Many women experience miscarriage every year. Every fourth woman who has given birth reports that she has previous experience of miscarriage. In a study of all women in the Swedish Medical Birth Register 1983-2003, we found that the number of cases of self reported miscarriage had increased in Sweden during this 21 year period. This increase can be explained by the introduction of sensitive pregnancy tests around 1990, as well as an increase in the mean age of the mothers, by approximately 3 years, during the observation period. The risk of miscarriage is 13% with the first child. With subsequent pregnancies, the risk of miscarriage is 8%, 6% and 4% with the second, third and fourth child, respectively.

Thirteen of these women who had suffered a recent miscarriage were interviewed four months later, and their feelings of guilt and emptiness were explored. Their experience was that they wanted their questions to be answered, and that they wanted others to treat them as the mothers to be that they felt themselves to be. They also experienced the need for time to grieve their loss.

Measurement of grief by means of the Perinatal Grief Scale (PGS) is used in research but has also been proposed for clinical use. We have translated this psychological instrument to Swedish, back-translated and tested it in a small pilot study. In a randomized controlled study, women with early miscarriage were allocated, either to a structured visit (study group) or a regular visit (control group) to a midwife. The structured visit was conducted according to the Swanson caring theory. We could conclude that the structured visit had no significant effect on grief compared to the regular visit, as measured using the PGS. However, women with the sub-diagnosis missed abortion have significantly more grief four months after early miscarriage, regardless of visit type.

We also performed a content analysis of the tape-recorded structured follow-up visit. The code-key used was Bonanno and Kaltman’s general grief categorization. Women’s expression of grief after miscarriage was found to be very similar to the grief experienced following the death of a relative. Furthermore, the grief was found to be independent of number of children, women’s age, or earlier experience of miscarriage.

Conclusions: Every fourth woman who gives birth reports that she has also experienced early miscarriage. The experience of these women is that they have suffered a substantial loss and their reaction is grief similar to that experienced following the death of a relative.

Background. Women's grief after miscarriage is substantial and important. Women who experience early miscarriage do not constitute a homogenous group. The aim of this study is to measure whether a structured follow-up visit to a midwife (group 1) at 21-28 days after early miscarriage could reduce the women's grief, measured using the perinatal grief scale Swedish short version (PGS) after a further 3 months (i.e. 4 months after the miscarriage), compared to a regular follow-up visit to a midwife (group 2). Methods. We performed an open randomized study of women who experienced early miscarriage (n = 88). The midwife's attitude in group 1 came from Swanson science theory of midwifery. In group 2, the women were offered only the ordinary type of consultation at a regular visit. A questionnaire with the PGS was used in both groups. Four months after the miscarriage, a second questionnaire with the same perinatal grief scale was sent by post. Results. There was a 30% greater reduction in grief in group 1 than that in group 2, when comparing the first and second measurements (not significant). The biggest differences were in the subscales active grief and difficulty in coping. Women with the subdiagnosis missed abortions had, as a group, significantly higher PGS scores at both visits, especially in active grief and difficulty in coping, regardless of the type of follow-up visit. Conclusions. A structured follow-up visit did not, in comparison with a regular follow-up visit, imply any significant reduction in grief as measured using the PGS scale. However, the subgroup missed abortion had more extensive grief than the other women with miscarriage. Structured follow-up visits are not imperative for all women with early miscarriage.

Background. Grief is a normal phenomenon but showing great variation depending on cultural and personal features. Bonanno and Kaltman have nonetheless proposed five aspects of normal grief. The aim of this study was to investigate if women with miscarriage experience normal grief.

Material and methods. Content analyses of 25 transcribed conversations with women 4 weeks after their early miscarriages were classified depending on the meaning-bearing units according to Bonanno and Kaltman's categories. In the factor analyses, these categories were compared with the Perinatal Grief Scale and women's age, number of children and number of miscarriages, and gestational weeks.

Results. Women with miscarriage fulfill the criteria for having normal grief according to Bonanno and Kaltman. All of the 25 women had meaning-bearing units that were classified as cognitive disorganization, dysphoria, and health deficits, whereas disrupted social and occupational functioning and positive aspects of bereavement were represented in 22 of 25 women. From the factor analysis, there are no differences in the expression of the intensity of the grief, irrespective of whether or not the women were primiparous, younger, or had suffered a first miscarriage.

