[Psychological consultation at a gynecologic clinic--a luxury or a necessity?]

The necessity for an integrated psychological care is proven by the example of the Psychological Ambulance in the University of Freiburg Women's Hospital. In 1993 387 out- or inpatients contacted the psychologist, mainly out of their own initiative. 819 consultations, each lasting for at least 45 minutes, were registered. Parameters influencing acceptance and implementation were as follows: formal qualification as well as medical and psychological competence of the staff; cooperation with the hospital physicians and other institutions providing psychosocial care. We found that further important is the integration within the hospital facilitated by the consultation-model plus the longterm perspective of the ambulance and its staff. Additional promotion of acceptance was generated by the informal recommendations among patients.

[Miscarriage in the first trimester--a "non-event"? An empirical study of 40 women and their physicians of experiences and coping]

Explored by structured dialogue, miscarriage meant for 31 women, a psychosocial stress but not a medical stress. They tried to convince themselves of the non-normative event via subjective causal attributions to obtain cognitive control. Social support, especially by the partner, minimising the importance of the miscarriage, and social comparisons were the main modes of coping with their problem. Doctors and nurses significantly undervalued the degree of psychosocial stress, which resulted in negative consequences in the doctor-patient-relationship.

Thyrotrophin-releasing hormone--a lactation-promoting agent?

OBJECTIVE

To study the lactational and hormonal responses to nasal administration of thyrotrophin-releasing hormone (TRH) in puerperal women with inadequate lactation.

DESIGN

Prospective randomized double-blind placebo-controlled study.

SUBJECTS

19 puerperal women with inadequate lactation (less than 50% of normal milk yield) on the 5th day postpartum.

INTERVENTIONS

10 women were allocated to receive TRH administered by a nasal spray of 1 mg, four times daily, between suckling episodes, for 10 consecutive days starting on day 6 postpartum. Nine women were allocated to receive placebo sprays.

MAIN OUTCOME MEASURES

Daily milk yield, serum levels of prolactin and thyroid hormones.

RESULTS

Before treatment all the women had significant prolactin responses to TRH and suckling stimuli. At the end of 10 days of treatment, milk yield increased significantly in the TRH group from a mean of 142.0 (SD 33.9) to 253.0 (SD 105.3) g/day (P = 0.014). There was no significant change in the placebo group. Basal prolactin levels increased from a mean of 117.4 micrograms/l (SD 45.2) to 173.3 micrograms/l (SD 55.5) (P less than 0.001) in the TRH group whereas in the placebo group prolactin levels decreased from 137.2 (SD 69.5) to 82.0 (SD 37.7) micrograms/l. A further rise in prolactin levels and milk yield was seen in seven women in the TRH group who received a second 10-day course of TRH treatment at their own request. There was no significant change in levels of thyroid stimulating hormone, thyroxine and triiodothyronine during treatment in either of the two treatment groups and no signs of hyperthyroidism.

CONCLUSION

Repeated nasal TRH administration between suckling episodes may improve defective lactation.

[Counseling in artificial fertilization]

Since 1 October 1990, German legislation requires compulsory counselling of an infertile couple before artificial insemination on the medical and psychosocial aspects, by a doctor not performing the treatment. A prerequisite of successful counselling, which enables the couple to take a decision and helps coping with the psychosocial stress of sterility and its consequences, is, in addition to the intrinsic motivation of the couple, also the empathy and the discussion with the doctor. Subject for counselling should be the burdens of therapy, effects of the sterility upon sexuality, partnership, and communication, motivations for wanting a child and the functions of the child for both partners individually and as a partnership. As a prophylactic measure against the development of a neurotic desire for a child and a fixation upon sterility therapy, alternative resolving strategies for therapy failure should be discussed and developed.

