between higher depression scores and greater insulin resistance and higher body mass, which the authors suggested might be explained by serotonin system dysregulation simultaneously causing depression and PCOS symptoms. A somewhat larger study conducted by Kerchner and colleagues [120] followed up 60 women from an original cohort of 103 finding a depression prevalence of 40% (24 out of 60) using the Beck Depression Inventory [121]. Of these, only 14 were receiving antidepressant medications. This study also found that 11.6% of the sample had anxiety syndromes as measured by the Beck Anxiety Inventory [122] and 23.3% met criteria for binge eating disorder. A relationship between PCOS and bipolar disorder has also been demonstrated, but the link is through treatments for bipolar disorder, specifically valproate, which appears to induce the symptoms of, or increase the risk of PCOS [123]. Weight is thought to be the strongest predictor of health-related quality of life in women with PCOS, and was reported in this study be the most significant concern of the participants. The few studies of anxiety in the PCOS population [117,118,124,125] have consistently found elevated rates of anxiety in their samples.
A review by Himelein and Thatcher in 2006 [126] confirmed that women with PCOS are at elevated risk of many psychological problems, including depression, anxiety, psychological distress, body dissatisfaction, sexual functioning and bulimia nervosa. The evidence from a number of studies suggests that concerns about weight are the common factor in the elevated rates of psychological problems in women with PCOS [126,127].
Treatment of PCOS
It is clear that the nature of PCOS and its symptoms can affect core aspects of women's sense of self, giving rise to significant psychological difficulties. Therefore, current guidelines for the treatment of PCOS [128] emphasize the importance of screening for psychological symptoms, for example using the Patient Health Questionnaire 9 [129]. Screening for disordered eating is also recommended [130]. Effective treatment of identified disorders, or other concerns, such as body image disturbance and obesity clearly require a multidisciplinary approach involving psychotherapy, pharmacotherapy and the adoption of weight control and physical activity strategies [127,128].
Incontinence
Prevalence & mental health aspects of incontinence
Urinary incontinence (UI) is both common and distressing, with increasing prevalence as women get older [131], yet often remains hidden because of shame in seeking help for this condition [132]. UI is commonly classified into three subtypes: stress UI (involuntary leakage on effort, exertion, coughing or sneezing), urge UI (leakage associated with a sense of urgency to urinate) and mixed UI. In women under the age of 65 years, the reported prevalence ranges from 18–46%, while the prevalence may be as high as 73% in older women [131]. With the aging of the population, this condition is likely to be increasingly common, with an associated increase in its emotional and financial costs [132]. Numerous studies have highlighted the associations between UI and social and psychological functioning [133–136], with the data from Bogner's study suggesting that there may be racial or ethnic differences in the emotional consequences of UI, such that African–Americans were more likely to experience psychological distress in association with UI than white Americans [134]. A very large community-based study of 12,568 women aged 40–80+ years in the UK found that 56.6% of women with urge incontinence reported clinically significant symptoms of anxiety, while 37.6% reported depression, both much higher than the rates observed in women without incontinence [135]. This was one of the few studies to adopt a longitudinal design and examine the temporal relationships between depression, anxiety and UI. The authors reported that UI was a significant predictor of new symptoms of anxiety and depression, but anxiety was itself also a predictor of incident cases of UI over a 1-year period. These findings are consistent with those of de Vries et al., who reported increased odds of new onset psychological distress in women with UI, especially when their UI was associated with functional impairment, such as avoidance of social occasions and physical activities [133].
Fecal incontinence (FI) has received far less attention than UI. Koloski and colleagues suggest that between 8 and 15% of community-dwelling adults may be affected by this condition and its associated personal and social consequences [137]. These authors reported data from a longitudinal study of both men and women showing that new onset FI was significantly associated with symptoms of anxiety and depression, after controlling for baseline symptoms. A study by Yip and colleagues collected data from 1412 women aged 57–85 years on daily UI, weekly FI and depression, anxiety and social isolation [138]. They found that the risk of social isolation in women with daily UI was three-times that of women without UI, after adjusting for age, race, education and overall health. By contrast, weekly FI was not associated with feeling isolated, perhaps because of its rarer occurrence as measured in this study. Both conditions, however, were associated with increased symptoms of depression and anxiety.
