medical news 6 - Journal of Medical Science

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MEDICAL NEWS
A BIMONTHLY SCIENTIFIC JOURNAL PUBLISHED BY
POZNAN UNIVERSITY OF MEDICAL SCIENCES
POLAND
NOWINY LEKARSKIE
DWUMIESIĘCZNIK NAUKOWY UNIWERSYTETU MEDYCZNEGO
IM. KAROLA MARCINKOWSKIEGO W POZNANIU
Founded in
Rok założenia
1889
6
2013
(82)
ISSN 0860–7397
Indexed in / Indeksowane w:
Polska Bibliografia Lekarska, MNiSW,
Index Copernicus, Google Scholar
Full texts on line / Pełne teksty prac:
www.medicalnews.ump.edu.pl / www.nowinylekarskie.ump.edu.pl
Medical News 2013, 82, 6, 421–427
PIOTR KORDEL1, MAŁGORZATA KORALEWSKA-KORDEL2
PARENTAL TESTING IN THE FORENSIC MEDICINE INSTITUTE
OF POZNAN UNIVERSITY OF MEDICAL SCIENCES 1980–2011
USTALANIE OJCOSTWA W ZAKŁADZIE MEDYCYNY SĄDOWEJ
UNIWERSYTETU MEDYCZNEGO W POZNANIU W LATACH 1980–2011
1
Laboratory of History of Public Health and Social and Health Policy, Chair of Social Sciences
Poznan University of Medical Sciences, Poland
Head: prof. Michał Musielak
2
Department and Institute of Forensic Medicine, Poznan University of Medical Sciences, Poland
Head: Czesław Żaba, MD, PhD
Abstract
Introduction. Stating or denying the identity between the biological and legal parentage has been a problem for centuries. Not
until the latter half of 20th century, thanks to advances in medical sciences, this problem couldn’t be solved. The classic serological
analysis, the HLA system analysis and DNA analysis enabled people to exclude or confirm paternity.
Aim. Presentation of the structure of non-paternity events in expert opinions provided by the Forensic Medicine Institute of
Poznan University of Medical Sciences in the years 1980–2011, judging the influence of the method used for parental testing on
the percentage of non-paternity events and presentation the influence of demographic changes in Poland on the number of paternity
tests run by the Forensic Medicine Institute of Poznan University of Medical Sciences.
Material and methods. The research material were the results of the paternity test conducted in the Forensic Medicine Institute
of Poznan University of Medical Sciences in the years 1980–2011: 4387 serological test, 679 HLA system tests and 1252 DNA
analyses.
Results. The percentage of non-paternity events in serological test in the years 1980–2004 reached 24.25%. In HLA system analyses
in the years 1980–1997 non-paternity events were 14.29% and in DNA analyses they were 20.85%.
Conclusions. The method used for parental testing does not influence the non-paternity events percentage but the demographic
changes had influenced the number of parental tests run by the Forensic Medicine Institute of Poznan University of Medical
Sciences.
KEY WORDS: parental testing, serological analysis, HLA analysis, DNA analysis.
Streszczenie
Wstęp. Ustalenie tożsamości między ojcostwem biologicznym i prawnym przez wieki było problemem nierozwiązywalnym.
Dopiero w drugiej połowie XX w., dzięki postępom w naukach medycznych, udało się rozwiązać ten problem. Klasyczna ekspertyza
serologiczna, badania układu HLA i analiza DNA pozwoliły na wykluczenie, a następnie potwierdzenie ojcostwa.
Cel. Przedstawienie struktury wykluczeń ojcostwa w ekspertyzach Zakładu Medycyny Sądowej UM w Poznaniu w latach 1980–
2011, ocena wpływu stosowanej metody analizy na procent wykluczeń oraz przedstawienie wpływu przemian demograficznych
w Polsce na liczbę wykonywanych badań w Zakładzie Medycyny Sądowej UM w Poznaniu.
Materiał i metody. Materiał badawczy stanowiły wyniki badań ustalenia ojcostwa przeprowadzonych w Zakładzie Medycyny
Sądowej Uniwersytetu Medycznego w Poznaniu w latach 1980–2011: 4387 ekspertyzy serologiczne, 679 badań układu HLA i 1252
analizy DNA.
Wyniki. Odsetek wykluczeń ojcostwa przy zastosowaniu klasycznej ekspertyzy serologicznej wynosił w latach 1980–2004 24,25%.
W przypadku ekspertyz układu HLA w latach 1980–1997 wykluczenia ojcostwa stanowiły 14,29% wyników. Z kolei w wyniku
analiz DNA w latach 1997–2011 wykluczenia ojcostwa stanowiły 20,85% wyników badań.
Wnioski. Stosowana metoda ustalania ojcostwa nie wpłynęła na odsetek wykluczeń w badaniach. Wpływ przemian demograficznych
na liczbę badań ustalenia ojcostwa w Zakładzie Medycyny Sądowej UM w Poznaniu jest wyraźnie zauważalny.
SŁOWA KLUCZOWE: ustalanie ojcostwa, ekspertyza serologiczna, ekspertyza HLA, analiza DNA.
Introduction
Each year in Poland courts hear several thousand cases
related to the problem of paternity. Those cases concern
mainly affiliation and denial of paternity. The trial in
those cases in ended by a verdict stating or denying the
identity between the biological and legal parentage.
The problem of parentage is dated back to the ancient
times. The only methods available used for checking
whether the man was the biological father of a child
ORIGINAL PAPERS
422
Piotr Kordel, Małgorzata Koralewska-Kordel
were, for many ages, the anthropological methods basing
on the physical resemblance between the father and the
child, which were an imperfect tool, and the knowledge
on the time of conception. The second method was also
faulty because promiscuous nature of human beings. The
thing that proves best the weakness of those methods is
the Roman maxim Mater semper certa est, pater semper incertus est and the legal presumption of legitimacy pater est, quem nuptiae demonstrant, which is also
present in Polish family law (art. 62 of the Polish Family and Guardianship Code, Polish Official Journal No
2012.788).
The advances of medical sciences enabled people to
solve the problem of stating the biological paternity.
The first method used for exclusion of paternity was
the serological expertise. Introduction of the study of
blood groups into courtroom practice as an evidence
was possible thanks to many discoveries such as Gregor
Mendel’s inheritance patterns or Karl Landsteiner’s
distinction of the main blood groups. In 1911 Ludwik
Hirszfeld proved that blood groups are inherited according to rules stated by Mendel. Poland was one of the first
countries which allowed serological expertise in courts
– in 1926 professor Jan Olbrycht ran serological test
for an alimony trial for a court in Krakow and professor Ludwik Hirszfeld did the same for a court in Warsaw
[1]. Through the years the range of serological expertise
changed thanks to discovering new serological systems.
The Polish Society of Forensic Medicine and Criminology set 11 systems, which were used for serological
expertise: AB0, MNSe, Rh, Kell-Cellano, Hp, Gm(1),
Gc, Blood Acid Phosphatase, Phosphoglucomutase, D
Esterase, GLO I. The efficiency of the classic serological
expertise in excluding paternity reached 88% [2].
In the latter half of the 1970’s the HLA system expertise became a legal evidence. The first HLA expertise in
Poland was conducted in Poznan in 1980 [3]. The HLA
system analysis was used as the 2nd degree analysis for
the classic serological expertise. The excluding power of
those two combined methods reached 97% [4, 5].
The 1990’s brought a significant change in paternity
testing. The DNA analysis methods developed by A.J.
Jeffreys i K. Mullins [6] enabled scientists not only to
exclude parentage but to confirm it with the probability reaching 99.99% [7]. Between 1991 and 1997 in the
Forensic Medicine Institute of Poznan University of
Medical Sciences the DNA analysis was used as the 3rd
degree analysis together with serological and HLA tests.
After 1997, due to high costs, the HLA expertise was
abandoned and the serological test were run extremely
rare because the DNA analysis turned out to be the most
effective method.
Aim
The aims of the article are:
– Presentation of the structure of non-paternity events
in expert opinions provided by the Forensic Medicine
Institute of Poznan University of Medical Sciences in
ORIGINAL PAPERS
the years 1980–2011 for the legal trials concerning
affiliation and denial of paternity.
– Judging the influence of the method used for parental
testing on the percentage of non-paternity events in
the expert opinions provided by the Forensic Medicine Institute of Poznan University of Medical Sciences.
– Presentation of the influence of demographic changes
in Poland on the number of paternity tests run by the
Forensic Medicine Institute of Poznan University of
Medical Sciences.
Material and methods
The research material were the results of the paternity test conducted in the Forensic Medicine Institute
of Poznan University of Medical Sciences in the years
1980–2011: 4387 serological test, 679 HLA system tests
and 1252 DNA analyses. The methods used for serological tests concerning red blood cells group antigens were
standard methods using diagnostic serums provided by
Biotest, Fresenius, Organon, Bheringwerke, Immuno
and Ortho. For marking the antigens of the HLA system
a microcytotoxicity tests were used with serums provided by Behringwerke, Biotest, Fresenius and Hintel and
a rabbit complement. The DNA analyses were run using
DNA hybridization and the polymerase chain reaction
with multiplex PCR amplification and analysis of STR
DNA Loci by AmpF Identifiler system by Applied Biosystems.
Results
The standard serological expertise was conducted in
the Forensic Medicine Institute of Poznan University
of Medical Sciences up to 2004. Since 1980 4387 test
were conducted in which 1064 excluded paternity of the
alleged father. As Table 1 shows it were 24.25% of all
tests. Depending on year the percentage of non-paternity
events varied from 28% to 11.7%.
Table 2 presents the percentage of non-paternity
events using the HLA system analysis. As it can be seen
the exclusion percentage for this method is much lower
and reaches 14.29%. It results from the fact that HLA
system analysis was used as the IInd degree analysis, that
means that it was used when the classic serological test
was unable to exclude paternity.
Table 3 presents the percentage of non-paternity
events for DNA analysis method which reaches 20.85%.
Conclusions
Analyzing Tables 1, 2 and 3 it is possible to say that
the method used for parental testing does not influence
the non-paternity events percentage. It seemed that the
increase in test sensitivity should produce growth of the
parentage exclusion percentage but we observed a significant drop from 24.25% for serological tests to 20.85%
for DNA analysis.
Parental testing in the Forensic Medicine Institute of Poznan University of Medical Sciences 1980–2011
423
Table 1. Non-paternity events in serological tests conducted in the Forensic Medicine Institute of Poznan
University of Medical Sciences 1980–2004
Tabela 1. Zaprzeczenia ojcostwa w ekspertyzach serologicznych przeprowadzonych w Zakładzie Medycyny Sądowej Uniwersytetu Medycznego w Poznaniu w latach 1980–2004
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Total
Number of serological tests
357
394
388
310
313
336
297
266
236
229
244
278
182
98
80
70
55
59
33
34
45
24
17
20
22
4387
Number of non-paternity events
98
110
107
89
80
91
70
60
62
62
37
50
31
24
20
17
10
16
4
4
7
4
3
4
4
1064
% of non-paternity events
27.45
27.92
27.58
28.71
25.56
27.08
23.57
22.56
26.27
27.07
15.16
17.99
17.03
24.49
25
24.29
18.18
27.12
12.12
11.76
15.56
16.67
17.65
20
18.18
24.25
Table 2. Non-paternity events in HLA analyses conducted in the Forensic Medicine Institute of Poznan
University of Medical Sciences 1980–1997
Tabela 2. Zaprzeczenia ojcostwa w analizach HLA przeprowadzonych w Zakładzie Medycyny Sądowej
Uniwersytetu Medycznego w Poznaniu w latach 1980–1997
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
Total
Number of HLA tests
34
22
45
48
41
32
63
57
78
60
51
56
39
27
13
9
3
1
679
4
7
11
10
17
7
6
9
11
3
1
3
1
4
1
2
0
0
97
11.76
31.82
24.44
20.83
41.46
21.88
9.52
15.79
14.1
5
1.96
5.36
2.56
14.81
7.69
22.22
0
0
14.29
ORIGINAL PAPERS
424
Table 3. Non-paternity events in DNA analyses conducted in the Forensic Medicine Institute of Poznan
University of Medical 1991–2011
Tabela 3. Zaprzeczenia ojcostwa w analizach DNA przeprowadzonych w Zakładzie Medycyny Sądowej
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Total
Number of DNA tests
5
9
3
10
48
40
40
45
53
72
95
72
87
85
72
76
89
88
81
93
89
1252
0
1
0
0
11
13
3
10
13
12
20
14
18
14
14
18
25
18
17
20
20
261
0
11.11
0
0
22.92
32.5
7.5
22.22
24.53
16.67
21.05
19.44
20.69
16.47
19.44
23.68
28.09
20.45
20.99
21.51
22.47
20.85
Table 4. Illegitimate births in Poland 1970–2011
Tabela 4. Urodzenia pozamałżeńskie w Polsce w latach 1970–2011
1970
1975
1980
1985
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Number of illegitimate births
27502
30638
33203
33948
34035
36291
37036
40588
43206
41003
43548
45286
45696
44688
45897
48326
51009
55542
60995
67239
70688
75488
82305
84527
85085
82434
Illegitimate as a percentage of total live births
5
4.7
4.8
5
6.2
6.6
7.2
8.2
9
9.5
10.2
11
11.6
11.7
12.1
13.1
14.4
15.8
17.1
18.5
18.9
19.5
19.9
20.2
20.6
21.2
Data from Demographic Yearbooks of Poland published by Central Statistical Office.
Opracowanie własne na podstawie roczników demograficznych GUS.
ORIGINAL PAPERS
Interesting conclusions come from comparing the
number of parental tests run in the Forensic Medicine
Institute of Poznan University of Medical Sciences
with the illegitimate births rate in Poland published by
the Central Statistical Office (Główny Urząd Statystyczny).
Table 4 illustrates that since 1970 up to 2011 a constant growth of illegitimate births rate can be observed.
In 2011 every fifth child was born outside marriage. This
could lead to a presumption that the number of court tri-
425
als related to the problem of paternity should grow and
so should the number of paternity tests. But as can be
seen in Figure 1 there is no such correlation.
What is more, a significant drop can be seen. When
it comes to the HLA system analyses (Figure 2) the drop
results from introducing the DNA analysis method.
But when the classic serological expertise is concerned (Figure 3) a significant difference between 1980’s
and 1990’s can be observed. It results from a severe drop
of the live birth rate in Poland (Figure 4).
Figure 1. Number of paternity test conducted in the Forensic Medicine Institute of Poznan University of
Medical Sciences 1980–2011
Rycina 1. Liczba ekspertyz w sprawach dotyczących ustalenia ojcostwa w Zakładzie Medycyny Sądowej
Figure 2. Number of HLA analyses conducted in the Forensic Medicine Institute of Poznan University of
Medical Sciences in cases related to the problem of paternity 1980–1997
Rycina 2. Liczba analiz HLA przeprowadzonych w Zakładzie Medycyny Sądowej Uniwersytetu Medycznego w Poznaniu w sprawach dotyczących ustalenia ojcostwa w latach 1980–1997
ORIGINAL PAPERS
426
Figure 3. Number of serological test conducted in the Forensic Medicine Institute of Poznan University of Medical Sciences in cases related to the problem of paternity 1980–2004
Rycina 3. Liczba ekspertyz serologicznych przeprowadzonych w Zakładzie Medycyny Sądowej Uniwersytetu Medycznego w Poznaniu w sprawach dotyczących ustalenia ojcostwa w latach 1980–2004
Figure 4. Live birth rate in Poland 1970– 2009
Rycina 4. Urodzenia żywe w Polsce w latach 1970–2009
Data from Demographic Yearbooks of Poland published by Central Statistical Office.
Opracowanie własne na podstawie roczników demograficznych GUS.
ORIGINAL PAPERS
427
Figure 5. Number of DNA analyses conducted in the Forensic Medicine Institute of Poznan University of
Medical Sciences in cases related to the problem of paternity 1991–2011
Rycina 5. Liczba analiz DNA przeprowadzonych w Zakładzie Medycyny Sądowej Uniwersytetu Medycznego w Poznaniu w sprawach dotyczących ustalenia ojcostwa w latach 1991–2011
The more or less constant level of number of DNA
analyses run by the Forensic Medicine Institute of Poznan
University of Medical Sciences from 2001 to 2011 (Figure 5) may be a result of counterbalance effect which the
growth of illegitimate birth rate has on the drop of the
total live birth rate.
References
1. Turowska B. Badania grupowe krwi w sprawach spornego
ojcostwa przeprowadzone w Katedrze i Zakładzie Medycyny Sądowej w Krakowie w latach 1926–1996. Archiwum
Medycyny Sądowej i Kryminologii, XLVII: 139–145.
2. Dobosz T, Świątek B. Dochodzenie spornego ojcostwa
poprzez badanie polimorfizmu DNA. Post Med Sąd Krym.
T. III: 339–343.
3. Stawarz M, Przybylski Z. Polimorfizm układu HLA –
locus A, B, C i jego przydatność przy dochodzeniu spornego ojcostwa. Archiwum Medycyny Sądowej i Kryminologii. XXX: 277–284.
4. Kordel M, Kątniak R, Kordel K. Częstość i struktura wykluczeń ojcostwa w układzie HLA. Post Med Sąd
Krym. 1988, T. I: 99–103.
5. Pepiński W, Janica J. Częstość antygenów HLA – ABC
oraz częstość i struktura wykluczeń w badaniach spornego ojcostwa w populacji Polski Północno-Wschodniej. Post
Med Sąd Krym. 1995; T. II: 363–369.
6. Mullis KB, Faloona F. Specific synthesis of DNA in vitro
a PCR reaction. Methods Enzymol. 155: 335–350.
7. Bjerie A, Syndercombe D, Lincoln P, Morling N. A report
of the 1995 and 1996 paternity testing workshop of the
English speaking working group of the International Society for Forensic Haemogenetics. Forensic Sci Int. 90: 41–55.
Correspondence address:
Chair of Social Sciences
Poznan University of Medical Sciences
79 Dąbrowskiego Street
60-529 Poznań, Poland
phone: +48 61 854 69 11
email: [email protected]
ORIGINAL PAPERS
Medical News 2013, 82, 6, 428–432
URSZULA KLUCZYŃSKA
HOW TO BE A FATHER? AN ANALYSIS OF SELF-HELP BOOKS
AND MAGAZINES FOR PARENTS
JAK BYĆ OJCEM? ANALIZA PORADNIKÓW I CZASOPISM DLA RODZICÓW
Department of Medical Education, Poznan University of Medical Sciences, Poland
Head: prof. Maciej Wilczak
Abstract
The aim of this article is to define mainstream and alternative ways of realizing roles and duties of a contemporary father presented
in magazines and self-help books for parents. The article shows the transformation of the concept of fatherhood and the ways of
defining roles of a contemporary father and mutual conditions and relations in constructing these categories. The main changes in
the concept of masculinity and fatherhood are presented. It also proposes periodization of the fatherhood portraits that are dominant
in the Western culture. It argues that just as there are many concepts of masculinities there are many patterns of fatherhood. The
impact is being put on the analysis of the category of new fatherhood which is said to be the dominant contemporary construction of
fatherhood. The division into culture of fatherhood and conduct of fatherhood proposed by R. LaRossa is presented as a vital element
in explaining the lack of precision with regard to the prevailing belief of the dominant pattern of fatherhood and implemented by the
fathers of tasks and activities. Results of research on magazines and self-help books for parents are presented.
KEY WORDS: fatherhood, gender, masculinity, magazines for parents, self-help books for parents.
Streszczenie
Celem pracy jest określenie propagowanego wzorca ojcostwa przekazywanego w ramach materiałów (czasopism, poradników)
skierowanych do rodziców, a także wskazanie alternatywnych modeli ojcostwa funkcjonujących w naszej kulturze. W ramach
artykułu autorka ukazała przemiany konstruktu ojcostwa i sposoby definiowania zadań współczesnego ojca, wzajemne
uwarunkowania i zależności konstruowania owych kategorii. Zaprezentowano główne przemiany w obrębie męskości, stanowiące
tło analiz ojcostwa. Przedstawiono propozycję periodyzacji portretów ojcostwa dominujących w ostatnim czasie, podkreślając, iż
współcześnie – wychodząc z założenia o istnieniu wielu męskości – można mówić także o funkcjonowaniu wielu wzorców ojcostwa.
Skupiono się na analizie kategorii nowego ojcostwa (new fatherhood) jako dominującej współcześnie kultury ojcostwa. Odwołano
się do zaproponowanego przez R. LaRossa podziału na kulturę ojcostwa (culture of fatherhood) i zachowania ojcowskie (conduct of
fatherhood), jako istotnego elementu wyjaśniającego nieścisłość w odniesieniu do panującego przekonania o dominującym wzorcu
ojcostwa i realizowanych przez ojców zadań i czynności. Zaprezentowano analizę poradników i czasopism dla rodziców.
SŁOWA KLUCZOWE: ojcostwo, gender, męskość, czasopisma dla rodziców, poradniki dla rodziców.
A fatherhood is social constructed and the way of being
a father is defined in various cultures and times in a different way. Patterns of fatherhood usually coexist, but
one of them is defined as the dominant one. A fatherhood is closely linked with the masculinity concept,
and changes among masculinities cause changes among
fatherhood concepts.
Social research shows that ‘there is no one pattern of
masculinity that can be found everywhere’ [1]. What is
more we need to speak of ‘masculinities’, not masculinity. The initial premise of the analysis of masculinity is
a rejection of an approach stating that there is only one
right and essential form of true masculinity and the conviction that we deal with masculinities which are socially
constructed and rendered within the discourse because
‘masculinities are neither programmed in our genes, nor
fixed by social structure, prior to social interaction. They
come into existence as people act. They are actively produced, using the resources and strategies available in
ORIGINAL PAPERS
a given social setting’ [1]. What is more ‘there is abundant evidence that masculinities do change. Masculinities
are created in specific historical circumstances and, as
those circumstances change, the gender practices can be
contested and reconstructed’ [1]. Different cultures, and
different periods of history, construct gender differently.
Following those assumption we cannot define masculinity or fatherhood in one way, because it is easily changeable category.
Changes of culture of fatherhood
In the past the answer to the question: what it means ‘to
be a father’? – was clear, standards of defining fatherhood were strictly defined with reference to masculinity.
It helped men to fulfill their social role. Nowadays the
answer is not as simple, it is more complicated, we cannot answer this question without any doubt because there
are various patterns of masculinities and fatherhood.
How to be a father? An analysis of self-help books and magazines for parents
Although it is a dizzying array of possibilities of forming an individual way of being the father of the man,
we can observe some crucial patterns. J. Pleck presents
the proposed periodization of the fatherhood portraits
which are dominant at the moment: ‘moral overseer’,
‘distant breadwinner’, ‘sex role model’, and ‘new father’.
Eighteenth century and the beginning of nineteenth
century was a period of ‘moral overseer’. A father used
to be a moral educator who taught his children what God
and the world expected from them [2]. According to J.
Demos emerged ‘picture, above all, of active, encompassing fatherhood, woven into the whole fabric of domestic
and productive life. Fathers were a visible presence, year
after year, day after day. Fathering was thus an extension, if not a part, of much routine activity’ [3].
The next model was called ‘distant breadwinner’
(XIX/XX). It was a time of growing importance of the
role of the mother, who was responsible for every domain of children’s life. In psychological theories the mother
played a crucial role in childrens’ development. At that
time the home and the father’s workplace became separated, causing a growing physical and emotional distance among the family. As J. Demos describes: ‘for the first
time, the central activity of fatherhood was sited outside one’s immediate household. Now being fully father
meant being separated from one’s children for a considerable part of each working day’ [3].
‘Sex role model’ (1940–1965) appeared as an effect of
the criticism of excessive influence of the mother. After
the wars the father was often defined by absence, which
was considered dangerous for the identity of the son [2].
As a critique of former models ‘new father’ appeared,
called by E. A. Rotundo the ‘androgynous father’ [4]. New
father is present during childbirth, and engaged in everyday care not only older children, but also infants. New
father is involved in the lives of his children, spends time
with them, feeds them, helps them with homework; he is
also responsible for children and takes part in everyday
decisions like buying clothes or going to the doctor [2].
‘New fatherhood’ in the context of cultural transformations of masculinity
It seems important to wonder how we can describe contemporary fatherhood. Researchers very often highlights
that new father can be defined by involvement. According M. E. Lamb parental involvement consists of three
components: engagement – time spent in one-on-one
interaction with the child (feeding, playing with the
child); accessibility – less intensive level of interaction,
parent doing one thing (e.g. cooking, cleaning) but is
available when the child needs them; and responsibility
– which can be described by things like making sure that
the child has clothes or shoes or like going to pediatrician [5].
New father, as a critique of former models, is described by J. Pleck as a father who ‘is present at the birth; he
is involved with his children as infants, not just when they
are older; he participates in the actual day-to-day work of
429
child care, and not just the play; he is involved with his
daughters as much as his sons’ [2] According to Rotundo
androgynous father ‘involves himself in a more expressive and intimate way with his children, and he plays a larger part in the socialization process that his male forebears had long since abandoned to their wives’ [4].
Appearing of the new fatherhood was an effect of few
coexisting occurrences. The most important seems to be
the critic of mother’s center role in the child development
but also mothers expectation directed to fathers. Women
expected from men commitment in parenthood. In this
situation a crucial role played femininity and masculinity changes, and gender order changes. J. Pleck points
up that ‘this image, like the dominant images of earlier
periods, is ultimately rooted in structural forces and
structural change. Wives are more often employed, and
do less in the family when they are; men are spending
more time in the family, both absolutely and relative to
women’ [2].
Changes in fatherhood models were the effect of the
social, cultural and economical transformation. Men and
their roles same as women, changed because of the modification of the social reality. New situation required redefinition of roles, duties, identity from women and men.
But the important thing is that it gave men the opportunity to participate in the private sphere without fear of
their masculinity. The appearance of a new model do not
mean that the older models does not exist any more, it is
rather – according to R. LaRossa – change in ‘the culture of fatherhood’ [6]. According to LaRossa ‘the institution of fatherhood includes two related but still distinct
elements. There is the culture of fatherhood (specifically
the shared norms, values, and beliefs surrounding men’s
parenting) and there is the conduct of fatherhood (what
fathers do, their parental behaviors)’ [6]. As researcher
stated we can observe the asynchrony between the culture and conduct of fatherhood; the culture of fatherhood
has hanged more rapidly than the conduct of fatherhood
[6]. Probably in various periods of time different models
of fatherhood coexisted, and depending on dominant version of masculinity or redefinition of masculinity, some
of them predominate over others. Those models of fatherhood which were established as dominant were describing culture of fatherhood of a particular period.
Portrayals of fatherhood in magazines for parents
Description of self-help books and magazines for
parents – who is a receiver?
It is important that titles of magazines and self-help books
are addresses to both parents. Whereas titles of self-help
books do not highlight gender of receiver, except situations when a book is directed to fathers (e.g. ‘You can
be super father’, ‘I am a father’), title of magazines are
never addressed directly to fathers (e.g. ‘I have a child’,
‘Your child’, ‘Parents’, ‘Child’, ‘My family’, ‘Your baby’,
‘M for mother’, ‘Mummy it’s me’). Subtitles of magazines intensify the message, that both parents are the targets of the product.
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Urszula Kluczyńska
It is worth to supplement this message with analysis
of covers of self-help books and magazines for parents.
The aim of covers is to inform readers of the theme of
a magazine or a book, and encourage people to buy
a magazine or a book. On covers of publications are presented a child or a mother with child. Pictures of fathers
are only on covers of self-help books directed to men. On
the basis of covers we can conclude that ‘a parent’ should
be read as ‘a mother’.
In magazines and self-help books for parents feminine grammatical form is used (sometimes plural form);
only books directed to fathers use masculine grammatical forms.
This construction of transmission in magazines
and self-help books indicate that a child affects women
identity rather than men identity. A father is defined as
a second parent, who is responsible just for some aspects of parenting. A father who wants to know more has
to read information in feminine grammatical form, so
he has to put himself into a mother’s place. It is more
possible that a man who wants to feel more secure will
read just information directed to fathers.
A distinctive feature of magazines for parents are
letters to the editor. Letters published in magazines for
parents contain information or advices, usually connected with everyday baby nurture, products for child or
health problems. But there are no letters from fathers,
that allows you to present some hypotheses. First, it is
possible that fathers do not read magazines for parents,
which is why they do not send letters to the editor. Or
perhaps fathers, who usually do not participate in daylong care or just participate partly, do not have enough
experience to share it. Finally men might read letters to
the editor, but do not perceive them as an area for men,
who often treat asking for help as a sign of weakness.
Mother’s and father’s duties and behaviors presented in magazines and self-help-books for parents
The main aim of the analysis is the description of ways
how fathers are presented and defying their parenting duties in contexts of masculinity. As I demonstrated earlier, the main receiver of magazines for parents
are women, whereas to fathers are directed short fragments, which usually are separated from the main part
of a magazine. Good example is the magazine ‘Mummy
it’s me’, which contains some parts: a main part, ‘mother
zone’ and ‘father zone’. ‘Mother zone’ contains information about beauty, spending free time without children,
fitness, diets, and relaxing. ‘Father zone’ shows fathers
who are engaged in children’s lives. When we compare
those zones, we get a clear message – mothers sometimes
have a break from taking care of their babies, whereas
men sometimes take up this role. What kind of subjects
are bring up in ‘father zone’ and self-help books directed
to fathers?
Analysis shows that fathers are perceived as a playmate, especially during out door activities [7]. According to researchers spending free time with children
ORIGINAL PAPERS
and playing with them are ways to maintain the bond
between them, to communicate and to inculcate values
in children. It is also important that this way of closeness does not undermine cultural masculinity standards,
because being active is a male practice [8]. In articles the
father is described not only as a everyday playmate, but
also as a person who organizes free time during weekends or holidays. To fathers are directed instructions
about arranging holidays, planning car journey or preparing first aid kid. But array of ‘men’s thing’ is limited to those tasks. There is nothing about packing child’s
clothes or toys.
Magazines for parents define carrying of child and
home duties as a natural women activity. Taking over
duties by father is an unusual situation:
Every day you take care of baby like every mother
does. But you need time to take care of yourself: go to
a hairdresser’s or beautician. So on Saturday let the father take care of your kid [9].
The article directed to fathers ‘A day without mum’
determines caring of baby as a woman’s task, whereas
a father day long care is a special event. Men are perceived as a helpless and unaware of ways of protecting and
carrying baby. Those special situation are define not as
a duty, but great fun: You can have a lot of fun [10]. There is no suggestion that fathers take over domestic duties
during such a day. What is more there is no suggestion
that fathers take over household duties and carrying for
child, while a mother goes to work.
Daylong care is define as a mother task. A good
example of this statement is the article ‘20 gadgets, which
make young mother life easier’ (not a mother and a father!). Magazines which determine receiver as a mother
show traditional way of sharing private and public sphere among women and men. Man is perceived as a person
who sometimes helps a mother in parenthood and take
part just in some duties. What is more those duties are
voluntary only for men.