Conclusion. Women's experience of grief after miscarriage is similar to general grief after death. After her loss, the woman must have the possibility of expressing and working through her grief before she can finish her pregnancy emotionally. The care-giver must facilitate this process and accept that the intensity of the grief is not dependent on the woman's age, or her number of earlier miscarriages.

Aim. The aim of this study is to find out how common miscarriages are among women who have delivered a child.

Methods. The numbers of deliveries and miscarriages were extracted from the Swedish Medical Birth Register between 1983 and 2003. Linear regression was performed in order to investigate whether the increasing mean age of mothers or differences in pregnancy identification methods could explain the increased frequency of miscarriage.

Results. The reported number of miscarriages increased each year during the 21-year period, with a marked increase between 1991 and 1993 and only a slight increase during the final 10 years. For primiparous women, the frequency of reported miscarriages per delivery increased from 8.6% in 1983 to 13.9% in 2003. The corresponding figures for 2-parous women showed an increase from 14.5% to 21.3% respectively. Women aged 30-34 years had an odds ratio of 1.43 (95% CI 1.40-1.45) to suffer spontaneous abortion compared to the age group 25-29 years. Linear regression showed that an increase in mean age at delivery could only partly explain the increase in the frequency of reported miscarriages. A possible explanation could be differences in methods of identifying early pregnancy.

Conclusion. Of all women who deliver a child, nearly 20% have experienced previous miscarriage. The increased mean age of women could only explain a small portion of the seen increase in miscarriage. The marked increase from 1991 to 1993 is interesting. Possible reasons for the increase are discussed.

Women who lose an early pregnancy are shocked when they are first given the information that they have miscarried. Later they feel guilt and emptiness. Heideggerian interpretive phenomenology has been used with 13 women from southwest Sweden to uncover their lived experience of miscarriage. Women plan their future with a child during early pregnancy. When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel abandonment and they grieve for their profound loss; they are actually in bereavement.

Introduction. Men with erectile dysfunction are often worried about their condition, have interpersonal difficulties, and have a reduced quality of life. Internet-delivered cognitive behavior therapy (ICBT) has been shown effective for a number of health problems but evidence is limited concerning the treatment of erectile dysfunction. less thanbrgreater than less thanbrgreater thanAim. The study investigated the effects of ICBT for erectile dysfunction. less thanbrgreater than less thanbrgreater thanMethods. Seventy-eight men were included in the study and randomized to either ICBT or to a control group, which was an online discussion group. Treatment consisted of a 7-week Web-based program with e-mail-based therapist support. Each therapist spent an average of 55 minutes per participant. less thanbrgreater than less thanbrgreater thanMain Outcome Measure. The International Index of Erectile Functioning five-item version was administered via the telephone at pretreatment, post-treatment, and 6 months after receiving ICBT. less thanbrgreater than less thanbrgreater thanResults. At post-treatment, the treatment group had significantly greater improvements with regard to erectile performance compared with the control group. Between-group differences at post-treatment were small (d = 0.1), but increased at the 6-month follow-up (d = 0.88). less thanbrgreater than less thanbrgreater thanConclusions. This study provides support for the use of ICBT as a possible treatment format for erectile dysfunction.

Background: An increasing body of research shows that a proportion of women experience significant symptoms of Post-Traumatic Stress Disorder (PTSD) following childbirth.

Aims and method: An international group of researchers, clinicians, and user-group representatives met in 2006 to discuss the research to date into PTSD following childbirth, issues and debates within the field, and recommendations for future research. This paper reports the content of four discussions on (1) prevalence and comorbidity, (2) screening and treatment, (3) diagnostic and conceptual issues, and (4) theoretical issues.

Conclusions: Current knowledge from the perspectives of the researchers is summarized, dilemmas are articulated and recommendations for future research into PTSD following childbirth are made. In addition, methodological and conceptual issues are considered.

Background. High numbers of incidents of abuse in health care (AHC) have been reported by patients in Sweden. In questionnaire studies (n=9600), every fifth Swedish woman and every tenth Swedish man reported any lifetime experience of AHC, and a majority reported suffering from their experiences. Female patients with experiences of AHC described them as experiences of being nullified, and male patients as experiences of being mentally pinioned. Little is known about why AHC occurs and how it can prevail in a health care system that aims to relieve patients’ suffering.

