Women's Health Medicine最新文献

This article looks at whether the psychiatric disorders that occur around childbirth can be predicted and if so can they be prevented. Childbirth does not present a risk to a woman’s mental health and the most serious psychiatric condition associated with it, puerperal psychosis, is particularly predictable with a past history of bipolar disorder increasing the risk to at least 1 in 3. The less severe types of postnatal depression are not so predictable, yet there are certain factors that seem to increase risk. These can be biological, obstetric and psychosocial but it has not yet been possible to use these to develop a powerful enough antenatal questionnaire which would predict women-at-risk. Prevention is divided into primary, secondary and tertiary and the article discusses possible strategies for women at risk. Universal primary prevention targets the population as a whole, selective all pregnant women and indicated just those at risk. Secondary prevention involves screening which does have its limitations and these are considered. The Edinburgh postnatal depression scale is widely used since it was developed in 1987 following the realisation that traditional depression scales were not suitable for depression occurring postnatally. There is some controversy over this and this is also discussed briefly. Tertiary prevention looks at how to minimise the effects of a condition which has already occurred with appropriate management and treatment. Finally there is a mention of how integrated care pathways can be used to facilitate screening and planning of care.

This paper examines schizophrenia in women, since it is now well established that men and women differ in terms of the onset, manifestation and longitudinal course of schizophrenia. The paper emphasizes the sex differences in schizophrenia, the epidemiological features of this group of disorders, treatment issues in relation to physical health and family factors, pregnancy and breastfeeding, and how sex differences might provide clues to the aetiology of schizophrenia. The focus is on explaining sex differences in schizophrenia in which men and women may be differently vulnerable to subtypes of those disorders currently classified under the label of ‘schizophrenia.’

This article briefly illustrates the complexities in the field of Female Sexual Dysfunction, both in terms of the circumstances in which the problems can arise, and the multiplicity of causations. It is often hard for a woman to find a language to describe the nature of her difficulty, which often means that obtaining access to appropriate professional help can be problematic. The main causes of female sexual dysfunction are outlined here, as described by the Working Group for a New View of Women’s Sexual Problems. These include social, political and economic factors, partner and relationship issues, psychological factors, and medical factors. There are difficulties with the classification of female sexual dysfunction, as current attempts neither reflect the full complexity of female sexuality, nor take account of the myriad possibilities of causation. The most commonly presenting sexual symptoms are described. These include desire and arousal problems, problems with orgasm, sexual aversion, phobia and ‘sexual anorexia’, sexual pain of non-medical origin, and vaginismus. Mention is made of life events which can trigger sexual dysfunction in women, making reference to physiological, emotional or relationship changes. The importance of careful assessment by a person skilled and trained in this field is stressed. A range of treatment options is covered, including psychological and physiological approaches, mechanical devices, and pharmacological agents. The sex therapy, programme, Sensate Focus, is included in table format. Possible referral routes are mentioned, and educational materials are listed after the references.

This article reviews our current understanding of depressive and bipolar disorders in teenage girls. It highlights issues related to causality, assessment and treatment. Early onset depression arises as a consequence of inter-related predisposing and precipitating factors which together lead to alterations to biological and psychological functioning and result in depression. Assessment needs to be carefully and thoroughly undertaken by a clinician with experience in child and adolescent mental health problems. Following a brief psychoeducational intervention, further treatment should be initially with psychotherapeutic approaches. Cognitive and interpersonal therapies are supported by the best evidence. Pharmacological treatments may be associated with increased suicidal ideation and behaviour and should only be initiated by those with specialist training and experience in child and adolescent mental health problems. Early onset bipolar disorder remains a controversial area of practice, with uncertainty over the application of diagnostic criteria, validity of the disorder and its relationship with other disorders such as ADHD. For those adolescents and, rarely, children with true bipolar disorder, the longer-term outcome for early-onset bipolar disorder appears to be similar to that for adults, although younger sufferers are more likely to have a more rapidly cycling clinical picture than adults. There is very little research evidence investigating response to medication although there is some evidence for the efficacy of lithium, valproic acid and carbamazepine in the treatment of early-onset mania.

The author’s personal experience of breast cancer is provided in this contribution.

The author’s personal experience of breast cancer is provided in this contribution.

Breast cancer is a multifactorial disease that has a worldwide annual incidence of over 1 million cases. In the UK this equates to over 39000 new diagnoses per year. Most of these cases occur in postmenopausal women, and the incidence in both this age group and in younger women is rising. Most of the major risk factors for breast cancer such as female sex, age and a family history of the disease cannot be avoided. However, there is established evidence that earlier detection of breast cancer through mammographic screening does significantly reduce mortality, by up to 24%. Since its inception in 1989, the National Health Service Breast Screening Programme (NHSBSP) has become increasingly effective at detecting breast cancer in the target population of women aged over 50, and together with advances in surgery, chemotherapy and other adjuvant medical treatments, mortality from breast cancer is significantly decreasing. This contribution aims to explore the principles behind the NHSBSP, and will review the key evidence which supports it. The advantages and pitfalls of screening will be examined and an overview of the actual screening and assessment process is included. Screening in high-risk groups is a new and controversial area that is now gaining prominence, and new imaging techniques being used in such groups, in addition to the screening and assessment of breast cancers in the conventional age range, will be covered.

Lump, nipple discharge and pain are the major presenting symptoms of breast disease. Around 60% of referrals are for a lump and less than 10% of these will be diagnosed to have breast cancer. Benign diagnoses are: fibroadenoma, a firm mobile lump considered as aberrations of normal development; breast cysts, which are discrete lumps accounting for 15% of all breast lumps; and nodularity, which is the most common cause for referral in all ages. All breast lumps need to undergo triple assessment. Around 8% of referrals are for nipple discharge. Physiological nipple discharge is usually bilateral, multi-duct and coloured white, yellow green or black. Duct ectasia is due to ductal involution and the change is often bilateral and associated with ‘slit-like’ nipple retraction. Increasing risk of significant pathology is associated with unilateral, single duct, serous and blood stained discharge, which needs to undergo triple assessment. Blood stained discharge may be due to duct ectasis, intra-duct papilloma, epithelial hyperplasia or malignancy. Breast pain is divided into cyclical and non-cyclical mastalgia (including chest wall pain), and 25% of breast clinic referrals will be for breast pain. Cyclical mastalgia is an exaggeration of normal cyclical changes and the patient can be reassured without investigation. If pain is severe treatment is with gamolenic acid, danazol or bromocriptine. Where pain is non-cyclical, unilateral and localized investigation with mammography is required. Chest wall pain is a common end diagnosis for referrals with breast pain and is treated simply with reassurance and simple analgesics or NSAIDs.

Adjuvant therapy for breast cancer, a rapidly changing area of management, has made the difference to the breast cancer mortality figures over the last ten years. Initial treatments used hormonal manipulation such as ovarian ablation. This was followed by the development of tamoxifen, an oestrogen receptor antagonist. This has been followed by other hormonal regimes such as aromatase inhibitors, which have been used initially in the metastatic setting but are now being transferred to the adjuvant setting for post-menopausal women. Chemotherapy is used routinely for many breast cancers and is now well tolerated. Newer treatments include the use of taxanes and an antibody against HER-2 receptors; both of these are currently being evaluated in the adjuvant setting. Radiotherapy is a local adjuvant treatment that is given after breast conservation treatment surgery and in some cases is required after a mastectomy to decrease the risk of local recurrence.