15.1

Introduction

• 1.
  

  The concept “clinical psychosomatic” brings together and emphasises the connection between mind and body as being relevant to clinical medicine when evaluating diseases that affect both physical and mental health concomitantly.

  
  
• 2.
  

  It accounts for the fact that the body and mind are not disparate entities. Rather, they are anatomically and physiologically linked via the neuroendocrine system, with their interplay influencing the maintenance of overall health and the generation of clinical psychosomatic disease conditions.

  
  
• 3.
  

  Obesity is often associated with diseases due to clinical psychosomatic interactions that can affect women’s reproductive health, such as menstrual problems, metabolic disorders, infertility, gender-related violence, and cancer.

  
  
• 4.
  

  Both physical and mental illnesses in such despondent patients can lead to overeating and obesity. Early recognition and appropriate attention to relentless weight gain, often due to burgeoning psychosomatic issues, would likely prevent many cases of obesity.

15.2

Psychosomatic aspect of menstrual problems and obesity

15.3

Psychosomatic insights into menstrual problems in the obese

• 1.
  

  Obese woman can present with complaints of dysmenorrhoea, menorrhagia, menometrorrhagia, premenstrual syndrome (PMS), oligomenorrhea, amenorrhoea, or menopause. All of these are usually considered benign conditions.

  
  
• 2.
  

  They may cause dysphoria (anxiety and/or depression) in those experiencing these menstrual deviations, which can compel some women to seek relief by comfort eating, even if they might become overweight.

  
  
• 3.
  

  Nonmalignant growths, such as fibroids, ovarian cysts, and endometriosis, may be associated with heavy blood loss and dysmenorrhoea, which can promote overeating with an obesogenic body habitus.

  
  
• 4.
  

  Endometrial cancer or other malignancies of the female reproductive organs could present with menstrual problems, and these conditions occur more frequently in the obese. These cancers are affecting obese younger women as well.

15.4

Clinical psychosomatic approach to menstrual disorder

• 1.
  

  Menstrual problems may be perceived as ill-health, even if these problems are considered as normal by many, thereby encouraging some to gormandise in order to “feel good.”

  
  
• 2.
  

  Such problems can be of significance in the obese teenager undergoing menarche, especially if discussions with parents/caregivers medicalise reasonable lifestyle restrictions as so-called menstrual abnormalities.

  
  
• 3.
  

  A medical referral that sometimes involves a gynaecological assessment could ensue. Gynaecologist may not be comfortable in assessing associated dysphoria that could lead to obesity.

• a.
  

  Young patients may need gentle handling during the history-taking, examination, and investigations.

  
  
• b.
  

  Relevant initiating/aggravating biopsychosocial factors deserve appropriate consideration when revealed at a medical consultation for menstrual irregularities; a clinician with psychosomatic expertise can often be successful in bringing about symptom relief with less invasive methods.

  
  
• c.
  

  If a constitutional delay at menarche is diagnosed without any pathological contributing factors, reassurance and lifestyle alterations could limit the risk of overeating because of anxiety/depression, which could lead to becoming overweight/obese.

  
  
• d.
  

  If endocrinological or chromosomal anomalies are confirmed, and complex hormonal/surgical treatments considered necessary to alleviate the menstrual problem, the patient may experience feelings of shock, grief, denial, or guilt, due to perceived loss of femininity.

• 4.
  

  Clear and empathetic communication can be enhanced by taking a psychosomatic viewpoint during discussions regarding the management of these health issues, even more so in the overweight/obese.

  
  
• 5.
  

  A greater appreciation for the psychosomatic management perspective could also benefit the gynaecologist facing such scenarios, by fostering better doctor–patient rapport, thereby making patients more likely to adhere to recommended lifestyle interventions with the goal of preventing obesity.

  
  
• 6.
  

  The problem warrants an evaluation by a gynaecologist with a clinical psychosomatic-oriented approach. Facilities for such evaluations are sparse, and there are limited numbers of trained staff who can deliver the necessary patient-cantered assessments.

15.5

Clinical psychosomatic approach to premenstrual syndrome

• 1.
  

  Premenstrual molimina (dysmenorrhoea, bloating, dysphoria, irritability, headaches, bowel symptoms, and breast tenderness) is perceived as normal and dealt with as trivial discomfort by many.

  
  
• 2.
  

  There is trend among many gynaecologists to classify such menstrual symptomatology as PMS.

  
  
• 3.
  

  A more severe form of premenstrual symptomatology, premenstrual dysphoric disorder (PMDD) is associated with tearfulness, sleeplessness, or a preference for being bed-bound, overeating or having food cravings—all factors that increase the risk of obesity, besides amplifying the psychological impact of menstrual molimina.

  
  
• 4.
  