Being a mother is described as natural, but being
a father is not. Mothers have to teach men how to be
a father:
Engage the future dad! You will be a mum because you
will give birth to your child. A future father has to learn
how to be a father, and you can help him do it [10].
It means that woman in a ‘natural’ way become
parent, and she is responsible for engage man and support him in discovering a new role. This conclusion
support once again that most of magazine and self-help
books form parents are directed to mothers, who are
obligated to educate their partners.
Articles in magazines highlight very often gender
differences with reference to parenthood: One thing is
obvious, mum love in different way than dad [11]. Further part of article contain statement about different way
of communication depended on gender. In the article the
How to be a father? An analysis of self-help books and magazines for parents
author describes a stereotypical way of communication,
and gives an example:
What mum says: Please put on your wellies. If your feet
get wet, you will stay in bed and take medicine. What
dad says: If you don’t put on your wellingtons, you will
not go outside [11].
A father is described as a less emotional, distant,
using orders and more consistent person than a mother.
Authors of magazines and self-help books assume
that a mother has more knowledge about child development and needs than a father, and present a stereotypical
picture of an irresponsible father and an over-protective
mother:
The father tosses the infant up to the ceiling, catches it
then tosses it again. Do you know such games? Don’t
allow them. Be firm [12].
Redefinition parental duties as a masculine
In ‘father zone’ we can observe attempts of redefinition
parental duties as masculine. Some behaviors are described as masculine to encourage men to take them up. On
the other hand a lot of subjects in magazines and selfhelp books are the reflection of stereotypical way of thinking and abilities of men and women.
First activity of men is he baby nurture. Some tasks
are redefined by emphasis different aspects than those
linked with mother’s task. Baby’s bathing and personal
hygiene become a way of confirming men’s strength and
domination:
Bathing an infant is a job for men. A baby will feel safe in
the big and strong hands of its father [13].
Next area, which is refined in magazines as a masculine is touch, closeness, and sensitivity. A model of
distance father is described as improper and destructive.
Authors of the article [14], refer to American psychologist, persuade fathers to the importance of intimacy and
touch. Touch is described as a kind of cure or therapy,
which supports child development. Touching and closeness are regarded as beneficial for a child and treat as
a kind of a masculine behavior:
It is time to get rid of men’s insensitivity [14].
Fatherhood is very often stereotypically described
as the end of freedom and irresponsibility. But in ‘father
zone’ we can find attempts to redefine this way of thinking:
Is it end of freedom? No, it’s not! Childbirth is just
a begging of new, different life [15].
In magazines men get information about ways of
supporting pregnant women. Most of magazines and
431
self-help books for parents try to redefine the moment of
turning into a father. Authors of articles convince men
that they are fathers since the moment of conception and
supporting pregnant women is a part of the father's role
and something what real men do. Fathers are described
as active during pregnancy and a childbirth. In magazines and self-help books we can find instructions like:
do shopping, support your women emotionally, and let
her take a rest [11].
Some of the tasks are interchangeably defined as
masculine, for example punishment. A fatherhood is linked with domination, exercising power, and controlling
a situation.
You’re a man. A rational guy, who is aware that in relation with his biggest treasure – child – will need to
punish his or her. As same as your father punished you,
and your grandfather punished your father [13].
The way of naturalization of fathers’ involvement is
presentation famous fathers (e.g. Marcin Baszczyński,
Marcin Prokop, or Bartosz Obuchowicz). Famous sportsmen, actors, newscasters declare that fatherhood is an
important part of their identity. One of the footballer said
that his son was for him more important than football.
Conclusions
Magazines and self-help books for parents confirm a traditional model of fatherhood in terms of conducts. In the
analyzed material we can find signs of involved fatherhood, or even suggestions like: ‘you should be an active father’ or ‘you should engage in your child's life’, but
there are limited examples of father’s ways of involvement in every day baby care. We can find more specific activities described or redefined as fatherly in ‘father
zone’, but those tasks are often traditional, clearly linked
with the stereotypical masculine role.
Magazines for parents define carrying of child and
home duties as a natural women activity. Daylong care
is define as a mother task, whereas taking over duties by
fathers is an unusual situation. Being a mother is described as natural, but being a father is not. Mothers are obligated to teach men how to be fathers. In terms of conducts fathers are mainly perceived as a playmate. Articles in magazines very often highlight gender differences
with reference to parenthood, and a father is described as
less emotional, distant, using orders and more consistent
than a mother.
Some of duties in child care are redefined as masculine. The most often baby’s bathing is described as
a father’s duty. This activity is perceived as a way of confirming men’s strength and domination. Another redefined task is touch. Touching and closeness are regarded as
a beneficial for a child and treated as a kind of masculine behavior. Most of magazines and self-help books for
parents try to redefine the time of turning into a father as
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Urszula Kluczyńska
a moment of conception. Some of the tasks are interchangeably defined as masculine, for example punishment, as
a result fatherhood is linked with domination, exercising
power, and controlling a situation.
LaRossa assumes that culture of the fatherhood fallows conduct seems to be justified. Beliefs surrounding men’s parenting, and idea of ‘new fatherhood’ is
just a part of culture, whereas particular conduct do not
change so rapidly. We can read in magazines and self
help books for parents about engaged fathers, but most
of behaviors and tasks connected with child care are still
described as a part of the feminine role.
References
1. Connell RW. University of California Press, Berkeley, Los
Angeles, 2000; 10, 10–12, 13–14.
2. Pleck JH. American fathering in historical perspective.
In: Kimmel MS, editor. Changing Men. New Direction in
Research on Men and Masculinity, Sage, Newbury-London-New Delhi, 1987; 84.
3. Demos J. The changing faces of fatherhood: A new exploration in American family history. In: Cath S, Gurwitt A,
Ross J, editor. Father and child: Developmental and clinical
perspectives. Litte, Brown, Boston, 1982; 425–450, 429.
ORIGINAL PAPERS
4. Rotundo EA. American Fatherhood. A historical perspective. American Behavioral Scientis. 1985;27:7–25, 17.
5. Lamb ME. Introduction. The Emergent American father.
In: Lamb ME, editor. The father’s role. Cross-cultural perspectives, Lawrence Erlbaum, Hillsdale, NJ, 1987; 3–25.
6. LaRossa R. Fatherhood and Social Change. Family Relations. 1988;37:451–457.
7. Russell G. Fatherhood in Australia. In: Lamb ME, editor.
The Father’s Role Cross-cultural Perspectives, Lawrence
Erlbaum, Hillsdale, NJ, 1987;331–358, 342.
8. Harrington M. Sport and Leisure as Contexts for Fathering
in Australian Families. Leisure Studies. 2006;25(2):181.
9. Mamo to ja. 2007;6:45.
10. Mamo to ja. 2006;3:94.
11. Twoje dziecko. 2008;6:96, 98.
12. Mamo to ja. 2007;5:36.
13. Mamo to ja. 2006;5:114.
14. Mamo to ja. 2007;2:92.
15. Mamo to ja. 2007;10:114.
Chair of Medical Education
70 Bukowska Street, level E1
phone: +48 61 854 73 06
Medical News 2013, 82, 6, 433–438
NATALIA MARKWITZ-GRZYB
WOMEN’S SEXUALITY DURING MENOPAUSAL TRANSITION
SEKSUALNOŚĆ KOBIET W OKRESIE KLIMAKTERIUM
Laboratory of Health Sociology and Social Pathology, Chair of Social Sciences, Poznan University of Medical Sciences, Poland
Abstract
Introduction. Sexuality is one of the most fundamental causes which motivate people to build bonds with each other. Biological,
emotional, intellectual, and social factors contribute to sexual health. If one of these factors is not functioning properly, the
remaining ones also suffer damage. Lack of sexual health may lead to various disorders and complexes. It is crucial for a woman
that menopausal transition should become a period in life which will not alter its quality both in psychological sphere as well as in
the range of sexual activity.
Aim. The aim of this study is to show the approach of women during menopausal transition to their own sexuality.
Material and methods. Survey questionnaire research method conducted on 286 women of different social status from Greater
Poland.
Results and conclusion. The majority of survey respondents 33.3% did not lose interest in sex life. The symptoms of menopausal
transition did not influence sexual activity of 32.6% of those questioned. Up to 37.8% of women do not agree with the statement that
a menopausal woman should stop being interested in sex. In the research group, the word ‘menopausal transition’ is most associated
with asexuality (44.6%).
KEY WORDS: menopausal transition, menopause, woman, middle age, sexuality.
Streszczenie
Wstęp. Seksualność jest jednym z zasadniczych powodów motywujących ludzi do budowania więzi. Na zdrowie seksualne
składają się czynniki biologiczne, emocjonalne, intelektualne i społeczne; jeśli któryś z nich nie funkcjonuje prawidłowo, cierpią
na tym pozostałe. Brak zdrowia seksualnego może prowadzić do różnych zaburzeń i kompleksów. Ważne jest, aby dla kobiety
klimakterium stało się okresem niewiele zmieniającym w jakości jej życia, zarówno w sferze psychicznej, jak i w zakresie
aktywności seksualnej.
Cel. Celem pracy jest ukazanie podejścia kobiet w okresie klimakterium do swojej seksualności.
Materiał i metody. Badaniami za pomocą kwestionariusza ankiety zostało objętych 286 kobiet o zróżnicowanym statusie
społecznym z Wielkopolski.
Wyniki i wnioski. U większości respondentek – 33,3% – nie wystąpiła utrata zainteresowania życiem płciowym. Dla 32,6% z nich
również objawy związane z klimakterium nie miały wpływu na ich życie seksualne. Aż 37,8% kobiet nie zgadza się ze stwierdzeniem,
że kobieta w okresie klimakterium powinna przestać interesować się seksem. W grupie badanej słowo „klimakterium” najczęściej
kojarzy się z aseksualnością – 44,6%.
SŁOWA KLUCZOWE: klimakterium, menopauza, kobieta, wiek średni, seksualność.
Introduction
Sexuality is one of the most fundamental causes that
motivate people to build bonds with each other. A contact with another human being can be a source of wonderful experiences. During respective periods of life,
the feelings of love reveal themselves in numerous ways
and, in many cases, they can have different shades. The
love of young people develops very quickly and often
draws on discovering the secrets of the opposite sex.
Middle age is the time for mature love to blossom, which
focuses on partners’ needs and mutual expectations. In
turn, throughout the twilight years, love manifest itself
in a positive attitude towards oneself, shared tenderness
and understanding. The decisive factor in maintaining
sexual activity until old age is the force of sex drive and
sexual arousal that a person exhibited during adulthood.
People in whom sex drive was strong usually maintain
it until advanced adulthood while those with low libido
watch its decline much sooner. The period of menopausal
transition is often identified with cessation of sexual activity. In the meantime, regular intercourse plays a vital
role in woman’s health and her sustenance of sexual activity. The research shows that 70% of 50-year old women
have a regular intercourse, more than 30% of those have
an intercourse at least once a week, and one in three
women claims that sex in old age provides her with more
intense experiences than during young adulthood. Sex
life depends of numerous factors: biological issues, personality, relations with partners and socio-cultural influORIGINAL PAPERS
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Natalia Markwitz-Grzyb
ences (for example, a conviction that from a certain age
one should not do ‘those things’) [1].
According to World Health Organization, sexual
health is an integration of biological, emotional, intellectual, and social aspects of sex life which are essential for
a positive development of personality, communication
and love. If one of those elements is dysfunctional, the
remaining ones suffer damage as well. Lack of sexual
health may lead to various disorders, complexes and self-esteem disturbances. In such cases there might occur:
metal health disorders, low self-esteem, conflicts and
tensions in relationship with partners as well as oversensitivity in interpersonal relations [2]. The meaning of
sexual practices (also during menopausal transition) is of
utmost importance for social research. Society encompasses the entirety of individuals. Emotional forces exerted on an individual become forces of social process [3].
A survey questionnaire research method was conducted on 286 women in 45–55 years of age who reside in
Greater Poland. A total number of respondents was constituted by women who were admitted as patients to
hospital wards because of menopausal syndromes and/
or hormonal disturbances, as well as those who visited
doctors’ offices in order to have preventive medical examination done. The average age of those questioned was
52 years. Women with higher education 41.7% as well
as with a secondary one 37.9% were the most numerous
group, while those with basic vocational education 11.6%
and with a primary one 2.8% were fewer in number. In
27.4% of indications, a rural area was the most common
place of residency of the respondents. In the second place was a city over 500 thousand inhabitants – 21.9%,
next a city from 21–100 thousand inhabitants – 21.5%,
a city under 20 thousand residents – 20.1% and a city
under 101–500 thousand residents – 9.1%. The respondents were in 79.6% working women, 7.8% of them were
retired, women on pension constituted 5.6%, 4.4% were
unemployed and 2.9% of women were keeping their houses. 77.6% were married, 7.7% of those questioned were
widows, unmarried women constituted 7.7%, 4% were
divorces and 2,9% respectively were made up of women
who were either legally separated from their partner or
living in cohabitation. The majority specified their income as lower than the average remuneration – 52.98%
(reference sum of money was 3,500 of gross income).
Results
In many societies there exist some prevailing myths and
stereotypes concerning eroticism during the period of
menopausal transition: women are less sensual, a woman
wishes to take a break from sexual activity, an aging
woman starts to show some masculine features. There
is a pre-established canon in which ‘everything connected to sex is not appropriate for a menopausal woman.’
It is commonly thought that women during this period
ORIGINAL PAPERS
‘are past their prime.’ Those difficult to reverse, atavistic
views contributed to seeing a women over 40 or 50 years
of age who enjoys sex life in a negative light. It was not
until the 1960s that the subject of sexuality in menopausal women was dealt with. The social atmosphere was
not favorable towards sex, seeing women at that age as
matrons, and post-reproductive meaning of sexuality was
not regarded as a value in the quality of life. The change
of customs, emancipation, lengthening of the average life
span, health promotion and the standard of therapeutics
contributed to the increase in research and publications
about sexuality in the age around menopausal transition.
The attitude of mature women towards subjects concerning sexual functions depends on a change in their
state of health during menopausal transition, a change in
a partner’s state of health or appearance of a new partner, as well as on cultural, social and religious aspects.
Woman’s sexual health is also influenced by her lifestyle (smoking, use of alcohol, exposure to toxins, physical activity), taken medicine, relationship with a partner
(partner’s sexual dysfunctions) and factors of psychological nature (depression, exhaustion, sleep deficiency,
stress, lack of sexual education, negative view of one’s
body, rigorism of customs and religion). It is believed that
a successful and fulfilling relationship, attractiveness of
a partner, a high level of sexual awareness, a good sexual
imagination and a low level of fear are advantageous to
one’s sexual activity during the period around menopause transition [4].
Respondents asked whether they lost an interest in
sexual life during menopausal transition answered that
they did not – 33.3%. 7% of women loses interest in sex
very often and to 15.1% of them it occurs quite frequently (Table 1). Similar answers were obtained for a question whether the symptoms of menopausal transition
have any influence on their sexual life. For 32.6% of those questioned the symptoms did not have any influence,
whereas for 7% of women they did indeed have a significant one (Table 2).
Age affects our needs and sexual vigor, although we
do often overestimate it. It is a great deal of work to learn
how to recognize this aspect and do not give into stereotypes. In order to take advantage of maturity for the rest
of one’s life, we should welcome what it gives us. The
longer the partnership lasts, the more obvious it becomes
that duties and the routine of everyday life cause a decline in mutual attraction and can lower a sexual interest. If
conflicts in a relationship such as disagreement, incompatibility of characters or sexual needs are not solved,
indifference and even animosity develops between both
partners. Sex in life declines or becomes another area of
conflict, violence and pretense [5].
The average life span lengthens and estimates show
that people over 60 years of age in the European Union
countries constitute one third of the general population.
The state of health of society also improves which has
an impact on sexual and partner relations. In addition to
being sexually and psychologically able, more and more
mature people look younger. It is enough to compare
Women’s sexuality during menopausal transition
435
Table 1. Frequency of occurrence of ‘menopausal transition’ symptoms. Source: own work
Tabela 1. Częstość występowania objawów „klimakterycznych”
Valid
Lack of data
Overall
Do you experience a decrease in interest in sex life?
Frequency
Percentage
Percentage of valid
does not occur
95
33.3
38.8
sometimes
87
30.5
35.5
quite often
43
15.1
17.6
very often
20
7.0
8.2
overall
245
86.0
100.0
Systematic lack of data
40
14.0
285
100.0
Cumulative percentage
38.8
74.3
91.8
100.0
Table 2. Influence of the symptoms on sex life. Source: own work
Tabela 2. Wpływ objawów na życie seksualne
Valid
Lack of data
Overall
Did the symptoms connected to menopausal transition influence your sex life?
Frequency
Percentage
Percentage of valid Cumulative percentage
not at all
93
32.6
33.9
33.9
somewhat
67
23.5
24.5
58.4
moderately
47
16.5
17.2
75.5
very
20
7.0
7.3
82.8
not applicable
47
16.5
17.2
100.0
overall
274
96.1
100.0
11
3.9
285
100.0
photographs of 55-year-old men and women from the
beginning of the 20th century with their contemporary
peers: matrons and old-looking men transformed into
people with younger looks. In the past, the average duration of a marriage was 25–30 years, today it is 40–50
years [6].
Women who took part in the survey, when asked
with which of the statements that evaluate the behavior
of women during menopausal transition they completely
agree with, answered that: a woman should stop indul-
ging in self-pity 51.6%, dress according to age 16.4%,
and take care of their grandchildren 7.3%. They were
entirely against such statements as: a woman should stop
thinking about herself 46.7%, quit her job 45.0% or stop
being interested in sex 37.8% (Figure 1). Only 9.9% of
respondents stated that their relations with a husband/
partner had also undergone some changes, especially in
the area of sex – they rarely have a sexual intercourse,
there are more conflicts between them, as well as the fact
that they stopped understanding each other (Table 3).
60
50
40
% 30
25.9
20
10
0
7.3
2.2
46.7
27.9
37.8
45
25.4
5.8
13.5
16.4
2.2
take care of
stop being be completely
dress
grandchildren interested in
devoted to
according to
sex
family
age
completely agree
51.6
stop thinking
about herself
3.6
stop
stop indulging
professional
in self-pity
work
completely disagree
Figure 1. Evaluation of behaviors (desirable and undesirable) in women during menopausal transition. Source: own
work
Rycina 1. Ocena zachowań (pożądanych i niepożądanych) kobiet w okresie klimakterium
ORIGINAL PAPERS
436
Table 3. Change of relationship with a husband/partner. Source: own work
Tabela 3. Zmiana relacji z mężem/partnerem
Did your relationship with a husband or a partner changed during the period of menopausal transition?
Frequency
Percentage Percentage of valid Cumulative percentage
yes
27
9.5
9.9
9.9
no
209
73.3
76.8
86.8
Valid
do not have a husband/partner
36
12.6
13.2
100.0
Overall
272
95.4
100.0
Lack of data
13
4.6
Overall
285
100.0
As Lew-Starowicz writes, in some couples erotic
fantasies, strong desire towards the other person and
a satisfying sexual life occur during the initial years
of a relationship; as time passes, the interest and desire
towards a partner decrease. That what was once a pleasure becomes an obligation. The reasons for such state of affairs might be a loss of physical attractiveness,
monotony and routine in the art of love, burnout of love,
the influence of illnesses and taken medicine, seeing
the other person as generally tiresome, and a decline in
sexual drive.
Our contemporary society, which is permeated
with a cult of youth, would like to treat mature people as sexually neutral. Sex of older people is considered as something unnatural and peculiar, even indecent. In reality, sex is present in our life until old age,
changing its intensity and form. In contrast with animals, sex and reproduction in human do not have to go
together. Touch, kisses, sexual intercourse are a form
of emotional expression, they realize the need of loving
another human being and being loved. If a woman is in
the right emotional state, the need to engage in sexual activity is constant, irrespective of the stadium of
sexual cycle in which she is in. The emotional state
is going to remain the most important element which
decides about the desire and willingness to have sex,
also after menopause. Sex drive seems to be controlled to the same extent by a physical state and sexual
hormones. Women at that age can fi nd pleasure and
contentment in an intercourse with no fear of getting
pregnant, however, they might also create a conviction
that losing fertility puts them in a position of less sexually attractive partners [7].
In the research group of women, the word ‘menopausal transition’ brings about the most common and strongest associations with such statements as: asexuality
44.6%, sex without protection 43.4% and for 25.1% with
cessation of fertility (Table 4).
Various sexual disorders occur during menopausal
period in both men and women. In women, the amount
of lubricato (vaginal lubrication) decreases, dyspareunia
occurs (painful during an intercourse); in men, erectile
and ejaculatory dysfunctions. In spite of what might be
expected, the period of menopausal transition in most of
people does not lead to more serious sexual dysfunctions.
It suffices to take a look at sociosexual reports devoted to
sex life after the age of 50 to learn that for the majority
of these people it is not only possible, but also successful.
According to the reports, people who do not have a sexual partner either start new relationships or realize their
sexual needs by sexual self-stimulation [8].
From the collection of studies on sex life conducted
by Zbigniew Izdebski entitled ‘Sexuality of Poles on
the edge of the 21st century’, which was issued in 2012,
it appears that sex is significant to us – 58.9% of men
and 47.4% of women thought it to be important and quite
important. In the group of people over 40 years of age,
57.7% of Poles is sexually active. In older people, the
Internet prompts activity (also a sexual one). The Internet
has become a tool through which one can meet new partners. In 2010 30% of surveyed Internet users had a sexual
intercourse with a person that they had met on the Internet. This group grows rapidly, also in the generation 50+.
Sexologists are unanimous that Poles are poorly educated
and are not demanding in intimate relations. Izdebski is
of the opinion that we did not learn to speak openly about our expectations, we have a problem with communicating our needs, we do not say when something is missing or lacking. Poland is a country of stereotypes about sexuality of both sexes, however, it changes. Women
have increasingly wider knowledge about sexuality,
they are less demanding in their relations with a partner.
Table 4. Degree of association of the respondents’ feelings with the word ‘menopausal transition’. Source: own work
Tabela 4. Stopień skojarzenia odczuć ankietowanych kobiet ze słowem „klimakterium”
Association
1. Asexuality
2. Unprotected sex, at last
3. Cessation of fertility
ORIGINAL PAPERS
Strong
N
119
104
67
Weak
%
44.6
43.4
25.1
N
32
71
136
%
12.0
29.6
50.9
N
116
65
64
No associations
%
43.4
27.1
24.0
Women’s sexuality during menopausal transition
437
is stress connected with such issues as: problems with
adolescent children, disappointment in marriage, extramarital ‘adventures’, troubles at work, financial difficulties, inability to realize one’s dreams and life aspirations, as well as every matter that preoccupies our mind
which, most probably, may also start to undermine our
interest in sex [11].
The most common life situation that causes stress in
the surveyed women, which took place during the menopausal transition, was leaving of home by a son or a daughter 40–8%, death of a family member 27.8% as well as
serious changes in material status (Figure 2).
Menopausal transition is also connected with personality changes. Men at that age often become more sensitive, emotional, domestic, while women judge others
more frequently, are more energetic, critical and aggressive. Therefore, there occurs a reversal of roles, but it
is not only a matter of hormones, but also a case of the
attitude towards oneself and life. Women compensate
feminine frustrations in such a way, whereas men, after
attaining their professional goals, begin to place greater
importance on domestic and social bonds.
This liberated woman is very bothersome for some men.
A female partner who is exacting and conscious of her
needs often makes men uneasy and causes anxiety of not
being good enough [9].
Changes around sexual organs will be smaller and
appear slower in women who have a regular sex life (in
which it is an activity included in their normal everyday
routine). Undoubtedly, the thesis that sexual problems
during menopause, which are generally much talked
about, are usually an expression of personal, emotional
or family issues. Perhaps, exactly in this point in life,
a woman draws up the most honest balance of failures
and successes which had directly influenced her perception of herself [10].
The respondents asked for an evaluation of feelings connected with menopausal transition, as an asset
during this period, among other things, they indicated
– safe sex with no fear of pregnancy and as a loss – fertility (Table 5).
Ability to engage in sexual activity and to experience sexual pleasures does not change with age. Anatomical parts of the body used during sexual intercourse
undergo changes. In the period of menopausal transition, libido might decrease because of numerous reasons, however, the most common cause is not the age of
partners, but the quality of their relationship. Other factor that negatively affects a middle-aged woman’s libido
Discussion and conclusions
It is necessary to ensure that for a woman in menopausal
age, menopausal transition becomes a period that does
Table 5. Evaluation of feelings connected to menopausal transition. Source: own work
Tabela 5. Ocena odczuć związanych z klimakterium
Yes
Feelings connected to menopausal transition
N
%
I gained something during menopausal transition
28
10.2
I lost something during menopausal transition
51
18.7
Justification
(in order of frequency and indication)
1. Safe sex with no fear of getting pregnant
2. New experience
3. Maturity
4. More time for oneself
1. Youth
2. Beauty, attractiveness
3. Wellbeing
4. Health
5. Fertility
6. Energy
7. Ability to concentrate
18.7
19
22.5
25
25.7
26.9
27.8
big changes in a fam ily m em ber's state of health
appearance of a new fam ily m em ber
big changes in living conditions
change in eating habits
change in the am ount of sleep
serious changes in a m aterial status
death of a fam ily m em ber
40,8
leaving hom e by a daughter/son
0
5
10
15
20
25
30
35
40
45
Figure 2. Life events in menopause transition period. Source: own work
Rycina 2. Sytuacje życiowe występujące w okresie klimakterium
ORIGINAL PAPERS
438
not change the quality of her life, both in the psychological sphere as well as in the range of sexual activity.
Our sexuality is a process which means that sexual needs, capabilities, choices, preferences and abilities change
according to numerous factors. Nothing is permanent,
unchangeable and given once and for all [12].
There is some evidence that those who are sexually
active until old age tend to be not only kinder in everyday
life, but they also do not wait in queues to see a doctor [13].
Menopausal transition can sometimes cause completely different phenomena and reactions in women. Some
of these women, precisely in this period, experience greater interest in sex, and their sexual drive is increasing
due to the influence of physiological and emotional factors. Emotional and sociological factors are a result of
changes which take place around a woman and society.
After children grow up, a woman does not necessarily
have to suffer from ‘the empty nest syndrome’. Transfer
of life energy on sex may follow, what, combined with
a feeling of being liberated from rigid rules and house
duties, might often have surprisingly positive results.
Also, in terms of sociology, the attitude towards sexually
active women in menopausal age has changes in recent
years. Realistically speaking, we should not expect any
growth of interest in sex or boosts in our sexual ability
as we age. Nevertheless, it is essential to maintain the
highest possible sexual ability and activity in the postmenopausal age as well, through a positive attitude in
life, taking care of one’s outward appearance and health
even more so than during young adulthood. Such highly
necessary knowledge about sex and an affirmative attitude towards one’s own sexuality is still not being implemented at home; there is no sensible sexual education in
school either.
ORIGINAL PAPERS
References
1. Depko A. Pytania do seksuologa. Warszawa: Wiedza
i życie; 2005: 279–287. Polish.
2. Skorupska S, Szeligowska J, Mamcarz A. Marsz dla zdrowia seksualnego. Prz Menopauz. 2011;6:454–456. Polish.
3. Jarząbek G, Pawlaczyk M, Friebe Z. Przekwitanie a aktywność seksualna. Prz Menopauz. 2007;3:177–179. Polish.
4. Skrzypulec V, editor. Wstęp do seksuologii. Katowice:
Wyd. Kwieciński; 2005: 104–111. Polish.
5. Jasturn T, Haller O. Aby dwoje naraz. Zwierciadło.
2011;12:117–119. Polish.
6. Lew-Starowicz Z. Ona i on o seksie. Warszawa: Świat
Książki; 2007: 229–253. Polish.
7. Grazul-Bilska A, Bilski J. Menopauza bez tajemnic. Warszawa: Iskry; 2009: 80–87. Polish.
8. Długołęcka A, Lew-Starowicz Z. Jak się kochać? Edukacja
seksualna dla każdego. Warszawa: Świat Książki; 2010:
227–233. Polish.
9. Zuchora A. Fantazja Polaków o seksie. Zwierciadło. 2013;8:
103–107. Polish.
10. Doucet G, Elia D. Zapomnij o menopauzie. Bądź zawsze
kobietą. Warszawa: W.A.B; 1994: 218–220. Polish.
11. Wells RG, Wells MC. Menopauza środek życia. Warszawa:
Vocatio; 1993: 115–137. Polish.
12. Skrzypulec V, editor. Wstęp do seksuologii. Katowice:
Wyd. Kwieciński; 2005: 104–111. Polish
13. Jasturn T, Korona K. Trenuj seks, choć to nie sport. Zwierciadło. 2013;3:113–115. Polish.
Laboratory of Health Sociology and Social Pathology
79 Dąbrowskiego Street, 60-529 Poznan, Poland
phone: +48 61 854 69 11
Medical News 2013, 82, 6, 439–442
MARCIN DE MEZER1, PRZEMYSŁAW KOPCZYŃSKI2
EVALUATION OF FACIAL SKELETON DEFORMATION IN PATIENTS
WITH ACHONDROPLASIA
OCENA ZABURZEŃ PROFILU SZKIELETU TWARZY U PACJENTÓW Z ACHONDROPLAZJĄ
1
2
Department of Orthodontics, Poznan University of Medical Sciences, Poland
Head: prof. Teresa Matthews-Brzozowska
Centre for Orthodontic Mini-implants at the Department and Clinic of Maxillofacial Orthopaedics and Orthodontics
Head: Przemysław Kopczyński, PhD
Abstract
Introduction. Achondroplasia is the most common form of dwarfism. It's characteristic feature, which is dysplasia in midface
seems to became greater problem to patients with achondoplasia after therapy of short stature.
Aim. The aim of this study was evaluation of chosen cephalometric parameters measured on cephalometric x-ray pictures in patients
with achondroplasia without history of orthodontic treatment.
Material and methods. Cephalometric x-ray picture was taken in 13 patients. Measured parameters were statistically analysed.
Results. Calculated mean values of cephalometric parameters in 13 cases are in norm range. Calculated correlations between
cephalometric parameters shows the highest level between N-S-Ba and N-S-Ar angles.
Conclusions. Cephalometric parameters analysis in patients with achondroplasia shows incorrect growth pattern for this group.
Due to wide range of result – individual approach for every patient is needed.
KEY WORDS: achondroplasia, cephalometric analysis, growth disorders.
Streszczenie
Wstęp. Achondroplazja jest najczęstszą formą karłowatości. Jej charakterystyczny objaw, jakim jest dysplazja środkowego piętra
twarzy, zdaje się stawać największym problemem pacjentów dotkniętych tym zespołem po korekcie niskiego wzrostu.
Cel. Celem pracy była ocena wybranych parametrów cefalometrycznych, mierzonych na zdjęciach bocznych głowy, wykonanych
u pacjentów z achondroplazją, bez wcześniejszego leczenia ortodontycznego.
