Background: Numerous studies have shown that estrogen replacement therapy (ERT) is an effective treatment for vasomotor symptoms, insomnia and vaginal dryness. Beneficial effects have also been shown on lipid patterns and on the incidence of osteoporotic fractures. As ERT increases the risk of endometrial adenocarcinoma, combinations with various progestogens have been developed in order to protect the endometrium. However, the addition of progestogens tends to reduce the beneficial effects of estrogens on mood, cognition and lipid metabolism. The added progestogen often causes side effects such as irritability and depression. There is evidence that the effect on wellbeing varies between women and with the type of progestogen used. Women who prefer to avoid withdrawal bleedings can be given continuous combined hormone replacement therapy (HRT). Unfortunately, irregular bleedings are common at the beginning of treatment and reduces compliance. Recently, several studies have reported an increased risk of breast cancer and venous thrombosis, and therefore long-term treatment with HRT for women without climacteric symptoms is no longer recommended. The ongoing debate has, for the time being, resulted in a recommendation that improving quality of life (QoL) by treatment of climacteric symptoms should be the only indication for prescribing HRT. Aims and methods: The aims of the study were to investigate bleeding patterns, changes in wellbeing at onset and during long-term treatment, and lipid and lipoprotein profiles with two different types of continuous combined HRT. In addition, women starting, and women switching from mainly sequential HRT were compared. The design was a randomised, double-blind, one year, prospective, multicentre study including 249 healthy postmenopausal women who were given continuous daily oral treatment with either combined 0.625mg conjugated estrogen (CE) and 5mg medroxyprogesterone acetate (MPA) or combined 2mg 17β - estradiol (E2) and 1mg norethisterone acetate (NETA). Bleedings, if any, were recorded daily throughout the study. The main outcome measures (changes in wellbeing and climacteric symptoms) consisted of daily ratings of 12 items on a validated symptom scale. Serum concentrations of lipids and lipoproteins were measured at baseline and after one year of treatment. Results and conclusions: The majority of drop-outs were confined to the first three months, and the main reasons were bleedings and/or decreased wellbeing. Drop-outs were three times more common in the E2/NETA group. During the first month, 67% of the women reported irregular bleedings. The number of bleeding days decreased on both treatments during the first four months. Treatment with CE/MPA resulted in less irregular bleedings and a shorter time to amenorrhoea compared to E2/NETA. As expected, "starters" experienced more sweats than "switchers" at the onset of treatment, but both groups improved significantly. Side effects such as breast tenderness, swelling, depression and irritability appeared during the first treatment week in both groups. The side effects of HRT appeared much more quickly than the benefits and were more frequent in women with a history of premenstrual syndrome (PMS). Breast tenderness was more common in the E2/NETA group throughout the whole study period. Apart from that, there were no differences between the two treatment regimens as regards effects on well-being at the end of the study. Lipoprotein(a) levels, an important risk factor for cardiovascular disease, decreased in both treatment groups. Triglyceride levels increased in women treated with CE/MPA, and levels of total cholesterol, high density lipoprotein and low density lipoprotein fell in the E2/NETA group. In conclusion, treatment with E2/NETA caused more bleeding problems than treatment with CE/MPA. CE/MPA was better tolerated than E2/NETA at the beginning of the study, but among the women remaining in the study there was no difference in QoL between the two treatment groups. HRT counselling should take into account that a history of PMS increases the likelihood of side effects and that these may precede any beneficial effects. Both treatments produced beneficial effects on lipid and lipoprotein levels, and neither of the regimens was superior in this respect.

Psychological problems are common in infertile women undergoing in vitro fertilization (IVF) treatment.  The aim of this thesis was to determine the prevalence of psychiatric disorders, such as mood and anxiety disorders, and related risk factors and personality traits in women and men undergoing IVF. Participants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was used for evaluating mood and anxiety disorders. The participation rate was 862 (79 %) subjects. Any psychiatric disorder was present in 31 % of females and in 10 % of males. Major depression was prevalent in 11 % of females and 5 % of males. Only 21 % of the subjects with a psychiatric disorder had some form of treatment. A negative pregnancy test and obesity (BMI ≥ 30) were risk factors for mood disorders in women and the only risk factor for depression in men was unexplained infertility. Anxiety disorders were less common than in the general population and no IVF-related risk factors were identified. The Swedish universities Scales of Personality (SSP), a self-rating questionnaire, was used for evaluation of personality traits. High scores of personality traits related to neuroticism were associated with mood and/or anxiety disorders among both women and men. Another objective was to explore the experience of childlessness three years after unsuccessful IVF by a qualitative-approach, assessing data by interviews. Failure after IVF was experienced by women in terms of grief, whereas men took upon themselves a supportive role not expressing grief. A need for professional support and counselling in how to handle grief was described. An unstructured end after IVF treatment left unanswered questions. Three years after the end of treatment, men and women were still processing and had not adapted to childlessness, indicating the grieving process was unresolved.