Aim. The overall aim of the thesis was to bring understanding to what AHC is and to start exploring what contributes to its occurrence, focusing on a female patient perspective.

Methods. In study I, a concept analysis of AHC was conducted based on the concept’s appearance in scientific literature and through case studies. Also, AHC was demarcated against the related concepts patient dissatisfaction, medical error, and personal identity threat, in order to analyze differences and similarities with these concepts. For studies II and III the Transgressions of Ethical Principles in Health Care Questionnaire (TEP) was developed to measure to what extent female patients remain silent toward the health care system after having experienced abusive or wrongful ethical transgressions in the Swedish health care system. It was hypothesized that to a high degree female patients remain silent toward the health care system after such experiences, and this lack of feedback may in turn contribute to the hampering of structural change toward better encounters. The questionnaire was answered by female patients recruited at a women’s clinic in the south of Sweden (n=530). Study IV built on a constructed grounded theory design and included informants who reported experiences of AHC in TEP (n=12). The interviews focused on the informants’ stories of what contributed to their experiences of AHC.Results.

Results. Based on the concept analysis, AHC was described as patients’ subjective experiences in health care of encounters devoid of care, in which they experienced suffering and loss of their human value. Study II showed that a majority of the female patients who perceived one or more transgressions as abusive or wrongful remained silent about at least one of them (70.3%). In 60% of all cases, patients remained silent about abusive or wrongful events. In study III it was examined whether patients remaining silent could be associated with any patient characteristics. Remaining silent was only found to be associated with younger age and a lower self-rated knowledge of patient rights. In study IV, female patients’ stories of what contributed to their experiences of AHC were analyzed. This was best characterized as a process where the patient loses power struggles. According to these patients, not only their vulnerability, but also their level of competence contributed to staff’s unintended use of domination techniques by which they felt abused.

Conclusions. As AHC is defined from patients’ subjective experiences it is necessary for the prevention of AHC to listen to patients’ stories and complaints. The prevalence of female patients’ silence after abusive events could be worrying, as it constitutes a loss of essential feedback for the health care system. Patients do not bear responsibility for the quality of health care processes, but their knowledge may be very valuable for structural improvement of these processes and could be valued as such. Clinical interventions that stimulate these patients to speak up, accompanied by health care staff’s reflections on how to respond to patients speaking up, must therefore be explored.

Objectives To identify which patient characteristics are associated with silence towards the healthcare system after experiences of abusive or ethically wrongful transgressive behaviour by healthcare staff.

Design Cross-sectional questionnaire study using the Transgressions of Ethical Principles in Health Care Questionnaire.

Setting A women's clinic in the south of Sweden.

Participants Selection criteria were: consecutive female patients coming for an outpatient appointment, ≥18-year-old, with the ability to speak and understand the Swedish language, and a known address.

Questionnaires were answered by 534 women (60%) who had visited the clinic, of which 293 were included in the present study sample.

Primary outcome measure How many times the respondent remained silent towards the healthcare system relative to the number of times the respondent spoke up.

Results Associations were found between patients’ silence towards the healthcare system and young age as well as lower self-rated knowledge of patient rights. Both variables showed independent effects on patients’ silence in a multivariate model. No associations were found with social status, country of birth, health or other abuse.

Conclusions The results offer opportunities for designing interventions to stimulate patients to speak up and open up the clinical climate, for which the responsibility lies in the hands of staff; but more research is needed.

Background

In Sweden, 20% of female patients have reported lifetime experiences of abuse in any health care setting. Corresponding prevalence among male patients is estimated to be 8%. Many patients report that they currently suffer from these experiences. Few empirical studies have been conducted to understand what contributes to the occurrence of abuse in health care.

Objectives

To understand what factors contribute to female patients’ experiences of abuse in health care.

Design

Constructivist grounded theory approach.

Settings

Women's clinic at a county hospital in the south of Sweden.

Participants

Twelve female patients who all had reported experiences of abuse in health care in an earlier questionnaire study.

Methods

In-depth interviews.

Results

The analysis resulted in the core category, the patient loses power struggles, building on four categories: the patient's vulnerability, the patient's competence, staff's use of domination techniques, and structural limitations. Participants described how their sensitivity and dependency could make them vulnerable to staff's domination techniques. The participants’ claim for power and the protection of their autonomy, through their competence as patients, could catalyze power struggles.