Materiał i metody. Zdjęcia cefalometryczne zostały wykonane u 13 pacjentów. Wartości parametrów cefalometrycznych zostały
przeanalizowane statystycznie.
Wyniki. Wartości poszczególnych parametrów wykazały zaburzenia we wzroście u pacjentów z achondroplazją.
Wnioski. Cefalometryczna analiza wybranych parametrów u pacjentów z achondroplazją wykazała nieprawidłowości dla tej grupy
chorych. Ze względu na szeroki zakres zaburzeń potrzebne jest indywidualne podejście do każdego pacjenta.
SŁOWA KLUCZOWE: achondroplazja, analiza cefalometryczna, zaburzenia wzrostu.
Introduction
Achondroplasia is the most common chondodyspasia and
also most common cause and form of dwarfism [1, 2]. This
condition was known for centuries, what shows examples
from art of ancient Egypt and from next epoques [3]. Parrot in the year 1878 as first described achondroplasia and
also he was first one, who used this therm [4, 5].
Achondroplasia is dominant, autosomal, with full
penetration, genetic disorder. This condition may have
family history, but usually (> 90%) arises as a novel
mutation. The birth incidence of achondroplasia is estimated to occur in between one in 10000 and one in
40000 live births, so it seems to be most common condition in group of osteochondrodysplasias [5, 6]. Almost
in every case is caused by same mutation of gene coding
fibroblast growth factor receptor 3 (FGFR3) [7, 8, 9, 10].
Achondroplasia is characterised by short stature, generally 125 cm by female an 130 cm by male.2 In shortened limbs, especially proximal parts, different disorders
of axis and torsion are observed. Hands are smaller as
a whole, fingers are shortened what affects their's efficiency. Radiologically brain skull is significantly enlarged,
posterior cranial base is shortened and cranial base angle
is smaller then normal and occurs in between 85° and
120° achondroplasia [4, 11, 12]. Changes in face are at
first maxillary bones hypoplasia with posterior rotation of
their base. Possibility of surgical stature elongation and
another deformations correction changes self-evaluation
of patients with achondroplasia. They focus on another
aspects of their look, also face and teeth, because of midface dysplasia is characteristic for achondroplasia [13].
For evaluation of craniofacial deformations, occurs
in achondroplasia, cephalometric analysis is used. It's
ORIGINAL PAPERS
440
Marcin de Mezer, Przemysław Kopczyński
this paper 14 cephalometric parameters are analysed. In
most cases, it means 8, mean value calculated on data
found in studied group places in norm range. In four
cases mean of present study was smaller than normal
values, and in two cases it was greater then norm. Computed mean value of SNA angle, 78.5º occurs be smaller
than the norm. But in three cases this angle was in norm
range, and further three cases shows values higher than
the norm. Mean result for SNB angle was between norm
limits. It should be underlined that not in every case
measured SNB angle responded to the norm. Also ANB
angle measured in studied group was statistically in normal values. But only three patients have this angle in
norm range. 2.4º is the mean value of NL-NSL angle in
studied group and is placed beneath of lower norm limit. Majority of patients has this parameter smaller than
norm. Next cephalometric parameter, ML-NSL angle,
has calculated value stayed in the norm range. In most
cases (ten patients) individual measurements have normal results. ML-NL angle with its value 33.5º is placed
over the upper norm limit. First parameter described cranial base it means N-S-BA with its mean value 130º is
placed in the norm. But only three patients have correct
values of this cephalometric parameter. Second parameter of the cranial base, N-S-AR angle has 130º as a calculated mean. It's slightly smaller, but still this mean value
placing between norm limits. In five patients this angle
was found as a norm, but it's still minority in studied
important for evaluation of face's growth pattern and in
effects decides of timing and ways of treatment.
Aim
The aim of study is evaluation of cephalometric parameters value in achondroplastic dwarfs.
Evaluated was data taken from 13 patients in age between
14 and 29 years. In studied group 7 individuals are
female and 6 are male. All patients diagnosis of achondroplasia have confirmed genetically. None of patients
was treated orthodontically. Cephalogram was made for
every patient. Cephalometric analysis included evaluation of angular values and proportions between linear
measurements taken from Björk's analysis completed
with elements from Segner-Hasund and Steiner analysis.
The results of cephlaometric evaluation were used in statistical analysis. Statistica (StatSoft) stat pack was used.
Results
Mean, standard deviation of founded values were calculated, which shows table 1. Further statistical analysis let to calculate correlations between cephalometric
parameters (p < 0.05). Table 2 shows correlations. In
Table 1. Values of cephalometric measurements
Tabela 1. Wartości pomiarów
S-N-A S-N-B A-N-B
MEAN
S.D.
MMIN.
MMAX.
78.5
5.1
69.5
85.2
77.2
5.8
65.4
85.8
1.2
3.1
-2.3
6.5
NL- ML-NSL -NSL
2.4
35.9
5.7
6.7
-5.0
25.0
13.2 48.5
ML-NL
33.5
7.4
21.9
44.6
NS-BA
130.1
9.1
114.2
144.9
NS-AR
120.7
9.8
107.2
134.1
Gonial
angle
127.6
6.7
117.4
136.9
CL-ML
74.7
4.6
69.0
82.2
ILS-ILI
126.0
13.2
113.6
158.8
NS-AR
-0.50
-0.64
0.39
-0.30
0.41
0.21
0.92
1.00
0.45
0.41
-0.21
0.22
-0.05
-0.72
Gonial
angle
-0.32
-0.09
-0.35
-0.29
0.51
0.82
0.45
0.45
1.00
-0.20
0.06
-0.45
-0.70
-0.54
CL-ML
-0.46
-0.72
0.59
-0.16
0.44
-0.24
0.56
0.41
-0.20
1.00
0.38
0.33
0.26
-0.46
ILSN-SP/
WITS
-ILI
SP-GN
-0.05 -0.08
0.16
-0.21 -0.45 -0.16
0.31 0.70
0.57
0.08 0.37
0.27
0.57 0.19
-0.21
-0.23 -0.67 -0.71
0.04 0.21
-0.02
-0.21 0.22
-0.05
0.06 -0.45 -0.70
0.38 0.33
0.26
1.00 0.04
-0.04
0.04 1.00
0.54
-0.04 0.54
1.00
0.05 0.10
0.28
WITS
1.7
3.8
-3.3
8.5
N-SP/
SP-GN
61.4
10.6
51.8
92.3
S-GO/
N-GN
64.6
5.6
56.4
73.4
Table 2. Correlations between cephalometric parameters
Tabela 2. Korelacje pomiędzy parametrami cefalometrycznymi
SNA
SNB
ANB
NL-NSL
ML-NSL
ML-NL
NS-BA
NS-AR
Gonial angle
CL-ML
ILS-ILI
WITS
N-SP/SP-GN
S-GO/N-GN
SNA
SNB
ANB
1.00
0.85
0.06
0.28
-0.74
-0.34
-0.66
-0.50
-0.32
-0.46
-0.05
-0.08
0.16
0.88
0.85
1.00
-0.48
0.05
-0.75
0.06
-0.78
-0.64
-0.09
-0.72
-0.21
-0.45
-0.16
0.77
0.06
-0.48
1.00
0.32
0.18
-0.67
0.39
0.39
-0.35
0.59
0.31
0.70
0.57
-0.00
ORIGINAL PAPERS
NL-NSL
0.28
0.05
0.32
1.00
-0.13
-0.42
-0.42
-0.30
-0.29
-0.16
0.08
0.37
0.27
0.28
ML-NSL
-0.74
-0.75
0.18
-0.13
1.00
0.25
0.66
0.41
0.51
0.44
0.57
0.19
-0.21
-0.65
ML-NL
-0.34
0.06
-0.67
-0.42
0.25
1.00
0.25
0.21
0.82
-0.24
-0.23
-0.67
-0.71
-0.52
NS-BA
-0.66
-0.78
0.39
-0.42
0.66
0.25
1.00
0.92
0.45
0.56
0.04
0.21
-0.02
-0.78
S-GO/
N-GN
0.88
0.77
-0.00
0.28
-0.65
-0.52
-0.78
-0.72
-0.54
-0.46
0.05
0.10
0.28
1.00
Evaluation of facial skeleton deformation in patients with achondroplasia
group. As expected, parameters describes mandible are
in the norm range. It concerns mandible angle (127.6º)
and CL-ML with mean 74.7º. Like for previous cephalometric parameters not every one has this angles in the
norm, but this is less than half of cases. There is no norm
range for ILS-ILI because it's a single value. Computed
mean in this group is 126º so it's 6º of difference. WITS
appraisal with its value (1.7 mm) is placed in the norm.
It should be underlined that WITS placed about upper
limit of the norm, and in cases of achondroplasia values
of III skeletal class are expected. WITS value beneath
of lower norm limit was measured only in two patients.
Face index in studied group is smaller, its calculated value (61.4%) is out of norm limits. Relation between facial
heights is another cephalometric parameter placing in
the norm range, with mean value 64.4%). But it should
be noted decreasing of this parameter in 9 patients.
Next data were delivered by analysis of correlations
between parameters studied in this paper. The highest
level of statistic correlation was found between angles
NS-BA and NS-AR. Next levels of correlation one
observes between angles SNA and SNB also SNA and
S-GO/N-GN also gonial angle and ML-NL. From other
side the most weak correlation was calculated between
ILS-ILI and N-SP/SP-GN. Next in row are SNA and
ANB also SNA and ILS-ILI also SNAm and WITS as an
angles with the smallest correlations.
441
of unilateral facial palsy with mechanism of it's creating – still no cephalometric parameters to discuss with
[18]. Study of Cohen et al. don't evaluate the masticatory
apparatus condition and direction of craniofacial growth.
They presenting quality evaluation of chosen cephalometric parameters don't show numeric values for achondroplasts and control group either [19].
It must be underlined that norm values, used in the
different methods of cephalometric analysis are different numbers. It makes header to compare with the results
achieved by the different authors. Norms for cephalometric analysis are specific of the different populations,
so objectification of results is hard [20].
Papers describing achondroplasia says, that in found
of facial skeleton development in achondroplasia lies cranial base deformation shows by closing of cranial base
angle (N-S-BA). The results achieved in present study
shows that the deformation of cranial base not always has
decreasing of N-S-BA values. This angle can be in norm
range or shows increasing of value over upper norm
limit. So every case of achondoplasia must be analyzed
individually. On the base of achieved results it seems to
be necessary to monitoring of cephalometric parameters
during and after orthodontic treatment of achondroplasts.
Achieved informations may help in choosing right treatment method and it's realization. They may influent on
treatment timing, specially beginning concerning fact of
early closing of cranial sutures in achondoplasia.
Discussion
Conclusions
Cephalometric analysis in presented group of achodroplastic dwarfs showed results out of the norm range what
makes examined achondroplast potential orthodontic
patients. Received values shows deformation's degree
and are base for monitoring of treatment and it's result.
They make treatment results evaluation more objective.
As the casuistic papers shows treatment result, which
is accepted by patient and physician isn't same thing as
achieving cephalometric parameters responding to the
norm. Discussion with achieved results is quite hard
because papers describing cephlometric analysis in
patients with achondroplasia aren't numerous. Ohba in
described case of achondoplasia found class II malocclusion and achieved in cephalometric analysis values which
are closed in value's range in recent study [14]. Dunbar describing case of achondroplasia observes partial
crossbite. Some of cephalometric parameters are shown
in that paper, but interesting value of cranial base angle
isn’t shown [15]. Barone and associates described another case of achondoplasia. In cephalometric examination
skeletal class III was found. But in paper only closing
of cranial base angle was presented, which is observed
also by the author of this paper. Patient was treated surgically, but authors of discussed study shows no numeric
results of cephalometric analysis, so one can’t compare
own results [16]. Likewise, but in smaller range, surgical
treatment presents in cases describe Elwood and associates, but also there is no result of cephalometric analysis [17]. Cerquiero-Mosquiera et al. presents two cases
In studied group mean values of angles SNA, NL-NSL,
ML-NL, ILS-ILI and S-GO/N-GN index were out of the
norm range, and difference was statistically significant.
Between analyzed parameters cranial base angle (N-SBA) must be underlined – it's value in present study was
in the norm range, but also over and under. Values of
cephalometric parameters in examined patients shows
incorrect direction facial skeleton development. Cephalometric parameters values in patients with achondroplasia must be evaluated individually for every patients.
Evaluation achieved results in own material is quite hard
cause to using by many authors different norms.
References
1. Trujillo-Tiebas MJ, Fenollar-Cortés M, Lorda-Sánchez
I, Díaz-Recasens J. Prenatal diagnosis of skeletal dysplasia due to FGFR3 gene mutations: a 9-year experience. J
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Marcin de Mezer
17 Kanclerska Street, 60-327 Poznań, Poland
Medical News 2013, 82, 6, 443–451
JESÚS MOLINA-MULA, CATALINA PERELLÓ-CAMPANER
ETHICAL CONFLICTS IN WOMEN’S SEXUAL AND REPRODUCTIVE HEALTH
KONFLIKTY ETYCZNE A ZDROWIE SEKSUALNE I REPRODUKCYJNE KOBIET
Department of Nursing and Physiotherapy, University of the Balearic Islands, Spain
Head: prof. Miguel Bennasar Veny
Abstract
Ethical conflicts are present in the daily practice of health care professionals, and dealing with them requires the development and
application of specific tools and abilities. This article offers the reader the chance of training decision-making in ethical conflicts
related to women’s sexual and reproductive health, by taking into account the ethical principles of beneficence, non-maleficence,
autonomy and justice. Three different situations are put forward related to issues such as emergency contraception in teenagers;
sexually transmitted diseases and professional secrecy; and the request for abortion by choice. Each situation poses an ethical
conflict for health professionals, who must analyse the different options for action suggested and choose the most beneficial and least
harmful one for the user. Finally, some data on sexual and reproductive health in the Spanish and international context is given.
KEY WORDS: sexual health, reproductive health, women, emergency contraception, abortion, AIDS, sexually transmitted
infections (STIs).
Streszczenie
Konflikty etyczne są nieodłącznym elementem w praktyce zawodów medycznych, a ich rozwiązywanie wymaga rozwoju
i zastosowania specjalnych umiejętności i kompetencji. Celem pracy jest charakterystyka dylematów etycznych związanych
ze zdrowiem seksualnym i reprodukcyjnym kobiet. Obierając za punkt wyjścia podstawowe zasady bioetyki: dobroczynność,
nieszkodzenie, autonomię i sprawiedliwość, opisano trzy sytuacje związane z antykoncepcją postkoitalną wśród nastolatek, chorobami
przenoszonymi drogą płciową i tajemnicą zawodową oraz aborcją na życzenie. Każda z nich stwarza szereg konfliktów etycznych
dla przedstawicieli zawodów medycznych, którzy w swych działaniach muszą kierować się powyższymi zasadami bioetycznymi.
W tekście opisano także wybrane zagadnienia związane ze zdrowiem seksualnym i reprodukcyjnym kobiet w Hiszpanii.
SŁOWA KLUCZOWE: zdrowie seksualne, zdrowie reprodukcyjne, kobiety, antykoncepcja postkoitalna, aborcja, AIDS, choroby
przenoszone drogą płciową (STIs).
Introduction
Ethical conflicts are present in the daily practice of
health care professionals. Decision-making in these contexts is usually difficult, so health practitioners must be
prepared and equipped with the necessary tools that are
good enough to be able to deal with these situations.
Competence for dealing with ethical conflicts is especially necessary when they involve vulnerable groups
such as women in scenarios as delicate as the ones related to sexual and reproductive health.
The World Health Organization (WHO) defines sexual
health as: “a state of physical, mental and social well-being
in relation to sexuality. It requires a positive and respectful
approach to sexuality and sexual relationships, as well as
the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” [1].
Thus, in order to be able to guarantee people’s full sexual
health, it is necessary for society to respect, acknowledge
and allow individuals to exercise their sexual rights [2].
On the other hand, reproductive health does not cover
only the right to decide on one’s own reproduction, but
also the right to suitable health care during the periods of
pregnancy, parturition, puerperium, and in the first care
to the new-born [2]. Following this tendency, the WHO
defines reproductive health as that which: “addresses
the reproductive processes, functions and system at all
stages of life. Reproductive health, therefore, implies
that people are able to have a responsible, satisfying and
safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often
to do so” [3].
Implicit to the above definition is the obligation of the
health care system to offer people the most up-to-date,
evidence-based information in relation to the effective,
safe options available to regulate fertility, so that they
can exercise their right to decide freely about these for
themselves [2, 3].
Hence, in order to ensure the right to a full sexual
and reproductive life of its citizens, the Spanish government published in 2011 the guidelines for the development of the National Strategy on Sexual and Reproductive Health. This document conducts an analysis of
the current status of Spanish society as a whole and the
health care system in particular as regards the sexual and
reproductive health of Spaniards, and lays down a series
of recommendations that are organized in different strategic lines of action (Table 1) [2].
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Jesús Molina-Mula, Catalina Perelló-Campaner
Table 1.
Strategic Lines in Sexual Health
Promotion of sexual health
Health care in sexual health
Training professionals in sexual health
Research, Innovation and Good practices in sexual health
Strategic lines in Reproductive Health
Promotion of health in pregnancy
Health care in pregnancy
Birth care
Birth care in the first week of life
Promotion of breastfeeding
Care of the hospitalised new-born infant
Postpartum care
Postpartum health care
Training professionals in reproductive health
Participation of women and their partners
Institutional coordination
Research, innovation and good practices in reproductive health
Although sexual and reproductive health programmes
frequently approach both fields together as they are closely related, the aforementioned National Strategy chooses
to separate the lines of action in order to ensure a comprehensive, differentiated approach to both sexual and
reproductive rights [2].
As pointed out above, ethical conflicts in sexual and
reproductive health are common in the clinical practice
of health professionals. To be able to deal with them from
an ethical point of view it is necessary to possess the
necessary knowledge, skills and attitudes to enable an
appropriate analysis of the different intervention options.
In order to achieve this goal, in the following section we
proceed to review the basis of principlism.
Ethical decision-making model
A model for ethical decision-making, according to Torralba [4], is a systematic set of principles that motivate
and guide ethical actions. These principles, in turn, serve
to justify and explain actions.
Therefore, it is necessary to define an ethical-clinical
issue as “a difficulty in decision-making about a user, in
the resolution of which it is necessary to refer to values or
principles that specify what should be done as opposed
to simply what can be done or is often done” [5: 141]. Yet
the difficulty, at this point, arises from the decision as to
whether to use one model or another and, where applicable,
the choice as to what values or ethical principles are established, whether they are universally accepted or are related
to different cultures, places and moments in history and
whether they take into account the emotional realm [5].
The most outstanding aspects when it comes to decision-making in clinical procedures are clinical parameters and the participation of the patient in this decision-making in which the nurse is involved, in this case
directly, such as Informed Consent, risk-benefit assessment, interaction with the health care team, patient and
family and their rejection of a certain practice (Spanish
Society of Emergency Nursing).
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Independently of the model used, we can summarise
some key aspects to be taken into account which can act
as pre-requisites:
– Correct knowledge of clinical aspects
– Professional competence to assume responsibility in
the conflict
– Possibility of choosing between different alternatives
– Assessment of the values of the people involved
– Quality criteria in the decisions to be made.
Analysing the factors from another perspective we
should take into account:
– Information that comes from objective aspects:
• Technical judgement; normally derived from
knowledge of the evidence
• Abilities of the person in decision-making: intellectual ability and its degree of influence in decision-making, information provided and understood and freedom to choose
• Information linked to the values and beliefs of
subjects: both users and professionals involved
• Information from the institution or legal framework.
Despite the above, it is worth noting a growing scientific movement which questions the current way of
understanding bioethics as merely an instrument of logic
or as a set of standardised principles based on criteria
related to efficiency, consistency and application [6].
According to Clouser and Gert [7], the main problem with the current model of ethics, is that it is usually presented in standard texts on bioethics as if it were
logically derivable from a harmonic umbrella of bioethical theories, when actually the principles contain internal inconsistencies and the theories upon which they are
based are discordant in themselves.
This leads to the fact that if the principles are not
firmly established and justified, people are deluded if
they believe in them as providers of moral imperatives.
A principle is not by any means a clear, direct imperative, but rather simply a collection of suggestions and
observations which occasionally converge.
To resolve the following clinical cases, we will use
a model to analyse principles of bioethics proposed by
Molina Mula [8].
This decision-making model is based on the four bioethical principles established by the Belmont Report and
consists of responding to the questions raised in the specific case analysed:
– Principle of Beneficence:
• Use of the most beneficial means (“doing good”).
The most beneficial means in an individual case
would be the specific application of all care and
treatments needed to do good.
• Maximise possible benefits and minimise possible risks.
• Praxis: To make available to others:
» Our knowledge of the science to be applied:
comprehensive knowledge of clinical criteria.
» Ethical values: professional ethics indicate
that means that may harm patients should not
be applied. Lex Artis considered ad hoc.
Ethical conflicts in women’s sexual and reproductive health
» Not resorting to paternalisms.
Principles of Beauchamp and Childress: obligation of the professional to work for the patient’s
benefit when:
» The patient is at risk of suffering a major loss
or injury.
» Professional action is needed to prevent harming the patient.
» Professional action will prevent this harm.
» This action does not harm the professional.
» The benefits to the patient outweigh the harm
to the professional.
– Principle of Non-Maleficence:
• Not using one’s privileged position and knowledge to inflict harm.
• Knowledge must always be channelled towards
preventing harm to the patient; thus, appropriate
use must always be made of professional privilege.
• Respect for non-disclosure and confidentiality.
• No distinction in treatment.
– Principle of Autonomy:
• Informed Consent: exceptions to consent.
• The patient as an autonomous being.
• Patients with diminished autonomy must be the
object of protection.
– Principle of Justice:
• According each patient their rights: equity.
• Equal treatment in equal cases: equality.
• Being the Ideal Observer:
» Omniscient: knowledge of the science and
clinical practice to be applied in each case.
» Omnipercipient: knowledge of the patient’s
cultural aspects, beliefs, thoughts and historical context etc.
» Impartial.
•
Decision making in situations of ethical conflicts
related to women’s sexual and reproductive health
Case 1. HIV Infection
Description of the situation
Lola, 37 years of age, has just been diagnosed with
HIV in the doctor’s surgery. During the interview, she
explains she has just become romantically involved with
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a person who doesn’t know her health situation. The doctor suggests she should make it clear to her partner that
she is HIV + and there is a risk of contagion during sexual relations, if the necessary protection is not ensured.
Lola refuses to tell her partner, explaining that he
will leave her if she tells him that. She doesn’t want that
to happen. She assures the doctor that she is going to
support the necessary level of protection during sexual
relations to avoid contagion.
Intervention options
– We should respect Lola's decision, after clearly
explaining to her the risk of infection for her partner,
if they have unprotected sexual relations.
– We should contact Lola’s partner to inform him that
Lola has something to tell him about her health situation.
– We should communicate the diagnosis of HIV + to
Lola’s partner, independently of Lola’s desires.
Ethical analysis of the intervention options
See tables 2–5.
Conclusions
On the basis of the bioethical analysis carried out, it can
be concluded that the balance leads us to consider the
correct option as A: We should respect Lola’s decision,
after clearly explaining to her the risk of infection for her
partner if she has unprotected sexual relations.
Case 2. The morning-after pill in teenagers: emergency
contraception
Sarah is a 13-year-old adolescent who comes to the
health centre accompanied by her 15-year-old boyfriend
to request the morning-after pill after unprotected sexual
intercourse. The emergency consultation nurse receives
them. They explain they used a condom, but it broke.
That happened approximately 12 hours ago. The parents
of the girl will be away for the next 2–3 days, because
of the death of a relative. The girl is under the supervision of her 80-year-old grandmother. Sarah insists that
she does not want to tell her grandmother, because she
suffers from a heart condition and will be scared.
Table 2. Analysis of the Principles of Non-Maleficence
Does it cause harm to the
patient if the partner is
informed?
Is there misuse of the
professional’s knowledge
and privileged position
regarding the patient?
Patient
– If the partner is informed, the patient’s right
to confidentiality is not respected.
– If the partner is informed professional
secrecy with the patient is broken (limits
of Professional Secrecy).
Partner
– If he is not informed, this could cause harm to
the partner, if the patient does not take
precautions during sexual relations.
– If the partner is not informed, a third party may
be harmed if the patient does not take the
necessary precautions to avoid contagion.
– If the professional informs the partner s/he
is using privileged information obtained
regarding the patient (Limits of Professional
Secrecy).
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Table 3. Analysis of the Principle of Beneficence
Patient
Are the best
– The professional informs of the risks entailed if the
means used to
necessary precautions are not taken to avoid
prevent
contagion (condom).
contagion?
Are the
– Not informing the partner means respecting the
benefits and
beliefs and values of the patient (benefits).
risks
– Informing means respecting the partner’s ability to
maximised?
decide in the situation.
– “The patient is in danger of suffering significant loss
or harm”. If the partner is informed, we are
jeopardizing confidentiality and professional secrecy.
– “Action on behalf of professionals is necessary
to avoid harm to the patient”. The professional’s
Analysis of the
decision will entail upholding professional secrecy
premises
or not.
proposed by
– “Action on behalf of professionals will avoid this
Beauchamp &
harm”. If not informed, professional secrecy will be
Childress (1)
upheld.
– “This action will not involve any harm to the
professionals”. If we uphold professional secrecy and
the right to patient confidentiality and privacy, no
harm will be caused to the professionals.
Partner
– By having no information, he cannot make decisions
or maximise precautions during sexual relations.
– Not informing entails a potential risk for the partner.
– Informing jeopardizes confidentiality.
– “The partner is in danger of suffering significant loss
or harm”. If he is not informed, he may be at risk if
precautions are not taken.
– “Action on behalf of professionals is necessary to
avoid harm to the partner”. If the professional
decides to inform the partner, he may decrease the
potential risk.
– “Action on behalf of professionals will prevent this
harm”. There is no harm a priori; he could only be
harmed if precautions are not taken.
professionals”. If the partner is informed, this would
not protect the patient’s privacy.
1. It must be remembered that the analysis of the situation is carried out from an ethical point of view, and occasionally the most ethical option does
not coincide with the most correct option from a legal point of view.
Table 4. Analysis of the Principle of Autonomy
What is the
information to be
provided like?
Informed Consent
Autonomy in
decision-making?
Patient
– She is informed she must take the necessary
precautions to avoid contagion, as well as the option of
letting her partner know so that he can be autonomous
in the decision.
– Limits of IC, in this case the professional cannot
inform the partner without explicit authorization from
the patient.
– If the partner is informed, her autonomy will not have
been respected.
Partner
– He is not given any information.
– It is not necessary.
– The lack of information does not allow him to
make autonomous decisions on the matter.
Table 5. Analysis of the Principle of Justice
Considers equity the main axis of its development, providing each one their rights and in equal cases, equal
Ulpian principle
treatment. In respecting this premise, we should respect the patient’s autonomy and not suppose she is going to
of justice
cause any harm a priori by not taking the precautions she herself indicates she will take.
Patient
Partner
– Omniscient: The professional knows the possible routes – Omniscient: The professional should know that
contagion occurs if precautions are not taken.
of transmission and the precautions and has informed the
patient of the risks and the possibility of informing her
– Omnipercipient: The professional should know
that his/her patient does not a priori pose
partner.
Ideal observer
– Omnipercipient: The professional should know all the
a threat to her partner’s health and the patient’s
circumstances, feelings, emotions, etc. concerning the
fears of abandonment.
situation so as to respect the patient’s decision and advise – Impartial: S/He should not influence, or
her so that she can make her own decisions.
persuade, or convince the patient of her
– Impartial: S/He should not influence, persuade, or
decisions.
convince the patient of her decisions.
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When the couple are interviewed, they both understand that the pill is an emergency resource and that the
main consequences of not using a condom are unwanted
pregnancies and sexually transmitted diseases.
The nurse offers them complete information about
emergency contraception: a single dose of levonorgestrel
within the first 72 h acts principally by delaying or inhibiting ovulation, thus preventing fertilization of the ovum.
Some studies suggest the pills might also act by altering
the lining of the endometrium to prevent the attachment
of the fertilized egg, but this fact has not been demonstrated. What is certain is that these pills are not an abortive method: once the egg is fertilized and implanted,
levonorgestrel has no effect on pregnancy.
– The nurse should ask Sarah to come back later accompanied by her grandmother, to be able to administer
the contraceptive pill.
– The nurse can administer the contraceptive pill
because the girl fits the criteria and the nurse thinks
that, despite her age, she is very mature and understands perfectly the consequences of not using a condom.
– The nurse shouldn't administer the contraceptive pill
because she is a minor and it is contraindicated.
See tables 6–9.
Conclusions
On the basis of the bioethical analysis carried out, it can
be concluded that the balance leads us to consider the
correct option to be B: You give her the contraceptive
pill because she meets the criteria and you think that,
despite her age, she is very mature and understands the
consequences of not using a condom.
Case 3. Abortion
Maria is a 32-year-old woman, 12 weeks pregnant. She
already has three children under 7 years of age. Her husband is unemployed and she works cleaning houses. She
earns just enough to survive, but they cannot afford to
have another child.
Maria and her husband go to the hospital for the abortion. This is the second time this year they have been to
hospital for the same reason. She recognizes that in the
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previous abortion visit, they were informed that they
must take contraceptive measures to prevent pregnancy,
but she explains they belong to a religious community
which is very strict regarding the use of condoms or the
like (intrauterine device, pills...).
– They should be advised that they must take contraceptive measures next time, and the abortion cannot
be performed as it is the second in one year.
– They should be advised that there are risks of having
repeated abortions, but we respect her decision and
perform the abortion.
– Indicate that the reasons presented are not ethical for
an abortion.
See tables 10–13.
Conclusions
On the basis of the bioethical analysis carried out, it
can be concluded that the balance leads us to consider
the correct option to be B: She is informed that there are
risks to undergoing repeated abortions, but her decision
is respected and the abortion is performed.
Conclusions
Day-to-day reality in health care demonstrates that the
cases of ethical conflicts in situations regarding sexual
and reproductive health are not isolated or infrequent
situations. Therefore, it is absolutely essential for health
practitioners to be trained, informed and prepared to
proceed with the correct ethical analysis of the different options for action in each case, always taking into
account the most up-to-date clinical information in relation to sexual and reproductive health.
On an ethical level, the interest stems from ethicalclinical deliberation, like the deliberation health professionals carry out whenever they come across cases such
as the ones put forward [9].
This type of deliberations may be considered by professionals from different standpoints. On the one hand,
those who make decisions as a reflex action, quickly,
without going through the long process of assessing the
user’s situation and justified by appealing to their socalled “clinical eye”. This assessment stems from an
aspect of insecurity and fear of this deliberation process on behalf of the professional who is dominated by
– If the pill is administered without the grandmother’s consent the patient’s confidentiality
is respected.
– If the grandmother is informed, professional secrecy with the patient is broken (limits of
Professional Secrecy).
