Listening to patients with unexplained menstrual symptoms: what do they tell the gynaecologist?

Assessing Abnormal Uterine Bleeding: Are Physicians Taking a Meaningful Clinical History?

INTRODUCTION

Women with abnormal uterine bleeding (AUB) report significant reductions in quality of life (QOL), which can be attributed in many cases to the fear of embarrassing episodes of bleeding. We performed this study to determine whether or not during clinical encounters physicians addressed the impact of AUB on patient-reported QOL.

MATERIALS AND METHODS

Between October 2008 and May 2009, we conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys were distributed using a mixed method (web- and mail-based) and included questions about physician characteristics and types of questions used when obtaining a clinical history from a patient with AUB. We calculated the proportion of physicians who endorsed asking each type of clinical question with 95% confidence intervals (CIs).

RESULTS

Four hundred seventeen questionnaires were returned (52%). Ninety-nine percent (95% CI 98.4%-99.9%) reported always asking a bleeding heaviness question, 87.2% (95% CI 83.2%-90.5%) reported always asking a QOL question, and 17.5% (95% CI 13.6%-21.9%) reported always asking a mood associated with bleeding question. Seventy-eight percent specifically asked patients about bleeding through their clothes, and 55% asked about changing social plans because of bleeding. Only 18% endorsed that asking about QOL was most essential for the evaluation of women with AUB. No physician characteristics such as years since completing residency, geography, or gender were associated with how commonly providers reported asking questions regarding impact of bleeding on QOL.

CONCLUSIONS

Physicians may not be optimizing patient-provider interactions during menstrual history taking with patients with AUB by failing to assess impact of AUB on QOL in a way that is meaningful to patients.

Questioning our questions: do frequently asked questions adequately cover the aspects of women's lives most affected by abnormal uterine bleeding? Opinions of women with abnormal uterine bleeding participating in focus group discussions

Objectives of this article are: (1) to explore the effects on women's lives by heavy or irregular menstrual bleeding; and (2) to examine whether aspects of women's lives most affected by heavy or irregular menstrual bleeding were adequately addressed by questions that are frequently used in clinical encounters and available questionnaires. We conducted four focus group sessions with a total of 25 English-speaking women who had reported abnormal uterine bleeding. Discussions included open-ended questions that pertained to bleeding, aspects of life affected by bleeding, and questions frequently used in clinical settings about bleeding and quality of life. We identified five themes that reflected how women's lives were affected by heavy or irregular menstrual bleeding: irritation/inconvenience, bleeding-associated pain, self-consciousness about odor, social embarrassment, and ritual-like behavior. Although women responded that the frequently used questions about bleeding and quality of life were important, they felt that the questions failed to go into enough depth to adequately characterize their experiences. Based on the themes identified in our focus group sessions, clinicians and researchers may need to change the questions used to capture "patient experience" with abnormal uterine bleeding more accurately.

Expectations and experience of labial reduction: a qualitative study

OBJECTIVE

To understand women's reasons for undergoing labial reduction surgery, their expectations and experiences.

DESIGN

A retrospective qualitative study.

SETTING

British National Health Service Hospital.

SAMPLE

Six women who had experienced surgery for labial reduction. Method Qualitative study using semi-structured interviews.

RESULTS

Results relating to 'Normality and defect', 'Sex lives' and 'The process of accessing surgery' are presented in this study. The women had seen their presurgery genital appearance as 'defective' and sought a 'normal' genital appearance. They thought that their presurgery genital appearance impacted on their sex lives, but their expectations of the effects of surgery on their sex lives were not all fulfilled. Information about labial surgery came from both the popular media and the health services. An emphasis on, for example, physical discomfort rather than appearance may have been used to legitimise a request for surgery. The process of accessing surgery had exposed them to potentially conflicting messages about their genital appearance.

CONCLUSIONS

Women presenting for labial reduction may have unrealistic expectations of surgery, but their perceptions and expectations are long-standing and seem to be based on strong cultural norms. The gynaecologist is also meeting those women who have already negotiated the referral process. As demand for this surgery appears to be increasing, further research is needed. These findings may add to the case for the potential value of specialist staff to provide psychosocial interventions within gynaecology services.

Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation

OBJECTIVE

To identify the basis of the communication problems that characterise consultations about medically unexplained symptoms (MUS) and to identify implications for clinical education.

METHOD

Recent research into the details of clinical communication about MUS was reviewed narratively and critically, and broader research literature was scrutinised from the perspective of a practitioner who wishes to provide patients with explanations for such symptoms.

RESULTS

Consultations about MUS often involve contest between patients' authority, resting on their knowledge of their symptoms, and practitioners' authority, based on the normal findings of tests and investigations. The outcome of consultations can therefore depend on the strategies that each party uses to press their authority, rather than on clinical need.

