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Der chronische Unterbauchschmerz der Frau stellt in der gynakologischen Praxis ein schwieriges diagnostisches und therapeutisches Problem dar, das im Umgang mit den betroffenen Frauen eine stete Herausforderung ist. Mogliche gynakologische Ursachen und Befunde sind Endometriose, Adhasionen bzw. die „pelvic inflammatory disease“ (PID), pelvine Varikosis und das „ovarian retention syndrome/ovarian remnant syndrome“. Andere somatische Ursachen sind das Reizdarmsyndrom, das „bladder pain syndrome“ bzw. die interstitielle Zystitis sowie Erkrankungen des muskuloskeletalen Systems und des Bindegewebes. Gesicherte psychosoziale Ursachen sind eine hohe Komorbiditat mit psychologischen Faktoren wie Angststorungen, Substanzabhangigkeit oder depressiven Storungen, wobei eine eindeutige Zuordnung zu sozialen Faktoren nicht nachgewiesen ist. Auch ein Zusammenhang mit korperlichem und sexuellem Missbrauch kann nicht abschliesend bewertet werden. In der Diagnostik sind die Anamnese, gynakologische Untersuchung und Durchfuhrung einer Laparoskopie als wichtige Schritte zu nennen. Multidisziplinare Therapieansatze sind als Erfolg versprechend anzusehen. Die psychosomatische Grundversorgung soll von Beginn an in das Behandlungskonzept integriert werden. Auch eine Psychotherapie ist fruhzeitig einzuleiten.

As gynaecologists frequently function as "general practitioners" for women, gynaecologists are frequently confronted with questions which initially appear to have only a tenuous connection to their field. Chronic pain syndromes represent a particular challenge, especially as pain syndromes are often associated with severe psychosocial stress for the affected woman. This article discusses some of the psychometric aspects of chronic pain in endometriosis and fibromyalgia together with practical therapeutic approaches.In seiner Funktion als „Hausarzt“ der Frau wird der behandelnde Gynäkologe nicht selten mit Fragestellungen konfrontiert, die zunächst nur bedingt in sein originäres Fachgebiet zu gehören scheinen. Eine besondere Herausforderung in diesem Kontext können chronische Schmerzsyndrome sein, die eine ausgeprägte psychische Belastung für die betroffene Frau mit sich bringen können. In dem folgenden Beitrag soll auf die psychosomatischen Aspekte der chronischen Schmerzen bei Endometriose sowie beim Fibromyalgiesyndrom (FMS) eingegangen werden sowie praxisorientierte Handlungsansätze aufgezeigt werden.

Purpose: Trastuzumab (T) was registered in 2006 for the treatment of early stage, HER2+ breast cancer, after surgery, (neo)adjuvant chemotherapy and/or radiotherapy, without specific age restrictions. However, the amount of data on elderly patients (EP) from the randomized studies is only sparse. E.g., in the HERA study, only 16% were ≥60 years (y) of age. In this prospective observation study the routine practice of HER2 antibody treatment in this setting was examined, with a special focus on the EP subgroup. Methods: At present, 1888 patients (pt) have been enrolled in this ongoing study; 1791 pt from 220 German centres were already sufficiently documented to be analysed. 38 were non-eligible due to either M1 or negative HER2 status. Results: The proportion of EP (≥65 y) steadily increased during the course of the project, with currently 436/176 (25%/10%) ≥65/≥70 y. As to be expected, performance status was more impaired in elderly compared to younger pt (ECOG 0: 51 vs 65%). EP more often presented with a larger tumor (pT≥2: 58 vs. 51%), while lymph node involvement was rather similar (52% vs. 49%). A positive hormone receptor status was recorded in 60 vs 61%. 92% received chemotherapy (CT), with neoadjuvant placement distinctly less common in EP (8 vs 18%), as well as anthracycline (A, 88 vs 95%) and taxane (Ta, 54 vs 64%) administration. An ATa combination was applied in 47 vs 59% only (p1%. After a follow-up period of up to a maximum of 5 years, 111 relapses were hitherto reported. The estimated recurrence-free survival is 95% (95% CI: 94 - 96%) and 89% (87 - 92%) after 2 and 3 years, respectively, with no detectable differences between age groups (p = 0.87). Conclusion: T can be applied safely in early breast cancer, without restrictions with respect to age, with higher age often accounted for by the choice of less aggressive CT. In the elderly, differences in cardiac toxicity and premature withdrawal can be detected, but seem to be of limited absolute magnitude and clinical relevance. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-12-01.