– If the professional informs the grandmother s/he is using privileged information obtained
Is there misuse of the professional’s
regarding the patient (Limits of Professional Secrecy).
knowledge and privileged position
– If the pill is not administered this may not prevent harm to the patient, if a pregnancy she
regarding the patient?
does not want is produced.
Is harm inflicted on the young girl
if she is given the pill without the
consent of her grandmother?
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448
Are the best methods – The professional informs of other existing methods for preventing pregnancies, and also STDs. S/He
being used to prevent
should insist on the fact that emergency contraception must never be considered a customary
pregnancy?
contraceptive method.
– Not informing the grandmother implies respecting the beliefs and values of the patient (benefits).
Are the benefits and
Informing the grandmother will cause moral harm to the patient.
risks maximised?
– Not taking into account the patient’s degree of maturity may represent a decision insufficiently thought
through due to her age and therefore a risk.
– “The patient is in danger of suffering significant loss or harm”. If the grandmother is informed the
patient is caused moral harm. If the pill is not administered an unwanted pregnancy may be produced.
– “Action on behalf of the professionals is necessary to avoid harm to the patient”. The professional’s
Analysis of the
decision may prevent an unwanted pregnancy. If the grandmother is not informed, the patient’s
premises proposed
autonomy and confidentiality are respected.
by Beauchamp &
– “Action on behalf of the professionals will prevent this harm”. If the pill is administered, an unwanted
Childress (1)
pregnancy may be prevented.
– “This action does not entail harm to the professionals”. If we respect professional secrecy and the
patient’s right to confidentiality and privacy, no harm will be produced to the professionals.
What is the
information to be
provided like?
Informed Consent
Autonomy in
decision-making?
Patient
– She is informed as to what the consequences of taking emergency contraception are (it delays ovulation
and therefore fertilization with the sperm; it is not proven whether it prevents the attachment of the ovum
to the uterus, and if pregnancy has already occurred, it is not an abortive method), as well as the
secondary effects (nausea, sickness, abdominal pain).
– Limits of informed consent. As she is over 12 years of age, the minor may give consent with no need for
representation, providing the professional considers she shows a high enough level of maturity to cope
with the situation, neither will it be necessary to inform her guardians if there is no serious danger to the
minor.1 (Government of the Balearic Islands, 2008).
– If the grandmother is informed, the patient’s autonomy will not have been respected or her right to
confidentiality.
Considers equity the main axis of its development, providing each one their rights and in equal cases, equal
Ulpian principle
treatment. In respecting this premise, we should ensure the patient’s right to have access to the emergency
of justice
contraceptive methods she meets the requirements for.
– Omniscient: The professional knows the criteria the patient must meet to be able to receive emergency
contraception. S/He ensures they have correct information regarding the prevention of STDs.
– Omnipercipient: The professional should know all the circumstances, feelings, emotions, etc. concerning the
Ideal observer
situation in order to respect the patient’s decision and advise her so that she can make her own decisions.
– Impartial: S/He should not influence, or persuade, or convince the patient of her decisions. She should not be
influenced by prejudices and personal beliefs.
Patient
Foetus
– The risk the mother may suffer would be a series of
– The harm caused to the foetus would
Is harm inflicted on the
complications due to performing curettage for the second
be real as with the abortion it would
patient/foetus if an
time in a year, but if the necessary precautions are taken
cease to exist.
abortion is practiced?
there is no need for any to appear. Therefore there is only
a potential risk.
– Both the professionals who attended her on the previous – The professionals understand that the
Is there misuse of the
professional’s knowledge
occasion and this time have informed her of the need to
foetus has no ability to make decisions;
and privileged situation
avoid pregnancy, if they so wish, by using contraceptive
it must be the mother, ideally with her
regarding the patient/
methods. Even so, the woman may decide with her
husband’s consent, who should make
foetus?
husband’s consent whether or not they want to use them.
the decision on the matter.
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anxiety or by unconscious emotions. Meanwhile, there
are others who deliberate on the basis of an analysis of
the problems in all their complexity, weighing up both
the principles and values involved and the circumstances
and consequences of the case, identifying all, or at least
most, of the possible courses of action [10].
We have shown the need to follow some sort of procedure for decision-making in general, and in particular in
the cases of sexual and reproductive health, as ethical problems always consist of conflicts of value, and values are
449
necessarily based on facts. Hence, the procedure of analysis must be based on a thorough study of the clinical facts.
This analysis will give rise to a series of analytical judgments based on experience. For this reason, the
quality of a possible course of action based on a clinical
case subjected to deliberation gains importance. These
courses of action must be contrasted with the principles
in play and with the foreseeable consequences.
Inside the aforementioned ethical deliberation, we
must include moral deliberation, which not only caters
Are the best
means used to
resolve the case?
Are the benefits
and the risks
maximised?
Analysis of the
premises
proposed by
Beauchamp &
Childress (1)
Patient
Foetus
– In the event of continuing with the pregnancy on the
– The partner does not want to use means for
parents’ decision, the necessary socio-medical means
preventing pregnancy; this may entail a high
should be provided to alleviate the family’s particular
number of pregnancies over a short period of time,
therefore they should be warned that this situation
situation.
may endanger the woman if she undergoes
repeated abortions, and the subsequent risk of not
being able to become pregnant in the future.
– The abortion should be performed with the
necessary means to ensure clinical safety.
– Performing the abortion will produce the death of the
– Performing the abortion respects the woman’s
foetus (risk).
decision with her husband’s knowledge (benefit).
– Possible risk of complications (Risk).
– Not performing the abortion may endanger the newborn’s care due to rejection by the woman and her
husband (potential risk).
– “The patient is in danger of suffering significant – “The foetus is in danger of suffering significant loss
loss or harm”. If the abortion is not performed,
or harm”. If the abortion is carried out, death of the
the psychological health of the woman and her
foetus is caused, even though it has no decisionhusband is endangered.
making ability.
– “Action on behalf of professionals is necessary to – “Action on behalf of professionals is necessary to
prevent harm to the patient”. The professional’s
avoid harm to the foetus”. The professional’s decision
decision can avoid this psychological damage.
can prevent this harm to the foetus but the choice of
– “Action on behalf of professionals will avoid this
the woman and her husband would not be respected.
harm”. If the abortion is performed this harm to
– “Action on behalf of the professionals will prevent
the psychological health of the woman and her
this harm”. If the abortion is not performed this harm
husband will be avoided.
to the foetus will be avoided but not to the
psychological health of the woman and her husband.
professionals”. Respecting the choice of the
woman together with her husband does not
professionals”. Respecting the choice of the woman
involve an unethical action on behalf of the
with the consent, should this be the case, of her
professionals.
husband, does not entail an unethical action on behalf
of the professionals.
What is the
information to be
provided like?
Informed Consent
Autonomy in
decision-making?
Patient
– She is informed of the need to take contraceptive measures in order
to prevent unwanted pregnancies.
– She is informed of the risks of undergoing a high number of
abortions in a short period of time.
– In this case, the informed consent should be the woman’s with the
relevant information to her husband.
– The woman with information to her husband is the person who
should make the final decision as to having an abortion, if the
necessary information measures concerning informing of the risks
and consequences have been taken.
Foetus
– Does not apply.
– IC is exercised by the woman’s
representation.
– Lacks the ability and it should be
the woman who decides.
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450
Ulpian principle of
justice
Ideal observer
Considers equity the main axis of its development, providing each one their rights and in equal cases,
equal treatment. In respecting this premise, we should ensure the patient’s right to have an abortion if that
is what she wants.
Patient
– Omniscient: The professional knows the ethical criteria the patient must meet to be able to have an
abortion. S/He makes sure they have all the correct information regarding the prevention of pregnancies
and the risks of repeated abortions.
– Omnipercipient: The professional should know all the circumstances, feelings, emotions, etc.
concerning the situation to be able to respect the patient’s decision and advise her so that she can make
her own decisions.
– Impartial: S/He should not influence, or persuade, or convince the patient in her decisions. She should
not be influenced by prejudices or personal beliefs.
for the objective dimension of the act, but assumes the
voluntary nature of the facts, posing possible exceptions
to a series of “universally” established ethical principles. This moral deliberation must contrast the event to
be considered with ethical principles and assess the circumstances and consequences as to whether they would
allow or call for an exception to the principles [11].
Finally, with respect to this deliberation, we should
remember that the object of this process is not to make
decisions, as it is not intended to be put into practice or
to be decisive but rather to be consulted. For this to actually become real decision-making, it entails the responsibility of the person who has to make these decisions.
Therefore, deliberation may be performed by a person or
group of people other than the person/people who have
to make the decision.
Contraception using the ‘morning-after pill’ is rising
in Spain as an emerging contraceptive use. According
to data from 2004, it is estimated that 305,000 women
between 15 and 24 years of age used the morning-after
pill in Spain, which represents a usage rate of 117 per
thousand women between 15 and 24 years. Approximately 63% of emergency contraception users are young
people under 30 years of age [12]. From a clinician’s
point of view, it is very important to point out that it is
not a contraceptive to be used on a regular basis, but that
it is restricted to emergency situations and that it does
not prevent catching sexually transmitted diseases. The
eradication of wrong beliefs that consider emergency
contraception as an abortive pill should also be part of
sexual education in relation to this method [13]. Hence, it
is necessary to step up information concerning the good
use of contraceptive methods, by placing special emphasis on those that also enable the prevention of STDs, as is
the case of the male condom.
In Spain, although the rate of voluntary interruptions of pregnancy continues to be high, it is one of the
lowest in comparison with other EU countries or countries such as the USA or Canada [12]. Nevertheless,
to be able to correctly analyse the data it is necessary
to take into account the legal framework for abortion.
Currently in Spain less restrictive legislation is applied
for performing voluntary interruption of pregnancy,
including up to 14 weeks of gestation at the woman’s
REVIEW PAPERS
request [14]. The current government is considering the
possibility of returning to more restricted legislation as
regards terms and circumstances [15, 16]. Either way, it
is wrong to think that more restrictive policies in this
sense result in a lower number of abortions, as these are
probably still carried out but in conditions of greater
insecurity or risk to health, and without a record [12].
The WHO calculates 22 million clandestine abortions
are performed every year, causing around 47,000 pregnancy-related deaths, especially in developing countries [17].
According to data from the World Health Organization, 448 million new infections of curable sexually
transmitted diseases such as syphilis, gonorrhoea, Chlamydia or Trichomoniasis, occur every year. Some of
these diseases develop without a specific clinical pattern,
a fact which hinders their early detection and treatment,
and facilitates their transmission [18].
The consequences of a sexually transmitted infection
are potentially serious, especially concerning women’s
reproductive health. Problems of infertility, ectopic pregnancies, cervical cancer, abortions, premature births and
even perinatal death are some of the adverse effects of
developing a sexually transmitted infection [18]. Nowadays, the most effective prevention of transmission of
this type of disease is still the male condom.
Taking into account all the above, in Spain the data
presented by the National Survey of Sexual Health of
2009 are alarming regarding the use of protection methods in casual sexual partners: 22.1% of men and 18.6%
of women say they have not used any method of protection against STDs [2].
Therefore, performing abortion in a safe, controlled
way or administering emergency oral contraception are
procedures that are currently part of the range of services offered by our health care system, although this does
not mean it should be used as a regular method of birth
control and reproduction. The same happens with education and the availability of contraceptive methods and
of protection against STDs. In this sense, the health professional plays a very important role in offering comprehensive, rigorous, accurate, evidence-based information,
which enables users to know the options before them,
their consequences and the good practice associated to
them, so that they can, on the basis of this knowledge,
make their own decisions in an autonomous way.
References
1. [Internet] World Health Organization. Health topics. Sexual Health. 2012a. Available at: http://www.who.int/topics/
sexual_health/en.
2. Ministry of Health, Social Policy and Equality. National
Strategy in Sexual and Reproductive Health. Quality Plan
for the National Health System. Government of Spain 2011.
3. [Internet] World Health Organization. Health topics.
Reproductive Health. 2012b. Available at: http://www.who.
int/topics/reproductive_health/en/Point 2
4. Torralba Madrid MJ. Método enfermero para aplicar la
ética en la práctica clínica. Madrid: VII Mesa Debate con
el Experto en Atención Urgente 2000. Spanish.
5. Hackspiel Zárate MM. Los comités de bioética y el Conflicto armado colombiano. Cuestiones bioéticas. 2007;45:
245–252. Spanish.
6. Murray SJ, Holmes D. Critical interventions in the ethics
of healthcare. Ashgate: Burlintong 2009.
7. Clouser K, Gert B. A critique of principlism. J Med Philos.
1990;15:219–236.
8. [Internet] Molina Mula J. Análisis ético-profesional de las
órdenes de no reanimación. Etica de los Cuidados 2009, 2.
Available at: http://www.index-f.com/eticuidado/n3/et6990.
php [13.07.2010]. Spanish.
9. Gutmann A, Thompson D. Why Deliberative Democracy?
Princeton: Princeton University Press, 2004.
10. Dillon JT. Using Discussion in Classrooms. Buckingham:
Open University Press, 1994.
11. Couceiro A. Los comités de ética asistencial: origen, composición y método de trabajo. In: Couceiro A. Bioética para
clínicos. Madrid: Triacastela; 1999, p. 269–282.
451
12. Ministry of Health and Consumption. The voluntary interruption of pregnancy and contraceptive methods in young
people. 2007.
13. [Internet] UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training
in Human Reproduction (HRP). Fact sheet on the safety of
levonorgestrel-alone emergency contraceptive pills. 2010.
Available at: http://www.who.int/reproductivehealth/publications/family_planning/HRP_RHR_10_06/en.
14. [Internet] Organic Law 2/2010, of 3 March, concerning
sexual and reproductive health and the voluntary interruption of pregnancy. Available at: http://www.boe.es/boe/
dias/2010/03/04/pdfs/BOE-A-2010-3514.pdf.
15. [Internet] The Government holds that an unwanted child
does not harm women’s health. El País, 5 November 2012.
Available at: http://sociedad.elpais.com/sociedad/2012/11/05/
actualidad/1352139441_000972.html.
16. [Internet] Government seeks changes to abortion legislation. El País, 9 November 2012. Available at: http://elpais.
com/elpais/2012/11/09/inenglish/1352468131_182547.html.
17. [Internet] World Health Organization. Health topics. Sexual Health. Safe abortion: technical and policy guidance for
health systems. 2012c. Available at: http://www.who.int/
reproductivehealth/topics/unsafe_abortion/en/index.html#.
18. [Internet] World Health Organization. Sexually Transmitted Infections. Fact sheet nº 110. August 2011. Available at:
http://www.who.int/mediacentre/factsheets/fs110/en/index.
html.
Department of Nursing and Physiotherapy
University of the Balearic Islands
Despatx 36, Beatriu de Pinós
Palma de Mallorca, Spain
phone: +34 971 173 123
REVIEW PAPERS
Medical News 2013, 82, 6, 452–457
ELISA BOSCH DONATE, Mª TERESA ARBÓS BERENGUER
PELVIC FLOOR PHYSIOTHERAPY IN THE BALEARIC ISLANDS, SPAIN
FIZJOTERAPIA DNA MIEDNICY STOSOWANA NA BALEARACH
Department of Nursing and Physiotherapy, University of Balearic Islands, Spain
Head: prof. Miguel Bennasar Veny
Abstract
Physiotherapy not only has become an effective treatment in pelvic floor impairment but also a preventive method that involves
health promotion. There is a wide range of physiotherapeutical techniques to approach pelvic floor impairments. Pelvic floor is
a set of muscles that can weaken due to several causes. When that happens, different dysfunctions may appear, such as urinary
incontinence. In Spain there is a high prevalence of this dysfunction, and even though physiotherapy has acknowledged its
effectiveness in these issues, it is still poorly implanted in Health Services.
KEY WORDS: urinary incontinence, pelvic floor, physiotherapy, Balearic Islands.
Streszczenie
Fizjoterapia jest dziś nie tylko skuteczną metodą terapeutyczną przy urazach dna miednicy, ale służy także jako metoda prewencyjna.
Istnieje wiele technik fizjoterapeutycznych przy tego typu urazach. Dno miednicy to zespół mięśni, który może ulec osłabieniu na
skutek szeregu przyczyn. Gdy to nastąpi, pojawić się mogą liczne dysfunkcje, w tym nietrzymanie moczu. W Hiszpanii obserwuje
się wzrost występowania tego zaburzenia i choć fizjoterapia jest powszechnie rozpoznaną metodą profilaktyczno-terapeutyczną, to
nadal nie jest należycie wykorzystywana przez służbę zdrowia.
SŁOWA KLUCZOWE: nietrzymanie moczu, dno miednicy, fizjoterapia, Baleary.
Introduction
For a long time, Urinary Incontinence (UI) has been
treated as an underlying symptom of a primary illness.
Nevertheless, its high prevalence and the consequences that derive from it have lead us to treat it as a real
public health problem [1]. There are many international
agencies such as World Health Organisation (WHO),
the International Continence Society (ICS) and national
agencies such as the Spanish Gynaecology and Obstetrics Society (SEGO), the Spanish Urology Association
(AEU), the Pelvic-perineum Physiotherapy Spanish
Society (SEFIP) and the National Incontinence Observatory (ONI), among others, that strongly defend on one
hand that UI in women is a disease that has to be treated and on the other hand that the most common causes
that cause it should be prevented [2]. They also state that,
even though life of those women who suffer it is not in
danger, it affects their quality of life negatively [3].
UI can affect population in general, independently
their age or sex. There are different types of UI. They
are classified by their etiology and severity. This paper
is exclusively focused on feminine urinary incontinence,
specifically on those types that are susceptible of being
prevented or cured by Physiotherapy treatment. In this
sense, these incontinences are effort urinary incontinence (EUI), urge urinary incontinence (UUI) and mixed
urinary incontinence (MUI). Their appearance is related to dysfunctions of support structures of any pelvic
REVIEW PAPERS
viscera. The pelvic floor (PF) is the most important. Pelvic floor is a set of muscles and fascia that enclose pelvis
underneath. It accomplishes different functions. Pelvic
floor muscles can weaken due to different causes. When
that happens, it can no longer perform effectively their
functions. The most frequent dysfunction of the pelvic
floor (or the main consequence of its weakness) is UI.
UI is underdiagnosed [4] and undervalued [1], and it
doesn’t receive proper attention even though the importance of the problem it represents. Despite all the technological and human resources available, neither any of the
UI stages are approached in an efficient manner in Spain
nor target population is achieved. Educational programs
for health developed at primary attention do not include UI. Prevention barely appears and treatment criteria
aren’t even alike.
On the other hand, UI does awake great interest on
laboratories and enterprises that commercialize absorbent pads or drugs, which are sheer palliative. Neither do
the media and advertising let go a commercial chance.
According to WHO data [5, 6], there are over three million persons who suffer from UI in Spain. Each one of
these people use several pads every day [7], so they have
become a desirable economic entrance.
It has to be highlighted that many UI studies are being
funded by these laboratories. Nowadays, legal frame protects the rights of pharmaceutical benefits for incontinent
women [8], drugs and absorbent pads, but there is no
policy in Spain focused on diagnosis or prevention [9].
Pelvic floor physiotherapy in the Balearic Islands, Spain
Meanwhile, in some other European countries such
as France, Belgium or Switzerland, UI is prevented in an
institutionalized way since the eighties [10, 11].
Usually, conservative treatment is reduced to drugs
prescription that diminishes the symptoms in some types
of UI. Few times is Physiotherapy treatment the chosen
option. However, there is backup evidence of perineal Physiotherapy [12, 13]. It is an effective and efficient
treatment because it can provide results at a low expense and it has no side effects [14, 15]. Depending on the
severity of symptoms or the failure of conservative treatment, the next option is surgery.
In the Balearic Islands there is a chance of pharmaceutical and surgical treatment whereas the Physiotherapy treatment is not drawn on.
Two Majorcan state hospitals, Son Espases and
Son Llàtzer, were the first ones in the Balearic Islands
to introduce perineal physiotherapy treatments, yet ten
years ago. Even though there is plenty of space, equipment and qualified staff, only a few patients get physiotherapeutic treatment. Physiotherapy department of
these two hospitals have more than twenty physiotherapist in its crew, but only one or two of them perform
this specialty, and only part time. Patients go referred
from their family doctor or from their midwife to urology and/or gynaecology to end in rehabilitation, where
somebody will decide if she is susceptible of getting treatment. More recently, perineal physiotherapy treatment
has been included in Manacor and Inca hospitals. There
is no consensus either protocol among these hospitals to
decide priority, techniques or number of weekly sessions
to be done.
In Menorca there is no perineal physiotherapy treatment in public health. Neither rehabilitation doctors, nor
clinical services director of the referral hospital Mateu
Orfila think of it as a priority.
In Ibiza, Physiotherapy department of the referral
hospital Can Misses, just as Majorcan hospitals, have
some weekly hours for attending patients with severe
pelvic floor diseases, usually UI. Moreover, in some primary attention centres, treatment in groups is offered,
consisting in hypopressive exercises.
In Formentera there is no perineal physiotherapy service as the hospital only has one physiotherapist.
In general, when symptoms are incipient, there is no
room for this kind of patients, and even less for those
who are interested in prevention.
The other option are private hospitals and private
specialized physiotherapy offices, which are very scarce
and, obviously, not accessible to all patients.
UI prevention should be taken into account in those
periods or situations described as risk factors: pregnancy, delivery, postpartum and menopause [16–19].
In primary attention, where all promotion, education and prevention for health should be done, no effort
is expent in UI, but recent initiative of some centre in
Ibiza. Some midwifes and gynaecologist explain guidelines and recommendations to their patients. But there is
no assessment or formal treatment when there is a pat-
453
hology neither there is specific prevention. We could
say that guidelines and recommendations depend on the
training and will of each one of the health professionals
crew. We cannot forget the few time there is available to
attend each patient (there is a general complaint on Primary Attention personnel about the scarce time there is
per patient).
There are resources but they are neither developed nor
implemented in a systematic way. Moreover, the main
problem is still that very few women seek for attention
directly to health professionals, and very few health professionals ask directly for this problem to their patients.
The urigynecology board of the Official Association of
Physiotherapists in the Balearic Islands (Colegio Oficial
de Fisioterapeutas de les Illes Balears) has conducted different actions in order to promote perineal physiotherapy
and to sensitize population since 2007. It has published
a n informative triptych that has been sent to all medical
community in Primary Attention. Talks and workshops
have been done for both health professionals and women.
Most of them declared not having asked (health professionals) or not having sought (women with UI).
Prevalence
UI prevalence is changeable and is unsettled. That happens because epidemiological studies vary when it comes
to UI definition, UI types and diagnostic test used [1, 20,
21]. Furthermore there is variability depending on the
range of age and sex used in the sample used. Another
variability cause is the country which is studied. Western
countries have the highest prevalence rates [22, 23, 26].
Bearing that in mind, we should highlight the WHO
as a resource. In one paper about UI, it reflected the
increase of the number of incontinent patients in European countries between 1997 and 2003. In Spain there are
more than three million people suffering from it [1, 5].
Likewise, the prevalence of other pelvic floor dysfunctions are remarkable as well, such as faecal incontinence, chronic constipation, dyspareunia, anorgasmia and
genital prolapse.
Background and theoretical frame
Women urinary incontinence has already been described
in a wide manner, in some aspects such as prevalence,
risk factors and different approach treatments. There are
many studies that relate UI and its impact on the quality of life of the persons who suffer it [3, 27]. Nevertheless, even though there is evidence of the shortage medical seek from women who suffer it [1, 4, 5, 20, 21], there
are not many studies about the causes of this behaviour.
Women who seek for help are few, and even when they
do it, it’s too late (sometimes they do it years after the
beginning of the disease [21], so the treatment gets very
difficult.
In the last decade, qualitative studies have been done.
They try to answer this question, and there can be classified some reasons. The most frequent ones are that UI
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454
Elisa Bosch Donate, Mª Teresa Arbós Berenguer
is seen as something natural, or consequent to pregnancy
and delivery, or something inevitable when aging, or that
it has no treatment and it is shameful to seek for help [17,
21, 28–31].
Reymert et al, in 1994, studied a group of Norwegian
women with UI, close to menopause. Most of them concurred that the cause they didn’t seek for help was that
they considered it normal or natural at their age.
Palmer et al, in 1999, interviewed more than one thousand incontinent women in Baltimore, to conclude that
most of them didn’d seek for help as they didn’t acknowledge there was a chance of treatment.
Lepiere et al, in another study published in 2007 where 382 Canadian women were involved with UI during
pregnancy and after the first six months of delivery, concluded that the reasons for not seeking for help were that
they considered it normal and/or shameful. Authors consider that UI is still nowadays a taboo.
Horrocks et al, in 2004, conducted a qualitative study in Bristol, and thoroughly interviewed 20 incontinent
women who had not sought for attention. Conclusions
were the same. They hadn’t consulted for shame and for
believing that UI is something natural in women when
aging . These women get isolated and leave their social
life to hide the problem.
It is true that participants of these studies feel identified with some of these statements, but interviews are
closed and answer options are given, so it cannot be
possible to go deeper in these qualitative aspects or to
answer others.
Ferri Morales et al step forward and in 2003 published the results of a qualitative study where discussion
groups are made in order to learn different experiences
of women with UI. Conclusions are that help is not sought for shame and because UI is considered something
natural, but there appear other reasons that are not strictly object of research: health system does no offer a different solution from the one they apply on their own and
because the solution that is being offered (drugs and surgery) is not satisfactory [10].
Studies are focused in acknowledging the causes
for lack of consulting by women with UI, laying all the
responsibility on them. It is necessary to find out the role
health professionals play in the causes of low consultation by women with urinary incontinence. Already in the
past nineties decade, the white book of urinary incontinence [17] recommended a greater participation of those.
Other studies point out the need of a more active engagement of health professionals in order to detect earlier UI
[1, 4, 5, 10, 32].
Salinas Casado et al, in 2010, state that only in 10%
of all UI cases, medical staff had searched for its existence, and in one of each five cases no diagnostic nor therapeutical measures were adopted.
Martínez Saura et al, in 2001, cut down to 6% the
cases of UI that received any kind of assessment and
medical assistance.
Despite all the existing evidence, yet nowadays, the
same recommendation in the National Observatory of
REVIEW PAPERS
Inconstancy is being made twenty years later: there is
a need of a proactive attitude from the medical staff [9].
Anatomopsyhological issues
Pelvic floor is a set of muscles and fascias that enclose underneath lesser pelvis. There can be distinguished two levels. One is located deeper and is known as
pelvic diaphragm (it has a correlation with the thoracic
diaphragm). The other layer is more superficial and is
called perineum.
Therefore, pelvic floor supplies support for all the
viscera located in the lesser pelvis. These viscera are stowed one over another, contributing with a hovering and
partition system to the stability needed to accomplish its
functions. Stability is possible too, thanks to the adherence of viscera amongst them, and to the holding up and
buffering that pelvic floor performs.
Pelvic floor main functions are [33]:
– buffering and holding up the low part of the abdomen. It preserves the integrity of the pelvic organs
(bladder, uterus and rectum), holding them up.
– evacuation: it controls the urethral and anal sphincters, keeping both urinary and faecal continence.
– obstetric: it plays a primordial role in the different
phases of delivery, such as the expulsive phase.
– sexual: it influences on sensitivity and eases orgasm
[34].
Pelvic floor weakness is directly related to the loss of
some of its functions. In effort urinary incontinence it
is due to incomplete closure of the sphincter. It is a failure of it in front an intravesical pressure increase, which
leads to a intraabdominal increase of pressure [35].
All these, added to the urethra modifications (tone
decrease, loss of structure elasticy and lack of strength to
block perineum) are at last, the physiological explanation
of urine leakage.
These disturbances commonly trigger pathology
associated to pelvic floor. Usually effort urinary incontinence is associated to prolapses and some kind of sexual
dysfunction.
Physiotherapy treatment
Not only can Physiotherapy provide specific treatment to
pelvic floor dysfunctions but also can perform prevention and health promotion.
Implementing measures such as early diagnosis to
urinary incontinence in primary attention and educational workshops during pregnancy and in postpartum
(both pregnancy and labour are some main risk factors
in pelvic floor dysfunctions), urinary incontinence prevalence could be cut down.
Perineal physiotherapy has its origins in 1948, when
the North American gynecologist Arnold Kegel [18] proposed exercises for re-educating Pelvic Floor with voluntary and repeated contractions.
Not until the seventies did this discipline start to
develop in Europe as well. Alain Bourcier introduced
in France the concept of urogynecological and colonproctological physiotherapy. He promoted education
and research for physiotherapist in this field. Later, physiotherapists like Guy Valancongne, Dominique Grosse
and Pierre Minaire in France, Marcel Caufriez in Belgium, and J. Laycock in United Kingdom have contributed to scientific development of perineal physiotherapy
and have taught generations of physiotherapist of many
nations, including Spain.
Perineal physiotherapy consist in an amount of behavioural, instrumental and manual techniques. Their aim is
to restore the control and quality of voluntary contraction
of pelvic floor muscles, the visceral static and viscolastic
properties of perineal tissues. This targets are in order to
prevent, treat and improve the urogynecoloproctological
dysfunctions. UI is the main one [13, 14, 33].
The amount of techniques that physiotherapy offers
is wide, and the choice of one depends on the assessment
of each case. It is a cheap treatment with very few side
effects. It can usually bring good results [10] as long as it
is suitable and stabilised terms are accomplished. Patient
involvement is essential.
Not only it is useful in the treatment of some pelvic floor dysfunctions but also is it fundamental in the
prevention of these dysfunctions. Some of the risk factors described are pregnancy, delivery and menopause,
among others, so that’s why it is important to perform
during these periods. From the eighth month of postpartum, a pelvi-perineal assessment should be done systematically [11, 36] and according to it, schedule physiotherapy performance.
Before physiotherapy treatment there’s always an
information and education lap. Treatment success depends
on it [33]. It has been confirmed that half of the women
who attend to physiotherapy consult does not know how
to voluntary contract pelvic floor muscles [14]. Training
and learning from manual techniques obtains better
results than explaining those in writing or orally [37].
Manual techniques
Manual treatment is intracavitary (intravaginal or intraanal). It is important to individualize treatments according
to the results of a previous physiotherapeutic assessment.
Manual intervention allows us to re-educate muscle tone,
strengh, resistance and fatigability of pelvic floor.
Other manual techniques are stretching, perineal massage, Cyriax techniques (deep transverse friction massage) and trigger point techniques (for relaxing
hypertonic points).
Intracavitary or intravaginal devices
Vaginal cones: it is a set of five plastic cones that are used
as a tampon. Its weight ranges from 20 to 70 gr. It is used
in a progressive way, starting by the lighter one. To avoid
it sliding from the vagina, muscles have to contract [13,
33]. Some authors like Caufriez or Bo, prefer other devices rather vaginal cones such as the ben wa balls.
