On Gynaecologicaldisorders

NORTH LONDON FACULTY SYMPOSIUM* ON GYNAECOLOGICAL DISORDERS IN GENERAL PRACTICE A SURGEON'S VIEW OF GYNAECOLOGICAL DISORDERS IN GENERAL PRACTICE PROFESSOR NORMAN MORRIS, M.D., M.R.C.O.G. Professor of Gynaccology and Obstetrics at Charing Cross Hospital I think it is now generally appreciated that a great number of the gynaecological symptoms ofwhich women complain are psychogenic in origin. Although this view is now widely accepted, a large number of operations are probably still performed for conditions which are not organic in origin. Surgery, of course, can be a rery effective form of " psychotherapy ", albeit rather costly and not infrequently quite disastrous. There are still some who challenge the basis of the psychosomatic approach. They dispute the evidence that is submitted and this is quite understandable, since accurate measurement of the factors involved is extremely difficult. Nevertheless I think they are wrong. Probably the two most frequent gynaecological symptoms related to emotional disturbance are menorrhagia and abdominal pain of one kind or another. This is not to suggest that others such as epimenorrhoea, dysmenorrhoea, vaginal discharge, dyspareunia and backache do not also occur, usually associated with other general symptoms such as tiredness, lack of energy, lack of concentration and insomnia. I believe that a large contributory factor in the development of psychosomatic disorders in women is the utter drudgery of their lives. The inescapable day-to-day routine often tends to sap their personality and reduce them to dull, drab, colourless creatures. Thus they have less and less ability to withstand the effect of emotional upsets. Furthermore, their dulled personalities may actually create domestic troubles with their husbands, children and relatives. I think this situation is now being recognized and more modem aids are being brought to the help of the housewife, but these will not solve the basic problem. *Held on Saturday, 6th December 1958, at the Hampstead General Hospital, Haverstock Hill, Hampstead, N.W.3, with Dr Harry N. Levitt in the chair. The faculty is indebted to Messrs Pfizer Ltd, for a grant sponsoring the symposium. J. COLL. GEN. PRAcr., 1959, 2, 233 234 NoRmAN MoRmz In many ways our social structure is very enlightened, and yet we still allow young men and women to embark on marriage and the rearing of children with little or no kno-wledge of the problems they will encounter. Instinct and common sense help to steer most of them past major disasters, but how much more profitable it would be if they were given carefully graduated instruction in sex and other matters, starting quite early in school and continuing right through the all important teenage period. Operations There are four different categories of operation: The first group is one where the operation must be performed, otherwise the patient will die. This includes such conditions as carcinoma of the cervix and uterus, and ruptured ectopic gestation. The second group includes those patients who have operations for obvious physical diseases such as large fibromyomata, severe vaginal prolapse and extensive endometriosis. Although these may not kill the patient, they make her life a misery. The third .group includes those patients with minor physical changes, such as small fibroids, cervical erosion and moderate vaginal laxity. Often these conditions are quite symptomless unless spotted by an enthusiastic doctor, who in his enthusiasm then imparts news of his findings to his patients: " I'm afraid you have got one or two small tumours on your womb, nothing to worry about ". To a patient any tumour spells disaster, and symptoms of one kind or another soon follow, until one day some unfortunate surgeon has to operate. Alternatively the patient may have symptoms and when these changes are detected it is assumed, without further question, that they are the only possible cause of the symptoms. The real trouble starts after a hysterectomy or vaginal repair has been completed- and the symptoms persist. Of course, large numbers of women do suffer minor anatomical changes as the result of childbirth, and it is often very easy to hold these changes responsible for all their symptoms. Furthermore it is not sufficiently appreciated that physical disorder and emotional disturbance frequently present in the same patient and that this makes it difficult to determine the true aetiological factors. The final group includes those patients who have operations for symptoms that are entirely emotional in origin. Sometimes the doctor may be partly responsible for the development of such symptoms. On one of the rare occasions when he does a vaginal examination he discovers a retroverted uterus. This, of course, is a normal finding in a considerable proportion of women. Once GYNAECOLOGICAL DISORDERS IN GENERAL PRACICE 235 again he discloses his findings to the patient: " I'm afraid your womb is upside down ". To a woman an " upside down" womb has an ominous significance