Chronic pelvic pain in women is a difficult subject that challenges the gynecologist in practice. Possible gynecological causes are endometriosis, adhesions/PID, pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome and fibromyalgia.Confirmed psychosocial factors contributing to chronic pelvic pain are comorbidity with anxiety disorders, substance abuse or depression, but the influence of social factors is less certain. The connection to physical and sexual abuse also remains unclear. Important diagnostic steps are studying the patient's history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are helpful. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage of the disease.

Endometriosis is a widespread chronic disease characterized by endometrial tissue located outside the uterine cavity. Clinical signs are chronic pelvic pain and infertility. Emerging evidence indicates that the immune system is profoundly involved in the onset and/or progression of endometriosis. However, mechanistic pathways have not yet been conclusively specified. In this study, women undergoing diagnostic laparoscopy due to infertility were recruited, and classified as early-stage endometriosis (n=30), advanced-stage endometriosis (n=8) or no endometriosis (n=31). The frequency and phenotype of leukocytes were evaluated in peritoneal fluid. While the frequency of lymphocytes was not significantly different, neutrophils were increased in endometriosis. Flow cytometry analysis revealed an increased frequency of CD4(+) and CD8(+) cells in peritoneal fluid of endometriosis patients. In addition, the frequency of CD4(+)CD25(+)CD103(+) cells and lineage(-)HLA-DR(+)CD11c(+)CD123(+) dendritic cells was decreased in peritoneal fluid in endometriosis, whereas CD57(+) NK cells and CD8(+)CD28(-) T suppressor cells remained largely unaltered. We conclude that therapeutic approaches in endometriosis might focus on peritoneal leukocytes as a target or surveillance marker; however, immune alterations in peritoneal fluid are subtle and their analysis will require highly standardized and harmonized protocols.

OBJECTIVE: Mammary duct fistula is a rare and poorly understood condition causing long-term distress to the affected patients. They suffer from pain, recurrent infections and poor cosmetic results after repeated operations. The preferred surgical approaches are uncertain and management is not yet standardised. In this article we give an overview of the literature and present our experiences of 13 years of fistulectomy with primary closure under antibiotic cover. MATERIAL AND METHODS: A retrospective analysis of the case notes of patients diagnosed with mammary duct fistula from 7/1993 until 10/2007 was undertaken. The patients were interviewed by telephone using a questionnaire. 110 patients were treated, 78 patients could be reached in the follow-up. RESULTS: The mean follow-up was 31 months (range 4 - 175 months). The mean age of the patients was 40.5 years (range 20 - 65 years). The mean duration of patients' complaints prior to operation was 39 months (range 0 - 27 years). 46 % of patients had undergone previous operations. In 12 % the fistula recurred. The mean values indicating perceived pain were high and reached 6.6 points on a visual analogue scale (range of scale 0 - 10). CONCLUSION: The long duration of complaints until a definite operation is performed illustrates the fact that proper management of mammary duct fistulas is still not sufficiently widespread. The affected women suffer considerable pain. An operative approach with a fistulectomy and primary closure under antibiotic cover offers good results and should be carried out in specialised centres.

Der chronische Unterbauchschmerz der Frau ist uneinheitlich definiert, historisch wurde er unterschiedlich beschrieben und beurteilt. Dadurch, dass derzeit keine internationale, allgemeingultige Definition vorliegt, ist es nicht moglich, die Pravalenz des chronischen Unterbauchschmerzes fur die Gesamtbevolkerung abzuschatzen. Insgesamt wird jedoch davon ausgegangen, dass seine Pravalenz weit hoher liegt als gegenwartige Studien darstellen. Praktisch alle Pathologien im kleinen Becken kommen in unterschiedlichem Mase einerseits als Differenzialdiagnosen, andererseits als zumindest verstarkende Begleitdiagnosen infrage. Eine Ubersicht uber die moglichen Differenzialdiagnosen wird gegeben. Dass psychosomatische Faktoren beim chronischen Unterbauchschmerz eine Rolle spielen, konnten viele Studien belegen. Daher wird zunehmend eine multimodale Betrachtungsweise unter Einbeziehung verschiedener Faktoren im Rahmen eines biopsychosozialen Modells favorisiert. Therapeutische Schwierigkeiten konnen sich daraus ergeben, dass die Behandelnden nicht ausreichend psychosomatische Kenntnisse besitzen und somit einen psychosomatischen Therapieansatz auser Acht lassen. Zudem kann es schwierig sein, Patientinnen, die sich mit somatisch empfundenen Beschwerden vorstellen, zu einer psychotherapeutischen Behandlung und zu einem psychosomatischen Krankheitsverstandnis zu motivieren.

