Gynaecological Disease – Physical and emotional- Body reaction to illness-Chapter 3:

Q 3. 1 How does the body react to illness?

• Physical or emotional attack on the body can each result in either physical or emotional disease. An infection is a physical problem but if it prevents you from undertaking an activity such as a vacation you may become depressed. Emotional disturbance may lead at one extreme to anorexia and at the other to obesity and these adversely affect general physical health.

• In most respects, our bodies function automatically without any conscious control. This is particularly true of defence mechanisms. Adrenaline is a hormone released from the adrenal glands which are situated above the kidneys. There is an adrenaline surge to take us through acute episodes of stress, so that adrenaline has been called a ‘fight or flight’ hormone. The immune system is a complex integrated mechanism for destroying any invasion into the body, whether this be by organisms (infection), a chemical, a foreign body, or transplanted tissue.

• The immune system is also responsible for removing damaged or dead cells from the tissues. It has been one of the more difficult areas of physiology and pathophysiology (the assessment of the body’s response to ill health) to study. Whereas, most body functions are largely confined to single organs (e.g. the skeleton, bowel, kidneys or the heart), much of the immune system is dependent on circulating cells and specialised immune cells spread throughout all the tissues of the body. 

Q 3. 2 What are the disease processes that could be causing symptoms?

• Modern medicine seeks to determine the disease process (pathology) accounting for a patient’s symptoms. Once the disease process has been identified, treatment can focus on counter measures, which have proven benefit (evidence based – Q 33.22). Table 3. 1 indicates the main groups of disease causation. This has been applied to the potential causes of recurrent miscarriage (Q12.11).

• Table 3. 1

• DISEASE

• PROCESS

• GENERAL

• EXAMPLE

• Gynaecological Example

• Question

• Number

• CONGENITAL

• Hole in the heart

• Absent uterus
  6.17

• TRAUMA

• Road traffic accident

• Pelvic floor injury during childbirth

• 30.3

• INFLAMMATION

• Influenza

• Pelvic Infection

• 20.2

• METABOLIC

• Malnutrition

• Absent periods due to malnutrition

• 6.8

• HORMONAL

• Diabetes

• Menopause

• 26.1

• AUTOIMMUNE

• Rheumatic Disease

• Recurrent miscarriage

• 12.17

• TUMOUR

• Lung cancer

• Fibroid / Cancer of cervix

• 23.14; 32.15, 32.32,

• AGEING

• Osteoarthritis

• Menopausal vaginal symptoms

• 26.17

• PSYCHOLOGICAL

• Depression

• Premenstrual Tension

• 25.1

• Frequently, a patient has two or more unrelated problems. You could, for example, have heavy periods and an abnormal cervical smear result. Sometimes there may be a combination of related processes: a lady may feel tired and lethargic due to anaemia (Q24.10) resulting from heavy periods associated with fibroids (Q23.14)and, as a result of these problems, she may feel depressed.

• The medical profession recognises that there may be a collection of inter-related problems. The concept that a patient should be treated as a whole person rather than as a disease process is part of the basic training of doctors although the term ‘holistic approach’ seems to have been adopted by those who advocate ‘alternative medicine’ to suggest that they invented the idea.

Q 3. 3 What is a congenital abnormality?

• A congenital abnormality is one that is present at birth. During development, there is a pair of tubes, called the Mullerian ducts, in the lower abdomen. The upper parts remain as the Fallopian tubes and the lower part unite to form the womb. The central septum between the two halves of the uterus should disappear. One of the two groups of congenital uterine abnormalities is due to some degree of failure of the septum to disappear (Figure. 3.1). The vagina may also be divided into two by a central septum in association with congenital septal anomalies of the uterus. The second group of congenital uterine abnormalities occurs if one of the Mullerian ducts does not develop. Rarely the uterus may be congenitally absent.

• We do not know the exact incidence of congenital uterine abnormality as identifying investigations are only undertaken when there is a problem. It is believed that 5% of women have some degree of congenital uterine abnormality.

Q 3. 4 How can trauma affect the female genital tract?

• The genital tract may be injured as in a road traffic accident.

• During my senior registrar years, a young women was injured when a bus hit a bus shelter. She sustained a fracture of her pelvis and the external genitalia were severely lacerated. Surgical correction of the problems was undertaken jointly with the orthopaedic team.

• It is not uncommon for young girls to injure themselves during exercise particularly in the gymnasium. If there is significant bleeding, suturing may be required. Injury in this area always places the professionals in a difficult position as there is inevitably the possibility of trauma having been inflicted by an adult. Failure to recognise this possibility could result in the child returning to a dangerous environment whilst on the other hand parents can understandably be aggrieved at the slightest suggestion of abuse. Everyone concerned should appreciate that it is the welfare of the child that is paramount.

• During childbirth, the vagina and perineum are invariably traumatised and suturing may be required. Inevitably, there will be associated pain for a few days but at times their may be long-term problems and intercourse may be painful (superficial dyspareunia – Q 23.38).

• Childbirth can weaken the pelvic floor support leading to prolapse problems in later-life (Q30.3).

Q 3. 5 What is the role of infection in disease processes?