455
Ben wa balls: these are usually two balls joint by
a string (it is recommended to throw one away, but nowadays only one ball is starting to be commercialized). In
its inner core there is a smaller ball. The ball remains
inside the vagina like a tampon, and the woman should
carry it during her everyday activities. With movement,
the inner ball moves producing a vibration that stimulates vaginal vibroreceptors. It leads into the contraction
of the involuntary smooth muscles of the vagina. On the
other hand, the weight of the ball stimulates the baroreceptors of the perineal muscles, leading into an increase
in the muscle tone [13, 33, 39–41].
Lumbo-abdomino-pelvic re-education
Besides the analytic work of the different structures
involved in the pelvic floor dysfunction, Physiotherapy counts on a global work that pretends to harmonize
and recover both muscles and static attitude. The hypopressive exercises described by Caufriez [38] consists in
a series of active positions. Their aim is to tone fibres
type I of the abdominal girth and pelvic floor, diminishing the intraabdominal pressure underneath zero. This
is the reason these exercises are specially indicated on
patients with effort urinary incontinence [11, 33, 39].
There are authors that only develop those exercises
created by Kegel, improving and including them into
intensive and supervised programs: pelvic floor recuperation exercises (RMSO) [37].
Instrumental techniques
Electrostimulation: the aim of this technique in effort
incontinence is to increase the capability of contraction
of the pelvic floor muscles. In urge incontinence it targets to relax the detrusor urinae muscle. A current is
applied through an electrode that has the shape of a vaginal or rectal probe. The principles are just the same of
any other muscle recovery work. This is done by stimulating the aferent fibers of the Pudendal nerve in the first
case or by stimulating the eferent fibers of the Pudendal
nerve in the second case [13, 33, 42].
Biofeedback: it is an active technique of feedback. It
is interesting because it's focused on the awareness of the
pelvic floor muscles [11, 14, 42]. This device can be either electromyographic or manometric.
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García MP, Moriano Bejar P, Pérez Lorente M, Serrano
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Department of Nursing and Physiotherapy
University of Balearic Islands
Despatx 36, Beatriu de Pinós
Palma de Mallorca, Spain
phone: +34 97 117 212
REVIEW PAPERS
Medical News 2013, 82, 6, 458–462
STANISŁAW ANTCZAK, AGNIESZKA ŻOK
FEMALE GENITAL MUTILATION IN SUB-SAHARAN AFRICA
AS A HEALTH AND CULTURAL PROBLEM
OBRZEZANIE KOBIET W AFRYCE SUBSAHARYJSKIEJ JAKO PROBLEM ZDROWOTNY I KULTUROWY
Laboratory of History of Public Health and Social and Health Policy, Chair of Social Sciences
Abstract
Female genital circumcision is defined as all procedures that involve partial or total removal of the external female genitalia, or
other injury to the female genital organs for non-medical reasons. This painful procedure leads to serious health consequences, the
circumcised women are exposed to health complications immediately after the procedure but some sequels of the procedure trouble
them throughout their life. According to approximate calculations of WHO, still 100 to 140 million of girls and women all over the
world have been subjected to circumcision. In the context of our analysis the most relevant seems to be understanding of a culture
as a set of common rules which decisively affect behavior of members in a community or society and „a set of values, beliefs and
attitudes shared by most of community members”. Such norms are inherited from generation to generation and control almost all
aspects of functioning in the human community.
KEY WORDS: FGM, culture, Africa, reproductive health.
Streszczenie
Obrzezanie kobiet, rozumiane jako wszelka ingerencja w żeńskie zewnętrzne narządy płciowe z przyczyn niemedycznych, jest
bardzo bolesnym rytuałem mającym poważne konsekwencje zdrowotne. Mimo to, według danych opublikowanych przez Światową
Organizację Zdrowia, od 100 do 140 milionów dziewcząt i kobiet na świecie poddano temu bolesnemu rytuałowi. W kontekście
dokonanej analizy szczególnie istotna wydaje się kwestia odniesienia obrzezania kobiet do obowiązujących w krajach Afryki
Subsaharyjskiej kultur. Kultura jest tu rozumiana jako zbiór wspólnych zasad, które zdecydowanie wpływają na zachowanie
użytkowników społeczności lub społeczeństwa oraz zestaw wartości, przekonań i postaw podzielanych przez większość członków
wspólnoty. Normy te są dziedziczone z pokolenia na pokolenie i kontrolują niemal wszystkie aspekty funkcjonowania w społeczności
ludzkiej.
SŁOWA KLUCZOWE: obrzezanie kobiet, kultura, Afryka, zdrowie reprodukcyjne.
Female circumcision, practiced nowadays in several
countries, is defined as all procedures that involve partial or total removal of the external female genitalia, or
other injury to the female genital organs for non-medical reasons [1]. According to evaluation made by WHO,
procedures of the type are performed in 28 countries of
western, eastern and north-eastern Africa as well as in
some countries of middle-eastern Asia. The practices
are also transferred by diasporas originating from Africa to Europe, North America and Australia [2]. According to approximate calculations of WHO, between 100
and 140 millions of girls and women all over the world
have been subjected to circumcision [3]. Most frequently, the female genital mutilation is performed on girls at
the age just few days before pubescence period. The circumcision used to be performed in conditions far from
those which used to characterize professional medical
offices, using „traditional tools”, such as a knife, razor,
piece of razor blade, glass or another sharp-pointed
object. The wound resulting from the mutilation used
to be supplied using a plant thorn, fisherman’s string or
REVIEW PAPERS
hairs. The tools used for „the procedure” are not subjected to sterilization, which leads to serious health consequences. Female circumcision results in much more
serious health consequences than those induced by circumcision of boys.
Wiesław Jaszczyński, a physician practicing for two
years in Egypt has described the way in which the procedure is conducted. The girls are not prepared for the procedure in any professional manner. The clitoris is brushed
with nettle leaves to induce its reddening and swelling,
the operator elevates it maximally upward using forceps
and cuts it off using a sharp object. Bleeding used to be
not staunched, just the wound is overplayed with rottenness plants or even animal faeces [4].
Experts of WHO, UNICEF and UNFPA distinguish
four types of Female Genital Mutilation:
– Type I: partial or total removal of the clitoris and/or
the prepuce (clitoridectomy). In type I one can distinguish subgroups: type Ia, removal of the clitoral hood
or prepuce only; type Ib, removal of the clitoris with
the prepuce.
Female genital mutilation in Sub-Saharan Africa as a health and cultural problem
– Type II: partial or total removal of the clitoris and
the labia minora, with or without excision of the labia
majora (excision). In type II one can distinguish subgroups: type IIa, removal of the labia minora only;
type IIb, partial or total removal of the clitoris and
labia minora; type IIc, partial or total removal of the
clitoris, labia minora and labia majora.
– Type III: narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or
without excision of the clitoris (infibulation). In type
III, one also can distinguish subgroups: type IIIa,
removal and apposition of the labia minora; type IIIb,
removal and apposition of the labia majora. Reinfibulation is covered under this definition. This is a procedure to recreate an infibulation, for example after
childbirth when defibulation is necessary.
– Type IV: unclassified – all other harmful procedures
to the female genitalia for non- medical purposes, for
example, pricking, piercing, incising, scraping and
cauterization [1].
FGM procedure may include also incisions/scarification of perineum and vaginal walls and introduction of
corrosives and herbs into vagina. All the procedures
are performed without anaesthesia. In some regions the
the FGM-subjected girls are administered with herbs os
anaesthetic properties, but taking into account the so
intense pain, their effect is doubtful.
The so drastic procedure leads to serious health
consequences, the circumcised women are exposed to
health complications immediately after the procedure
but some sequels of the procedure trouble them throughout their life.
The direct health consequences are linked, first of
all, with a nagging pain, resulting from transsection of
nerves in female genitals, intensely supplied with nerves.
Also the healing period, particularly long and painful in
the case of FGM type III, is a very persistent experience.
The pain and bleeding result in a post-traumatic shock.
Moreover, the girls subjected to the third type of FGM are
exposed to the risk of a „reparative” circumcision, resulting from improper healing of the wounds. Persistent pain
accompanies urination and problems with urination frequently trouble the circumcised women throughout their
life. This is so because the suturing of perineum levaes
behind just a small opening, supposed to permit urination and menstrual bleeding. The situation leads also to
frequent infections. The circumcised women frequently
experience serious problems with their gynaecological
health. They may not be able to pass all of their menstrual blood. They may also have infections over and over
again. It can also be hard for a health care professional
to examine a woman’s reproductive organs if she has had
a more severe form of FGC. Normal tools cannot be used
to perform a Pap test or a pelvic exam [5].
Serious health consequences may also result from
the manner in which „the procedure” is performed. The
tools used in its course are not sterilised, which is linked
to an elevated risk of infection transmission, involving
459
HIV, STD or viral hepatitis between persons exposed
one after another to FGM.
Serious health consequences of FGM include also
problems related to sexual life of the women subjected
to such a procedure. The most severe form of FGC leaves
women with scars that cover most of their vagina. This
makes sex very painful. These scars can also develop
into bumps (cysts or abscesses) or thickened scars (keloids) that can be uncomfortable [6].
Also, FGM is not neutral for psychic health of the
victims. This procedure is typically performed on very
young girls. Some may not understand what is being
done to them or why. The psychological effects of this
painful experience are similar to those of post-traumatic
stress disorder [7].
FGM brings about enormous problems related to
reproductive health. Apart from the above mentioned
problems with sexual life complications are encountered
during delivery and they can be risky for life of the newborn: studies confirm an increased risk for an intrauterine foetal death and an increased mortality of respective
newborns. The risk of complications and risks for the
foetus and the newborn depend on the type of the performed procedure. In type I FGM the risk is increased
by 15%, type II FGM increases the risk by 32%, while
in women subjected to type III FGM the risk of complications during pregnancy and delivery is increased by
as much as 55% as compared to women not subjected to
FGM. Moreover, Wiesław Jaszczyński claims that the
procedure of infibulation results in infertility in around
10% women subjected to this procedure [8]. The consequences of FMG for the course of delivery have been
pointed out also by Nura Abdi, who recalls experience of
her own mother linked to her own delivery: „As for every
circumcised woman, also for my mother delivery presented a severe torture. She suffered for five hours even
if a midwife performed episiotomy. And just after I was
born she was sutured again. It had to be so, this was what
experienced all Somali women and my mother without
protest had to subject to this for already the fourth time”
[9]. Similar practices in Nigeria were described by Ilona
Maria Hilliges, graduate of Third World sociology, specializing in topics related to Africa. „Delivery following
circumcision used to provide a bloody torture. Nevertheless, almost all women agree to be sutured again to preserve their attractiveness to their husbands” [10]. Apart
from this the delivery following circumcision brings
about serious risks both for the delivered child and for the
delivering woman since „a child delivered through the
so reduced opening may be choked up while the mother
may bleed out to death” [11]. All the risks for the delivering circumcised woman should be supplemented by the
risk of ruptured tissues during delivery, increased bleeding, diastasis of wounds and an excessive load not only
to pelvic floor but also to the newborn. Finally, circumcision increases risk of infection with sexually transmitted diseases, including HIV infection [12]. Circumcised
women living in diaspora in Europe after getting pregnant full of anxiety are confronted with a double probREVIEW PAPERS
460
Stanisław Antczak, Agnieszka Żok
lem. One of them involves clear fear of delivery and the
other the need to take advantage of assistance of a physician, frequently a man, against their own cultural rules
which forbid contacts of the type [13].
Since circumcision precipitates the so numerous negative health consequences of both somatic and psychic
nature it is worth to consider why so drastic procedures
continue to be widely practiced in some societies.
The most important factors which in a decisive way
shape human behaviour include cultural heritage. Individual cultures frequently in a significant way differ
from each other and the contemporary form of the world
manifests an extreme cultural variability. Clarification of
forms and of significance of cultural effects requires that
the terms should first be well defined. The choice of an
appropriate way in which the term should be understood
poses a difficult goal because the scientific terminology
contains an extreme number of definitions of a culture.
In the context of our analysis the most relevant seems to
be understanding of a culture as a set of common rules
which decisively affect behaviour of members in a community or society and „a set of values, beliefs and attitudes shared by most of community members” [14]. Such
norms are inherited from generation to generation and
control almost all aspects of functioning in the human
community. Thus, the so understood culture constitutes
a specific property of a social, national or tribal group and
represents one of principal factors affecting the process
in which identity of an individual is shaped and, in this
way, which is „programming” of his/her mind. Cultural
norms determine the way in which causes and course of
diseases are perceived, the choice of their treatment but
represent also a significant source of differences in the
way health problems are perceived and in the preferred
strategies of resolving the problems. Conditioning of the
social/cultural nature exert also a decisive effect on the
shape of our views on human body since it affects also
the relationship between culture and health. The question acquires a particular significance in the context of
problems linked to female circumcision in Africa and the
resulting consequences for the altered shape of female
external genital organs [15].
Female circumcision has no religious background:
in Africa it is practiced by Moslems, local Christians,
Fellasha Jews and by animists. It reflects local, deeply enrooted African tradition, the beginnings of which
reach back four hundred years [16]. Among the traditional values providing base for cultural identity of an
African man a specific role is played by values linked to
a traditional African family. They include respect for the
elders, which warrants continuation and transfer of tradition and the honour, aimed to assure observation of the
compliance with orders of the local moral code. Moreover, a significant role among the fundamental values is
played by maternity, assuring coherence of the group in
time and provision of progeny. It symbolizes prosperity and tribe continuation and it warrants an appropriate standard for the family [17]. Pointing to significance
of the ritual, Jomo Kenyatta, later the first president of
REVIEW PAPERS
independent Kenya said that „initiation is not reduced
only to sexual life, it also provides a hard lesson of
respect for the elders and of obligations toward the country” [18]. For this reason he was an ardent advocate and
a defendant of circumcision ritual while his book „Facing Mount Kenya” (London 1938) „provides an apoteosis
of initiation as an extremely important institution in an
educational process and a significant element of patriotism of Kikuju people” [19].
Circumcision exerts a significant effect on female status in the community in which she lives and on honour
of her family. It provides also an indispensable condition
for establishing marriage since an uncircumcised woman
has no chances to find a husband in a society which practices it. This was confirmed by Khady, a female author
originating from Soninké people, inhabiting Senegal.
She wrote that „a worthy his family Soninké would never marry an „unclean” girl” [20] since, according to the
author, multi-year tradition requires that parents should
for their daughters „an appropriate preparation for roles of
a wife and a mother, circumcision and selection of a husband. For them neglect of such a duty would harm their
daughters much more than circumcision” [21]. Girls who
would not be subjected to circumcision would be exposed
to social stigmatization and, due to this, to isolation or
even exclusion [21]. Just for these reasons, the girls themselves want to be subjected to the procedure. In a report
prepared by UNICEF its authors draw readers’ attention
to the fact that genesis of the cruel custom is enrooted in
the male fear of female sexuality present in several African cultures and male attempts to control it. Circumcision is thought to reduce sexual drive in women, which
favours her moral behaviour [22]. Attempting to clarify
practice of this „bloody ritual”, Bruno Bettelheim, a representative of the so called psychoanalytic microanthropology, quoted views of F. Bryk, another investigator also
representing psychoanalytic orientation, who thought that
„excision of the external centre of stimulation reduced
sexual freedom of a Nandu girl and in this way the girl
becomes transformed from a generally accessible property to a private one, the exclusive property of her husband.
This meant that, in opinion of the investigator, removal of
the easiest to stimulate externally exciting organ attenuated female sexual drive. According to him this was the
only way to enforce monogamy in the female, „a monogamy which contradicts female nature” [22]. The author,
however, continued quoting the marginally distinct from
the preceding one opinion of Maria Bonaparte. The latter author thought that submitting girls to the crude excision procedure aimed not at promotion of their feminization but rather at their sexual intimidation. According
to the female investigator „some men wish that a female
carries in herself nothing which is male. The elements
which in a female seem to be phallic provides them with
a source of anxiety and therefore they require elimination
of external stimulation organs in females” [23]. Moreover, the investigator thought that „ all the customs seem
to provide satisfaction only in the sphere of imagination
in humans who introduce the customs (…) and no female
Female genital mutilation in Sub-Saharan Africa as a health and cultural problem
mutilation can cause that a man uncertain of his masculinity will feel less endangered by women” [24].
In several societies uncircumcised women are regarded unclean and even treated as harlots, which in practice
excludes them from social life. The arguments for subjecting a female to circumcision used to include her chastity, certainty as to her virgin character up to the day of
marriage and, ironically, hygiene, aesthetics and health.
In this case various prejudices play a significant role [25].
„In certain countries people think that uncircumcised
women cannot deliver a baby or that contact of a newborn with clitoris induces death of the newborn” [12].
Joseph Campbell, an eminent anthropologist and a specialist in matters of religion presented a concept enrooted
in the African tradition, according to which cliterodectomy involving removal of clitoris in a woman is substantiated by the fact that „(…) humans are delivered in an
androgynic, male-female form and circumcision is supposed to release full masculinity from a mother’s womb.
This is how it is symbolically interpreted. In a similar
way removal of clitoris eliminates the male element and
the person becomes fully female. The ritual takes place
during pubescence” [26]. In turn, another anthropologist,
Nigel Barley, accentuated that a clitoris used to be taken
as a rudimental form of the penis, which should not be
present in women since the substitute of male penis casts
doubts as to their feminity. Therefore, „it is required that
culture should correct the imperfect nature” [27]
Also Africans share the conviction that a circumcision-subjected woman will not break somebody’s else’s
marriage. Occasionally, African women trust that a circumcision-induced sexual frigidity represents a price
which has to be paid for reduction of temptations which
draw off men from the family. The earlier quoted Khady,
originating from Senegal, wrote: „Women accuse men
that they initiate the „operation” but in many villages
fathers are not informed about it unless the circumcision
is performed in common, treated as an initiating ritual,
when entire village knows about it. In towns, on the other hand, the procedure is conducted in privacy so that
neighbours should know nothing about it” [20]: contemporary African towns are inhabited mostly by multi-ethnic people which not necessarily practice the same customs and frequently are adherent to frequently very distinct traditions. Finally, it is worth stressing that in view
of protests and condemnation of the practice in the western world many African women begins to treat circumcision as a symbol of African identity. A similar view is
presented by some marginal relativists and cultural pluralists in the western world. In their opinion representatives of the West enjoy no rights to criticize practices
cultivated in other societies, such as ritual mutilation of
female sexual organs [28].
References
1. World Health Organization. Global strategy to stop healthcare providers from performing female genital mutilation.
2010:1.
461
2. World Health Organization. Eliminating Female Genital
Mutilation. 2008:4–28.
3. World Health Organization. Female Genital Mutilation:
integrating the prevention and the management of the
health complications into the curricula of nursing and midwifery, a teacher’s guide. Geneva; 2000.
4. [Internet] Jaszczyński W. Obrzezanie kobiet [accessed:
12.08.2012]. Available at: www.racjonalista.pl/kk.php/
s,3140.
5. [Internet] [accessed: 19.10.2011]. Available at: http://www.
womenshealth.gov/publications/our-publications/fact-sheet
/female-genital-cutting.cfm.
6. [Internet] GHN [accessed: 19.10.2010]. Available at: http://
ghanahealthnest.com/female-genital-mutilation-the-faqs/
7. WHO. An update on WHO’s work on female genital mutilation. Progress report. 2011.
8. World Health Organization. A Systematic Review of the
Health Complications of Female Genital Mutilation including Sequelae in Childbirth. Geneva; 2000: 1–186.
9. Abdi N, Linder LG. Łzy na piasku. Warszawa; 2008: 30.
10. Hilliges IM. Biała czarownica. Warszawa; 2008: 126.
11. Dirie W, Miller C. Kwiat pustyni. Z namiotu nomadów do
Nowego Yorku. Warszawa; 2007: 168.
12. Dirie W. Milborn C. Przełamać tabu. Warszawa; 2005:
168.
13. Dirie W, Miller C, Widy M. Życie codzienne
w muzułmańskim Paryżu. Warszawa; 2005: 89.
14. Tavris C, Wade C. Psychologia. Podejście oraz koncepcje.
Poznań; 1999: 372; Staszczak Z, editor. Słownik etnologiczny. Terminy ogólne. Warszawa-Poznań; 1987: 187–191.
15. Matsumoto D, Juang L. Psychologia międzykulturowa.
Gdańsk; 2007: 251–255. Hofstede G, Hofstede GJ, Minkov M. Kultury I organizacji. Zaprogramowanie umysłu,
Warszawa; 2011: 20–23. Weisner TS. Kultura, dzieciństwo
I postęp na obszarze Afryki Subsaharyjskiej. In: Harrison
LE, Huntington SP, editors. Kultura ma znaczenie. Poznań;
2003: 228–232.
16. Veran S. Krwawa tradycja. Francja wypowiada walkę
obrzezaniu dziewczynek przez niektórych imigrantów
z Afryki. Observateur, 4–10.02.1993. Forum. 1993;11:21.
17. Szupejko M. Afrykańska tożsamość u progu XXI wieku.
Anglojęzyczna literatura Czarnej Afryki i jej twórcy. Warszawa; 2007: 47. On the role of family see also: Vorbrich
R. Plemienna i postplemienna Afryka. Koncepcje I postaci
wspólnoty w dawnej i współczesnej Afryce. Poznań; 2012:
27–35. Dozon J-P. Afrika: Die Familie am Schceideweg,
Geschichte der Familie, Burguiẻre A, Klapisch-Zuber C,
Segalen M, Zonabend F. Band 3, Neuzeit, Frankfurt/Main;
1997: 385–433.
18. Zins H. Historia Afryki Wschodniej. Wrocław; 1986: 161.
19. [Internet] Kenyatta J. Available at: http://en.wikipedia.org/
wiki/Jomo_Kenyatta.
20. Khady. Okaleczone, Warszawa; 2007: 166; Kazimierczyk M. ONZ bije na alarm. Szokujący raport o obrzezaniu. Gazeta Wyborcza. 2005 November 26–27.
21. Hussein MA. Obrzezanie dowodem kobiecości. Rzeczpospolita. 25th November 2005. Significance of initiation ritual;
see also: Słownik etnologiczny. Terminy ogólne. 160–161.
22. Bryk F. Die Beschneidung bei Mann und Weib, Neu Brandenburg; 1931: 279, quoted after Bettelheim B. Rany symboliczne, rytuały inicjacji i zazdrość męska. Warszawa;
1989: 271.
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23. Bettelheim B. Rany symboliczne, rytuały inicjacji
i zazdrość męska. Warszawa; 1989: 271–272.
24. Bonaparte M. Notes on Excision, in: Psychoanalysis and
the social Science, New York 1938, vol. II, 81, quoted after:
Bettelheim B, 272–273. See also: Piłaszewicz S. Religie
Afryki. Warszawa; 2000: 145.
25. Staszczyk Z, editor. Słownik etnologiczny. Terminy
ogólne. Warszawa–Poznań; 1987: 297–299.
26. Campbell J. Kwestia bogów. Warszawa; 1994: 66.
27. Barley N. Plaga gąsienic. Powrót do afrykańskiego buszu.
Warszawa; 1998: 49.
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28. Harrison LE. Dlaczego kultury nie sposób przecenić? In:
Harrison LE, Huntington SP, editors. Kultura ma znaczenie. Poznań; 2003: 29.
Laboratory of History of Public Health and Social
and Health Policy
79 Dąbrowskiego Street, 60-529 Poznań, Poland
phone: +48 61 854 68 39
Medical News 2013, 82, 6, 463–466
MARIA KŁODZIŃSKA-BERKAU
THE INFLUENCE OF BIPOLAR AFFECTIVE DISORDER
ON FEMALE REPRODUCTIVE HEALTH
WPŁYW CHOROBY AFEKTYWNEJ DWUBIEGUNOWEJ NA ZDROWIE REPRODUKCYJNE KOBIET
Laboratory of Health Sociology and Social Pathology, Chair of Social Sciences
Abstract
Mood disorders in the course of affective bipolar disease affect sexual functions in women and also frequently handicap their cognitive
functions. CHAD may, on one the hand, trigger anxiety and, on the other hand, provoke sexual arousal. All depends on the current
disease phase of a woman. Even 30% of women with CHAD stimulated depression show sexual and marriage problems, which are,
unfortunately, considered quite marginally by both, doctors and the patients themselves. The decision to have children is a dilemma
of many women with CHAD, the more that 50% of pregnancies are those unplanned. In this group of women pregnancy entails huge
risk of recurrence and even 50% face necessity to be hospitalized due to aggressive behaviour, self-mutilations or suicidal thoughts.
When choosing the right pharmacotherapy during a pregnancy toxic symptoms occurrence in the infant should be considered.
Studies show that a half of pregnant women with CHAD or those who sought medical advice about getting pregnant were instructed
to make an abortion or avoid pregnancy at all. Whereas, previous knowledge on behaviour of women with CHAD during pregnancy and
puerperium allows to determine guidelines for pharmacotherapy and psychoeducation, pregnancy process monitoring and puerperium
procedures. It is essential for a woman, in described circumstances, to receive understanding and support from her family.
KEY WORDS: bipolar disorder, reproductive health, sexual needs, sexual dysfunctions, mania, depression, support.
Streszczenie
Zaburzenia nastroju w przebiegu choroby afektywnej dwubiegunowej wpływają negatywnie na funkcje seksualne kobiet, częstokroć
upośledzają też funkcje poznawcze. CHAD może wywoływać z jednej strony lęk, z drugiej – pobudzenie seksualne. Wszystko
zależy od fazy chorobowej, w której znajduje się kobieta. Aż u 30% kobiet w depresji wynikającej z CHAD obserwuje się problemy
seksualne i małżeńskie, które niestety traktowane są dość marginalnie zarówno przez lekarzy, jak i przez same pacjentki. Decyzja
o posiadaniu dzieci to dylemat wielu kobiet z CHAD, tym bardziej iż 50% ciąż to te nieplanowane. W tej grupie kobiet ciąża wiąże
się z dużym ryzykiem nawrotu; aż u 50% zdarza się, że muszą być one hospitalizowane w związku z zachowaniami agresywnymi,
samookaleczeniami lub myślami samobójczymi. Wybierając opcję farmakoterapii, należy rozważyć ryzyko wystąpienia objawów
toksycznych u noworodka. Z badań wynika, iż połowa cierpiących na CHAD kobiet, będąc w ciąży lub szukając porad w sprawie
zajścia w ciążę, została poinstruowana, żeby ją usunąć lub jej unikać. Tymczasem dotychczasowa wiedza na temat zachowań kobiet
w czasie ciąży i połogu pozwala na określenie wytycznych dotyczących farmakoterapii i psychoedukacji, monitorowania przebiegu
ciąży oraz postępowania w czasie połogu. Niezwykle ważne jest zrozumienie i wsparcie rodziny.
SŁOWA KLUCZOWE: choroba afektywno-dwubiegunowa, zdrowie reprodukcyjne, potrzeby seksualne, dysfunkcje seksualne,
mania, depresja, wsparcie.
Introduction
Reproductive health of women can and should be
assessed from the perspective of their sexual health. It
is a component of human reactions that secures well-being, lifts self-esteem and quality of life of a woman.
Mood disorders in the course of CHAD have a negative
effect both, on sexual functions and attitude towards
sexual life. Sexual life is also connected with mood
impact on cognitive functions efficiency. Cognitive
impairment in mania and depression disturbs regularity
of these reactions. Detrimental influence of depression
weakens erotic stimuli which do not act on hearing, eyesight, smell or taste strong enough to arouse a woman
sexually. CHAD may on the one hand stimulate anxi-
ety, sexual prejudice, total libido disappearance and, on
the other hand, sexual arousal and even erotic illusions
occurrence. Elevated mood is often coupled with lowered criticism, it triggers provocative, tactless behaviour
that facilitates casual sexual contacts. The state of sexual
health of women with bipolar affective disorder changes
with the current phase of a patient. In mania, due to elevated sexual need, it may even come to attempted rape,
sexual abuse towards the juvenile, homosexual compulsive contacts and, in extreme cases, to sexual homicide.
Unwanted pregnancies are an often consequence of such
actions. The risk of sexually transmitted disease infection also increases. Patients' moral standards get violated what provokes strong remorse reaction in the remission period.
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Maria Kłodzińska-Berkau
Discussion
Bipolar affective disorders are often accompanied by
so-called comorbidities connected with general anxiety,
agoraphobia or social phobia that result in a sexual contact and marriage limitation. While, an increased tendency to get divorced can be observed. Additional somatic
depression symptoms such as backache, stomach ache,
genital pain or increased sweating enhance resistance
towards sexual activity.
Pharmacological therapy and its side effects can be
enough to trigger sexual disorders in the disease. Patients
can suffer from sexual frigidity and inability to have an
orgasm. Other issues like abnormal menstrual cycle, its
irregularity, reduced fertility, pain appearing during an
intercourse, vaginismus or glactohorrea may occur [1].
In many cases sexual satisfaction with a so far attractive partner vanishes due to overwhelming anhedonia.
Studies show that 30% of women with CHAD related
depression have sexual and marriage issues. Unfortunately, patients as well as doctors happen to treat these
problems quite marginally. The decision to have children is a dilemma of many women with mental disorders, including CHAD. Such decision should be made
after medical consultation with the treating physician.
Threats to baby's development and health that should
be taken into consideration are those connected with
the disease, possible lack of its treatment or an impact
of medicaments taken during pregnancy. It should be
remembered that the first pregnancy trimester is at biggest risk of developmental fetus defects to form. Whereas, studies show that even 50% of pregnancies in women
with CHAD are those that were not planned. Pregnancy
in the course of CHAD disorder involve the risk of the
relapse – even in 50% of the cases. 40–70% of mothers
with untreated disease suffer from postpartum disorders,
half of them starts already during pregnancy. Hence,
this is of ultimate importance to combine treatment with
relapse prevention. If it is at all possible to create a recipe
for optimum behaviour of a CHAD patient who is planning to have children, it should involve:
– planning a pregnancy
– slow coming off a mood-stabilizing medication
before the conception
– monitoring mental state of a pregnant woman
– and resumption of treatment in the second half of
pregnancy.
Four episodes of patient's exacerbation of the disease in
the disease history are connected with considerable risk
of a relapse after coming off a mood-stabilizing drug.
Additional factors of depression risk are:
– young age of patients
– ambivalent attitude towards pregnancy
– poor socio-economic status
– weak family and social support
– negative experiences, marriage conflicts
– poor general health condition.
Pregnant women with CHAD often do not cooperate
with their physician, they eat badly, take stimulants and
REVIEW PAPERS
after giving birth they do not start a positive relationship
with the baby.