When the guideline was compiled, the available evidence was heterogeneous; the evidence varied depending on the subject addressed and was often of only moderate quality. Nevertheless, a strong consensus was reached on almost all subjects. It is recommended that physicians develop a collaborative working relationship with the patient, focus on symptoms and coping strategies and avoid making stigmatising comments. A biopsychosocial diagnostic evaluation with a sensitive discussion of the signs of psychosocial stress allows problems of this type and co-morbid conditions to be recognised early on and reduces the risk of iatrogenic somatisation. In uncomplicated cases, establishing a biopsychosocial explanatory model and physical/social activation are recommended. More serious cases call for collaborative, coordinated management with regular appointments (as opposed to ad-hoc appointments when the patient feels worse), gradual activation and psychotherapy. The comprehensive treatment plan can be multimodal and can potentially include physical management strategies, relaxation techniques and antidepressants.Bei der Erstellung der Leitlinie war die Evidenzlage heterogen und erreichte bei vielen Fragen nur mittleren Evidenzlevel; starker Konsens wurde jedoch fast durchgehend erzielt. Empfohlen werden der Aufbau einer partnerschaftlichen Arbeitsbeziehung, eine symptom-/bewältigungsorientierte Grundhaltung und das Vermeiden stigmatisierender Kommentare. Biopsychosoziale Simultandiagnostik mit behutsamem Aufgreifen von Hinweisen auf psychosoziale Belastungen ermöglicht die Früherkennung einschließlich komorbider Erkrankungen und verringert das Risiko iatrogener Somatisierung. Bei leichteren Verläufen helfen das Erarbeiten eines biopsychosozialen Erklärungsmodells und körperliche/soziale Aktivierung. Schwerere Verläufe erfordern ein kooperatives, koordiniertes Vorgehen mit regelmäßigen Terminen, gestufter Aktivierung und Psychotherapie. Innerhalb eines Gesamtbehandlungsplans bis hin zu multimodaler Therapie können körperorientierte und Entspannungsverfahren sowie antidepressive Medikation sinnvoll sein.

In diesem Ubersichtsbeitrag werden die pathophysiologischen Mechanismen des chronischen Unterbauchschmerzes der Frau erlautert. Es wird ein Uberblick uber die historische Entwicklung des Krankheitsverstandnisses gegeben. Die psychosomatischen Zusammenhange und wichtigen organischen Ursachen dieses letztlich noch sehr unklaren und vielschichtigen Krankheitsbildes werden diskutiert. Auf einen grosen Teil der betroffenen Frauen treffen die Diagnosekriterien der somatoformen Schmerzstorung (ICD-10: F45.4) zu. Die therapeutischen Moglichkeiten, welche zum Grosteil auf Erfahrungsmedizin basieren, werden dargestellt. Fur die Auseinandersetzung mit dem chronischen Unterbauchschmerz der Frau sind psychosomatische Kenntnisse von groser Bedeutung und tragen zu einer zufrieden stellenden Arzt/Arztin-Patientinnen-Beziehung bei.

Chronic pelvic pain in women represents a difficult diagnostic and therapeutic problem in the gynecological practice which is always a challenge when dealing with affected women.Possible gynecological causes are endometriosis, adhesions and/or pelvic inflammatory disease (PID), pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome, interstitial cystitis and fibromyalgia.Psychosocial causes contributing to chronic pelvic pain are a high comorbidity with psychological factors, such as anxiety disorders and substance abuse or depression but the influence of social factors is less certain. The association with physical and sexual abuse also remains unclear.Important diagnostic steps are recording the patient history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are considered to be very promising. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage.

(2001). Emotional aspects of assisted reproductive medicine. Journal of Psychosomatic Obstetrics & Gynecology: Vol. 22, No. 3, pp. 181-185.