• Many illnesses can be attributed to infection. Each of the groups of organisms responsible for illness may be related to a wide spectrum of diseases. The smallest organisms are the viruses.
• They account for diseases including influenza and the common cold. They are also the cause of poliomyelitis and AIDS (Q20.14). We have very few medicines to eradicate viruses. The best form of treatment is prevention by immunization. The gynaecological problems associated with viruses are discussed in (Q31.2)

• Bacteria are responsible for diseases varying from folliculitis (a boil), some forms of meningitis and some chronic conditions including tuberculosis. Bacteria are responsible for pelvic inflammatory disease (Q20.2) and bacterial vaginosis (Q22.7).

• In non-gynaecological areas of medicine, infections have unexpectedly been found to be associated with disease. Examples are Helicobacter in peptic ulcers and Chlamydia pneumoniae in coronary heart disease. Some gynaecological conditions including dysfunctional uterine bleeding (Q24.6), unexplained infertility, recurrent miscarriage, pelvic pain and premenstrual syndrome prove elusive to adequate scientific explanation. There are likely to be a variety of causes, which makes analysis difficult. The author has recently introduced the concept that some of these unexplained conditions may be related to bacteria within the uterus (bacteria endometrialis). A great deal of research will be required to evaluate this concept.

Q 3. 6 Can metabolic (chemical) disorders affect the female reproductive system?

• Women who are underweight may have no periods (Q6.8) and have difficulty conceiving. Obesity is a factor in infertility and in cancer of the endometrium (Q32.20). Weight problems may affect self-esteem, which in turn affects libido (sex-drive Q25.12). At one time there was a suggestion that iron deficiency caused heavy periods but we now believe that the reverse is true.

Q 3. 7 What is the role of the immune system in gynaecological disease?

• The immune system has a fundamental role in the prevention and limitation of infection. At times there may be an overreaction to either physical or emotional stress (excess reaction). There are a set of physical illnesses known as autoimmune disorders where the body’s immune reaction starts to damage its own organs. Rheumatic heart disease is one example. There is evidence that antiphospholipids antibodies, which are an endpoint, in some immune reactions, are present in 15% of women who recurrently miscarry (Q12.17).

Q 3. 8 Are tumours a frequent consideration in gynaecology?

• Fibroids (Q23.14) are the commonest tumour of women and ovarian cysts are frequently seen at ultrasound examination, although the majority come and go with menstrual cycles (Q23.8).
• Prevention of malignancy is a principle of gynaecology. The causation and management of malignancy is discussed in Chapter 32.

Q 3. 9 How can the gynaecologist counter the ageing process?

• Hormone replacement therapy (Chapter 27) has been seen as one of the most significant developments in promotion of health since immunisation.

Q 3. 10 Do psychological problems enter the realms of gynaecology?

• By its very nature, gynaecology is an emotive subject. Psychological problems may underlie gynaecological symptoms and gynaecological disease may result in psychological disturbance.

• Stress is more often emotional than physical as we all experience the downs as well as the ups that life has to offer. In the USA it is thought that each year between 5 and 8% of the population have an anxiety related disorder. A similar number are prone to depression. Learning to cope with stress can reduce the risk of depression.

• With bereavement, we become depressed after an initial shock feeling of numbness. We may lose our appetite and wonder whether life is worthwhile. We may become angry and, perhaps inappropriately, blame ourselves or others for the loss. These feelings are natural when we lose a member of our family or a friend. The emotional turmoil associated with bereavement may be encountered in a number of gynaecological situations. A miscarriage may feel just like a bereavement. For those with infertility, each period may seem like a bereavement for a baby. Many women undergoing hysterectomy (hysterectomy) seem to have no more emotional attachment to their uterus than to their appendix, but others find the experience as devastating as the loss of a friend. A diagnosis of cancer could cause bereavement symptoms for the patient and her family (Q32.10). Counselling may play in an important place in the caring management of these difficult situations.

• Some illnesses are psychosomatic: the patient seems to have a physical disorder such as pain or breathing difficulty but the cause is emotional. These illnesses are never easy to diagnose as a physical causation needs to be excluded. To complicate the issue, every physical illness is associated with emotional overlay.

Q 3. 11 What is a syndrome?

• A syndrome is a recognised combination of symptoms or clinical observations. Turner’s syndrome (Q 6.13), for example, is characterised by short stature and webbing of the neck. Syndromes are frequently named after the clinician who first described the condition. Stein Leventhal Syndrome as polycystic ovary syndrome is associated with absent or infrequent periods, infertility, hirsutism (excess body hair) and obesity (Chapter 7).

• Q 3. 1 How does the body react to illness?
• Q 3. 2 What are the disease processes that could be causing symptoms?
• Q 3. 3 What is a congenital abnormality?
• Q 3. 4 How can trauma affect the female genital tract?
• Q 3. 5 What is the role of infection in disease processes?
• Q 3. 6 Can metabolic (chemical) disorders affect the female reproductive system?
• Q 3. 7 What is the role of the immune system in gynaecological disease?
• Q 3. 8 Are tumours a frequent consideration in gynaecology?
• Q 3. 9 How can the gynaecologist counter the ageing process?
• Q 3. 10 Do psychological problems enter the realms of gynaecology?
• Q 3. 11 What is a syndrome?
• Q 3. 12 Could I have some useful Web sites?

Q 3. 12 Could I have some useful Web sites?

• Evaluation of the quality of Web sites is discussed in Q4.27.
• You may find that several general women’s health sites may help you (Q4.28).
• The following are more specialised Web sites on topics found in this chapter.