Nursing a pregnant woman with affective disorders
varies depending on the disease course, on whether she
can receive outpatient treatment or whether there are
indications for hospitalization. Hospital treatment is recommended with the occurrence of aggressive behaviour,
self-mutilation, suicidal thoughts, denial of food and drug
intake. Women with untreated depression during pregnancy more often give Caesarean birth and their infants
require to be treated at ICU (Intensive Care Unit). Miscarriage, foetus death or bad foetus condition are observed in
the group of patients with CHAD who suffer from chronic psychosis. In such cases pharmacological treatment
is advisable due to the risk of the disease deterioration,
suicidal tendencies or eating disorders. Discontinuation
of pharmacotherapy in the above clinical circumstances
leads to the necessity of increased drug doses and hospitalization later on. Foetus can be endangered because of
disturbed mother's behaviour. Hence, it should be carefully analysed whether to choose pharmacotherapy and
connected with it risk of toxic symptoms in the infant or
allow the psychosis to escalate, which can pose a threat
to both the mother and the infant in case treatment is
discontinued. With the second option there frequently
come thoughts of harming a child. Statistically, 0.6–
2.5/100000 thousands of infants get killed by their mothers. The risk of psychosis (delusions and hallucinations)
and bipolar affective disorders within a month after the
birth is 1/1000 in women. The most frequently diagnosed conditions are manic symptoms, elevated mood,
increased activity, rarely lowered mood with the sense
of guilt as well as poor speech and bad cognitive ability.
A Danish study confirms that admission to psychiatric
ward is three times more frequent in all women within
10–19 days after giving birth. During a year after birth
27% of women with bipolar affective disorder come to
psychiatric ward.
Viguera et al. in their prospective-cohort research
observed pregnant women with CHAD and reported
that he risk of relapse during pregnancy is even 71%.
What is really interesting, the majority of observed episodes was of depressive nature, almost a half appeared
in the first trimester of pregnancy. Relapses occur
more often in women who came off a drug and in
women with affective disorder of type 2 and in those
studied patients who took mood-stabilizing drugs in
the past. From among 70 respondents with bipolar affective disorder and looking for advice about getting pregnant and having children in their difficult disease condition, half received psychiatrist's or obstetrician's instruction or family members advice to avoid pregnancy. This
is due to the widespread prejudice that women with
CHAD should not get pregnant [2].
It is difficult to advise, forejudge or decide as each
case of a pregnant woman with CHAD is different, it is
essential to find a balance between threats to the foetus
and continuing treatment or affective disorders resulting
from relapse in case treatment is not continued.
The influence of bipolar affective disorder on female reproductive health
Children of mothers with depression during pregnancy three times more often have depressions, phobias
or anxiety disorders. Addiction to alcohol is five times
more frequent, and depression develops earlier for the
age span between 15–20, whereas anxiety disorders
between 5–10.
Data about the course of bipolar affective disorder in
pregnant women indicate a lower number of re-hospitalizations during that period of time. The number of hospitalizations decreases by 25% whereas before the birth
increases 8 times [3].
Untreated manic disorders pose a threat to a child
and a mother because of hyperactivity of a patient, her
insomnia, alcohol abuse and impulsive behaviour can
also be observed.
Mood disorders prevention during pregnancy and
puerperium should include:
– identification of women from the risk group
– psychoeducation employment
– supportive psychotherapy
– interpersonal therapy
– pharmacotherapy [4].
Existing knowledge about behaviour of women with
CHAD during pregnancy and puerperium allows to
establish guidelines for pharmacotherapy in this period
of time. With long remission periods in affective disorders of type 2 (depression and hypomania episodes)
discontinuation of treatment can be considered for the
moment of conception and first trimester of pregnancy.
With planned pregnancy lit should be discontinued slowly (a sudden come off may trigger a sudden relapse). In
case of unplanned pregnancy lit should be discontinued
immediately and considered introducing it again to the
second trimester in a dose reduced by 25–30%. The level
of lit in the serum should be monitored once a month and
thyroid activity controlled. Two weeks before the expected date of childbirth lit should also be discontinued or
reduced by 50% – therapy should be continued 48 hours
after the childbirth. Valproate and carbamazepine should
be avoided, folic acid and vitamin K are recommended.
Treatment of affective disorders during lactation
involves:
– Depression episodes therapy.
– Therapeutic proceeding in mania episodes.
– Relapses prevention.
Proceedings in mood disorders prevention during lactation are as follows:
– Continuing treatment recommended during pregnancy.
– Taking minimal recommended drug dose.
– Avoiding polypharmacy.
– Elimination of long biological half life time medicaments.
– Avoiding feeding during drug concentration peak.
– Taking medicament in a single night dose.
– Monitoring health condition of a suckling [5] .
Correlation between occurrence of postpartum psychosis and biopolar affective disorder has been found. Its
frequency in the general population is 1–2 / 1000 childbirths whereas in women with CHAD it is 100 times
465
more often. Even 72–80% of patients with psychosis suffered before from psychiatric disorders or/and there was
a positive family history towards CHAD. Postpartum
psychosis often occurs with cognitive function impairment, eccentric behaviour, disorganized thinking, lack
of insight, persecutory delusions and infanticide thoughts
and tendencies. Additionally, visual, tactile and olfactory hallucinations or delirium can appear. Kadrmas et al.
noticed that 62% of patients had Schneiderian disorders
and hallucinations:
– Audible thoughts.
– The feeling of alienation.
– Emotions and behaviour controlled by an external
force.
– Dependence of thoughts and doings on some external
institution.
4% of women with postpartum psychosis commit infanticide. This can be related to the lack of adequate postpartum mood disorders diagnosis. Condition of depressed
mood is mistaken for frequent emotional discomfort that
does not require an intervention, so-called 'baby blues'.
In such a case, family support is enough and symptoms
disappear after a few days.
While, psychosis is a result of life-long susceptibility
to affective disorders and a childbirth, in such a case, is
a triggering factor. During childbirth estrogen and progesterone hormones concentration decreases 200 times
and this has enormous influence on feminine mental
health [6].
Women can be exposed to other mental disorders
together with CHAD:
– Psychoactive substances addiction.
– Anxiety disorders (social phobias, panic disorders,
posttraumatic stress disorder).
– Personality disorders.
– Eating disorders 2 [7].
Moreover, BASCO proposes cognitive-behavioural model of affective disorders:
Affective episode
– sleep disorders
– stress
– changes in social
functioning
– changes in cognitive domain
– changes in emotional
domain
– changes in social behaviour
domain
General functioning deterioration
Counteraction for this negative cognitive triad is
supposed to be cognitive-behavioural psychotherapy
[8]. When talking about reproduction process the creativity feature should be mentioned, as one that has an
intensifying effect on it. Creativity has developed in
the process of Homo sapiens brain evolution. It fosters
better adjustment to the environment and reproductive
success. Creative activity is connected with elements
of psychopathology characteristic to mental disorders,
including bipolar affective disease. Women with CHAD
are open to experience and are prone to divergent thinking, they perceive what others cannot. It is worth menREVIEW PAPERS
466
Maria Kłodzińska-Berkau
tioning, that they have high IQ scores that aid their creative achievements. Activity of mesolimbic dopaminergic system provoke motivation increase to operate and
a sense of hedonia. Habituation processes are weakened. Dopaminergic receptor gene D4 is related with
the tendency to seek novelty (novelty seeking). Studies
support the concept that artistic creativity can function as a factor attractive to a sexual partner and in the
evolutionary context it enhances reproductive success.
There is a relationship between creative activity and
bigger number of sexual partners. Women with CHAD
and their children receive significantly higher scores on
the creativity Baron Welsh Art Scale (BWAS) [9]. When
considering an aspect of self-awareness and knowledge
about CHAD, psychoeducation plays an important role.
Nowadays, it would be difficult to imagine a CHAD
therapy without taking into account psychoeducational activities. What is more, psychoeducation helps to
respect basic right of a patient to information access
about the disease. Persons who participated in psychoeducational programmes have high opinion about them,
some of such courses can even change the attitude to the
disease and the treatment. A big advantage are partner
like physician-patients relations. Group nature of sessions facilitates sharing experiences, practical information and solutions. Psychoeducational session participants can support one another and try to live a rewarding life despite the disease.
Therapeutic sessions involve such issues as pregnancy, genetic counselling and the risk of treatment discontinuation [10].
Conclusions
The period of pregnancy and postpartum condition are
critical for women with CHAD.
They can entail numerous consequences for the
woman herself and her child, as well as for their relationship. It is essential for the mother to be, especially during pregnancy and puerperium, to maintain good men-
REVIEW PAPERS
tal state. Pharmacological treatment should be properly
adjusted and the risk of mood deterioration calculated.
References
1. Heitzman J. Dysfunkcje seksualne w chorobie afektywnej
dwubiegunowej. Psychiatr w Prakt Ogólnolek. 2003;3(1):
33–37.
2. Viguera AC, MD. Reproductive decisions by women with
bipolar disorder after pregnancy psychiatric consultation.
Am J Psychiatr 159:12 December 2002, 2102–2104.
3. Rzewuska M. Ograniczenia stosowania leków psychotropowych w okresie ciąży i laktacji. Rzewuska M, editor. In: Leczenie zaburzeń psychicznych. Warszawa, PZWL; 2000: 11–34.
4. Altshulter L. Cohen L. Szuba MP, Burt VK, Gitlin M,
Mintz J. Pharmacologic management of psychiatric illness
during pregnancy: dilemmas and guidelines. Am. J. Psychiatr. 1996;153:592–606.
5. Bazire S. Psychotropics in problem areas. Breast feeding.
Pregnancy. Bazire S, editor. Psychotropic drug directory. The professionals' pocket handbook and aide memoire.
Salisbury: Quay Books Division; 2002: 172–178, 205–217.
6. Spinelli MG. Postpartum psychosis. Psychiatr Med Prakt.
1(12) styczeń-luty 2010. Psychoza poporodowa. 37–43.
7. Jakuszkowiak-Wojten K, Gałuszko-Węgielnik M, Wojtas
A. Rola psychoterapii poznawczo-behawioralnej w leczeniu zaburzeń afektywnych dwubiegunowych. Psychiatr.
2012:36–42.
8. Basco RM, Rush JA, Cognitive-behavioural therapy for
bipolar disorder. Psychiatr. 2012;9(1):244–272.
9. Rybakowski J. Udręka i ekstaza. Mag PAN 1/09;(17):4–7.
10. Mączka G, Gierowski JK, Dudek D. Psychoedukacja
grupowa w kompleksowym leczeniu choroby afektywnej
dwubiegunowej, doświadczenia krakowskie. Psychiatr Pol.
2010;XLIV(1):89–100.
Laboratory of Health Sociology and Social Pathology
79 Dąbrowskiego Street, 60-529 Poznan, Poland
phone: +48 61 854 69 11
Medical News 2013, 82, 6, 467–471
ALEKSANDRA MOTYKA, EWELINA WIERZEJSKA, ALEKSANDER WAŚNIOWSKI, MATEUSZ COFTA
CURRENT TRENDS IN EPIDEMIOLOGY OF CHLAMYDIA TRACHOMATIS INFECTIONS,
GONORRHOEA AND SYPHILIS IN POLAND AND EUROPE
AKTUALNA SYTUACJA EPIDEMIOLOGICZNA W ZAKRESIE ZACHOROWAŃ NA CHLAMYDIOZĘ,
KIŁĘ I RZEŻĄCZKĘ W POLSCE I EUROPIE
Laboratory of International Health, Chair of Preventive Medicine, Poznan University of Medical Sciences, Poland
Head: prof. Jacek Wysocki
Abstract
Sexually transmitted infections are still present in Europe. Data gathered on STIs in Europe in the period between 2006 and 2009
is becoming more and more homogenous, but still lacks satisfactory comparability due to legislative differences between countries
(notifiable or not notifiable status of STIs), instututions from which data is gathered and ongoing screening programs which target
certain age, gender or other patient groups. Although syphilis and gonorrhea all-European incidence rate has decreased by 9%, the
data is not sufficient to proclaim a persisting trend. On the other hand, the incidence rate of Chlamydia trachomatis infections has
increased in recent years reaching 185 per 100 000 in 2009, mostly due to improved reporting. Recent years have shown well-defined
trends among men having sex with men – an ongoing epidemic of syphilis and outbreaks of lymphogranuloma venereum, which are
limited to only this specific group. Situation in Poland is obscured by underreporting. There is a downward tendency in the number of
blood tests performed regarding dermatological and venereal diagnosis while the incidence rates of Chlamydia trachomatis infections,
gonorrhea and syphilis show an upward trend.
KEY WORDS: STIs, epidemiology, Chlamydia trachomatis, gonorrhea, syphilis.
Streszczenie
Choroby przenoszone drogą płciową nie przestają istnieć w Europie. Dane zbierane w Europie między 2006 a 2009 r. uległy
ujednoliceniu, lecz ciągle w zbyt małym stopniu, by móc doszukiwać się faktycznych różnic między poszczególnymi krajami.
Nie we wszystkich krajach istnieje prawny obowiązek zgłaszania chorób przenoszonych drogą płciową, dane zbierane są z różnej
liczby i różnych typów placówek medycznych (dane zebrane dzięki programom profilaktycznym, skierowanym do konkretnych
grup, np. ludzi młodych czy kobiet w ciąży, zaburzają strukturę wieku i płci w ogólnokrajowych danych). W latach 2006–
2009 ogólnoeuropejska zapadalność zarówno na kiłę, jak i rzeżączkę spadła o 9%, ale dane nie są wystarczające, by ów spadek
nazwać wyraźnym trendem. Wiadomo, głównie dzięki zwiększeniu liczby placówek, z których zbierane są dane, że wzrosła
ogólnoeuropejska zapadalność na chlamydiozę – 185 przypadków na 100 000. Zaobserwowano dwa zjawiska wśród mężczyzn
uprawiających seks z mężczyznami: pierwszym jest epidemia kiły, drugim są ogniska lymphogranuloma venereum ograniczone
tylko do powyższej grupy. Sytuacja w Polsce wynikająca z danych epidemiologicznych jest zafałszowana przez niedopełnianie
lekarskiego obowiązku zgłaszania chorób przenoszonych drogą płciową. Tendencję malejącą obserwuje się w liczbie badań krwi
w kierunku chorób skórno-wenerycznych, a tendencję zwyżkującą w zapadalności na chlamydiozę, rzeżączkę i kiłę.
SŁOWA KLUCZOWE: choroby przenoszone drogą płciową, epidemiologia, Chlamydia trachomatis, rzeżączka, syfilis.
Introduction
Chlamydia trachomatis infections
In the XXI century Europe sexually transmitted diseases are not among the main causes of death or disability,
nor are they on the way to elimination. The STI are not
preventable by vaccines, except for genital warts caused
by the Human papillomavirus. Some of them, particularly those which cause ulceration of genital areas, make
people prone to be infected with HIV – the youngest of
sexually transmitted infections and still an incurable one
[1]. Below are presented current trends in epidemiology
of the three most common in Europe bacterial STI: Chlamydia trachomatis infections, gonorrhoea and syphilis.
Chlamydia trachomatis infections – situation in Poland
Statistics that were gathered and presented by the Centre of Diagnostic and Treatment of Sexually Transmitted Diseases of Medical University of Warsaw did not
show Chlamydia trachomatis infections separately but
presented the data on non-gonococcal urethritis. NGU
are caused by numerous agents, among which Chlamydia trachomatis is one of most common. In 2007 there
were 1276 cases of NGU (that is 205 less cases than in
2006). The incidence rate in 2007 was 3.35 per 100 000
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468
Aleksandra Motyka, Ewelina Wierzejska, Aleksander Waśniowski, Mateusz Cofta
(3.89 in 2006). In 2008 there were 1127 cases (incidence
rate 2.96) and in 2009 there were 1082 (incidence rate
2.84). The highest incidence rate was reported from Dolnośląskie Voivodeship – from sixfold of country average
in 2007 to threefold of country average in 2009 [1, 2, 3].
According to data gathered by the European Centre for
Disease Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe
2011, there were 612 of Chlamydia trachomatis infection
cases in 2006 (incidence rate 1.6 per 100 000), 627 cases
in 2007 (incidence rate 1.6), 695 cases in 2008 (incidence
rate 1.8) and 908 cases in 2009 (incidence rate 2.4) [4].
Chlamydia trachomatis infections – situation in Europe
Disease Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe
20101, there were 335329 confirmed cases of Chlamydia
trachomatis infections in 2008 reported by 23 European countries (there were no data from: Bulgaria, Czech
Republic, France, Germany, Italy, Portugal and Liechtenstein). The all-european incidence rate was 150 per
100 000 of the general population. Since not in all countries is chlamydia a notifiable disease, the true burden
of Chlamydia trachomatis infections is unknown. The
highest incidence rates were reported from: Iceland (581
per 100 000), Denmark (532), Norway (496) and Sweden
(475), United Kingdom (329) and Finland (262). These
6 countries reported about 95% of all European cases.
The lowest incidence rate, lower than 1 per 100 000 was
registered from: Cyprus (0.13), Romania (0.59), Greece (0.63) and Luxemburg (0.83). For 327682 of reported
cases information on age was enclosed. The highest incidence rate was found among people of 15 to 24 years old
(976 per 100 000). Among people between 25 to 44 years
old the chlamydia incidence rate was 203 per 100 000.
For 334000 of reported cases information on gender was
enclosed. Male to female ratio was 0.72:1. The ECDC
underlines that gender and age structure data are dimmed by more screening programs for women and young
people. Besides a large and plausibly mostly hidden burden of chlamydia there is also an alarming phenomenon
of Lymphogranuloma venereum outbreaks in Europe.
LGV is an infection of the lymphatic system, caused by
some of serovars of Chlamydia trachomatis, transmitted
sexually, co-factoring in transmission of HIV and hitherto almost absent in the western world. In 2008 United Kingdom reported 211 cases of LGV, Netherlands
reported 100 cases, Denmark reported 29 cases and 12
cases were reported from Belgium. All LGV cases were
registered among men. Total number of registered LGV
cases in 2008 was 314 [5].
According to data gathered by the European Centre for Disease Control and Prevention in their Annu1
European Centre for Disease Prevention and Control gathers data
from 27 countries of the European Union as well as data from Iceland, Norway and Liechtenstein: all in all 30 countries, that will be
further referred as European countries or Europe.
REVIEW PAPERS
al Epidemiological Report on Communicable Diseases
in Europe 2011, there were 343958 confirmed cases of
Chlamydia trachomatis infections in 2009 reported by
23 European countries (as in previous year, there were
no data from: Bulgaria, Czech Republic, France, Germany, Italy, Portugal and Liechtenstein). About 95% of all
European cases were reported by only 5 countries: United Kingdom, Sweden, Denmark, Norway and Finland
(in order by the number of cases). The incidence rate was
185 per 100 000. The highest incidence rate was reported
from: Iceland (711 per 100 000), Denmark (541), Norway
(474) and Sweden (408), United Kingdom (357.5) and
Finland (250). Romania and Cyprus reported an incidence rate below 1 per 100000, as in the previous year
(Greece reported an incidence of 2.9, which still was one
of the lowest in Europe). For 339053 of reported cases
information on age was enclosed. The highest incidence
rate was found among people of 15 to 24 years old (976
per 100 000, as in previous year) – that group consists of
¾ of all age specified cases. For 342118 of reported cases
information on gender was enclosed. Male to female
ratio was 0.7:1. As opposed to the ECDC Report from the
previous year, data on the way of transmission are enclosed. Unfortunately the way of transmission was annotated only for 15% of cases. Among this scanty amount
of data 89% of cases were marked “heterosexual way
of transmission”, 4% marked “men who have sex with
men” and for 7% the way of transmission was unknown.
LGV was reported from 3 countries: 142 cases from United Kingdom, 86 from the Netherlands and 17 from Belgium. All of 245 cases reported in 2009 were reported
among men, except one female case from UK. The number of LGV cases in Europe increased since 2006. All in
all there were 183 cases of LGV reported in 2006 (mostly
from United Kingdom, Netherlands and Denmark), 261
cases in 2007 and 314 in 2008 and 245 in 2009. Chlamydia cases in Europe increased by 42% between 2006 and
2009, which is mainly credited to an increased number
of screenings and performed tests as well as including
data gathered by sentinels other than STI clinics rather
than an actual increased in a number of cases. True differences between burden across countries are overshadowed by: often asymptomatic course of the infection that
cause underdiagnosing, legislative differences between
countries (notifiable or not notifiable status of chlamydia), gathering data from STD clinics only or also from
other sentinels and existence of ongoing screening programs. The latter also dim age and gender structure data,
as screening programs are addressed to certain groups,
like young people or pregnant women [4].
Gonorrhoea
Gonorrhoea – situation in Poland
Gonorrhoea is one of the diseases that compels to obligatory treatment according to The Polish Prevention and
Control of Contagious Diseases Act. Statistics that are
gathered by the Centre of Diagnostic and Treatment of
Sexually Transmitted Diseases of Medical University of
Current trends in epidemiology of Chlamydia trachomatis infections, gonorrhoea and syphilis in Poland and Europe
Warsaw are presumably showing only the tip of an iceberg. In 2006 there were 409 registered cases, 488 cases
in 2007 (incidence rate of 1.28 per 100000), 303 in 2008
(incidence rate of 0.79 per 100000), 408 in 2009 (incidence rate of 1.07 per 100000). About 1/5 of all Polish
gonorrhoea cases are detected and treated in one sentinel, that is the Clinic of Dermatology and Venerology of Medical University of Warsaw. In 2007 the largest incidence rate of 5.25 was presented in Dolnośląskie Voivodeship (that is fourfold of the country average
and fourfold of the 2006 incidence rate in this province).
Other voivodeships that reported incidence rate above
country average in 2007 were: Lubuskie, Mazowieckie
and Pomorskie. Podkarpackie Voivodeship reported
0 incidence rate as it did in 2006. In 2008 the highest
incidence rate was noted in Lubuskie Voivodeship (2.38
per 100000) followed by Mazowieckie Voivodeship.
All in all 5 of 16 voivodeships reported an incidence
rate higher than the country average and Opolskie Voivodeship did not report a single case. In 2009 3 of 16
voivodeships registered an incidence rate above country
average, these were: Mazowieckie Voivodeship (4.3 per
100000, that is fourfold country average), KujawskoPomorskie Voivodeship (2.42) and Lubuskie (1.49). The
abovementioned data are partial and probably do not
reflect true differences between voivodeships, but rather
mirror lacks in the number of diagnostic tests performed
and the proportion of diagnosed cases that were properly reported [1, 2, 3].
Gonorrhoea – situation in Europe
The Data gathered by the European Centre for Disease
Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe 2010
shows 26880 cases reported by 28 European countries
in 2008 (Report lacks data from Germany and Liechtenstein). The all-european incidence rate was 8.6 per
100 000 population. Almost 60% of all European cases
were registered in United Kingdom (incidence rate of 27
per 100000). Following countries presenting an incidence rate above the European average are: Latvia (21.0),
Lithuania (16.0), Malta (12.0), Netherlands (12.0), Estonia (11.0), Ireland (10.0), Hungary (8.9). The incidence
rate under 1 per 100 000 was reported by Cyprus, Italy,
Portugal and Poland. For 25 877 of reported cases information on age and gender was enclosed. The number of
cases in age groups 15–24 and 25–44 was almost even
and made 90% of all cases. Differences among these two
age groups were recognizable when considered an incidence rate: 38.02 per 100 000 in 15–24 group and 16.15
in 25–44 group. More cases were registered among men
than women. The all-european male to female ratio was
2.59. In Austria and Estonia the male to female ratio was
below 1.82% of all cases in Austria and 62% of all cases
in Estonia were registered among women. In the rest of
European countries cases among men were more frequent than among women. There was a decrease of 12% in
notification rate between 2006 and 2008. Incidence rate
in 2006 was 9.7 per 100000 population. The ECDC in
469
their Report is cautious in naming this decrease a persistent trend, due to heterogeneity and lacks in gathered
data [5].
According to data gathered by the European Centre
for Disease Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe 2011, there were 29202 confirmed cases of gonorrhoea in 2009 reported by 28 European countries (lack of
data from Germany and Liechtenstein). As in previous years, almost 60% of all cases were reported from
United Kingdom. The all-european incidence rate was
9.7 per 100000 population. The smallest incidence rate
was reported by Poland (1.1 per 100000), Portugal (1.1),
Luxemburg (1.2), Greece (1.5) and Slovenia (1.5), while
the largest incidence rate was registered in United Kingdom (27.6), Latvia (18.5) and Iceland (14.7). For 26 255 of
reported cases information on age was enclosed. About
45% of all cases were reported among people between
15 and 24 years old and 31% among people between 25
and 34 years old. For 27 209 of reported cases information on gender was enclosed. Men form a share of 72%
in all above mentioned cases. The all-european male to
female ratio was 2.6:1 and varied across countries. Ratio
below 1 signifying more detected cases among women
then men was registered in Austria, Iceland and Estonia (a situation similar to one reported previous year).
The biggest male to female ratio in 2009 was registered in Italy – 9.6:1. 13 countries enclosed data on transmission category, covering 80% of all registered cases.
Unfortunately as much as 60% of data were marked as
an unknown way of transmission, followed by 24% marked “men who have sex with men” and 18% marked as
a heterosexual way of transmission. This hiatus in data is
caused by only enclosing the MSM transmission category and not annotating others way of transmission among
cases detected and confirmed in United Kingdom [4].
Syphilis
Syphilis – situation in Poland
Number of cases detected as well as incidence rate elevated since 2003–4. According to data gathered by the
Centre of Diagnostic and Treatment of Sexually Transmitted Diseases of Medical University of Warsaw there were 938 overall syphilis cases in Poland in 2006,
followed by 915 cases in 2007, 906 cases in 2008 and
1234 in 2009. The incidence rate of syphilis in Poland
in previous years was: 2.45 per 100 000 in 2006, 2.39 in
2007, 2.38 in 2008 and 3.24 in 2009. Early latent syphilis
was detected in 254 cases in 2006, 248 cases in 2007,
265 cases in 2008 and in 362 cases in 2009. During this
stage there are no visible symptoms, however serological evidence of ongoing disease can be found. Opportunistic screening, as well as screening of certain groups
like pregnant woman or medical students is very important to reveal asymptomatic cases. On the other hand, an
increase in tertiary syphilis cases detection shows that
the number of tests performed in Poland is still insufficient. There were 215 cases of tertiary syphilis in Poland
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470
Aleksandra Motyka, Ewelina Wierzejska, Aleksander Waśniowski, Mateusz Cofta
in 2007, followed by 207 cases in 2008, 265 cases in
2009 [1, 2, 3]. Despite of VDRL tests advised to be performed twice during pregnancy and an available method
of treatment for both mother and foetus, cases of congenital syphilis still occur, moreover gathered data are
suspected to be underestimated [6]. There were 14 cases
of congenital syphilis registered in 2006 in Poland, 6 in
2007, none registered in 2008 and 13 in 2009. Data that
are gathered in Poland are still partial and incomplete
[1]. According to The Polish Prevention and Control of
Contagious Diseases Act doctors are obligated to report
every detected case of Chlamydia trachomatis infections, gonorrhoea, syphilis or HIV. Data that shows unevenly located cases in Poland are impaired due to doctors negligence in fulfilling their reporting duty. About
1/3 of all Polish syphilis cases are detected and treated
in one Clinic of Dermatology and Venerology of Medical
University of Warsaw [3].
People suffering from syphilis and gonorrhoea and
their sexual partners are subject to obligatory, free of
charge treatment according to The Polish Prevention and
Control of Contagious Diseases Act. People who had sex
with patients diagnosed with syphilis or gonorrhoea, and
may or may not got infected, are advised to obtain expedited treatment alongside with supervision, diagnosis
and follow up, regardless of their insurance status [7].
Syphilis – situation in Europe
Disease Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe 2010, there were 16928 confirmed cases of syphilis in
2008 reported by 29 European countries. The incidence
rate was 4.13 per 100 000 of the general population. The
lowest incidence rate was recorded in Iceland and Portugal (0.63 and 0.89 respectively). The highest incidence
rate was reported from Romania, Latvia and Lithuania
(19, 10 and 9,7 respectively). More men than women were
afflicted by syphilis – an all European male to female
ratio of 2.99 shows almost threefold incidence rate of
men among confirmed cases (data on gender was available for 16874 cases). This disproportion, that shows
the biggest hiatus in the age group 25 to 44, varies from
country to country. In Romania, Lithuania and Latvia
the incidence rate of syphilis infected women and men
is comparable and both high. Data on age was available
for 15337 of cases. 60% of afflicted patients were people between 25 and 44 years old. The same age group
contains the biggest number of infected men. The biggest number of infected women is placed in the younger group of 15 to 24 years old; the same group presents
smallest hiatus between incidence rates among men and
women. There is an ongoing epidemic of syphilis among
men who have sex with men in Europe. In comparison
to year 2006, there was 10% less of all syphilis cases in
2008.
Congenital syphilis cases of 2008 were enclosed
in statistics sent by 17 European countries, 8 of which
reported 0 incidence rate. Among 44 confirmed cases 14
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were resisted in Portugal, 10 in Spain, and 9 in Romania.
As many countries do not register congenital syphilis,
thus true incidence is unknown [5].
According to data gathered by the European Centre for Disease Control and Prevention in their Annual Epidemiological Report on Communicable Diseases in Europe 2011, there were 18317 confirmed cases
of syphilis in 2009 reported by 28 European countries
(comparing to the previous year, The Report lacks data
from Iceland). The incidence rate was 4.5 per 100 000
of the general population. Almost 2/3 of all cases were
registered in four countries, that is Germany, Romania, Spain and United Kingdom. The lowest incidence
rate was reported by Portugal (1.4 per 100000), Norway
(1.6), Sweden (1.9), Ireland (2.2), Greece (2.3) and Slovenia (2.3). The highest incidence rate was registered by
Romania (15.0 per 100000), Lithuania (9.7), Latvia (7.3)
and Czech Republic (6.6). Data on gender were gathered for 15710 cases, bulk of them was registered among
men (76%). The male to female ratio for European cases
was 3.1:1 and varies greatly between countries. Very
small differences between the number of male and female cases were reported again in Romania (slightly more
female cases), Latvia and Lithuania. The highest disproportion between male and female cases (above 10:1) was
registered in Denmark, Norway, France, Slovenia, Germany and Netherlands. More female cases ware reported by Austria, Cyprus and Romania. Data on age were
available for 14107 of cases, 58% of which were reported in the age group of 24–44. In almost all age groups
there were more male than female cases, except for 0–14
and 15–19 age groups. Data on transmission were provided by 14 countries for 3417. 41% of these cases were
ascribed to the heterosexual way of transmission, 8%
to unknown and 51% were men who have sex with men
(MSM). Congenital syphilis cases of 2009 were enclosed
in statistics sent by 21 European countries, 11 of which
reported 0 incidence rate. Among 71 confirmed cases 30
were registered in Bulgaria, 13 in Portugal, 12 in Italy, 11
in Spain, and 7 in Romania. Although 4 more countries
sent their statistics on congenital syphilis in comparison
to 2008, there is still a huge hiatus in data on this subject
and true incidence is unknown. In comparison to year
2006, there were 9% less of all syphilis cases in 2009.
Syphilis is third the most frequently reported sexually transmitted disease in Europe, yet due to differences
in reporting systems across countries, lack of countrywide screening programs and very likely a large number
of unreported cases, no consistent trends can be proclaimed [4].
