This document discusses psychosomatic disorders related to gynecology. It describes interactions between psychiatric and gynecological conditions, including functional hypothalamic amenorrhea, premenstrual symptoms, infertility, and menopausal syndrome. Specific disorders covered include psychosomatic aspects of amenorrhea, premenstrual syndrome, infertility, and menopause. The roles of gynecologists and psychiatrists are to evaluate and treat these conditions through hormonal and psychological therapies.

1. Psychosomatic Disorders
Related to Gynecology
Mohamed Abdelbadie
Specialist psychiatrist
Sharjah medical services

2. Explanation!
 What kind of interactions between psychiatric
and gynecological disorders could be?
 What is the role of Gynecologist?
 What is the role of Psychiatrist?
 Major disorders:
 Functional Hypothalamic amenorrhea
 Premenstrual symptoms
 Infertility
 Menopausal syndrome.
M.Abdelbadie

3. Psychogenic Amenorrhea
 Berga and Girton 1989 used the term of:
‘functional hypothalamic amenorrhea' rather than
psychogenic amenorrhea because of the
multifactorial nature of this state.
 Features typical of these patients:
(1) Psychosexual immaturity & Stress (rejection of the female role).
(2) Oral conflicts (eating disorders, drug abuse).
(3) Schizoid thinking (odd and eccentric).
(4) Physical exercise, low body weight and weight loss.
M.Abdelbadie

4. Functional hypothalamic
amenorrhea Diagnosis
 Gynecological and Psychological Evaluation
 Biochemical Testing (hCG, TSH, Free T4, FSH, LH,
Progestin Challenge test).
 Imaging (US, MRI)
 Bone density testing (DXA)
M.Abdelbadie
exclude 1ry causes due to abnormal GnRH, absent LH surge and low
serum estradiol.

5. Comorbid psychiatric conditions
with Amenorrhea:
 Eating Disorders (DSM-IV) & (ICD-10).
 Major depressive disorders (DSM-V) & (ICD-11) 28%.
 Generalized anxiety disorder 22%.
 Antipsychotics induced Amenorrhea
 Alcohol and Drug Abuse
 Pseudocyesis
 Spinal cord injury
Amenorrhea relevant psychiatric diagnosis was ascertained
in 48.8% (Fava G. et al 1984).
M.Abdelbadie

6. Comorbidity of eating disorders
with Amenorrhea:
 Anorexia (10% 1ry Amenorrhea) and Bulimia
nervosa (DSM-IV) & (ICD-10).
 Menstrual dysfunction occurred across all eating
disorder subtypes. (Pinherio et al., 2007).
 A majority of the women with primary amenorrhea
reported Anorexia Nervosa onset prior to menarche
(McDowell, et al., 2007).
M.Abdelbadie

7. Cont.,
M.Abdelbadie

8. Management of functional
hypothalamic amenorrhea
1. Increase caloric intake, decrease exercise and
avoidance of stress.
2. Follow up bone density for a year after
improvement and give bisphosonates only if
estrogen replacement therapy ineffective to
prevent fractures or contraindicated.
3. Delay ovulation therapy until achieving a
healthy weight and psychological improvement.
M.Abdelbadie
(HORMONAL THERAPY + PSYCHOTHERAPY)

9. Premenstrual symptoms
Symptoms start 7-10 days prior to menses
and clear by menstrual flow.
 Somatic (bloatness, headache, breast
tenderness, water retention)
 Psychological (mood upset, irritability,
depression, food craving)
M.Abdelbadie

10. Premenstrual Syndrome PMS
 PMS is a recurrent luteal-phase condition characterized
by physical, psychological, and behavioral changes of
sufficient severity to result in deterioration of
interpersonal relationships and normal activity
(interferes the individual's lifestyle ICD-11).
 Premenstrual dysphoric disorder PMDD added to DSM-V
depressive disorders. Criteria must have been met for
most menstrual cycles that occurred in the preceding
year and associated with clinically significant distress or
interference with functioning excluding the other causes.
M.Abdelbadie

11. PMDD Pathophysiology
Evidence supporting the following etiologies:
 Serotonin deficiency (SSRIs)
 Magnesium and calcium deficiencies (Supplements)
 Rapid shifts in hormonal levels
 Other theories: increased endorphins, alterations in
the (GABA) system, and hypoprolactinemia.
 A large longitudinal study suggest that the
experience of abuse (emotional, sexual, or physical)
in early life places women at higher risk.
M.Abdelbadie

12. Epidemiology
 Symptoms of PMS affect 90% of women
(increase with obesity and smoking).
 Approximately 10% are affected severely.
(more severe symptoms in older women)
 Only 3-5% of women meet the criteria for PMDD.
 >20% of PMDD has Comorbid psychiatric conditions
PMS associated with higher risk of bulimia nervosa and
future hypertension.
M.Abdelbadie

13. PMDD Management
Exclude Physical conditions
Patient Education:
Behavioral counseling, stress management Relaxation
techniques and Diet control.
Supplements: Chasteberry, Minerals & Vitamins
Pharmacologic therapy:
NSAIDs
Diuretics
Anxiolytics, antidepressants, and mood stablizers
Hormones (drospirenone + ethinyl estradiol), leuprolide …
M.Abdelbadie

14. Psychosomatic aspects of
Infertility
M.Abdelbadie

15. Infertility Influences Psychological
Well-Being:
– frustrated, lack self-esteem, feel less
feminine, feel guilty and depressed.
– incidence of suicide is double.
– women with unexplained infertility presented
higher neuroticism scores.
M.Abdelbadie