Hysterektomi är ett kirurgiskt ingrepp där man opererar bort livmodern på kvinnor där en genital rubbning uppkommit. Syftet med detta arbete var att ge en klarare bild om hur kvinnor upplever detta ingrepp samt hur vårdpersonalen skall bemöta och kunna ge kvinnan stöd om så skulle behövas. Syftet med studien var att genom en litteraturstudie belysa kvinnors upplevelser av hysterektomi samt behov av stöd. En systematisk litteraturstudie gjordes där tretton vetenskapliga studier har inkluderats. Resultatet presenteras i två huvudkategorier, kvinnors upplevelser vid hysterektomi samt kvinnors behov av stöd. Båda kategorierna innefattade underkategorier vilka var livskvalitet, sexualitet, stöd samt information. Resultatet visade på att större delen av kvinnorna som genomgått hysterektomi var nöjda med ingreppet, då ett stort handikapp de dragits med en lång tid lättade eller försvann helt. Kvinnorna saknade information om tiden efter operationen. Information har en stor betydelse av hur kvinnorna upplever hysterektomi. Sammanfattningsvis är det viktigt att sjukvårdspersonal har den kunskapen att ge rätt information vid rätt tillfälle. För att hjälpa de kvinnor som skall genomgå hysterektomi bör vårdpersonalen även kunna vara ett stöd, så att sjukhusvistelsen blir en god upplevelse för dessa kvinnor.

The inspiration for the present studies was the learning concept that used professional patients (PP) as instructors for medical students in learning how to perfom the pelvic examination (PE). Interviews performed with women who were PPs showed that they experienced a continuous beneficial increase in knowledge. This promoted personal development related to bodily awareness and affirmed their femininity, making them less vulnerable and reversing their approach to their own body of being an object to becoming a subject. The growing ability to contribute to students’ learning and the feeling of being valuable enhanced the PPs self-esteem and well-being and promoted independence in the learning situation. Being a PP was rewarding and contributed to the feeling of being empowered and growing as a woman in the examination chair. Two models of teaching the PE to medical students were compared: with PPs or with clinical patients (CP). The outcome showed that the PP students were more skilful in palpating the terus and ovaries and performed more PEs during the clinical clerkship than did CP students. Female and male medical students were interviewed after they had performed their first PE with PPs as instructors. The female students’ most obvious concern was about looking and touching another women’s vulva whereas male students were concerned about how to establish rapport with the PP. The interactive and supportive feedback from the PPs enabled the students to overcome their hesitation and encouraged creative learning of interpersonal and palpation skills. The LS positively enhanced the female students’ awareness of own bodies and promoted a deeper interest in PEs, both as an examiner and as patients. The male students became aware of the importance of creating a beneficial interaction with the woman and gained an insight into a previously “unknown” female world that deepened their understanding of women’s possible vulnerability during a PE. Women at an outpatient clinic participated in individual LSs about the female anatomy and the PE, and performed a PE on a mannequin prior to visiting the gynaecologist. Following the visit interviews were performed to gain a deeper understanding of the impact of the LS. The womens’ active participation during the LS generated increased self-confidence and knowledge, triggered emowerment and promoted a creative ability to interact subsequently during their own PE. Part of the studies involved developing a questionnaire to measure the fear of performing the pelvic examination, the Fear of Pelvic Examination Scale (F-PEXS). The questionnaire was shown to have a very good reliability (e.g. Cronbach alpha is .96) and good construct validity. Engaging voluntary, healthy and knowledgeable women as instructors in the PE situation creates a safe and ethical learning environment and promotes interaction with students. Immediate constructive feedback enables students to integrate communication and behavioural skills in a professional manner whilst learning to palpate the uterus, facilitating an inner security as a future examiner. The learning sessions were of benefit to the PPs, the female students in the PP model, and the women in the clinical study. The acquired knowledge started something positive within the women; a will to act and find out more about themselves. The LSs initiated empowerment in the sense that an empowered person has increased capacity to act in goal-directed ways.