Conclusion
Data that are gathered in Europe concerning STI lacks
homogeneity and shows signs of underreporting. The
ECDC underlines in their reports a heterogeneous character of surveillance systems on STI across countries
that hinders comparing of data. Data on chlamydia,
a disease of a huge incidence rate, are incomplete becau-
Current trends in epidemiology of Chlamydia trachomatis infections, gonorrhoea and syphilis in Poland and Europe
se of lack of information from 7 countries (not in every
country chlamydia is a notifiable disease).
Trend that can be observed, taking into account
imperfections of data, is an increased incidence rate of
chlamydia cases, mainly due to an improved surveillance system in the United Kingdom, that stands for the
bulk of reported cases. Recent outbreaks among MSM
of Lymphogranuloma venereum, which was very rare
in the western world, are a concerning phenomena since LGV co-factors in transmission of HIV. Although allEuropean incidence rate of gonorrhoea has decreased by
9% between 2006 and 2009, particular countries seem
to present diverse trends (increased incidence rate in e.g.
Denmark, Iceland and Spain). The most concerning trend
regarding syphilis is an ongoing epidemic among men
who have sex with men. All-European incidence rate
of syphilis has also decreased by 9% between 2006 and
2009, but no persisting trend concerning whole Europe
can be observed, since some countries, like Poland, the
Czech Republic or Denmark reported an increased incidence rate [4, 5].
In Poland true trends are hard to observe due to
underreporting and a constantly decreasing number of
performed diagnostic tests. There were 514 969 blood
tests performed regarding dermatological and venerological diagnosis in 2007 in Poland; that is about 7% of
tests performed a decade ago. In 2008 the number of tests
decreased to 468 504. In 2009 there were only 154 993,
which makes about 2% of the number of tests performed
in ’90. Nevertheless, in the period 2006 to 2009 a trend of
an increase in incidence rate of chlamydia, syphilis and
gonorrhoea can be observed, which connected with a decreasing number of tests performed raises the question of
the true burden of these diseases in Poland [1, 2, 3].
As much as already was done to limit STIs in Europe, an insufficient number of performed tests, a lack of
countrywide screening combined with rapid changes
in lifestyle and sexual behaviors, as well as a common
belief that STIs are mainly related with prostitution or
homosexual behaviors can result in a great come back of
STIs in the western world.
Therefore, there is an urgently growing need of
introducing into the educational process new technologies, concerning not only specific risk factors, but also
the heterogeneity of the target groups and new means
of search for the sexual partners such as internet chats,
social networks, dating portals, available for the users of
tablets, smartphones etc. Results of the study of efficacy of smartphone apps in increasing society’s awareness
of STIs danger shows that this kind of information may
be the right way to improve the primary and secondary
prophylaxis rates, only if prepared in cooperation with
health-providers and other specialists, as a part of wide
interdisciplinary program [8]. On the other hand, properly set internet applications may be helpful especial-
471
ly among people from specific, often hermetic groups,
being at increased risk of STIs, as MSM, providing multidirectional support not only for STIs negative individuals, but also for those who are carriers or live with certain STIs [9].
Increasing awareness of a need of testing, knowledge
about the main symptoms and signs of STIs in risk factor groups, combined with improvement in reporting
cases, and introduction of screening programs should be
the most advisable actions to undertake in order to limit
the spread of the diseases, which should eradicated rather than growing in numbers of new cases, in the healthy
and well-educated society of modern world.
References
1. Majewski S, Rudnicka I. Choroby przenoszone drogą
płciową w Polsce w 2009 roku. Przegl Epidemiol. 2011;65:
307–311.
287–291.
281–285.
4. European Centre for Disease Prevention and Control,
Annual Epidemiological Report 2011. Reporting on 2009
surveillance data and 2010 epidemic intelligence data. Stockholm, ECDC; 2011.
5. European Centre for Disease Prevention and Control.
Annual Epidemiological Report on Communicable Diseases in Europe 2010. Stockholm, ECDC; 2010.
6. Rozporządzenie Ministra Zdrowia z dnia 20 września
2012 w sprawie standardów postępowania medycznego
przy udzielaniu świadczeń zdrowotnych z zakresu opieki
okołoporodowej sprawowanej nad kobietą w okresie fizjologicznej ciąży, fizjologicznego porodu, połogu oraz opieki nad noworodkiem.
7. Ustawa z dnia 5 grudnia 2008 o zapobieganiu oraz zwalczaniu zakażeń i chorób zakaźnych u ludzi, Dz.U. z 2008 r.
Nr 234, poz. 1570.
8. Muessig KE, Pike EC, Legrand S, Hightow-Weidman LB.
Mobile Phone Applications for the Care and Prevention of
HIV and Other Sexually Transmitted Diseases: A Review.
J Med Internet Res. 2013;15(1):e1.
9. Wohlfeiler D, Hecht J, Volk J, Fisher Raymond H, Kennedy T, McFarland W. How Can We Improve Online HIV and
STD Prevention for Men Who Have Sex with Men? Perspectives of Hook-Up Website Owners, Website Users, and
HIV/STD Directors. AIDS Behav. 2013 Nov;17(9):3024–33.
Laboratory of International Health, Chair of Preventive Medicine
79 Dąbrowskiego Street
phone: +48 61 854 68 40
REVIEW PAPERS
Medical News 2013, 82, 6, 472–473
JAN NOWAK, KLAUDIA ŁOCHOCKA, SŁAWOMIRA DRZYMAŁA-CZYŻ
SKUTKI NIEDOBORU WITAMINY K INDUKOWANEGO LECZENIEM
PRZECIWZAKRZEPOWYM
THE EFFECTS OF VITAMIN K INSUFFICIENCY INDUCED BY ORAL ANTICOAGULATION
Department of Pediatric Gastroenterology and Metabolism, I Chair of Pediatrics
Head: prof. Jarosław Walkowiak
Streszczenie
Białka, dla których prawidłowej funkcji potrzebna jest karboksylacja z udziałem witaminy K, odgrywają rolę także poza układem
krzepnięcia. Ich obecność chroni ściany naczyń przed wapnieniem oraz sprzyja utrzymaniu prawidłowej masy kostnej. Z tego powodu
niedobór witaminy K może prowadzić do zwiększenia ryzyka chorób serca i naczyń oraz złamań kości. Szczególny przypadek małej
dostępności witaminy K stanowi leczenie acenokumarolem i warfaryną. Dane z badań klinicznych i eksperymentów na modelach
zwierzęcych wskazują na związek między stosowaniem antywitamin K a wynikającym z kalcyfikacji wzrostem sztywności naczyń
oraz spadkiem gęstości mineralnej kości. Dlatego istotne z punktu widzenia profilaktyki chorób cywilizacyjnych jest uwzględnienie
w codziennej praktyce wymienionych działań niepożądanych antywitamin K oraz opracowanie skutecznych strategii suplementacji
witaminy K w populacji ogólnej.
SŁOWA KLUCZOWE: witamina K, antywitaminy K, miażdżyca, osteoporoza.
Abstract
Several proteins undergoing vitamin K-mediated carboxylation have functions outside of coagulation. They protect against
vascular calcification and help to maintain optimal bone mineral density. For this reason vitamin K deficiency may increase risk of
cardiovascular disease and bone fractures. Reduction of vitamin K availability induced by warfarin and other coumarins constitutes
a particular case. Data from clinical and basic research point to a correlation between the use of antivitamins K and loss of vascular
elasticity and bone mineral density. Thus, it is important to manage aforementioned side effects of antivitamin K therapy at an early
stage and develop vitamin K supplementation strategies so as to allow for more efficient prevention of civilisational diseases.
KEY WORDS: vitamin K, antivitamins K, atherosclerosis, osteoporosis.
Witaminą K nazywany jest zbiór molekuł, które mogą
odgrywać rolę kofaktorów karboksylacji białek prowadzącej do powstania wiążących wapń reszt kwasu gamma-karboksyglutaminowego [1]. Do protein podlegających temu procesowi należą między innymi czynniki II,
VII, IX, X i protrombina [2]. Działanie leków przeciwzakrzepowych z grupy antywitamin K polega na blokowaniu redukcji witaminy K, co uniemożliwia jej powtórne wykorzystanie w procesie karboksylacji. Skutkuje
to zahamowaniem produkcji aktywnych form nie tylko
czynników krzepnięcia, ale też kilkunastu innych białek
wymagających karboksylacji z udziałem witaminy K [3].
Te molekuły, m.in. białko macierzy Gla (MGP, matrix
Gla protein) i osteokalcyna, odgrywają rolę w ochronie
naczyń przed kalcyfikacją i w utrzymaniu prawidłowej
gęstości mineralnej kości [4]. Ich karboksylacja, w przeciwieństwie do czynników krzepnięcia syntetyzowanych w wątrobie, zachodzi w innych tkankach, do których witamina K wchłonięta w jelitach dociera w drugiej
kolejności. Dlatego ustrojowe funkcje tych białek łatwiej
ulegają upośledzeniu w przypadku niedoboru witaminy
K, także indukowanego farmakologicznie [5].
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Jak wykazali w 2004 r. Geleijnse i wsp., ryzyko
względne zgonu z przyczyn sercowo-naczyniowych
i ciężkiego zwapnienia aorty u osób, których dieta była
bogata w menachinon (witaminę K2), było niższe niż
w reszcie populacji [6]. W innym eksperymencie stwierdzono również, że suplementacja witaminy K w okresie
3 lat była związana z utrzymaniem elastyczności ścian
naczyń, przy pogorszeniu elastyczności o 12% w grupie kontrolnej [3]. Uważa się, że niedobór witaminy K
może prowadzić do wapnienia ścian tętnic w mechanizmie związanym z utratą funkcji białka MGP, które jest
inhibitorem wapnienia w tkankach miękkich [7]. Przyspieszenie wapnienia naczyń związane ze stosowaniem
antywitamin K opisano zarówno w modelach zwierzęcych, jak i u ludzi [8].
Jak wykazała przeprowadzona w 2012 r. metaanaliza badań klinicznych, suplementacja witaminy K prowadziła do wzrostu gęstości mineralnej kości mierzonej w odcinku lędźwiowym kręgosłupa [9]. Sugeruje się
również, że dieta bogata w witaminę K może zmniejszać
ryzyko złamań kości [10]. W części doniesień dotyczących stosowania antywitamin K przedstawiano ich zwią-
Skutki niedoboru witaminy K indukowanego leczeniem przeciwzakrzepowym
zek ze spadkiem masy kostnej [11]. W badaniu przeprowadzonym przez Caraballo i wsp. opisano wzrost ryzyka złamań kręgów i żeber u osób leczonych przewlekle
antywitaminami K [12]. U pacjentów, którzy byli leczeni
przeciwkrzepliwie przez co najmniej rok, stwierdzono
ponad pięciokrotnie więcej przypadków złamań kręgów
niż w grupie kontrolnej.
Stosowanie antywitamin K, takich jak acenokumarol i warfaryna, wywołuje przewlekły stan niedoboru zredukowanej witaminy K, co może zwiększać
ryzyko chorób sercowo-naczyniowych i złamań kości.
Z tego względu jest wskazane, aby specjaliści medycyny rodzinnej byli świadomi zwiększenia labilności
blaszki miażdżycowej i potrzeby interwencji zwiększających masę kostną u pacjentów przyjmujących antywitaminy K. Wyzwaniem pozostaje opracowanie optymalnych strategii suplementacyjnych dla chorych leczonych
acenokumarolem i warfaryną oraz dla populacji ogólnej,
w której częstość występowania niedoboru witaminy K
jest względnie wysoka [4].
Źrodło finansowania: grant Uniwersytetu Medycznego
im. Karola Marcinkowskiego w Poznaniu
Piśmiennictwo
1. Krzyżanowska P, Walkowiak J. Witamina K i jej biologiczne znaczenie. Fam Med Prim Care Rev. 2010;12(3):
932–933.
2. Kidd PM. Vitamins D and K as pleiotropic nutrients: clinical importance to the skeletal and cardiovascular systems
and preliminary evidence for synergy. Altern Med Rev.
2010;15(3):199–222.
3. Theuwissen E, Smit E, Vermeer C. The role of vitamin K
in soft-tissue calcification. Adv Nutr. 2012;3(2):166–73.
473
4. Cranenburg EC, Schurgers LJ, Vermeer C. Vitamin K:
the coagulation vitamin that became omnipotent. Thromb
Haemost. 2007;98(1):120–5.
5. McCann JC, Ames BN. Vitamin K, an example of triage
theory: is micronutrient inadequacy linked to diseases of
aging? Am J Clin Nutr. 2009;90(4):889–907.
6. Geleijnse JM, Vermeer C, Grobbee DE et al. Dietary intake of menaquinone is associated with a reduced risk of
coronary heart disease: the Rotterdam Study. J Nutr. 2004;
134(11):3100–5.
7. Shea MK, Holden RM. Vitamin K status and vascular calcification: evidence from observational and clinical studies. Adv Nutr. 2012;3(2):158–65.
8. Schurgers LJ, Joosen IA, Laufer EM et al. Vitamin K-antagonists accelerate atherosclerotic calcification and induce
a vulnerable plaque phenotype. PLoS One. 2012;7(8):e43229.
9. Fang Y, Hu C, Tao X et al. Effect of vitamin K on bone
mineral density: a meta-analysis of randomized controlled
trials. J Bone Miner Metab. 2012;30(1):60–8.
10. Pearson DA. Bone health and osteoporosis: the role of vitamin K and potential antagonism by anticoagulants. Nutr
Clin Pract. 2007;22(5):517–44.
11. Binkley N, Krueger D, Engelke J et al. Vitamin K deficiency from long-term warfarin anticoagulation does not alter
skeletal status in male rhesus monkeys. J Bone Miner Res.
2007;22(5):695–700.
12. Caraballo PJ, Heit JA, Atkinson EJ et al. Long-term use
of oral anticoagulants and the risk of fracture. Arch Intern
Med. 1999;159(15):1750–6.
Adres do korespondencji:
Jan Nowak
Department of Pediatric Gastroenterology and Metabolism
I Chair of Pediatrics
27/33 Szpitalna Street, 60-572 Poznań, Poland
phone: +61 849 15 83
REVIEW PAPERS
Medical News 2013, 82, 6, 474–481
MAŁGORZATA SZKUDLAREK1, KOSMA WOLIŃSKI1, DOROTA SIKORSKA2, PATRYCJA KŁYSZ2,
KRZYSZTOF HOPPE2, KRZYSZTOF SCHWERMER 2, KRZYSZTOF PAWLACZYK 2, ANDRZEJ OKO2,
KATARZYNA ZIEMNICKA1, MAREK RUCHAŁA1
ZABURZENIA HORMONALNE U CHORYCH Z PRZEWLEKŁĄ CHOROBĄ NEREK.
CZĘŚĆ I – PODWZGÓRZE I PRZYSADKA; HIPOGONADYZM
HORMONAL DISORDERS IN PATIENTS WITH CHRONIC KIDNEY DISEASE.
PART I – THE HYPOTHALAMUS AND PITUITARY; HYPOGONADISM
1
Department of Endocrinology, Metabolism and Internal Medicine
Head: prof. Marek Ruchała
2
Department of Nephrology, Transplantology and Internal Diseases
Head: prof. Andrzej Oko
Streszczenie
Wraz ze zjawiskiem starzenia się społeczeństw i wzrostem częstości występowania chorób cywilizacyjnych, takich jak cukrzyca
czy nadciśnienie tętnicze, liczba osób z rozpoznaniem przewlekłej choroby nerek (PChN) stale rośnie. W PChN zaburzona jest
nie tylko sekrecja hormonów, ale także odpowiedź tkanek docelowych na substancje hormonalne. Obserwuje się spadek działania
hormonów anabolicznych i wzrost stężeń niektórych hormonów o działaniu katabolicznym.
Wspólnym polem zainteresowań nefrologów i endokrynologów w opiece nad pacjentami z PChN jest diagnostyka, profilaktyka
i leczenie m.in.: zaburzeń wzrostu i odżywienia, gospodarki wodno-mineralnej, dyslipidemii, nadciśnienia tętniczego, niewydolności
serca, wtórnej i trzeciorzędowej nadczynności przytarczyc, zaburzeń mineralizacji kości czy anemii nerkopochodnej. W terapii
pacjentów z PChN istnieje możliwość prowadzenia leczenia hormonalnego, które może mieć szerokie, pozytywne efekty
metaboliczne.
W niniejszej pracy poruszony został temat zaburzeń hormonalnych na poziomie podwzgórzowo-przysadkowym u chorych
z PChN. Omówione zostały zagadnienia związane z: hormonem wzrostu i opornością na hormony anaboliczne; insulinopodobnym
czynnikiem wzrostu 1 (IGF-1) i jego najważniejszym czynnikiem wiążącym IGF-BP3, hiperprolaktynemią czy gospodarką
wodno-mineralną ustroju regulowaną przez wazopresynę i oksytocynę. Szczególną uwagę poświęcono tematowi hipogonadyzmu
u pacjentów z PChN oraz zaburzeniom cyklu miesiączkowego i płodności u kobiet z PChN.
Jak wynika z dostępnych prac naukowych, zaburzenia hormonalne mają modyfikujący wpływ na ryzyko sercowo-naczyniowe
chorych z PChN. Leczenie hormonalne może w znaczący sposób poprawić jakość życia tych chorych i poprawić stopień wyrównania
chorób współistniejących oraz wpłynąć na rokowanie długoterminowe tej grupy pacjentów.
SŁOWA KLUCZOWE: przewlekła choroba nerek, hiperprolaktynemia, hipogonadyzm, testosteron, IGF-1, IGFBP-3, oksytocyna,
wazopresyna.
Abstract
Due to an aging population and an increasing incidence of diseases such as diabetes and hypertension the number of patients
diagnosed with chronic kidney disease (CKD) has been increasing. In CKD, there is not only a disturbance in hormone secretion,
but also in the response of target tissues to the hormones. In this group of patients, a decrease in anabolic hormones and a higher
concentration of catabolic hormones are observed.
The shared areas of interest, for both nephrologists and endocrinologists in the care of patients with CKD include: growth and nutrition
disorders, water and mineral management, dyslipidemia, hypertension, heart failure, secondary and tertiary hyperparathyroidism,
bone mineralization disorders or anemia of renal orgin. In the treatment of patients with CKD, a hormonal therapy is applicable and
can bring vast, positive metabolic effects.
This paper discusses hormonal disorders at the hypothalamic-pituitary level in patients with CKD. It raises the subject of growth
hormone (GH) and the resistance to anabolic hormones, Insulin-like growth factor-1 (IGF-1) and its most important binding factor
– IGF-BP3, the problem of hyperprolactinemia and the regulation of water and sodium excretion under control of vasopressin
and oxytocin. Particular attention was given to the topic of hypogonadism in patients suffering from CKD and disorders of the
menstrual cycle and fertility in women with CKD.
According to available literature, there is a modifying effect of hormonal disturbances on cardiovascular risk in patients with CKD.
Hormone therapy can significantly improve the quality of life of these patients and improve the control of comorbid conditions,
benefiting long-term prognosis in this group of patients.
KEY WORDS: chronic kidney disease, hyperprolactinemia, hypogonadism, testosterone, IGF-1, IGFBP-3, oxytocin, vasopressin.
REVIEW PAPERS
Zaburzenia hormonalne u chorych z przewlekłą chorobą nerek. Część I – podwzgórze i przysadka; hipogonadyzm
Wstęp
Przewlekła choroba nerek (PChN) jest częstą jednostką
chorobową i dotyczy prawie 600 mln osób w całkowitej
światowej populacji i ponad 4,24 mln ludności polskiej
[1, 2]. Uwzględniając potencjalne ryzyko schyłkowej
niewydolności nerek (SNN), PChN jest ważnym problemem z punktu widzenia epidemiologicznego. Głównymi czynnikami powodującymi taką sytuację są starzenie
się populacji i wzrost częstości występowania cukrzycy
typu 2 oraz nadciśnienie tętnicze. W przebiegu chorób
nerek dochodzi do rozwoju wielu zaburzeń o podłożu
hormonalnym, których znaczenie, patogeneza oraz skutki mylnie mogą wydawać się drugoplanowe.
W nerkach zachodzą procesy nie tylko wydzielania, ale także inaktywacji czy produkcji wielu kluczowych substancji hormonalnych. Cewki nerkowe są miejscem działania m.in. takich hormonów jak: wazopresyna
(ADH), hormon natriuretyczny (ANP) oraz aldosteron
[3]. W PChN zaburzona jest sekrecja hormonów, a także
odpowiedź tkanek docelowych na substancje hormonalne [4]. Następuje spadek stężeń hormonów o działaniu
anabolicznym i wzrost poziomów niektórych hormonów
o działaniu katabolicznym [5].
W opiece nad pacjentami z PChN zarówno endokrynolodzy, jak i nefrolodzy koncentrują się przede
wszystkim wokół diagnostyki i leczenia m.in. wtórnej
i trzeciorzędowej nadczynności przytarczyc, zaburzeń
mineralizacji kości, dyslipidemii, nadciśnienia tętniczego, chorób serca czy anemii nerkopochodnej. Nie można
zapominać też o nadrzędnym celu leczenia, jakim jest
poprawa ogólnej jakości życia tej grupy chorych. W terapii pacjentów z PChN istnieje możliwość prowadzenia
leczenia hormonalnego, które może przynieść wymierne
efekty metaboliczne.
Nieustanny rozwój wiedzy na temat leczenia chorych
z PChN jest tak istotny, ponieważ chorzy ci znajdują
się w najwyższej grupie ryzyka umieralności z powodu chorób układu sercowo-naczyniowego. Jak wynika
z dostępnych publikacji naukowych, zaburzenia hormonalne mają wpływ modyfikujący na ryzyko sercowo-naczyniowe chorych z PChN [4, 6–8].
W pierwszej części tej pracy poglądowej zostały
poruszone zagadnienia związane z rolą i zachowaniem
hormonu wzrostu (GH), insulinopodobnego czynnika
wzrostu 1 (IGF-1) i jego najważniejszego czynnika wiążącego – IGFBP-3, oksytocyny, wazopresyny, a także
problem hiperprolaktynemii i hipogonadyzmu u chorych
z PChN. W kolejnej części omówione zostaną choroby
tarczycy oraz przytarczyc u pacjentów z PChN.
Hormon wzrostu (GH)
Funkcjonowanie osi GH/IGF-1 wpływa na funkcję
i morfologię nerek, co wykazano w grupie pacjentów
z nadmierną sekrecją GH, nieobciążonych wywiadem
chorób nerek. GH zwiększa filtrację kłębuszkową (GFR),
ma efekt antydiuretyczny, powoduje przerost kłębuszków, a także oddziałuje na cewki, prowadząc do wzro-
475
stu poziomu fosforanów i wzrostu wydalania wapnia
z moczem [9].
PChN jest chorobą, w której dużą rolę odgrywają przewlekłe zapalenie i oporność na hormony anaboliczne, takie jak insulina, GH i insulinopodobny czynnik 1 (IGF-1) [10]. Stan metaboliczny i hormonalny
tych chorych jest zatem przede wszystkim wynikiem
oporności na działanie ww. hormonów, a nie efektem
ich bezwzględnego niedoboru [11, 12]. Mechanizmami
odpowiedzialnymi za tę oporność są m.in.: zmniejszona
gęstość receptorów GH w narządach docelowych, wzrost
IGFBP-3 i związany z tym spadek wolnego IGF-1 oraz
zaburzenia postreceptorowe, uszkodzona transdukcja
sygnału, w tym sygnalizacji JAK/STAT [13]. Stężenie
GH w osoczu rośnie wraz z progresją PChN, stąd obecność nadmiaru absolutnego GH, pomimo braku jego
efektywnego działania [5].
Podejmowane są liczne próby leczenia dzieci z niskorosłością i PChN rekombinowanym hormonem wzrostu (rhGH). Jednym z efektów takiej terapii jest wzrost
poziomu IGF-1 i stosunku IGF-1 do jego najważniejszego czynnika wiążącego IGF-BP3 oraz wzrost poziomu
glukozy i insuliny [12].
Nawet krótkotrwałe leczenie rhGH ma wpływ na
metabolizm węglowodanów i profil lipidowy, powodując
obniżenie poziomu LDL i wzrost stężenia trójglicerydów.
Terapia ta obniża także stężenie homocysteiny i transferryny oraz wpływa na ogólną poprawę jakości życia [12,
14]. Krótkoterminowe leczenie rhGH znacząco poprawia
i podnosi przepływ kapilarny krwi, aczkolwiek ma niewielki wpływ na całkowity opór naczyń obwodowych
i frakcję wyrzutową serca [15].
Inne efekty terapii rhGH to podwyższenie poziomu
leptyny, obniżenie stężenia fosforanów i 25-hydroksywitaminy D oraz wzrost stężenia albumin [5, 12]. Stosowanie w farmakoterapii AKL-0707 – super agonisty
GHRH – stymulując sekrecję GH i pokonując katabolizm w mocznicy, powoduje szybką poprawę stanu odżywienia chorych z PChN, zwiększa masę beztłuszczową
i gęstość mineralną kości [5, 10]. W niedawno opublikowanych pracach wykazano, że długoterminowe podawanie GH obniża stężenie zapalnych czynników ryzyka chorób sercowo-naczyniowych i zmniejsza częstość
występowania i nasilenie otyłości centralnej [16]. Podkreślana jest potrzeba dalszych długofalowych badań,
aby móc oszacować wpływ rekombinowanego GH
(rhGH) na układ sercowo-naczyniowy i śmiertelność
sercowo-naczyniową w omawianej populacji pacjentów
[12]. Ujemnymi efektami leczenia GH mogą być nasilenie retencji płynów i wzrost stężenia glukozy, jednak te
negatywne efekty są ograniczone [5]. Leczenie rhGH jest
efektywne i bezpieczne w populacji dzieci z PChN, jednak pomimo tego leczenia i stosowania procedur przeszczepu nerek w tej grupie pacjentów często ich wzrost
ostateczny odbiega od genetycznie uwarunkowanego
wzrostu docelowego [13]. Dostępne są również publikacje wykazujące sprzeczne informacje, sugerujące szkodliwe działanie GH na wzrost nerek, bliznowacenie oraz
progresję PChN [5].
REVIEW PAPERS
476
Małgorzata Szkudlarek et al.
Jak wiadomo, PRL i GH są hormonami biorącymi udział w regulacji odpowiedzi immunologicznej.
U pacjentów hemodializowanych mamy do czynienia
z zaburzeniami zarówno B-, jak i T-komórkowozależnych odpowiedzi układu odpornościowego, z przewagą odpowiedzi typu Th1. Prawdopodobnie zaburzenia
stężeń i działań wyżej wspomnianych hormonów przysadkowych odgrywają ważną rolę w rozwoju dysregulacji immunologicznej w grupie pacjentów z PChN [17].
Co ciekawe, podawanie antagonistów GH, takich jak
somatostatyna czy oktreotyd, zmniejsza albuminurię
u pacjentów z cukrzycową chorobą nerek [18].
Insulinopodobny czynnik wzrostu 1 (IGF-1)
U pacjentów cierpiących z powodu przewlekłej choroby
nerek występują zaburzenia dotyczące stężeń i działania
insulinopodobnego czynnika wzrostu (IGF-1). Poziomy
IGF-1 obniżają się w przebiegu niewydolności nerek na
skutek utrzymującej się kwasicy i stosowania ubogobiałkowej diety [3]. W populacji pacjentów hemodializowanych dochodzi także do wzrostu stężeń białek wiążących IGF-1 (IGFBP), co powoduje spadek stężenia jego
bioaktywnej formy. Fakt ten może po części wyjaśniać
przewaga procesów katabolicznych nad anabolicznymi
w przebiegu hemodializ [19].
Według licznych doniesień obniżone stężenia IGF-1
u chorych z PChN korelują z wartościami nadciśnienia tętniczego, wyrównaniem metabolicznym cukrzycy
i podwyższonym ryzykiem sercowo-naczyniowym [6,
7]. Udowodniono m.in. wyraźnie ujemną zależność między stężeniem IGF-1 a skurczowym i rozkurczowym ciśnieniem tętniczym krwi [7]. Wpływ zaburzeń regulacji
i nieprawidłowych stężeń IGF-1, leptyny, insuliny i GH
na patogenezę chorób sercowo-naczyniowych w przebiegu PChN nadal pozostaje przedmiotem wielu badań.
Zarówno GH, jak i IGF-1 modulują strukturę miokardium i prawdopodobnie zwiększają kurczliwość mięśnia
sercowego [3]. Stąd, zarówno spadek, jak i wzrost stężeń IGF-1 skorelowany jest ze zwiększonym ryzykiem
sercowo-naczyniowym chorych ze schyłkowa niewydolnością nerek SNN [6].
U pacjentów z cukrzycą typu 2 i SNN stwierdzane są
wysokie poziomy IGFBP-1 pomimo insulinooporności
i wysokich stężeń insuliny [20]. U pacjentów otyłych, bez
chorób nerek, IGF-1 jest ważnym mechanizmem łączącym insulinooporność z obniżoną filtracją kłębuszkową
(GFR) [21]. Oporność na GH i IGF-1 u chorych z PChN
prowadzi także do osłabienia mięśni i utraty masy mięśniowej [22]. Cześć badań pokazuje, że wprowadzenie
długotrwałego programu treningu fizycznego wpływa
korzystnie na poziom IGF-1, jednak nie wszystkie publikacje potwierdzają istnienie związku między wysiłkiem
fizycznym i stężeniami krążącego IGF-1 [23].
Poziom IGF-1 koreluje ze stanem odżywienia chorych
z PChN. W grupie chorych dializowanych otrzewnowo
stężenie bioaktywnej formy IGF-1 okazało się czulszym
wskaźnikiem natychmiastowej odpowiedzi na interwencje żywieniowe niż całkowity poziom IGF-1 [24]. IGF-1
REVIEW PAPERS
koreluje pozytywnie także ze współczynnikiem T-score, negatywna korelacja zaś obserwowana jest między
T-score a IGFBP-1 i IGFBP-3 [25]. IGF-1, podobnie jak
erytropoetyna, ma zależny od kłębuszkowego przepływu
krwi wpływ na stymulację erytropoezy. Stężenia hemoglobiny są znacząco niższe w grupie pacjentów z PChN
i współistniejącą cukrzycą niż w grupie chorych z PChN
bez cukrzycy. Co więcej, w grupie pacjentów z PChN
i cukrzycą Kim stwierdził istotną zależność pomiędzy
stężeniem hemoglobiny oraz IGF-1 w surowicy [26].