Conclusions

Central to the participants’ stories was that their experiences of abuse in health care were preceded by lost power struggles, mainly through staff's use of domination techniques. For staff it could be important to become aware of the existence and consequences of such domination techniques. The results indicate a need for a clinical climate in which patients are allowed to use their competence.

Aims and objectives:  To analyse the concept of abuse in health care. This analysis also covers how abuse in health care is different from the related concepts of medical error, patient satisfaction and personal identity threat.

Background:  Abuse in health care is an emerging concept in need of a clear analysis and definition. At the same time, boundaries to the related concepts are not demarcated.

Design:  Concept analysis as developed by Walker and Avant.

Method:  The databases Cumulative Index to Nursing and Allied Health Literature, Medline, and Google Scholar were used to obtain articles published between 1997 and 2009. A total of eleven articles are referred to on abuse in health care, four on medical error, six on patient satisfaction and three on personal identity threat.

Results:  Abuse in health care is defined by patients’ subjective experiences of encounters with the health care system, characterized by devoid of care, where patients suffer and feel they lose their value as human beings. The events are most often unintended. We also found differences with the aforementioned related concepts: medical error does not share the patients’ perspective, and patient satisfaction does not offer room for patients’ abusive experiences. The concept of personal identity threat shares all attributes with abuse in health care, but it lacks an antecedent that signifies the social structures underlying the phenomenon.

Conclusions:  Abuse in health care covers a phenomenon that has severe consequences but is invisible if seen from a medical error or patient satisfaction perspective.

The aim of this study was to examine to what extent patients remained silent to the health care system after they experienced abusive or wrongful incidents in health care. Female patients visiting a women’s clinic in Sweden (n = 530) answered the Transgressions of Ethical Principles in Health Care Questionnaire (TEP), which was constructed to measure patients’ abusive experiences in the form of staff’s transgressions of ethical principles in health care. Of all the patients, 63.6% had, at some point, experienced staff’s transgressions of ethical principles, and many perceived these events as abusive and wrongful. Of these patients, 70.3% had remained silent to the health care system about at least one transgression. This silence is a loss of essential feedback for the health care system and should not automatically be interpreted as though patients are satisfied.

Objective. The intrauterine contraceptive device (IUCD) is the most preferred method of reversible contraception in the world today. The Swedish Medical Products Agency currently recommends that women who had a copper IUCD inserted around age 40 do not need to have it extracted until one year after the menopause. Design. Retrospective study. Setting. Skovde Central Hospital, Sweden. Population. All 114 women receiving in-patient treatment for pelvic inflammatory disease (PID) over five years between January 2001 and December 2005. Methods. Comparison between cases of tubo-ovarian abscesses and salpingitis with focus on the effects of IUCDs used continually for andgt; 5 years after insertion. Main outcome measures. Age-adjusted risk of PID within or after five years of use, microbiological findings in blood, intraabdominal pus, cervical secretions or on extracted IUCDs. Results. There were 31 cases of tubo-ovarian abscesses, 63 of salpingitis, four of endometritis, and 16 of mild genital infection. When comparing women with the same IUCD andgt; 5 years to women having the same IUCD andlt;= 5 years, the risk of tubo-ovarian abscess was higher than the risk of salpingitis (OR 19.7; 95% CI 4.5-87.2). The risk remained significant after adjustment for age, both on multiple regression analysis (OR 13.5; 95% CI 2.5-72.9) and in stratified analysis for the age group 35-50 years (OR 12.0; 95% CI 1.8-81.7). Blood or abdominal cultures from patients operated upon were positive in 47.7% of the sampled cases. Intestinal tract microbes and upper respiratory tract microbes were more common than sexually transmitted infection microbes. Conclusions. The current Medical Products Agency recommendation that a woman nearing the end of her reproductive phase can safely use the same IUCD for a period exceeding five years is challenged.