Background: Sex and stress steroids are metabolized to 3a-hydroxy-pregnane-steroid metabolites such as allopregnanolone (Allo) and tetrahydrodeoxycorticosterone (THDOC). Allo and THDOC are neuroactive steroids that are metabolized in the brain and act in brain as potent positive GABAA receptor function modulators. Allo as well as THDOC levels increase during stress. Allo has been associated with a number of symptoms and malfunctions such as impaired memory function and negative mood symptoms in a subgroup of individuals both for animals and humans. Pregnane steroids with 3b-hydroxy-configuration (3b-steroids) have been shown to reduce the Allo enhanced GABA effect. Aims: The aims for the present thesis were to investigate the effect of 3b-steroids on the GABA mediated GABAA receptor function in presence of positive GABAA receptor modulators. Further, the regional variances between the 3b-steroids as well as the mechanism of the effect were studied. Finally, the effect of stress steroid metabolites on the GABAA receptor function was investigated. Results: 3b-OH-5a-pregnane-20-one reduced the Allo enhanced GABA mediated chloride ion uptake into cortical microsacs. The 3b-isomer reduced the efficacy of Allo without shift the concentration response curve. It is therefore suggested that the 3b-isomer has a non-competitive effect. Further, it was shown that the 3b-isomer reduced the Allo effect in a selective way since the 3b-isomer did not interact with other positive modulators or with GABA itself. Five tested 3b-steroids reduced the Allo enhanced GABA mediated chloride ion uptake in cerebral cortex and hippocampus as well as the Allo prolongation on spontaneous inhibitory postsynaptic currents (sIPSCs) in preoptic nucleus. In cerebellum on the other hand the 3b-steroids showed to have weaker or no effect compared to the other tested regions. Interestingly, in absence of Allo, two of the 3b-steroids positively modulated the GABA stimulated GABAA receptor function. In absence of Allo, 5b-pregnane-3b,20(R)-diol increased the desensitization rate of current response. In contrast to the reducing effect on the Allo induced prolongation on sIPSCs, the effect of the 3b-steroid on GABA application, was not altered in presence of Allo. The mechanism of the 3b-steroid is therefore suggested being desensitization dependent in contrast to Allo, which has been suggested to decrease the GABA unbinding rate. In contrast to the enhanced effect of Allo, glucocorticoid metabolites reduced the GABA mediated chloride ion uptake in a concentration dependent way. The results in present thesis indicate that both sex and stress steroid metabolites interact with the GABAA receptor function. The knowledge that diversity of endogenous steroids interact with the GABAA receptor function is of importance for further understanding of different sex and stress steroid related symptoms and syndromes.

Bakgrund: Sexualitet hos äldre är precis som hos yngre en viktig del av livskvaliteten. Den sexuella förmågan och de sexuella behoven fortsätter långt upp i åren. Ett aktivt sexualliv har visat sig vara bra för välbefinnandet. Syfte: Syftet var att undersöka vilka faktorer som har en positiv påverkan på äldre kvinnors sexuella välbefinnande. Metod: En kvantitativ metod har används på ett redan insamlat datamaterial. Detta material består av omfattande enkäter som samlades in under åren 2000-2003. Huvudvariabel sexuellt välbefinnande har testats mot flera relevanta variabler. Analysmetoderna som användes var Chi-square test, univariat analys och slutligen en multivariat analys. Vi har valt att titta på den positiva odds kvoten, det vill säga vad som påverkar det sexuella välbefinnandet positivt. Resultat: Av den undersökta populationen skattade 25 % av kvinnorna att de hade ett bra sexuellt välbefinnande. Studien visade ett starkt samband mellan att känna sig uppskattad i hemmet och att vara nöjd med sitt sexuella välbefinnande. Att vara nöjd med sin kropp var en positiv faktor för det sexuella välbefinnandet. Signifikans fanns också för att ha ett bra humör, att vara icke rökare och att inte ha passerat menopaus. / Background: Sexuality among older persons are just as important to quality of life as it is to younger people. The sexual ability and sexual needs will continue up in years. An active sex life is good for the sexual satisfaction. Objective: The objective was to examine factors that have a positive impact on older women's sexual satisfaction. Method: A quantitative method was used on already collected material, consisting of extensive surveys collected during the years of 2000-2003. The main variable sexual satisfaction has been tested against several relevant variables. The analytical methods used were chi-square test, univariate analysis and finally a multivariate analysis. We chose to examine the positive odds ratio, (POR), that affects the sexual satisfaction positively. Results: Among the respondents 25% estimated that they had very good sexual satisfaction. The results indicates to be appreciated at home and happy with ones own body affected the sexual satisfaction positively. Having a good mood and not have passed menopause also have a positive affect of the older womens sexual satisfaction.