Hyperprolactinemia and nonpuerperal mastitis (duct ectasia)

In 108 patients with nonpuerperal mastitis (inflammatory symptoms of duct ectasia), serum prolactin levels were determined before, during, and after treatment. Twenty-nine patients (26.8%) exhibited transiently elevated prolactin levels during the period of inflammation (mean +/- SD level, 42 +/- 22 micrograms/L) that returned to normal within 4 weeks. Twenty-two patients (20.4%) presented with more severe hyperprolactinemia (78 +/- 56 micrograms/L), and 15 were found to have pituitary microadenomas. In 11 cases, mastitis was the first symptom of hyperprolactinemia. A second group of 83 patients with known hyperprolactinemia and 83 normoprolactinemic controls were interviewed with regard to recent symptoms or past treatment of nonpuerperal mastitis. Sixteen hyperprolactinemic women (19.3%) and none of the controls reported that they had experienced mastitis. We conclude that duct ectasia is due in part to increased prolactin secretion. Thus, nonpuerperal mastitis may be a symptom of hyperprolactinemia. On the other hand, nonpuerperal mastitis may induce transient hyperprolactinemia (neurogenic hyperprolactinemia) of about 3 weeks' duration that is less pronounced than central hyperprolactinemia.

[Self-inflicted necroses (mastitis factitia) as an unusual course of non-puerperal mastitis]

The present paper reports of a long lasting necrotising mastitis which, regarding the psychiatric aspect of the patient as well, has to be interpreted as artefactual mastitis. The uncommon localisation, the unusual history and histology as well as the hardly accessible personality may be indicative of a self inflicted injury with subsequent inflammation. Additional to the local therapy, these patients need a psychological guidance, avoiding direct confrontation with the suspected pathogenesis.

[Manual obstetrical examination method. Current status in West Germany]

Until the middle of the eighteenth century the manual method of obstetrical examination involved exterior examination in addition to vaginal exploration. During the post-Semmelweis era, that is particularly following the introduction of the rubber glove, vaginal examination was omitted in favour of combined rectal and exterior examination. Since about the 1970 the vaginal form of examination is again preferred, although this procedure is described with some controversy in most present-day textbooks on obstetrics and midwifery. Representative sample examination tests performed by 625 obstetricians and 1478 various clinics showed clearly that for the purpose of controlling uncomplicated pregnancies and births, most physicians employ the vaginal form of examination. Moreover, even in those cases involving pathological pregnancies and risk the vaginal examination is preferred, possibly all too unreservedly so.

Serum prolactin levels in patients with fibrocystic breast disease

In 193 patients suffering from fibrocystic breast disease, basal serum prolactin concentrations were determined and compared to serum prolactin levels in 193 healthy women. In 45 additional patients and 23 healthy control subjects, a thyrotropin-releasing hormone (TRH) stimulation test was performed. The response to TRH in seven healthy female volunteers and in one patient with fibrocystic breast disease, was correlated with the mean serum prolactin levels over 24 hours. Serum prolactin levels were above normal in 45.6% of the patients and in 21.2% of the control subjects. Mean values of the two groups were significantly different (P less than .001). The maximum prolactin response to TRH stimulation was significantly higher in the study patients than in the control subjects (P less than .001). The TRH-stimulated prolactin response correlated positively with the mean 24-hour level (P less than .01, r = 0.8705). These results indicate that a high proportion of patients with fibrocystic breast disease exhibit increased daily prolactin secretion.

[Psychosocial status of the patient with extensive and advanced ovarian cancer]

The psychosocial situation of the patient with ovarian cancer is characterized by interacting of the individual experiencing of the disease and the therapy and of the reactions of the social environment, especially of the next of kin and the physicians. The disease and the therapy cause a severe threat of psychophysical integrity, followed by prejudice of self-esteem and plans for the personal future. If this threat is not solved, often depression, loss of social status, and social withdrawal with isolation are following. The patient concentrates her hope for recovery on the attending physician in a central, projective superelevated way. For that reason, he is highly responsible to react on the subtile signals of distress in a patient, empathical, and encouraging attitude.

[Psychoanalytic viewpoints on adolescent sexuality]

With the beginning of puberty the youth is challenged to transform this primarily biological development into a psychological experience and to integrate it into his personality. Depending on the quality of development of personality up to then and on the arrangement with environment this process will be experienced as a crisis, through which the youth at last will find a new positive identity or it ends in a permanent identity-crisis and manifestation of a neurosis. The doctor's sympathetic, understanding attitude is more effective for managing a critical development of puberty than a classical psychoanalytic treatment.