Objective. To describe the frequency of police reporting among rape victims based on two hypotheses: (1) victims of rape more often report poor health than those who have not been victims of any abuse, and (2) victims who report abuse to the police are more likely to state poor self-reported health than those who do not report any abuse. Design. Cross-sectional questionnaire study. Setting. Three Swedish departments of obstetrics and gynecology. Sample. From an original sample of 2,439 women, those who had experienced rape and those who had no history of abuse were included (n=1,319). Method. Analysis of associations between self-reported poor health, rape, and police reporting among rape victims were assessed by multivariate models adjusted for type of abuse, perpetrator, and sociodemographic factors. Main outcome measures. Odds ratios (ORs) for poor health among rape victims. Results. Rape was seldom reported to the police (23.5%, 44/187). Both hypotheses were confirmed; rape victims more often state poor health than non-abused women (adjusted OR 3.9; 95% confidence interval (CI) 2.4-6.3), and women who had reported abuse to the police stated poor health more often than those who had not reported abuse to the police (adjusted OR 3.0; 95% CI 1.1-8.1). Conclusions. Three of four rape victims had not reported any abuse to the police, and those who had were more likely to report poor health. Rape myths are prevalent in society and affect how victims of sexual abuse are treated both by formal and informal support providers, which in turn may affect the recovery and health of victims. Our results send an urgent message to the current debate on sexual abuse against women: Why do women not report rape to the police?

Objective: Study the reproducibility of wet smear interpretation of clue cells, lactobacillary grades and leukocyte dominance with conventional bright light and phase contrast microscopy. Study design: Sets of vaginal specimens were taken from unselected consecutive women attending an outpatient gynaecology clinic. Air-dried vaginal fluid on a microscope slide was rehydrated with isotonic saline before examination by six independent international investigators. Some investigators initially used a conventional bright light microscope, followed by phase contrast technique. Results: Using phase contrast microscopy, an excellent inter-observer agreement was obtained among all investigators for clue cells detection (Kappa values from 0.69 to 0.94) and lactobacillary grades (Kappa 0.73-0.93). When conventional light microscopes were used, poor agreement was obtained for these criteria (Kappa index 0.37-0.72 and 0.80, respectively), but switching to phase contrast microscopy by the same investigators, improved Kappa to 0.83-0.85 and 0.88, respectively. The inter-observer agreement for estimation of the leukocyte/epithelial cell ratio (Kappa index 0.17-0.67) was poor, irrespective of the type of microscopy applied. Intra-observer agreement of clue cell detection and lactobacillary grading was also found to be excellent if phase contrast microscopy was used (Kappa 0.87-0.93), and poor with conventional bright light microscopy (Kappa 0.45-0.66). Conclusion: Clue cells and the lactobacillary grades are reliably identified by phase contrast microscopy in wet smears, with excellent intra- and inter-observer reproducibility agreement, and better than when simple bright light microscopy was used. Evaluation of leukocyte grading, on the other hand, was inconsistent among the different microscopists, irrespective of the type of microscope used. We propose to grade the leukocytes in a different way than searching for leukocyte dominance over epithelial cells, namely by counting them per high power field and per epithelial cell.

Many women suffer from excessive hair growth, often in combination with polycystic ovarian syndrome (PCOS). It is unclear how hirsutism influences such womens experiences of their bodies. Our aim is to describe and interpret womens experiences of their bodies when living with hirsutism. Interviews were conducted with 10 women with hirsutism. We used a qualitative latent content analysis. Four closely intertwined themes were disclosed: the body was experienced as a yoke, a freak, a disgrace, and as a prison. Hirsutism deeply affects womens experiences of their bodies in a negative way.

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Many young women today are concerned about their sexual health; an increasing number of them consult gynaecologists, youth centres (YCs) and general practitioners with vulvar problems such as painful sensations associated with vaginal intercourse (VIC). It is known that some women continue to have VIC despite pain. Theoretically, repeated painful VIC might elicit vaginistic reactions, which may increase the pain and induce vicious circles. Since many clinicians and researchers nowadays notice that pain during VIC often starts at young age, it is important to investigate how pain during VIC starts and is maintained in younger populations. The overall aim of this thesis was to investigate young women’s experiences of ideal sexual situations and pain during VIC.

Women aged 13-22 years participated in our studies, which used both quantitative (study I and IV) and qualitative (study II and III) methods. For paper I, a questionnaire was developed and used in a YC sample (n=300); informants for paper II were selected from that sample to participate in qualitative interviews (n=16). Another qualitative interview study for paper III with a complimentary research question was conducted in a different YC sample (n=14). For paper IV, a questionnaire was developed based on the results from study I, II and III to test the hypotheses derived from study II in a sample of female high school students (n=1566).