  PMS and the more severe form PMDD have been considered as psychosomatic disorders related to endocrinological and autonomic alterations associated with changes in the woman’s body and certain brain centres during the menstrual cycle.

  
  
• 5.
  

  These conditions can also promote weight gain from being sedentary and overeating, accordingly promoting obesity. In certain social groups, comfort eating is encouraged for women with PMS/PMDD as a coping strategy, often with little regard for potential weight increases.

  
  
• 6.
  

  Gynaecologists who are unfamiliar with psychosomatic issues usually prescribe hormonal medication, failing which surgical treatment is advised including hysterectomy, yet the problem often persists.

  
  
• 7.
  

  Consultation with a psychosomatically oriented clinician may persuade the patient to accept a trial of noninvasive management with risk of fewer potential side effects, including lifestyle modifications that could also remedy the ill effects of obesity.

15.6

Psychosomatic aspect of infertility and obesity

• 1.
  

  Infertility or subfertility is the inability to conceive despite regular unprotected intercourse for a defined period of time and can results in psychosomatic consequences that are often associated with obesity in women.

  
  
• 2.
  

  Woman has often been blamed for failures to conceive, which has persisted in many cultures even if investigations disclose that she is fertile.

  
  
• 3.
  

  Obesity can impact on fertility by impairing the development of ovarian follicles, causing defective oocyte maturation, and disrupting meiosis that causes abnormal embryo preimplantation.

  
  
• 4.
  

  Disappointing pregnancy outcomes can result in stress with guilt and self-blame because of unforgiving sociocultural attitudes. Thus infertile women facing failed attempts at conceiving, notably if obese, can acquire depression, phobic anxiety, and paranoid ideation.

  
  
• 5.
  

  Psychosocial distress can promote overeating and obesity, which further potentiates infertility due to ovulatory or unexplained causes in 50% of couples.

  
  
• 6.
  

  In vitro fertilisation is said to bring about lower live birth rates for couples with unexplained infertility, along with a higher risk of complications in the obese.

  
  
• 7.
  

  Endocrinological milieu associated with obesity also causes early miscarriages or pregnancy complications that result in the noncontinuation of pregnancy.

  
  
• 8.
  

  Couples can be steeped in dysphoria following repeated failed attempts to conceive and may welcome an obesogenic diet that is comforting.

  
  
• 9.
  

  Women undergoing assisted conception have high levels of stress. Stress associated with infertility may also cause sexual or marital conflicts, which have long-lasting effects, and comorbid dysphoria could manifest in couples.

  
  
• 10.
  

  Pregnancy rates may increase in obese infertile women after they undergo behavioural treatment for stress management and weight loss.

  
  
• 11.
  

  A gynaecologist with clinical psychosomatic skills could help resolve intense situations in the infertile couple by assessing specific needs, and appropriately counselling the obese who want to start a family.

15.7

Psychosomatic aspect of gender violence and obesity

• 1.
  

  Data from the United States confirms that Interpersonal violence (IPV) can lead to obesity. Although underreported for fear of reprisal from the male partner, IPV causes 4 million injuries annually, with 36% of women reporting rape, physical violence, or stalking, and 48% complaining of psychological aggression.

  
  
• 2.
  

  These can result in clinical psychosomatic issues and obesity in many affected women.

  
  
• 3.
  

  Women who experience both physical and nonphysical IPV are at an increased risk of experiencing numerous adverse health problems, such as chronic pain, gastrointestinal disorders, depression, anxiety, posttraumatic stress disorder, and sleep disorders, along with their overeating habits.

  
  
• 4.
  

  Besides, women may experience nonphysical forms of IPV, such as control through humiliation, verbal abuse, or threats of abuse to her or someone she loves, so that she lives in fear of her partner, thereby making her resort to comfort eating as a panacea for her dysphoria.

  
  
• 5.
  

  This is relevant to the practice of gynaecology worldwide as these women ignore weight gain even if it leads to obesity.

  
  
• 6.
  

  A large proportion of obesity in many populations would be prevented if IPV and linked overeating could be stopped.

  
  
• 7.
  

  The vital importance of ending violence against women to facilitate improved psychosomatic health internationally has been recognised by key international organisations such as the WHO and United Nations (UN).

  
  
• 8.
  

  The United Kingdom’s National Institute for Health and Clinical Excellence developed relevant guidance to prevent/stop IPV.

  
  
• 9.
  

  Educating health professionals to deal effectively with women’s clinical psychosomatic illnesses due to gender-related violence remains vital.

15.8

Psychosomatic aspect of severe pelvic/perineal dysfunction and obesity

• 1.
  

  Pelvic floor/perineal dysfunction, also referred to as pelvic/perineal dysfunction, relates to symptoms that bring about physical and mental ill-health.

  
  
• 2.
  