Psychological problems are common in infertile women undergoing in vitro fertilization (IVF) treatment.  The aim of this thesis was to determine the prevalence of psychiatric disorders, such as mood and anxiety disorders, and related risk factors and personality traits in women and men undergoing IVF. Participants were 1090 consecutive women and men, 545 couples, attending a fertility clinic in Sweden during a two-year period. The Primary Care Evaluation of Mental Disorders (PRIME-MD), based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), was used for evaluating mood and anxiety disorders. The participation rate was 862 (79 %) subjects. Any psychiatric disorder was present in 31 % of females and in 10 % of males. Major depression was prevalent in 11 % of females and 5 % of males. Only 21 % of the subjects with a psychiatric disorder had some form of treatment. A negative pregnancy test and obesity (BMI ≥ 30) were risk factors for mood disorders in women and the only risk factor for depression in men was unexplained infertility. Anxiety disorders were less common than in the general population and no IVF-related risk factors were identified. The Swedish universities Scales of Personality (SSP), a self-rating questionnaire, was used for evaluation of personality traits. High scores of personality traits related to neuroticism were associated with mood and/or anxiety disorders among both women and men. Another objective was to explore the experience of childlessness three years after unsuccessful IVF by a qualitative-approach, assessing data by interviews. Failure after IVF was experienced by women in terms of grief, whereas men took upon themselves a supportive role not expressing grief. A need for professional support and counselling in how to handle grief was described. An unstructured end after IVF treatment left unanswered questions. Three years after the end of treatment, men and women were still processing and had not adapted to childlessness, indicating the grieving process was unresolved.

Diss. (sammanfattning) Umeå : Umeå universitet, 2007. / Härtill 4 uppsatser.

Background: In Sweden, approximately 440 children die in intrauterine fetal death annually. Losing a child before birth causes great sadness and despair to the parents. Midwives' have a significant role in supporting and nurturing parents in those situations, which is often experienced as a difficult and emotional task. Aim: To describe midwives' experiences associated to intrauterine fetal death. Method: Focus group interviews made with midwives working at a delivery ward in central Sweden, data were analyzed with  qualitative content analysis. Result: The data analysis resulted in ten subcategories,four categories and an overall theme. The categories were Presence, A meaningful task, Being both professional and a human being, and Support at work. The overall theme was To make meaning of the seemingly meaningless. The midwives needed time to be able to be fully present with the parents. According to the midwives it was a meaningful experience to be supportive and make a difference for the parents. To be professional while at the same time dealing with their own feelings appeared as a difficult task. They received the best support from their colleagues. Conclusion: Supporting the parents and creating a memorable moment with their stillborn baby was experienced as the most eager in these situations, and made the task meaningful for the midwives.

Abstract   Objective To study midwives' experiences of working with normal birth in multidisciplinary teams.
 Methods This was a qualitative study based on Semi-structured interviews in focusgroups with 20 midwives at four maternity wards in mid-Sweden. Results The interviews revealed a theme as The midwifery profession is both strong and torned at normal birth in hospital. The results describe that midwives are working independently and are responsible for the normal birth in multidisciplinary team. Hierarchies and relationships influence the independence of the midwives in their work with normal birth. The midwives were also using tools as risk evaluation and medical rounds to identify normal birth. There are no independent guidelines designed by midwives for the normal birth in maternity care. Heavy workload affects the midwives’ ability to work evidence-based and resulted in changes of practices in normal birth. Conclusion The midwives consider they sometimes share involuntary the responsibility in normal birth. A good cooperation and communication is important within a multidisciplinary team for the midwives to support normal birth. Keywords: collaboration, midwives, normal birth, professional responsibility / Sammanfattning                   Bakgrund Att arbeta som barnmorska i Sverige innebär att ansvara för kvinnans vård vid den normala förlossningen. När denna avviker vidtas adekvata åtgärder samt en bedömning av när samverkan krävs med andra professioner. Barnmorskans arbete och ansvar har förändrats över tid och tvärprofessionellt samarbete har växt fram som en rådande arbetsmodell inom förlossningsvården. Syfte: Att studera barnmorskors upplevelser av att handlägga normala förlossningar i tvärprofessionella arbetsgrupper. Metod: Semistrukturerade fokusgruppsintervjuer med 20 barnmorskor vid fyra olika förlossningsavdelningar i Mellansverige. Resultat: Ur fokusgruppsintervjuerna framkommer temat Barnmorskeprofessionen är både stark och söndrad vid normala sjukhusförlossningar. Resultatet visar att barnmorskorna är oftast självständigt ansvariga för den normala förlossningen i en tvärprofessionell arbetsgrupp. Hierarkier och relationer påverkar barnmorskornas självständighet vid handläggningen av den normala förlossningen. Barnmorskorna använder förutom sin professionella kunskap olika verktyg som riskevaluering och rond för att identifiera normala förlossningar. Det saknas självständigt utformade riktlinjer av barnmorskor för normal förlossning inom förlossningsvården. Hög arbetsbelastning påverkar barnmorskans möjligheter att arbeta från ett evidensbaserat perspektiv vilket resulterar i ett förändrat arbetssätt vid normal förlossning. Slutsats: Barnmorskor anser att de ibland har ett ofrivilligt delat ansvar vid normal förlossning. Ett gott samarbete och kommunikation har betydelse inom ett tvärprofessionellt team för att barnmorskan kan stödja kvinnans normala födande.   Nyckelord: barnmorskor normal förlossning, professionellt ansvar, samarbete