The findings revealed that 65% of the women reported pain related to first VIC. Among those who reported VIC during the previous month, 49% had experienced pain and/or discomfort during VIC during that same period (paper I). In paper IV, 47% of the women reported experience of pain and/or discomfort during VIC, and among those, 47% continued to have VIC, 22% feigned enjoyment, and 33% omitted telling the partner about their pain. In paper II, the women’s reasons for continuing to have VIC despite pain were: striving to reach their ideal image of a woman, characterized as always willing to have VIC; being perceptive of their partner’s sexual needs; and being able to satisfy their partner. In paper IV the hypotheses derived from study II were confirmed and showed, for example that a significantly higher proportion of women who continue to have VIC despite pain than women who did not had difficulty refusing sex when the partner wants it, felt inferior to the partner during sex, regarded the partner’s satisfaction as more important than their own, felt dissatisfaction with their sex life, and feigned enjoyment despite pain. In a multivariate model, continuing to have VIC despite pain was associated with feelings of being inferior to the partner during sex (adjusted OR 1.82; CI 1.10-3.02), dissatisfaction with their own sex lives (adjusted OR 1.76; CI 1.14-2.72) and feigning enjoyment while having pain (adjusted OR 7.45; CI 4.37-12.69).

The major reason for continuing to have VIC was that the partner’s enjoyment was prioritized higher than their own (paper IV). In paper III, we found that women without pain during VIC also felt pressure from social norms and demands and had experienced partners “driving their own race”. However, they managed to some extent to resist these unequal gender norms because of their urge to experience pleasure.

In conclusion, pain during VIC is a common complaint among young Swedish women, and a high proportion of them continue having VIC despite pain. The women’s notion of prioritizing the partners´ enjoyment before their own illustrates that unequal gender regimes affect young women’s (hetero)sexuality negatively.

Purpose: Many young women suffer from pain and discomfort during sexual intercourse, and an increasing number of them seek help for their problems. It seems that some young women continue to have sexual intercourse despite pain. However, their motives are unclear.

Methods: A total of 16 women, aged 14-20 years, with variable degrees of coital pain were selected at a youth center in a city in southeastern Sweden, to explore why they continued to have sexual intercourse despite pain. The women participated in audiotaped qualitative individual interviews, which were analyzed using the constant comparative method from grounded theory.

Results: During the analysis we identified the core category striving to be affirmed in their image of an ideal woman and the categories resignation, sacrifice and feeling guilt.

The perceived ideal women had several distinct characteristics, such as willingness to have sexual intercourse, being perceptive of their partner’s sexual needs, and being able to satisfy their partners.

Having sexual intercourse per se was considered to be an affirmation of being a normal woman, irrespective of pain or discomfort.

Conclusions: These young women’s focus on a constructed ideal explains why they continue to have sexual intercourse despite pain.

Greater awareness of these beliefs among gynaecologists, sexologists, and other healthcare professionals involved in the management of young women with coital pain would be beneficial.

Purpose: We wanted to identify young women’s ideal images of sexual situations and expectations of themselves in sexual situations.

Methods: We conducted audiotaped qualitative individual interviews with 14 women aged 14 to 20 years, visiting two youth centers in Sweden. The data were analyzed with constant comparative analysis, the basis of grounded theory methodology.

Results: The women’s ideal sexual situations in heterosexual practice were characterized by sexual pleasure on equal terms, implying that no one dominates and both partners get pleasure. There were obstacles to reaching this ideal, such as influences from social norms and demands, and experiences of the partner’s “own race”. An incentive to reach the ideal sexual situation was the wish to experience the source of pleasure.

Conclusions: Our research further accentuates the importance of finding ways to focus on the complexity of unequal gender norms in youth heterosexuality. A better understanding of these cognitions is essential and useful among professionals working with youths´ sexual health.

CONTEXT: Pain during vaginal intercourse (VIC) is a frequent complaint among young Swedish women, of whom a considerable proportion continues to have VIC despite pain.

METHODS: In 2008, a sample of 1566 female high school students (aged 18-22 years) completed a questionnaire concerning their experiences and attitudes toward body and sexuality. In the present study we examined the prevalence of women who despite pain continue to have VIC, omit telling the partner, and feign enjoyment; as well as the reasons for such behavior.  Chi-square tests and binary logistic regression were used to examine data.