Warto wspomnieć, iż jednym z fizjologicznych efektów działania IGF-1 jest zwiększenie przepływu krwi
przez nerki i wzrost GFR. Przykładowo, w grupie pacjentów z nadciśnieniem bez choroby nerek, nigdy wcześniej
nieleczonych z powodu nadciśnienia, obserwowany jest
silny związek między IGF-1 i GFR, co prawdopodobnie
jest skutkiem oporności na insulinę i hiperinsulinemii,
która często współtowarzyszy ciężkiej chorobie nadciśnieniowej [27]. W tym miejscu należy wspomnieć,
że 48% sekwencji aminokwasowej IGF-1 jest identycze
z sekwencją proinsuliny. IGF-1 zwiększa wrażliwość
na insulinę zarówno u zwierząt doświadczalnych, jak
i u ludzi [28]. Podejmowane są liczne próby leczenia hormonalnego z udziałem IGF-1 u chorych z PChN. Krótkotrwałe podawanie rekombinowanego ludzkiego insulinopodobnego czynnika wzrostu 1 (rhIGF-1) zwiększa GFR
zarówno u pacjentów zdrowych, jaki i chorych z PChN
[29]. Wg niektórych doniesień terapia rhIGF-1 podwyższa poziom całkowitego i wolnego IGF-1, nie wpływając
na stężenie IGFBP-3 [30]. W innych pracach wykazano,
że leczenie pacjentów dializowanych rhIGF-1 w skojarzeniu ze średnimi dawkami rhGH powoduje wzrost
procesów anabolicznych, wzrost stężeń aminokwasów
w osoczu, wzrost stężenia insuliny i IGFBP-3 oraz spadek IGFBP-1 [11]. Jednakże dłuższe podawanie tego
czynnika czy prowadzenie terapii przerywanej prowadzi do rozwoju oporności na leczenie. W zaawansowanej
PChN obserwuje się podwyższone poziomy IGFBP różnych typów i TNF-alfa, które prawdopodobnie odpowiadają za rozwój tolerancji na IGF-1 [29].
Jak dowodzą publikacje naukowe, IGF-1 i IGFBP-3
wpływają w sposób wielokierunkowy na metabolizm
u chorych z PChN. Pamiętać należy jednak, że całkowite stężenie IGF-1 może nie być w pełni adekwatnym
parametrem ze względu na obecność szeregu czynników
ograniczających jego bioaktywność, w szczególności
kilku typów białek IGFBP. Spośród nich w szczególności IGFBP-3 był wielokrotnie opisywany jako czynnik
silnie wpływający na bioaktywność IGF-1. Tworzy on
z IGF-1 osoczowe kompleksy o masie zbyt dużej (ok. 150
kDa), by poprzez śródbłonki opuścić naczynia włosowate i dotrzeć do receptorów dla IGF-1 zlokalizowanych
w poszczególnych tkankach [31].
Zaburzenia wzrostu u dzieci z SNN mają podłoże
wieloczynnikowe, na które składają się nie tylko zaburzenia w obrębie osi GH-IGF-1, ale także zaburzenia
metaboliczne, takie jak przewlekła kwasica, niedostateczna podaż substancji białkowych i energetycznych,
niedobór czynnej formy witaminy D3 i postępująca
osteodystrofia czy szkodliwe działanie toksyn mocznicowych [32]. W licznych badaniach pokazano, że poziomy IGF-1 u dzieci z PChN są znacząco niższe niż w grupie dzieci zdrowych. W badaniu Farquharson i wsp. nie
stwierdzono korelacji między stężeniem IGF a GFR,
masą ciała i wzrostem badanych dzieci. Ekspresja białka SOCS2, hamującego sygnalizację w obrębie osi regulującej wydzielanie hormonu wzrostu, jest zwiększona
w niewydolności nerek (NN), co przyczynia się do nasileń zaburzeń wzrostu u tych chorych [33].
Prolaktyna (PRL)
Hiperprolatynemia występuje u 20% do nawet 75%
pacjentów z PChN. Skutkami hiperprolaktynemii
u kobiet są m.in.: hipoestrogenizm, nieregularne cykle
miesięczne i brak owulacji, zaś u mężczyzn obniżone libido czy impotencja [34]. Stężenie PRL koreluje z progresją PChN i jej stadium. Najwyższe stężenia
PRL obserwowane są u chorych z SNN poddawanych
hemodializie. Wzrost stężenia PRL w omawianej grupie pacjentów nie jest związany z obecnością izoformy
PRL – makroprolaktyny, wynika natomiast ze zmniejszonego usuwania PRL przez niewydolne nerki, a także
pierwotnego zwiększenia produkcji PRL, spowodowanego zarówno zaburzeniami na poziomie przysadki, jak
i zmniejszonym podwzgórzowym hamowaniem produkcji PRL [19]. Wydzielanie PRL w PChN jest autonomiczne, a odpowiedź na czynniki hamujące zmniejszona. Profil dobowy wydzielania PRL u chorych leczonych nerkozastępczo jest zaburzony, bez nocnego wzrostu prolaktyny i z mniejszymi dobowymi wahaniami stężenia tego
hormonu [19]. Diagnostyka hiperprolaktynemii w PChN
jest utrudniona, ponieważ czułość testów stymulacyjnych w SNN jest niska, a odpowiedź PRL obniżona.
Podawanie pochodnych erytropoetyny (EPO) zwiększa
odpowiedź na leczenie metoklopramidem w przypadku
farmakologicznej terapii hiperprolaktynemii w tej grupie chorych [35]. Badania pokazują jednak, że leczenie
podnoszące poziom hemoglobiny, poprawianie ogólnej sprawności chorych czy wprowadzanie modyfikacji metod dializy pozostają bez wpływu na uszkodzony
rytm dobowy wydzielania PRL [19].
Gonadotropiny. Hipogonadyzm męski
Blisko 70% całkowitego testosteronu w organizmie mężczyzny występuje w postaci związanej z globuliną wiążącą hormony płciowe (SHGB), pozostałe 27–29% wiąże
się z albuminami i tylko 1–3% to wolny testosteron [8].
Niedobór testosteronu jest jednym z najczęstszych zaburzeń w gospodarce hormonalnej u mężczyzn z PChN.
Oznaczanie tylko stężeń całkowitego testosteronu może
skutkować niewłaściwym zdiagnozowaniem hipogonadyzmu w tej grupie chorych, gdyż stężenie SHGB rośnie z wiekiem, zaś poziom albumin w PChN jest często
obniżony. W diagnozowaniu omawianej grupy chorych
słuszniejsze wydaje się zastosowanie definicji hipogonadyzmu opartej na obniżonych wartościach wolnego
477
testosteronu. Podłoże tak częstego rozpowszechnienia
hipogonadyzmu wśród pacjentów z PChN wciąż jest
nie do końca jasne [4]. W omawianej grupie pacjentów
niedobór testosteronu wynika m.in. ze wzrostu stężenia
prolaktyny, wpływu toksyn mocznicowych na działanie hormonu luteinizującego (LH) na poziomie komórek
Leydiga w jądrach i dysfunkcji osi podwzgórze-przysadka-jądro oraz wpływu zwiększonych strat białek na
kształtowanie się poziomu wolnego testosteronu [4, 8].
Współwystępowanie cukrzycy czy nadciśnienia tętniczego może przyczyniać się również do rozwoju hipogonadyzmu w populacji mężczyzn z PChN [4]. Także
powszechnie stosowane u tych pacjentów leki, takie jak
inhibitory konwertazy angiotensyny (ACEI), blokery
receptora angiotensyny (ARB) spironolakton, ketokonazol i glikokortykosteroidy (GKS), a nawet statyny, mogą
nasilać zaburzenia gonadalne u mężczyzn [8].
Wśród populacji ogólnej mężczyzn w wieku 40–75
lat niedobór testosteronu występuje u 6–9,5% mężczyzn.
Nawet 30% mężczyzn z cukrzycą, otyłością czy zespołem metabolicznym ma zbyt niski poziom testosteronu.
Szacuje się, że średnio około 33% mężczyzn z PChN
cierpi na hipogonadyzm, a jego częstość występowania
zależy od stopnia uszkodzenia funkcji nerek i w pierwszym stadium PChN wynosi 17%, zaś w piątym stadium
sięga 57% pacjentów płci męskiej [4]. Częstość hipogonadyzmu rośnie też z wiekiem, podobnie jak w populacji
ogólnej [8].
Mężczyźni w ogóle są 2–3 razy bardziej narażeni na
przedwczesną śmierć sercową niż kobiety [8], zaś mężczyzn z niedoborem testosteronu jeszcze częściej dotykają incydenty sercowo-naczyniowe i cukrzyca [4]. Niski
poziom testosteronu w grupie mężczyzn zarówno zdrowych, jak i tych hemodializowanych jest czynnikiem
ryzyka chorób sercowo-naczyniowych i śmiertelności
z powodu incydentów sercowych [4]. W grupie pacjentów z SNN niski poziom testosteronu związany jest także z szybszym postępem miażdżycy i gorszą funkcją
śródbłonka, wykazywaną m.in. w badaniu FMD (ocena
względnej zmiany średnicy tętnicy w odpowiedzi na niedokrwienie) [4]. Wynika to prawdopodobnie z współistniejącego z niedoborem testosteronu zaburzonego procesu wazodylatacji na skutek niedoboru tlenku azotu czy
antagonizmu względem bezpośredniego działania wapnia
[4, 36]. Na podstawie poziomu tak całkowitego, jak i wolnego testosteronu można oszacować ryzyko przyszłych
incydentów sercowo-naczyniowych u chorych mężczyzn
z PChN. Częstość tych incydentów spada o 17–22% na
każdy nmol/litr wzrostu stężenia testosteronu całkowitego we krwi [4, 8]. Niski poziom testosteronu jest również czynnikiem ryzyka zdarzeń sercowo-naczyniowych
u postmenopauzalnych zdrowych kobiet. Do tej pory brak
jednak badań z udziałem kobiet hemodializowanych [37].
W niektórych badaniach wykazano również ujemną korelację między poziomem testosteronu a stężeniem fosforanów w surowicy krwi, jednak korelacja ta
w dużym stopniu zależna jest od poziomu parathormonu
(PTH) [38] . Niedobór testosteronu związany jest nie tylko z obniżonym libido i chorobami sercowo-naczyniowyREVIEW PAPERS
478
mi, ale również z rozwojem anemii, opornością na czynniki stymulujące erytropoetynę, zaburzeniami poznawczymi oraz sarkopenią (katabolizmem mięśni szkieletowych) i obniżoną gęstością mineralną kości [8]. Proponuje się, obok pomiaru stężenia testosteronu we krwi, także
pomiar stężenia testosteronu w ślinie, jednak miarodajność takiego pomiaru jest nadal dyskutowana [39].
Ważnym problem w leczeniu chorych z PChN jest
hiporeaktywność na EPO, związana ze zwiększoną
umieralnością tych pacjentów i gorszym komfortem ich
życia. Nadal pozostaje nieznany dokładny mechanizm,
w jakim erytopoeza jest pobudzana przez testosteron.
Prawdopodobnie dzieje się to na drodze stymulacji produkcji erytropoetyny i bezpośredniego oddziaływania
testosteronu na komórki progenitorowe linii czerwonokomórkowej [40]. Trzeba jednak pamiętać, że, zgodnie
z ostatnimi doniesieniami, testosteron może hamować
syntezę hepcydyny w komórkach wątroby [41]. Hepcydyna to hormon peptydowy odkryty w 2000 roku, który
jest produkowany w wątrobie i odpowiada za homeostazę
żelaza w organizmie człowieka i innych ssaków poprzez
wiązanie się do kanału ferroportyny i jego inaktywację
[41, 42]. W latach 70–80 poprzedniego wieku stosowano
androgeny w leczeniu anemii [43]. Dziś wraca się do tego
leczenia, sugerując większą jego skuteczność w połączeniu z EPO [44–46].
Niedobór testosteronu u przedstawicieli płci męskiej
z PChN jest jednym z czynników ryzyka utraty masy
mięśniowej. Suplementacja androgenami zwiększa masę
mięśniową i siłę mięśniową nie tylko w przypadku hipogonadyzmu u mężczyzn, ale także u kobiet i mężczyzn
bez hipogonadyzmu z PChN [8]. Testosteron i GH stymulują wzajemnie swoje działanie i ich łączona suplementacja daje większy efekt anaboliczny niż stosowanie
tylko jednego z nich [47]. Suplementacja testosteronem
poprawia także pamięć przestrzenną i przypuszczalnie
ma działanie poprawiające funkcje poznawcze i podnoszące nastrój [8]. U pacjentów z PChN występuje wiele
zaburzeń metabolicznych i, jak już wyżej wspominaliśmy, podwyższone ryzyko chorób sercowo-naczyniowych. Należy zatem rozważyć prowadzenie suplementacji testosteronem nie tylko ze względu na korzyści
psychologiczne, ale także ze względu na potencjalne
działanie poprawiające ogólną przeżywalność chorych
i poprawiającą stan ich układu krążenia [8]. W niedoborze androgenów należy dążyć do osiągnięcia normalnych
do średnich poziomów testosteronu [8]. Przy suplementacji testosteronem należy pamiętać o dokładnym monitorowaniu funkcji nerek, ponieważ część badań podnosi kwestię progresji choroby nerek powodowaną przez
androgeny [48, 49].
Zaburzenia cyklu miesiączkowego i płodności
u kobiet z PChN
Z powodu zaburzeń miesiączkowania cierpi około 73%
kobiet poddawanych leczeniu nerkozastępczemu w wieku przedmenopauzalnym [7]. Najważniejszymi zaburzeniami cyklu są: brak miesiączki, który stanowi średnio
REVIEW PAPERS
połowę z tych zaburzeń, oraz rzadkie lub częste miesiączkowanie. Zaburzenia krwawienia miesiączkowego
są niezwykle częste w tej populacji kobiet. Najczęstszym
podłożem zaburzeń miesiączkowania u pacjentek dializowanych jest hiperprolaktynemia oraz zaburzenia osi podwzgórzowo-przysadkowej ze wzrostem poziomu gonadotropin. U kobiet z wtórnym brakiem miesiączki nierzadko obserwowane są zarówno bardzo wysokie poziomy
PRL, jak i niskie poziomy estrogenów z towarzyszącym
wzrostem gonadotropin. Kobiety ze SNN w większości
mają niskie poziomy estradiolu i poziomy gonadotropin w graniach normy. Przyczyna defektu na poziomie
podwzgórza u pacjentów z PChN pozostaje nadal nie do
końca jasna [7]. Częściowo tłumaczona jest przez hiperprolaktynemię oraz zmniejszone usuwanie gonadoreliny
(GnRH) i luteotropiny (LH) [34]. Co ciekawe, u kobiet
z PChN i zachowanymi miesiączkami stężenie estradiolu
– E2 – w surowicy jest często nieznacznie podwyższone [7]. W PChN zaburzone jest wydzielanie pulsacyjne
zarówno GnRH, jak i LH i folitropiny (FSH), co częściowo tłumaczy niskie poziomy estrogenów u kobiet chorujących na PChN. Brak piku LH u tych kobiet skutkuje
zaburzeniami owulacji. Pomimo suplementacji estradiolem nie uzyskuje się piku LH w środku cyklu, co sugeruje brak lub niewłaściwą odpowiedź przysadki na estradiol [7]. Na niepłodność mogą cierpieć kobiety z poziomem kreatyniny 1,5 mg/dl i wyższym. Po przeszczepie
nerki około 60% kobiet w wieku przedmenopauzalnym
odzyskuje owulacyjne cykle i płodność [50].
Wazopresyna i oksytocyna
Wazopresyna (ADH) i oksytocyna (OXT) są 9-aminokwasowymi peptydami, z których 7 aminokwasów jest
wspólnych dla obu hormonów. Mają strukturę cykliczną tworzoną poprzez obecność wiązania dwusiarczkowego między cysteinami w pozycji pierwszej i szóstej
[51]. Wydzielanie ośrodkowe wazopresyny jest zależne
m.in. od pobudzenia osmoroceptorów TRV1 obecnych
w podwzgórzu oraz od stymulacji obwodowych receptorów TRPV4 obecnych w żyle wrotnej. Centralne osmoregulatory, wzmacniając działanie angiotensyny, uczestniczą w uwalnianiu wazopresyny na drodze nieosmotycznej, indukowanej przez hipowolemię [52]. ADH
produkowany przez tylny płat przysadki mózgowej jest
kluczowym regulatorem homeostazy wodnej kontrolującym wbudowywanie akwaporyny 2 (AQP2) do błony
wierzchołkowej komórek nabłonka kanalików nerkowych oraz regulującym ekspresję genu AQP2. Badania
in vitro i in vivo wykazują, że zarówno sekretyna, jak
i oksytocyna zaangażowane są w wazopresyno-niezależne mechanizmy regulujące reabsorpcję wody, translokację i ekspresję AQP2 [53]. AQP2 jest białkiem błonowym tworzącym kanał wodny. Białko to ulega ekspresji
na wszystkich poziomach kanalików nerkowych, jednak
najbardziej obficie w komórkach głównych przewodu
zbiorczego [54]. Kluczowa rola AQP2 w procesie zagęszczania moczu jest najbardziej podkreślana w moczówce
prostej pochodzenia nerkowego [55]. ADH odgrywa rolę
w patogenezie przewlekłej niewydolności serca, powodując zaburzenia równowagi wodno-elektrolitowej oraz
w rozwoju hiponatremii i niewydolności nerek [56].
Mniej więcej jedna trzecia pacjentów dializowanych
cierpi z powodu niewydolności serca [57].
Niewydolność serca może doprowadzić do ostrej niewydolności nerek i odwrotnie. Podobnie PChN zwiększa zachorowalność i śmiertelność sercowo-naczyniową, a przewlekła niewydolność serca może powodować
PChN. Wszystkie te zaburzenia obejmuje wspólny termin zespołu sercowo-nerkowego. Zaburzenia czynności nerek u pacjentów z niewydolnością serca stanowią
niezależny czynnik ryzyka zachorowalności i śmiertelności, gdyż powodują zmniejszanie rzutu serca i spadek ciśnienia systemowego, zwiększenie aktywności
współczulnej, wzrost aktywności układu renina-angiotensyna-aldosteron i zwiększenie wydzielania wazopresyny. Wszystkie wyżej wymienione mechanizmy
powodują retencję wody i sodu, skurcz naczyń obwodowych oraz wzrost obciążenia serca [58]. Patofizjologia
zespołu sercowo-nerkowego obejmuje szereg powiązanych ze sobą hemodynamicznych i neurohormonalnych
mechanizmów, w tym pobudzenie współczulnego układu nerwowego i układu renina-angiotensyna-aldosteron
(RAA), zwiększenie wydzielania endoteliny oraz aktywację systemu wazopresyny. Leczenie zaburzeń czynności nerek może doprowadzić do zmniejszenia częstości hospitalizacji i śmiertelności u pacjentów z zespołem
sercowo-nerkowym [57]. Badania pokazały, że wazopresyna, działając poprzez receptor V2, przyczynia się
do progresji przewlekłej choroby nerek, w szczególności w przebiegu autosomalnie dominującej wielotorbielowatości nerek. Nowe badania epidemiologiczne sugerują rolę wazopresyny w patogenezie cukrzycy i zaburzeń metabolicznych poprzez aktywację receptorów V1a
w wątrobie i/lub receptorów V1b obecnych w wyspach
trzustkowych [59]. ADH jest rozpatrywana jako czynnik przyczyniający się do rozwoju i progresji PChN,
zarówno w sposób bezpośredni, jak i pośredni poprzez
aktywację układu RAA. W szczególności Bankir podkreślał, że uruchomienie konkretnych receptorów ADH
sprzężonych z białkiem G, poprzez regulację ekspresji
akwaporyny 2 (AQP2) i jej późniejsze wbudowywanie
do bieguna szczytowego komórek głównych kanalików
zbiorczych, zwiększa obrót mocznika, zmniejsza stężenie sodu w aparacie przykłębkowym i stymuluje uwalnianie reniny [60].
Powyższe procesy mogą prowadzić do hiperfiltracji kłębuszkowej, białkomoczu i uszkodzenia nerek [26,
27, 61]. Potencjalny szkodliwy wpływ wazopresyny jest
prawdopodobnie potęgowany przez nadciśnienie tętnicze [62]. ADH odgrywa rolę w regulacji ekspresji receptorów V1 w naczyniach przedkłębuszkowych i receptorów V2 w cewkach zbiorczych oraz regulacji syntezy
tlenku azotu, wpływając na rozwój nadciśnienia i jego
powikłań [63]. Trwałe pobudzenie receptorów wazopresyny wywołuje wewnątrznerkową aktywację układu renina-angiotensyna, zmiany w obrębie podocytów
oraz hipertrofię i hiperfiltrację kłębuszkową, skutkują-
479
ce wzrostem białkomoczu. ADH w sposób bezpośredni stymuluje skurcz i proliferację komórek mezangialnych oraz akumulację macierzy zewnątrzkomórkowej,
powodując stwardnienie kłębuszków nerkowych [64].
Zwiększenie spożycia wody i podawanie antagonistów
receptora wazopresyny stanowią metody terapeutyczne,
których użyteczność w zapobieganiu i leczeniu PChN
pozostaje przedmiotem badań klinicznych [64]. Perico i wsp. donoszą, iż podwójny antagonista receptorów
wazopresyny V(2) i V(1a) powoduje obniżenie ciśnienia
tętniczego krwi, zmniejszenie stwardnienia kłębków
nerkowych i białkomoczu u szczurów, które przeszły
nefrektomię 5/6; badacze wskazują na jego potencjalną
wartość w leczeniu PChN [65]. Wiele dowodów sugeruje, że wazopresyna powoduje progresję PChN u chorych
bez cukrzycy i cukrzycowej choroby nerek [63].
Oksytocyna ma kluczowe znaczenie w czasie porodu i karmienia piersią [66]. Ta substancja hormonalna
wykazuje również moczopędne i antydiuretyczne działanie w zależności od swojego stężenia oraz gatunku
i stanu metabolicznego zwierzęcia [67, 68]. Badania Joo
i wsp. z 2004 r. wykazały, że wlew oksytocyny, tak jak
1-desamino-8-d-arginino-wazopresyny, wywołał efekt
antydiuretyczny i wzrost osmolalności moczu zarówno w grupie kontrolnej, jak i u pacjentów z centralną
moczówką prostą [69]. Oksytocyna wywiera swoje działanie antydiuretyczne poprzez receptor V2R [70]. Efekt
antydiuretyczny oksytocyny obserwowany po zastosowaniu dawek farmakologicznych wynika przynajmniej
częściowo z wbudowywania AQP2 do błon komórkowych oraz aktywacji AQP2 i AQP3, co stanowi część
pozawazopresynowego mechanizmu regulacji reabsorpcji wody w nerkach [53].
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33. Farquharson C, Ahmed SF. Inflammation and linear bone
growth: the inhibitory role of SOCS2 on GH/IGF-1 signaling. Pediatr Nephrol. 2013;28(4):547–56.
34. Holley JL. The hypothalamic-pituitary axis in men and
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35. Niemczyk S et al. Metoclopramide test in the patients with
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36. Jones RD et al. The vasodilatory action of testosterone:
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Adres do korespondencji:
Prof. UM Katarzyna Ziemnicka, MD, PhD
Department of Endocrinology, Metabolism and Internal Medicine
49 Przybyszewskiego Street
phone: +48 61 854 72 18
fax: +48 61 869 16 82
REVIEW PAPERS
Nowiny Lekarskie – Medical News
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Standard journal articles
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Chapter in the book
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oryginalny przedstawia wyniki oryginalnych badań przeprowadzonych w dziedzinie szeroko pojętej medycyny. Artykuł powinien być podzielony na:
Streszczenie, Wprowadzenie, Materiał i Metody, Wyniki i Dyskusję. Tekst nie powinien przekraczać 6000 słów (łącznie ze streszczeniem i bibliografią),
a także zawierać nie więcej niż 8 tabel i/lub rycin. Lista piśmiennictwa nie powinna przekraczać 45 pozycji.
Krótkie doniesienia: Prace w tej kategorii powinny dotyczyć wstępnych wyników badań przeprowadzonych na małej grupie i/lub przy użyciu nowej
metodologii. Struktura pracy powinna być podobna do artykułu oryginalnego, a objętość słów nie przekraczać 2500 (łącznie ze streszczeniem
i piśmiennictwem), a także zawierać nie więcej niż 3 tabele lub ryciny. Lista piśmiennictwa nie może być dłuższa niż 25 pozycji.
Prace kazuistyczne: Praca kazuistyczna opisuje jeden lub więcej interesujących rzadkich przypadków lub stanów klinicznych. Praca powinna mieć
następujący układ: Streszczenie, Wprowadzenie, Opis Przypadku i Dyskusja. Streszczenie (limit słów 250) powinno zawierać Założenia, Prezentację
Przypadku i Wyniki. Objętość słów nie może przekraczać 2500 (łącznie ze streszczeniem i piśmiennictwem), a ilość tabel i/lub rycin nie więcej niż 3.
Lista piśmiennictwa nie powinna być dłuższa niż 25 pozycji.
Prace poglądowe: Manuskrypty w tej kategorii dotyczą ważnych, fundamentalnych odkryć w dziedzinach będących w zakresie zainteresowania NL –
MN. Artykuł poglądowy nie może przekraczać 8000 słów (łącznie ze streszczeniem i piśmiennictwem) i zawierać więcej niż 8 tabel i/lub rycin. Lista
piśmiennictwa nie powinna być dłuższa niż 45 pozycji.
Doniesienia zjazdowe: Podsumowania zjazdów i warsztatów z uwzględnieniem tematyki czasopisma. Artykuły w tej kategorii nie powinny przekraczać
1000-1500 słów.
Prace na temat historii medycyny: Artykuły w tej kategorii (eseje, rysy biograficzne o postępach medycyny) nie powinny przekraczać 3–4 stron, łącznie
ze stroną tytułową, słowami kluczowymi, streszczeniem i piśmiennictwem.
Recenzje książek: W sprawie recenzji książek prosimy o kontakt z Redakcją.
Podziękowania
W podziękowaniach umieszczamy osoby, które przyczyniły się do powstania pracy jednak inne niż autorzy artykułu (np. tłumacze, korektorzy). W tym
miejscu wymieniamy także instytucje, które pomogły w realizacji pracy (np. rządowe agencje przyznające granty naukowe, prywatne fundacje itp.).
Należy podawać pełną nazwę instytucji.
Piśmiennictwo
Styl „Vancouver” dla piśmiennictwa jest obowiązujący dla wszystkich artykułów. Prace cytowane powinny być numerowane według kolejności w jakiej
pojawiają się w tekście. Pozycje cytowane tylko w tabelach i rycinach należy umieścić na końcu. W tekście cytowania powinny być zaznaczone cyframi
arabskimi umieszczonymi w nawiasach kwadratowych.
Przykłady:
Wynik ten został później podważony przez Smith i Murray [3].
Smith [8] argumentuje, że...
Liczne badania kliniczne [4–6, 9] pokazują...
Należy wymienić wszystkich autorów, jeśli jest ich nie więcej niż sześciu. W przypadku, gdy jest więcej współautorów należy wymienić pierwszych
sześciu i dopisać „et al.” Nazwy czasopism powinny być skrócone zgodnie z Index Medicus.
Przykłady
Artykuły z czasopism
1. Fassone E, Rahman S. Complex I deficiency: clinical features, biochemistry and molecular genetics. J Med Genet. 2012 Sep;49(9):578–90.
2. Pugh TJ, Morozova O, Attiyeh EF, Asgharzadeh S, Wei JS, Auclair D et al. The genetic landscape of high-risk neuroblastoma. Nat Genet. 2013
Mar;45(3):279–84.
Książki
1. Rang HP, Dale MM, Ritter JM, Moore PK. Pharmacology. 5th ed. Edinburgh: Churchill Livingstone; 2003.
2. Beers MH, Porter RS, Jones TV, Kaplan JL, Berkwits M, editors. The Merck manual of diagnosis and therapy. 18th ed. Whitehouse Station
(NJ): Merck Research Laboratories; 2006.
Rozdziały z książek
1. Phillips SJ, Whisnant JP. Hypertension and stroke. In: Laragh JH, Brenner BM, editors. Hypertension: pathophysiology, diagnosis, and management. 2nd ed. New York: Raven Press; 1995. p. 465–78.
TABELE: Tabele powinny być dostarczone w oddzielnych plikach (jedna tabela – jeden plik) i numerowane w kolejności za pomocą cyfr arabskich.
W tekście tabele powinny być zawsze cytowane (np. Tabela 2) w kolejności numerycznej. Każda tabela powinna obowiązkowo zawierać zwięzły tytuł
w języku polskim i angielskim oraz legendę. Opisy powinny znajdować się pod tabelą. Opisy prezentowane wcześniej w tekście artykułu nie powinny
być powtarzane w tabeli.
RYCINY: Zdjęcia, rysunki i fotografie powinny być umieszczone w oddzielnych plikach i zapisane w jednym z następujących formatów: JPG, TIFF,
EPS lub PDF (rozdzielczość minimum 300 dpi). Ryciny należy numerować w kolejności za pomocą cyfr arabskich. W tekście ryciny powinny być
zawsze cytowane (np. Rycina 3) w kolejności numerycznej. Do każdej ryciny powinien być dołączony zwięzły opis w języku polskim i angielskim.
Wszystkie skróty i symbole użyte na rycinie powinny być wyjaśnione, chyba że są powszechnie znane lub wcześniej objaśnione w tekście. Opisy rycin
muszą być umieszczone po części Piśmiennictwo.
Kolorowe ryciny: Kolorowe ryciny należy dołączać tylko w sytuacjach, gdy kolor oddaje istotę informacji naukowej. Koszt kolorowej reprodukcji
w czasopiśmie drukowanym wynosi 500 dolarów za stronę. Kolorowe ryciny będą publikowane w wersji elektronicznej czasopisma bez dodatkowych
opłat.
MATERIAŁY UZUPEŁNIAJĄCE: Autorzy mogą dołączać pliki z materiałami uzupełniającymi, które będą umieszczone w wersji elektronicznej
artykułu. Materiały te muszą być utrzymane w podobnych standardach edytorskich do tekstu głównego i podlegają procedurze recenzowania.
Procedura recenzowania
Wszystkie artykuły podlegają wstępnej ocenie Redaktora Naczelnego lub jednego z członków Rady Naukowej, którzy mogą odrzucić pracę lub
przesłać ją do recenzji zewnętrznej. Podwójnie anonimowy system recenzji przez przynajmniej dwóch ekspertów w danej dziedzinie jest stosowany
dla artykułów zaakceptowanych do dalszej oceny. Po otrzymaniu recenzji Redaktor Naczelny podejmuje decyzję o akceptacji artykułu do druku,
akceptacji po drobnej poprawie, akceptacji po zasadniczej poprawie lub odrzuceniu. Autorzy otrzymują uwagi do manuskryptu niezależnie od decyzji.
W przypadku akceptacji pracy wymagającej poprawy autorzy zobowiązują się ustosunkować do recenzji w ciągu 60 dni.
Prawa autorskie
W przypadku akceptacji artykułów do druku Wydawca nabywa do nich prawa autorskie, a wszelkie reprodukcje wersji elektronicznej lub papierowej
nie mogą być dokonywane bez zgody Wydawcy.

medical news 6 - Journal of Medical Science

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