Treatment of incontinence
Psychological assessment is not considered a routine part of the assessment of incontinence [136], yet UI is both prevalent and associated with considerable social and psychological burden. There is some disagreement in the literature as to the relationship between UI and psychological distress. On the one hand, Perry and colleagues have argued that an understanding of continence requires more than attention to its physical aspects [135], while other studies [139] have shown that relatively conservative, behavioral and physically based treatments improve anxiety and depression as well as the symptoms of UI. Such treatments typically include learning to understand bladder functioning better by keeping a bladder diary, learning techniques for responding adaptively to urge sensations and learning about the pelvic floor muscles.
Most studies of UI and its treatment have focused on physical and behavioral treatments. Few studies have investigated whether improvements in bladder function are reflected in psychological symptom improvement. Burgio and colleagues [139] examined psychological distress as measured by the Symptom Checklist-90-Revised (SCL-90-R; [140]) in a sample of 197 women aged from 55 to 91 years who were allocated to either behavioral treatment, drug treatment or placebo with the aim of reducing urge incontinence. The authors found that UI symptoms were reduced in both treatment conditions, as were symptoms of distress. Although the behavioral group showed the greatest reductions on the SCL-90-R, this difference was not correlated with a reduction in the number of accidents reported. The authors commented that other aspects of quality of life, such as social and intimate relationships also need to be considered. Work by Perry and colleagues does incorporate a more complex psychological model, proposing that a woman's distress about continence is “as dependent on her perceptions and feelings as on the actual severity of her symptoms” [135].
Discussion & conclusion
All the conditions commonly encountered by clinicians in the gynecological setting that were addressed in this review can be associated with an increased risk of psychological symptoms and disorders. In fact, anxiety and depression are common in women of reproductive age, and are associated with significant morbidity [55,100]. Moreover, gynecological conditions, by their nature, are likely to be accompanied by impairments in social, occupational and personal functioning. For example, PCOS confers an elevated risk of depression, but is also associated with serious concerns about body image, which may mediate this relationship [126], while UI, a condition for which women often delay seeking treatment, is associated with an elevated risk of depression and social isolation [133]. These findings highlight the complex relationships between physical conditions, psychological reactions and the factors that mediate those.
Another issue highlighted by the literature reviewed is the challenge of distinguishing between the causes of the psychological symptoms. In relation to depression and anxiety during the menopausal transition, for example, there is debate as to whether symptoms such as sleep disturbance or low mood should be attributed to depression or seen as direct symptoms of the MT and its associated hormonal changes [46]. If depressive symptoms are more severe, and if there are prominent depressive cognitions (particularly suicidal ideation/intent) referral for further assessment and treatment of depression by a mental health specialist is indicated.
Furthermore, the treatment of the psychological aspects of gynecological conditions is still relatively neglected, despite ample evidence from many studies that psychological symptoms are commonly associated with, and worsen functional impairment accompanying these conditions. Research into psychological models for treating different physical conditions presenting in the gynecological setting is still low, in quantity as well as in quality [61]. It seems that a bio-psychosocial understanding of such conditions is not fully accepted and the utility of such a broad approach not realized. Consequently, the focus seems to be on treating the physical symptoms themselves and accompanying psychological and social impairments are somewhat neglected. Indeed, pharmacological treatments are widely regarded as the first-line treatment in gynecological conditions, such as PMS [9]. However, pharmacological, particularly hormonal, interventions can produce side effects [11] in addition to the symptoms of the gynecological condition. As a consequence, patients often increasingly focus their attention on their physical and/or emotional symptoms that in turn can go along with negative health beliefs, feelings of loss of control and negative emotions. A vicious circle of anxious and depressive reactions can develop that can also reinforce the physical/emotional symptoms associated with the gynecological condition. This strengthening of patients' biomedical perspective about their illness can lead to relentless pursuit of investigations and interventions, many of which are of limited value. In addition, it can make it more difficult for them to accept that psychological aspects play an important role in the etiology and maintenance of their symptoms, and less willing to consider psychological interventions as part of the management of their disorder. These psychological interventions can be provided within the clinical setting, but other treatment options include referral to private practitioners or psychological services provided in the primary care setting, where these are available. Reference to treatment guidelines for anxiety and depression, such as those provided by the NICE may be useful. For example, the treatment guidelines for generalized anxiety disorder emphasize a stepped care model, in which treatment moves from education and advice to low intensity treatment and, finally individualized specialized psychological intervention [141].
