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STRESS DISORDERS IN GYNAECOLOGY

DESMOND O'NEILL, M.C., M.D., D.P.M.
Physician in Psychological Medicine, St Mary's, Queen Charlotte's and Chelsea Hospitals.

The menstrual cycle in women is especially sensitive to stress, and in some women is very readily disordered during a spell of emotional storms. Indeed, the whole of the area of structure and function which is the province of the gynaecologist is " highly charged" with feeling, and the proportion of stress disorder in the total volume of illness in gynaecological practice is greater than, for example, in an eye clinic. There is good evidence for the view that much of the illness which women bring to the family doctor and the surgeon, is in fact the product of emotional disharmony and not of physical disease. Definitions Stress may be defined as the internal or resisting force brought into being in the human organism by interaction with the environment: that is, the human environment-those around the patient who are in closest contact with her. (O'Neill, 1958a). A stress disorder is an illness which (1) begins at a time of crisis in the patient's life, (2) shows a time correlation with events provoking stress in the patient, and (3) clears up when the situation changes, or the patient learns to adapt to it better. Some new categories have had to be devised to accommodate the kinds of illness that are seen so often in a gynaecological clinic. one of these is tension pain, the disorder named by Philip Hench " psychogenic rheumatism ". This will be mentioned later. Patterns of Illness In the medical practice of today, the single symptom or disorder is uncommon. Most illnesses are complex, and contain dysfunctions of more than one system: most patients have multiple symptoms. In a recent survey of women attending an outpatient clinic, it was found that only 7 of 60 consecutive patients had one symptom, and in all the rest there were two symptoms or more. (Morris and O'Neill, 1958). Thirty-six of the total complained of symptoms indicative of emotional tension. Although a menstrual disorderperiod pain for example-is brought to the doctor for help, this will as a rule prove to be only one manifestation of a state of stress; others are there too, and can be found if they are looked for. Some
J. COLL. GEN. PRAcr., 1959, 2, 243

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types of disorder will not be mentioned at the first interview, because the patient is embarrassed about them: falling-off of sex feeling is one of these. An unhurried approach, and a sympathetic attitude, are essential if the full story of disharmony in life and health is to be uncovered.
Common Disorders Pain. In the series mentioned above, pain was much the most common presenting symptom. Twenty-two women gave pain (apart from period pain) as a leading symptom, and of the rest, twelve described pain as part of their complaint. In only three cases was the pain adequately accounted for by the demonstration of a physical disorder; in all the rest the clinical picture was consistent with the diagnosis of tension pain. (O'Neill, 1958b). This has been defined as pain or discomfort associated with mental tension; it is usually felt over an extensive area, and symmetrical about the body axis; it may be described in terms such as " burning " whereas pain from the muscles and joints has an aching or throbbing quality. The origins of tension pain are not in the " gynaecological system " and its treatment is best attempted by measures directed at the relief of tension. Of the common stress disorders, however, tension pain is the least amenable to therapy; this seems to be because the pain so often has a " purpose ", and is valuable to the

patient. Menorrhagia. This disorder outnumbers the other three common stress disorders of the period. Its importance is that the patient may, if the bleeding continues, be recommended for hysterectomy as a last resort, and this is a very grave step indeed. Stress bleeding can be heavy and disabling. Fortunately its sources, in the woman's emotional life, are generally near the surface; little exploration is needed, and the disorder (unlike tension pain) responds well to therapy, the main elements of which are brief psychotherapy (Hopkins, 1958a), mild sedation, and work with the patient's relatives and social conditions. Period Pain. The pathogenesis of period pain is obscure. In some women the pain is plainly a stress response, and can be relieved by the same kind of treatment as is used elsewhere in the field of stress disorder. The woman who has pain-free periods up to a certain point in her life, then has a spell of pain, and perhaps menorrhagia as well, and later reverts to normal menstruation; this kind of history points to stress, and the causes are seldom far to seek. Tension-relief by suggestion, the use of drugs such as chlorproma-

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zine, or.the injection of a small amount of thiopentone (1-2 ml.) into a vein, the day before the period, have been shown to relieve pain in many women in whom the pain is an expression of fear. Amenorrhoea. The most common cause of secondary amenorrhoea is pregnancy, and the second most common is depression. The depressive state can be quite obvious and on the surface, or it can be hidden, so that the patient herself does not realize how ill she is. Secondary anxieties (for example, that the amenorrhoea is due to an unwanted conception) contribute to the pathogenesis. In relation to menorrhagia and period pain, amenorrhoea is not one of the most frequent disorders of the menstrual cycle; its presence, however, calls for a full enquiry into the woman's personal situation at that time. Interview with the husband or mother may be most rewarding. Irregularity of the period. This is such a frequent concomitant of stress reactions that it is almost " normal ". It is rarely brought as a leading symptom for medical advice; more often it is a symptom of other disorders. Vaginal discharge. Simple discharge can be regarded as a vasomotor rhinitis of the vagina (Reading and O'Neill, 1954); it fulfils the criteria of a stress disorder, and can be treated as such. It is surprisingly common in an outpatient clinic; in our reported series, it was second only to pain. Therapy The ingredients for successful therapy are time, patience and privacy. Perhaps the most important part of it is good listening. Special skill is not required, and disorders of the kind I have listed above have been effectively treated by medical students. By and large, the stress disorders most often met with are not difficult to handle; the patients want to get well and will co-operate. Only if the home situation is very bad, or the patient dull or unusually anxious, is therapy of no avail. Emotional ventilation with the aid of intravenous methedrine is a valuable ancillary method; it has the advantage of saving time, and helping the patient to discharge feelings that might, without a stimulant, be difficult to bring to the surface.