  The pelvic/perineum diaphragm comprises myofascial structures that support the pelvic organs and facilitate normal urogenital function by preserving their anatomical integrity and innervation from segments L3 5, S2 5 of the spinal cord.

  
  
• 3.
  

  Derangement of the nerve supply or injury to the muscles and ligaments of the pelvic floor or perineum can lead to the symptoms of pelvic/perineal dysfunction.

  
  
• 4.
  

  Bladder and bowel continence is a voluntarily acquired, socially appropriate behaviour learnt through a process of conditioning during childhood, so the loss of continence, especially in obese women, can impair physical and mental health.

  
  
• 5.
  

  Women who suffer from pelvic floor symptoms (which comprise urinary incontinence, anal incontinence, dyspareunia, prolapse, and haemorrhoids) will have severe biopsychosocial repercussions.

  
  
• 6.
  

  These symptoms can lead to severe physical and mental ill-health, yet studies of the impact on the relevant clinical psychosomatic health issues that are generated remain scarce. It is clinically important to evaluate the relationship of pelvic/perineal symptoms with physical and mental wellbeing that is compromised by urinary/faecal incontinence, too often in the obese.

  
  
• 7.
  

  The perceived psychosomatic misery borne by those with severe symptoms was not given enough attention. Incontinence causes anxiety/depression/phobias, which impact on overall welfare and health-seeking behaviour, thereby underscoring the importance of the psychosomatic approach toward symptom relief.

  
  
• 8.
  

  Clinical evidence for the sufferer’s psychosomatic issues is scarce, particularly in obese/overweight patients.

  
  
• 9.
  

  Further research on obesity and the psychosomatic aspects of pelvic floor/perineal dysfunction in the obese would be clinically useful for improving patient-centred care as novel management insights accrue.

15.9

Psychosomatic aspect of gynaecological tumours and obesity

• 1.
  

  The incidence of endometrial cancer has risen over the last three decades to affect many at a younger age, mirroring the trend in obesity.

  
  
• 2.
  

  In utero foetal metabolic programming in the obese gravida can promote obese offspring, who would in turn be expected to be at increased risk of cancer.

  
  
• 3.
  

  There should be a multidisciplinary approach to support obesity gravida to lose weight during postnatal phase, as they are at increased risk of developing type 2 diabetes over the next 10 years,

  
  
• 4.
  

  Reduction of obesity would positively influence prevention of this cancer and other malignancies, thereby averting considerable clinical psychosomatic health burden.

  
  
• 5.
  

  Advising weight loss, ideally beginning with individualised lifestyle interventions may prevent endometrial cancer in those with a raised BMI.

  
  
• 6.
  

  Improvement in clinical psychosomatic health of younger women who wish to start a family is particularly relevant, as cancer treatment may permanently preclude natural childbearing.

  
  
• 7.
  

  Physical, mental, and social wellbeing in cancer survivors treated for early-stage endometrial cancer, showed improvement which is inversely related to BMI.

  
  
• 8.
  

  American Society for Clinical Oncology has been particularly active in promoting awareness among professionals and public alike of the links between obesity and cancer, including preparing a guide to aid physicians in advising weight reduction in obese women.

  
  
• 9.
  

  Primary and secondary preventative strategies for obesity and its complications seem sensible, such prudence may seem unacceptable to those who overeat due to familial/social pressures. Many patients who reach the obese habitus require tertiary management measures, such as weight-reducing or bariatric surgery.

15.10

Conclusions

• 1.
  

  A clinical psychosomatic approach aiming to reduce the urge to overeat seems reasonable for many facing these.

  
  
• 2.
  

  The trend for coping with menstrual irregularities using a calorie-rich diet seems unnecessary but is nevertheless followed by certain groups. Other treatments for menstrual problems, including PMS and PMDD, have ranged from pharmacotherapy to surgery, but these maladies could merit less-invasive management in many health issues.

  
  
• 3.
  

  Infertility/subfertility, with its psychosomatic implications, continues to be of great significance. Psychosomatic approaches that promote a healthy lifestyle could enable natural conception to childbirth after desired weight reduction in the obese.

  
  
• 4.
  

  Obesity can be promoted by inescapable IPV. This behaviour is associated with major clinical psychosomatic implications that promote overeating.

  
  
• 5.
  

  Pelvic floor dysfunction have a penchant for the obese. Psychosomatic aspect aggravated by the overweight habitus and symptom relief success is encouraged by weight loss in the obese.

  
  
• 6.
  

  Primary and secondary prevention of cancer and obesity could be a sound clinical psychosomatic approach. Prevention of obesity would reduce the disease burden of such cancers.

  
  
• 7.
  

  Health providers ought to consider the biological, psychological, social, and cultural factors that influence clinical psychosomatic interactions and promote obesogenic behaviour.