Epidemiology Adjustment disorders affect men and women equally. An estimated 5% to 20% of patients undergoing outpatient mental health treatment suffer from adjustment disorders. There is little literature on the subject; one study reported a prevalence of 2.3% among a sample of patients receiving care in a walk-in general health clinic (180).
Management Patients with adjustment disorders can be treated effectively with brief counseling in the primary care setting (180). The counseling can be provided by the gynecologist or by a nurse clinician, social worker, or psychologist, preferably a member of the office or hospital staff who is familiar with the gynecologist and the practice. The medical setting is sometimes the only place where the patient can vent her feelings and think through her situation. Counseling is aimed at facilitating the patient’s own coping skills and helping her to make thoughtful decisions about her situation. The gynecologist should follow the patient’s progress and facilitate referral to a psychiatrist if symptoms do not resolve.
The etiology of eating disorders is neurobiological as well as psychosocial (182). Preoccupation with thinness, sometimes to the point of pathology, is a major problem for women in North America (183). Only a small number of women profess to be satisfied with their weights and body shapes. Nearly all admit to current or recent attempts to limit food intake. Physicians often share social prejudices against overweight patients and can easily exacerbate patients’ concerns by making chance comments. In some cases, such comments by the physician or others can precipitate, if not cause, an eating disorder.
Diagnosis Anorexia nervosa is characterized by severe restrictions on food intake, often accompanied by excessive physical exercise and the use of diuretics or laxatives. Clinical features include menstrual irregularities or amenorrhea, intense and irrational fear of becoming fat, preoccupation with body weight as an indicator of self-worth, and inability to acknowledge the realities and dangers of the condition. Some patients approach gynecologists for treatment of infertility (184).
Bulimia is characterized by eating binges followed by self-induced vomiting or purging.
Patients’ weights may be normal or somewhat higher than normal. Patients have drastically low self-esteem, and the condition frequently coexists with depression (185).
Obesity is an increasingly frequent health problem, and there is little evidence that any nonsurgical approach is effective over time. Sensible eating should be encouraged, and fad or crash diets, which are rampant, are medically and psychologically counterproductive (186). Given the stigma against being overweight in our society, patients may avoid the doctor’s office just because they will be weighed there. The best approach with overweight patients is to acknowledge that being overweight is detrimental to health but that changing one’s diet and lifestyle, and losing weight, is very difficult. Primary care physicians should indicate that they are not going to judge the patient, but are available to provide support and information at the patient’s request.
Epidemiology More than 90% of cases of anorexia and bulimia occur in female patients. The prevalence is 0.5% to 1.0% in late adolescence and 1% to 3% in early adulthood. There is some evidence of familial transmission (182–185).
Assessment The clinician treating the anorexic patient needs to know how much insight she has into her problem and to assess her mood, relationships, and general level of function. Anorexia poses significant risks of severe metabolic complications and death, often from cardiac consequences of electrolyte abnormalities. Thorough physical and laboratory examination is critical; immediate hospitalization may be necessary (182–185).