Die Sterilitatssprechstunde scheint ein Ort zu sein, an dem Emotionen nicht unbedingt notwendig sind oder zu Tage treten. Aber unsere tagliche Erfahrung zeigt deutlich, dass Gefuhle in der Arzt-Patient-Beziehung von auserordentlicher Bedeutung sind. Die Ursache fur die verschiedenen Formen des Arzt/Arztin-Patientinnen-Kontraktes findet sich in der Personlichkeit sowohl von Patientin, Arzt/Arztin als auch den weiteren Teammitgliedern. Durch Supervision und Teamsitzungen konnen herrschende Mechanismen aufgedeckt werden und eine hohere Zufriedenheit im Team verwirklicht werden.

In den letzten Jahren geht die Tendenz in der Geburtshilfe hin zum “Kaiserschnitt auf Verlangen”. Bei der Tatsache, dass einige in diese Richtung weisenden Arbeiten auf so fruchtbaren Boden fielen, spielen eine Vielzahl von Grunden (z. T. auch unbewusste) eine Rolle. Diese sind zum einen in der verstandlichen Angst der Frau vor der schmerzhaften Geburt und einem daraus resultierenden Kontrollverlust begrundet, kommen aber zum anderen auch den Bedurfnissen von uns Medizinern entgegen, die wir 1. mit der Sectio den scheinbar ungefahrlicheren und forensisch sichereren Weg gehen konnen und 2. eine gewisse Erleichterung durch aktives Vorgehen erhalten. Es erscheint daher notwendig, auch die aus psychologischer Sicht relevanten Hintergrunde eines solchen Vorgehens zu beleuchten, um eine freie und evidenzbasierte Grundlage fur die Entscheidung zur Sectio zu finden, da insbesondere aufgrund der wissenschaftlich-medizinischen Daten der Kaiserschnitt auf Wunsch kein vertretbares Routinevorgehen sein sollte. Es ist daher unerlasslich, jedes Begehren nach der Wunschsectio individuell zu prufen und daraus die gemeinsame Entscheidung zu treffen. Eine generelle Empfehlung fur oder gegen den Kaiserschnitt auf Wunsch erscheint nicht sinnvoll.

Caesarean section on request of the mother turned out lately to be very actual in obstetrical discussions. To come to rational decisions the scientific results of several medical disciplines should be taken into consideration. There is no scientific evidence for benefits of such elective c-section in paediatrics and psychosocial medicine. The obstetricians view shows both benefits and disadvantages, the later overweighing the first. In the light of these data, elective caesarean without other indication but the mothers request does not show to be an acceptable routine procedure.

We describe a 42-year-old Turkish woman admitted to the hospital for tubal sterilization. The patient also reported chronic pelvic pain. She had been treated in Turkey for a fallen navel. According to the patient her navel, considered the bodys epicenter, had slipped and thus caused pelvic pain, Evaluation showed a woman in conflict between the roles of a traditional Turkish housewife and a modern European woman. Returning to her familiar environment gave her her center back. This case suggests that subjective or cultural assumptions should be taken into account when evaluating chronic pelvic pain and planning an integrated therapeutic approach.

Chronic pelvic pain in women is a difficult subject that challenges the gynecologist in practice. Possible gynecological causes are endometriosis, adhesions/PID, pelvic varicosis and ovarian retention syndrome/ovarian remnant syndrome. Other somatic causes are irritable bowel syndrome, bladder pain syndrome and fibromyalgia.Confirmed psychosocial factors contributing to chronic pelvic pain are comorbidity with anxiety disorders, substance abuse or depression, but the influence of social factors is less certain. The connection to physical and sexual abuse also remains unclear. Important diagnostic steps are studying the patient's history, a gynecological examination and laparoscopy. Multidisciplinary therapeutic approaches are helpful. Basic psychosomatic care and psychotherapy should be integrated into the therapeutic concept at an early stage of the disease.

Was sind die Bedurfnisse der Frauen mit Kinderwunsch, und welche Verantwortung haben die Frauenarzte in der Reproduktionsmedizin? Primares Bedurfnis der Frauen ist es, ein (gesundes) Kind zu bekommen. In der Sterilitatsbehandlung sind die begrenzte Aussicht auf Erfolg, die Problematik von Fehlgeburten und Mehrlingsgeburten, aber auch unzureichende Information, Aufklarung und Beratung wesentliche Hindernisse, um den Bedurfnissen der Frauen gerecht zu werden. Gesetzliche Restriktionen im Embryonenschutzgesetz, wie das Verbot der Eizellspende oder der Embryoselektion widersprechen ebenfalls den primaren Bedurfnissen von Frauen in der Reproduktionsmedizin.