CONCLUSION

Contest is a product of patients and practitioners occupying separate conceptual 'ground'. Avoiding contest requires the practitioner to find common conceptual ground within which each party can understand and discuss the symptoms. Finding common ground by collusion with explanations that patients suggest can damage clinical relationships. Instead the practitioner needs to fashion explanation that is acceptable to both parties from available medical and lay material.

PRACTICE IMPLICATIONS

Although practitioners commonly fashion such explanations, this aspect of their professional role seems not to be greatly valued amongst practitioners or in medical curricula. Clinical education programmes could include curricula in symptom explanation, drawing from research in medicine, psychology and anthropology.

Primary care consultations about medically unexplained symptoms: patient presentations and doctor responses that influence the probability of somatic intervention

OBJECTIVE

In primary care, many consultations about physical symptoms that the doctor thinks are not explained by physical disease nevertheless lead to somatic interventions. Our objective was to test the predictions that somatic intervention becomes more likely a) when doctors provide simple reassurance rather than detailed symptom explanations and do not help patients discuss psychosocial problems and b) when patients try to engage doctors by extending their symptom presentation.

METHODS

Consultations of 420 patients presenting physical symptoms that the doctor considered unexplained by physical disease were audio-recorded, transcribed, and coded. Analysis modeled the probability of somatic intervention as a function of the quantity of specific types of speech by patients (symptomatic and psychosocial presentations) and doctors (normalization, physical explanations, psychosocial discussion).

RESULTS

Somatic intervention was associated with the duration of consultation. Controlling for duration, it was, as predicted, associated positively with symptom presentations and inversely with patients' and doctors' psychosocial talk. The relationship with doctors' psychosocial talk was accounted for by patients' psychosocial talk. Contrary to predictions, doctors' normalization was inversely associated with somatic intervention and physical explanations had no effect.

CONCLUSION

Somatic intervention did not result from the demands of patients. Instead, it became more likely as patients complained about their symptoms. Facilitating patients' psychosocial talk has the potential to divert consultations about medically unexplained symptoms from somatic interventions. To understand why such consultations often lead to somatic interventions, we must understand why patients progressively extend their symptom presentations and why doctors, in turn, apparently respond to this by providing somatic intervention.

Medical Therapies for Chronic Menorrhagia

An estimated 10%-30% of menstruating women experience menorrhagia at some time during their reproductive lives. Acute menorrhagia may present as an emergency requiring prompt medical or surgical intervention. Chronic menorrhagia affects a woman's quality of life in her work, family, and social interactions. Medical management is the first line of therapy for chronic menorrhagia. Agents that have been used to treat menorrhagia include iron, cyclooxygenase inhibitors, desmopressin, antifibrinolytics, gonadotropin-releasing hormone agonists, androgens, combined oral contraceptives, and progestins. Progestins can be administered systemically or locally and may be given cyclically or continuously. Increased use of effective medical therapies has the potential to reduce the number of surgical procedures, such as endometrial ablation and hysterectomy.

Do illness perceptions predict health outcomes in primary care patients? A 2-year follow-up study

OBJECTIVE

Little is known about whether illness perceptions affect health outcomes in primary care patients. The aim of this study was to examine if patients' illness perceptions were associated with their self-rated health in a 2-year follow-up period.

METHODS

One thousand seven hundred eighty-five primary care patients presenting a new or recurrent health problem completed an adapted version of the illness perception questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline and 3, 12, and 24 months' follow-up. Linear regressions were performed for (1) all patients, (2) patients without chronic disorders presenting physical disease, and (3) patients presenting medically unexplained symptoms (MUS).

RESULTS

Negative illness perceptions were associated with poor physical and mental health at baseline. They most strongly predicted changes in health status at follow-up for the whole group of patients. Patients presenting with MUS had more negative illness perceptions and lower mental and physical components subscale of the SF-36 scores at all time points.

CONCLUSIONS

Patients' perception of a new or recurrent health problem predicts self-reported physical and mental health up to 2 years after consulting the general practitioner and offers an obvious starting point for addressing nonbiomedical aspects of illness.

Physicians' responses to patients' medically unexplained symptoms

OBJECTIVE

To understand how physicians communicate may contribute to the mistrust and poor clinical outcomes observed in patients who present with medically unexplained symptoms (MUS).

METHODS

After providing informed consent, 100 primary care physicians in greater Rochester, New York, were visited by two unannounced covert standardized patients (actors, or SPs) portraying two chest pain roles: classic symptoms of gastroesophageal reflux disease (GERD) with nausea and insomnia (the GERD role) and poorly characterized chest pain with fatigue and dizziness (the MUS role). The visits were surreptitiously audiorecorded and analyzed using the Measure of Patient-Centered Communication (MPCC), which scores physicians on their exploration of the patients' experience of illness (component 1) and psychosocial context (component 2), and their attempts to find common ground on diagnosis and treatment (component 3).