16. Psychological Influences on
Fertility:
– Higher anxiety traits in normal women have a
lower probability of conception. And predicts with
depression scales who will conceive during IVF.
– Psychotherapy dealing with pregnancy-related
conflicts may affect physiological factors and
thereby enhance reproductive potential in couples
with unexplained infertility.
– 'Sisyphuslike": women with high depression score
and high active coping (with lower pregnancy
rates during IVF).
M.Abdelbadie

17. Pathways for an Effect of
Stress on Fertility:
- Cigarette smoking can be a stress-linked
behavior.
- An unconsumed marriage caused by
female vaginism, male impotence or both
combined sometimes
- The night syndrome “being tested”
- Sexual arousal and satisfaction levels
- Body image (weight) and Excessive
exercises
M.Abdelbadie

18. Psychoendocrinological
Mechanisms of infertility:
Stress responses (Prolactin):
-Daytime noise stress increases, for example,
nocturnal prolactin levels.
-coping mechanisms
The HPA axis (corticoid hormones):
'Sisyphuslike shows high cortisol levels
M.Abdelbadie

19. Psychosomatic Aspects
During Menopause
 Stages of Reproductive Aging Workshop (STRAW)
 Vasomotor symptoms vs Psychological symptoms
- Hot Flashes
- Migraines
- Urinary incontinence
- Sexual changes
 Treatment recommendations and Guidelines
M.Abdelbadie
- Anxiety and Depression
- Cognitive changes
- Sleep Disturbances
- Decreased Lipido

20. Stages of Reproductive Aging
Workshop (STRAW)
M.Abdelbadie

21. Perimenopausal depressed women often
describe additional symptoms like:
 Multiple sleep interruptions (with/out insomnia complaint),
causes extreme irritability, emotional hypersensitivity.
 Memory difficulties and Poor concentration
 Skipped and otherwise irregular periods
 Vasomotor symptoms (hot flashes, cold sweats, perspiration).
 Vaginal dryness with painful intercourse and libido.
M.Abdelbadie

22. The first-ever guidelines for the evaluation
and treatment of perimenopausal
depression (Sep. 2018)
 Antidepressants and psychotherapy are best for treating
major depressive episodes during perimenopause.
 Antidepressants can be given to perimenopausal women
at doses typically prescribed to adults.
 Estrogen therapy has been shown to be ineffective as a
ttt for depressive disorders in postmenopausal women.
 Hormonal contraceptives may improve depressive
symptoms in women approaching menopause.
M.Abdelbadie
North American Menopause Society and the National Network on
Depression Centers Women and Mood Disorders Task Group

23. Vasomotor vs Psychological
symptoms and how to manage
 Hot Flashes: are the most common and distressing
symptom of menopause. They start earlier than the other
symptoms and may be the most common complaint in cases
seeking medical consultation. > 80% of cases suffer < 1 Y
 Sleep disturbance: usually with sleep apnea and restless
leg syndrome, so it might be due to vasomotor instability or a
1ry sleep disorder or a depression symptom.
 Menstrual Migraines: at time of periods (estrogen
associated migraine).
M.Abdelbadie

24. Cont.,
 Anxiety and depression:
 Women with history of depression are more susceptible.
 Treated with SSRIs / Dysvenlafaxine or with
hormonal therapy (estradiol 0.1 mg) if the vasomotor
symptoms are more predominant or temporally related to
depressive symptoms. It could be justified with rapid
response in a matter of few weeks.
 Herbal or complementary treatments
 Psychotherapy
 Self-help and group of quality of life help
 Cognitive changes: memory and concentration problems.
Supporting the hypothesis that estrogen preserves cognitive
functions in non-demented women.
M.Abdelbadie

25. Cont.
 Urinary incontinence
 due to changes in genitourinary tissues and recurrent cystitis
for the same cause and due to lower antimicrobial proteins
 Sexual changes:
 Dyspareunia
 Deterioration in sexual interest, Orgasm and activity might be
due to hormonal changes or relationship problems,
aesthetic/weight changes or negative life events.
Treatment options:
-Flibanserin Addyi (FDA approval) 5HT1a agonist+2A antagonist NDDI.
-using OTC lubricants and different positions.
M.Abdelbadie

26. Cont.,
 Estrogen and progesterone are also approved for relief
of hot flashes and symptoms of vulvar and vaginal
atrophy. But, for vulvar and vaginal atrophy low doses of
vaginal estrogen are the preferred modality of hormonal
treatment.
The risk-benefit ratio is more favorable in the direction of
benefit for: – Women less than 60 years of age, and
– Women who are less than 10 years
postmenopause.
Due to: CVS events, thrombosis, dementia and cancer risk.
 Escitalopram is commonly prescribed SSRI
M.Abdelbadie

27. References
 Fabio Facchinettia et al; Psychother Psychosom. 1992:58:137-154.
 Pinherio et al., 2007;40:424-434. Patterns of menstrual disturbance in
eating disorders.
 Fava G. et al. 1984:25:905-908. Depression and anxiety associated
with secondary amenorrhea. Psychosomatics.
 McDowell MA, et al., Adolesc Health. 2007 Mar; 40(3):227-31.
 Jessica H. Baker et al., 2014. Primary Amenorrhea in Anorexia
Nervosa.
 Berga SL. Girton LG, 1989:12:105-116. Psychiatr Clin North Am.
 Elizabeth R et al., 2014 Sep 1; 23(9): 729–739. J Womens Health.
 The North American Menopause Society and the National Network on
Depression Centers Women and Mood Disorders Task Group Sep
2018

28. Questions
Psychiatrist.net@gmail.com