RESULTS: Forty-seven percent (207/576) of those women who reported pain during VIC continued to have VIC despite pain. The most common reasons were that they did not want to destroy sex for or hurt the partner by interrupting VIC. Feigning enjoyment and omit telling the partner about their pain were reported by 22% and 33% respectively. Continuing to have VIC despite pain was associated with feelings of being inferior to the partner during sex, dissatisfaction with their own sex lives and feigning enjoyment while having pain.

CONCLUSION: Pain during VIC is reported by every third young Swedish woman and almost half of those still continue to have VIC. The major reason given is noteworthy --- prioritizing the partner’s enjoyment before their own --- and demonstrates that young women who continue to have VIC despite pain take a subordinated position in sexual interactions.

Objective. To study experience and prevalence of (1) pain related to first sexual intercourse; (2) pain and/or discomfort associated with sexual intercourse during the previous month; and (3) associations between these experiences.

Design. Cross-sectional study. Setting. A youth center in southeast Sweden. Sample. Three hundred consecutive women, aged 13-21 (response rate 98%).

Method. During a two-month period, women consulting a youth center, participated in a questionnaire study. Main outcome measures. Pain and/or discomfort during sexual intercourse.

Results. The majority of the participants, 98%, had had sexual intercourse and of those, 65% reported pain related to first sexual intercourse. Forty-nine percent (99/203) of those who reported sexual intercourse during the previous month had experienced coital pain and/or discomfort during that period, and for almost every second woman (46/99), those experiences constituted a problem. We found no association between experience of pain during first sexual intercourse and pain and/or discomfort during the previous month.

Conclusions. Prevalence of pain and/or discomfort associated with sexual intercourse is high among women visiting a youth center. Our results show that coital pain in young women is a problem which needs to be further explored.

Vaginismus is a sexual pain disorder, where spasm of musculature of the outer third of the vagina interferes with intercourse. Vaginismus exists in two forms: total vaginismus, where intercourse is impossible, and the more seldom described partial vaginismus, in which intercourse is possible but painful.

The aim of the thesis was to develop a useful definition of partial vaginismus for both clinical and scientific purposes; to describe the prevalence of partial vaginismus among women with superficial coital pain; to report on symptoms and clinical findings in women with partial vaginismus; and to present treatment results for women with vaginismus.

In a clinical sample of 224 women with superficial coital pain, we found a great overlap of the clinical diagnoses of partial vaginismus (PaV) and vulvar vestibulitis (VVS) (nowadays called provoked vestibulodynia); 102 women had both PaV and VVS. All women with VVS had vaginismus. Partial vaginismus was more common in all our samples than total vaginismus.

sEMG of pelvic floor muscles was found to be of no value in distinguishing women with partial vaginismus with or without vulvar vestibulitis (PaV+/-VVS) (n=47) from each other or from an asymptomatic group (n=27).

Women with PaV+/-VVS (n=53) reported not only burning pain but also itch during a standardized penetration situation (sEMG of pelvic floor muscles), while asymptomatic women (n=27) did not. In most cases, the appearance of burning pain preceded the appearance of itch.

In a retrospective interview study, 24 women with PaV+/-VVS reported pain after intercourse more often than pain during penetration at the onset of the problem. When the women ceased having intercourse, both symptoms were equally common. Intensity of pain during penetration increased dramatically from very low at onset of the problem to very high when the women ceased having intercourse, while intensity of pain after intercourse was already high at onset of the problem and increased to very high when the women ceased having intercourse.

Pain after intercourse in women with PaV+/-VVS was described as burning and/or smarting and lasted in mean for two hours, while pain during penetration was described with words like sharp/incisive/bursting and lasted for one minute.

At long-term follow-up (more than three years) of a group of women treated with cognitive behaviour therapy for vaginismus (n=59, response rate 44/59 on a questionnaire), a majority were able to have and enjoy intercourse. The proportion of women with positive treatment outcome was, however, associated to the definition of treatment outcome. An ability to have intercourse at end of therapy was maintained at follow-up. Every tenth women with vaginismus healed spontaneously after thorough assessment.

Conclusion: Partial vaginismus was more common in our studies than total vaginismus, and all women with vulvar vestibulitis had partial vaginismus. Women with PaV+/-VVS reported not only burning pain during standardized penetration but also itch. When the problem started in women with PaV+/-VVS, pain after intercourse was more common than pain during penetration. Pain after intercourse was described as longlasting and burning and/or smarting, while pain during penetration was described as short and sharp/incisive/bursting. Long-term follow-up results of a series of women treated with CBT for vaginismus show good treatment outcome.