RESULTS

In multivariate analyses, MUS visits yielded significantly lower scores on MPCC component 1 (p = .01). Subanalysis of component 1 scores showed that patients' symptoms were not explored as fully and that validation was less likely to be used in response to patient concerns in the MUS than in the GERD visits. Component 2 and component 3 were unchanged.

CONCLUSION

Physicians' inquiry into and validation of symptoms in patients with MUS was less common compared with more medically straightforward patient presentations. Further research should study the relationship between communication variables and poor clinical outcomes, misunderstandings, mutual distrust, and inappropriate healthcare utilization in this population, and test interventions to address this problem.

The potentially somatizing effect of clinical consultation

Many patients who present physical symptoms that their doctors cannot explain by physical disease have persisting symptoms and impairment. An influential view has been that such symptoms are the somatization of emotional distress, but there has also been concern that medical practice contributes to shaping these presentations. Analysis of patients' accounts indicate that they approach these consultations with a sense of being the expert on the nature and reality of their symptoms and, in primary care at least, they seek convincing explanations, engagement, and support. They often describe doctors as doubting that their symptoms are real and as not taking their symptoms seriously. Observational research has demonstrated that patients presenting idiopathic symptoms in primary care generally provide cues to their need for explanation or to psychosocial difficulties. Their doctors tend to provide simple reassurance rather than detailed explanations, and often disregard psychosocial cues. Patients seem to intensify their presentation in consequence, elaborating and extending their accounts of their symptoms, perhaps in the effort to engage their doctors and demonstrate the reality of their symptoms. When doctors propose physical investigation and treatment in response to such escalating presentation, they thereby inadvertently somatize patients' psychological presentation. Consultations, therefore, have elements of contest, whereby patients seek engagement from doctors who seek to disengage. Although provision of a medical label, such as a functional diagnosis, can legitimize patients' complaints and avoid contest, this is at the risk of indicating that medicine can take responsibility for managing the symptoms. More collaborative relationships rely on doctors recognizing patients' authority in knowing about their symptoms, and providing tangible explanations that make sense to the patient and allow them to tolerate or manage the symptoms. Researchers need to study how doctors can best achieve these aims within routine consultations.

The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms

Patients with symptoms that doctors cannot explain by physical disease are common in primary care. That they receive disproportionate amounts of physical intervention, which is largely ineffective and sometimes iatrogenic, is usually attributed to patients' belief that they are physically diseased, their denial of psychological difficulties, and their demand for physical intervention. The evidence for this view has mainly been doctors' subjective reports. By observing what patients and doctors say in consultation, we tested hypotheses arising from recent qualitative evidence. In particular, that physical intervention is proposed more often by general practitioners (GPs) than by patients, that most patients indicate psychosocial needs, and that GPs offer little effective explanation or empathy. Consultations of 420 consecutive patients identified by British GPs as presenting medically unexplained symptoms (MUS) were audio-recorded, transcribed and coded, utterance-by-utterance, using a specially developed coding scheme based on the previous qualitative analyses of these kinds of consultation. Physical intervention was, as predicted, proposed more often by GPs than patients. Also as predicted, almost all patients provided cues concerning psychosocial difficulties or their need for explanation. Although, contrary to prediction, most GPs did provide explanations other than physical disease, most also suggested physical disease. Few GPs empathised. The findings suggest that the explanation for the high level of physical intervention for MUS lies in GPs' responses rather than patients' demands, and we propose that explanations for 'somatisation' should be sought in doctor-patient interaction rather than in patients' psychopathology.

Do patients with unexplained physical symptoms pressurise general practitioners for somatic treatment? A qualitative study

OBJECTIVES

To identify the ways in which patients with medically unexplained symptoms present their problems and needs to general practitioners and to identify the forms of presentation that might lead general practitioners to feel pressurised to deliver somatic interventions.

DESIGN

Qualitative analysis of audiorecorded consultations between patients and general practitioners.

SETTING

7 general practices in Merseyside, England.

PARTICIPANTS

36 patients selected consecutively from 21 general practices, in whom doctors considered that patients' symptoms were medically unexplained.

MAIN OUTCOME MEASURES

Inductive qualitative analysis of ways in which patients presented their symptoms to general practitioners.

RESULTS

Although 34 patients received somatic interventions (27 received drug prescriptions, 12 underwent investigations, and four were referred), only 10 requested them. However, patients presented in other ways that had the potential to pressurise general practitioners, including: graphic and emotional language; complex patterns of symptoms that resisted explanation; description of emotional and social effects of symptoms; reference to other individuals as authority for the severity of symptoms; and biomedical explanations.

CONCLUSIONS

Most patients with unexplained symptoms received somatic interventions from their general practitioners but had not requested them. Though such patients apparently seek to engage the general practitioner by conveying the reality of their suffering, general practitioners respond symptomatically.