In this review we discuss the pathophysiological mechanisms and diagnostic criteria of chronic pelvic pain in women. The psychosomatic correlations and important somatic reasons of this complicated disease picture is discussed. For a large number of the patients the diagnostic criteria of somatoform pain disorder are fitting. The therapeutic approaches, which to a large extend are based on experience, are described. Psychosomatic knowledge is very helpful in the management of chronic pelvic pain in women and contributes to a satisfying doctor-patient-relationship.

Caesarean section on request of the mother turned out lately to be very actual in obstetrical discussions. To come to rational decisions the scientific results of several medical disciplines should be taken into consideration. There is no scientific evidence for benefits of such elective c-section in paediatrics and psychosocial medicine. The obstetricians view shows both benefits and disadvantages, the later overweighing the first. In the light of these data, elective caesarean without other indication but the mothers request does not show to be an acceptable routine procedure.

We examined the possible connection between mood state of patients during IVF/ICSI-treatment and pregnancy rate. Which influence does the patient's age and the social support have on the mood state?Questionnaires were handed out to 100 patients of our fertility center during an IVF/ICSI-treatment-cycle. We used the standardized Leipziger Stimmungsfragebogen (LSB), a visual analogue-scale for free indication of mood state and the questionnaire for social support (SOZU).Per oocyte pick up 32 women became pregnant (32.7%), 58 women did not become pregnant (59.2%). Lower rating on the aggressivity-scale showed a tendency (p = 0.085) and higher rating on the balance-scale showed a trend toward higher pregnancy rates. There was no significant relation shown on the visual analogue-scale as well as on the LSB-scales grief, activity and fatigue. There was no correlation between age and mood state or between social support and pregnancy rate.We could not show a significant relation between general mood state and pregnancy rate. Yet there was a tendency concerning certain components of mood. Increasing age of the patient does not have a negative influence on the mood state either. The individual situation and adjustment seem to be decisive.

1080 Background: The utility of anthracyclines/taxanes in MBC is decreasing as their use in EBC increases. Alternative agents are needed for treatment-resistant/-refractory pts presenting in the fi...

665 Background: Anthracyclines and taxanes are used increasingly in neoadjuvant and adjuvant chemotherapy (CT) in breast cancer. Consequently, MBC is frequently diagnosed in anthracycline- and/or taxane-pretreated pts. Retreatment with these agents is commonly compromised by resistance and/or cumulative toxicity. C is effective in the management of first-line MBC; the current analysis was undertaken to determine the first-line clinical efficacy of C in pts pretreated with adjuvant CT. Methods: 3 studies of C 1000 mg/m2, bid, d1-14 q3w, were included: a retrospective study of single-agent C (n=226; Debled et al 2009); a phase II study of single-agent C (n=161; Kaufmann et al 2009); a phase III, randomized study (RIBBON-1) of C ± bevacizumab (A; 15mg/kg, d1 q3w; n=615). Results: Prior exposure to neoadjuvant and adjuvant CT was reported in around 50-75% of pts. Of these, around 60-75% and 40-45% received anthracyclines or taxanes, respectively. Overall response rate (ORR) and CBR (CR+PR+SD) were around 25% ...

Secondary side-effects often occur in women undergoing hormonal stimulation treatment with clomiphene citrate. In general 10.4% of women experience hot flushing, 5.5% have complaints caused by enlargement of the ovaries and 3.5% experience central nervous symptoms (nervousness, sleeplessness, headaches, visual disturbances, vertigo). During ovarian stimulation with clomiphene citrate for in-vitro fertilization, a 32 year old patient developed psychotic symptoms, commencing 3 days after initiation of treatment. Hospitalization in the psychiatric ward became necessary when severe formal and rational thought disturbances arose together with perceptory and sensory delusions. Under neuroleptic treatment the symptoms improved. Nevertheless, follow-up psychiatric care on an outpatient basis was deemed necessary. The infertility treatment was continued with human menopausal gonadotrophin stimulation. Psychiatric instability occurred neither at this point nor during the 2 year follow-up observation period. Both an exogenous psychosis (ICD F23.9) as well as the exacerbation of an endogenous psychosis (ICD F29) may be considered for the differential diagnosis. The stimulation with clomiphene citrate in connection with the physical and psychic stress of the infertility therapy can be regarded as the trigger factor. For patients with evidence of psychiatric illness in their case history, ovulation-inducing substances such as clomiphene citrate should be implemented with particular care.