Finally, it is clear that the mental health aspects of gynecological conditions will interact with their presentation, as well as influence treatment outcomes. In the gynecological setting sensitive issues may arise in relation to assessment and treatment of women with menopausal symptoms, chronic pain, PCOS or PMDD. Yet, most who experience psychological distress welcome enquiry about their mood and emotional state. In the Melbourne gynecology study [4] only one in five patients was asked about their emotional well-being, but two-thirds of them reported that they would like their doctor to enquire about this. It may be that clinicians working in these settings would benefit from training in how to ask women the relevant questions about mood, body image, sexual functioning and the like. Given the strong evidence for the physical and psychosocial consequences of psychological symptoms and disorders not being adequately addressed, together with the growing body of evidence that effective treatments are available, it seems clear that greater emphasis should be placed on the mental health aspects of gynecological conditions.
Future perspective
A focus on pharmacotherapy and potentially invasive physical investigations for gynecological conditions that are accompanied by psychological problems should be questioned more critically, and research on multidisciplinary treatment approaches should be fostered. In this context, psychotherapeutic interventions could be an effective complement to pharmacological treatments because they provide active strategies for coping with both physical symptoms and accompanying psychological problems, but they remain under-researched. It is likely that internet-based interventions will take on greater importance in the next few years.
Financial & competing interests disclosure
The Centre for Women's Mental Health is supported by the Pratt Foundation. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Executive summary
Premenstrual syndrome (PMS) is a complex condition best understood as comprising psychological, environmental and social aspects together with biological factors.
Psychological approaches play an important role in the treatment of women with PMS. They primarily include making lifestyle changes as well as cognitive-behavioral interventions. Lifestyle changes in regard to both dietary changes as well as graded activity seem to have beneficial effects for women with PMS.
Although menopausal transition has been regarded by some authors as a time of particular vulnerability to depression, the precise relationship between depression and hormonal status remains unclear.
Midlife is also a time of psychosocial adjustment that may influence psychological well-being.
Studies of anxiety during this period are sparse and of variable quality.
There is overlap between vasomotor symptoms and the symptoms of anxiety, leading to a lack of clarity regarding whether the menopausal transition is associated with an increase in anxiety.
Some authors suggest increases in anxiety at midlife are attributable to lifestyle factors, such as being overweight, high levels of alcohol consumption and low participation in exercise.
Chronic pelvic pain is a common, but under-researched problem.
It can have a serious impact on mood and social and personal functioning.
Further research to develop effective treatments is urgently needed.
Polycystic ovarian syndrome is a chronic disease that poses complex physical and body image challenges.
It reduces health-related quality of life, and increases the risk of depression and anxiety in affected women.
Psychological screening for symptoms of anxiety and depression is now recommended for women diagnosed with polycystic ovarian syndrome.
Incontinence is both common and distressing, with increasing prevalence as women get older.
It often remains hidden because of shame in seeking help for this condition.
Psychological assessment is not regarded as routine, but should be considered in light of the common psychological symptoms seen in women experiencing this condition.
Many gynecological conditions, by their nature, affect personal relationships, as well as social and professional roles, and are associated with elevated risk of anxiety and depression.
Clinicians may lack the confidence or skill to ask questions about these issues, but in general, women attending gynecological consultations want to be asked about their mental health.