and she does not rest content until some surgeon has put it " right side up ". Other women, believe it or not, are told or rather led to understand that their womb is " too big, too small, too long, too short or rather off-centre ". They too seek corrective operations. Whilst I consider that a uterine curettage is often a most valuable and effective therapeutic procedure, yet I am still puzzled regarding the processes involved. I find it very difficult to understand how scratching away at the endometrium can correct quite a variable range of gynaecological symptoms. I am not suggesting that this operation is always a form of psychotherapy but I think it is true for many cases. Probably the majority of operations for psychosomatic disorder are done firstly for menorrhagia, and secondly for abdominal pain. Often, in spite of recognizing the emotional factors involved, psychotherapy fails and an operation has to be done. It is frequently not possible to provide a new husband, mother-in-law or home, which are often root problems. One particular case that falls into this group was the patient who had had a son when she was unmarried and then allowed him to be adopted. Later she married but had no children. Unfortunately she knew the whereabouts of her son's school and she had a compulsion to watch him at games and when he left to go home in the afternoon. She had never disclosed knowledge of the boy's existence to her husband. She saw me because of a most intense menorrhagia. Psychotherapy was attempted but only produced a temporary response. After consultation with a psychiatrist I did a hysterectomy. She withstood the operation well but has now developed the most extensive dermatitis, which is proving very resistant to treatment. When a patient complains of abdominal pain we are all afraid that even though the tests are negative nevertheless something may have been missed. When hysterectomy is resorted to for pain syndromes associated with some organic disease of the uterus, the results in my experience are often quite disastrous. Far from being relieved, the pain is often greatly exacerbated and institutional care may often become necessary. In conclusion it is probably true to say that of all decisions we make, the decision to operate is one of the easiest. Clinics are often long and overcrowded and our critical faculties become blurred. It is therefore not always easy to sort out the complicated emotional pattern which brought the patient for our opinion. When she is told an operation is necessary the English patient usually very readily accepts this advice. It absolves her from any further personal responsibility for her troubles. When told that something in her domestic life is really the basis for her symptoms she often KATHERINA DALTON replies " You're not trying to suggest that I am imagining all this ". A former chief of mine was just setting off to operate on a titled patient of some importance. Just as he went through the door he said " This will be her seventeenth operation and they have all been necessary-except the first! " II. MENSTRUAL DISORDERS IN GENERAL PRACTICE KATHERINA DALTON, M.R.C.S., L.R.C.P. London In my practice, charts are used extensively by my women patients to note the duration and frequency of menstruation, and the time ofany recurrent symptoms. The charts are simple, easily understood by patients, and the necessary information can be obtained at a glance. Figure 1 shows the chart with a " perfect " cycle of 28 days and of four days duration. Figure 2 shows the pictures seen on the chart with different types of menstrual cycles, and figure 3 demon- strates its value in differentiating regular and irregular inter-menstrual bleeding. The charts are particularly valuable in the four conditions to be discussed, with particular reference to the satisfactory response to hormone therapy, viz.: dysmenorhoea, premenstrual syndrome, menorrhagia and amenorrhoea. From the therapeutic angle dysmenorrhoea may be conveniently divided into two groups, the oestrogen-responsive and the progest- erone-responsive. There are only a few cases which fall into both groups. The oestrogen-responsive group is the largest and best known, but the very chronicity of patients in the second group makes their treatment most satisfactory. Table I notes the chief differentiating features. Premenstrual syndrome may be defined as the presence of symptoms which recur each month with the same time relationship to menstruation, and the diagnosis is essentially by the use of charts, as in figures 4 and 5. Symptoms are varied and include depression, headache, lethargy, backache, nausea, abdominal pain, asthma, allergic rhinitis and epilepsy. In severe cases, if day-to-day observations are made throughout the month, a premenstrual weight gain, oedema, albuminuria, and hypertension may be found, all signs similar to those of toxaemia of pregnancy, indeed Greenhill (1940) has called this syndrome the " toxaemia of menstruation".

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