The aim of this study was to investigate to what extent women with superficial dyspareunia can be diagnosed for both partial vaginismus (PaV) and vulvar vestibulitis (VVS) and to discover to what extent surface electromyography (sEMG) of the pelvic floor muscles (PFM) can distinguish between women with PaV solely, PaV + VVS, and asymptomatic women. A total of 224 consecutive women with superficial dyspareunia were examined clinically for both PaV and VVS diagnoses. We examined 47 women with PaV ± VVS and 27 asymptomatic women with sEMG of the PFM. The results showed that 102/224 women with superficial dyspareunia and 33/47 women with PaV in the sEMG part of the study had both PaV and VVS. All women with VVS had vaginismus, while 42/224 had PaV but not VVS. sEMG measurements revealed no significant differences between the three groups of women (PaV solely, PaV + VVS, and asymptomatic). Almost half of the women with superficial dyspareunia referred to our clinic have both the diagnosis PaV and VVS. sEMG was not a method of any value to distinguish between women with PaV solely, PaV + VVS, or asymptomatic women. The increased tone found clinically in the PFM of women with PaV ± VVS may be of other origin than electrogenic contractions.

Fifty-three women with partial vaginismus with or without vulvar vestibulitis and 27 asymptomatic women estimated sensations of burning pain and itch at 20 standardized moments during a standardized penetration situation, including vaginal muscle contractions. Forty-three women with partial vaginismus (81.1%) reported burning pain, 23 (43.4%) itch, and 22 (41.5%) both complaints, compared to 0% of the asymptomatic women. In 17 of 22 cases, burning pain preceded the appearance of itch and in four cases the two complaints coincided. The median time from the moment when burning pain started until itch appeared was 150 seconds.

The purpose of the present study was to investigate long-term coital behaviour in women treated with cognitive behaviour therapy (CBT) for superficial coital pain and vaginismus. Data were taken from a questionnaire concerning long-term coital behaviour sent to 59 women who presented to Linköping University Hospital because of superficial coital pain, had been diagnosed with vaginismus, and had been treated with CBT. Data were also traced from therapy records: mean follow-up time was 39 months, the women had suffered for an average of almost 4 years, and required a mean of 14 treatment sessions. Forty-four of the 59 women returned the questionnaire, for a response rate of 74.6%. At follow-up, 81% of the treated women had had intercourse. A majority (61%) rated their ability to have intercourse without pain as 6 or higher (on a scale from 0-10), and 61% rated their ability to enjoy intercourse as 6 or higher (on a scale from 0-10). The proportion of women with positive treatment outcome at follow-up ranged from 81% (able to have intercourse) to 6% (able to have pain-free intercourse). An ability to have intercourse at end of therapy was maintained at follow-up. Two-thirds of the women reported high fulfillment of individual treatment goals. At follow-up, the women estimated a significantly higher self-worth as sex partners, and as women and human beings, than before treatment. Twelve per cent of the original sample had healed after a few assessment sessions and without treatment.

Twenty-four women with partial vaginismus with or without vulvar vestibulitis participated in a semi-structured telephone interview concerning early signs and development of their pain symptoms during/after intercourse. At the onset of the problem, pain after intercourse was more common than pain during penetration. Pain intensity during penetration increased from the onset of the problem to when the women ceased having intercourse. Pain during penetration lasted for 1 minute, and was most often described as sharp/incisive/bursting, while pain after intercourse had a duration of 2 hours and was described as burning and/or smarting. Post-coital pain during micturition was described by 70% of the women.

The aim of the study was to describe the prevalence and age distribution of bacterial vaginosis (BV) during an observation period of 15 years in a population study with cross-sectional samples of adult women living on the Aland Islands. The Aland Islands form an archipelago in the Baltic Sea and are a province of Finland. Every fifth year, specific age groups in the adult female population are invited to participate in a screening program for early diagnosis of cervical cancer using a papanicolaou (PAP)-stained vaginal smear. Women in the age groups of 20, 25, 30, 35, 40, 45, 50, 55, and 60 years are called each year. BV diagnosis of the PAP-stained smears uses the classification according to Nugent. The PAP-stained smears from the screening program of cervical cancer 1993, 1998, 2003, and 2008 were used in this study. A total of 3456 slides were investigated and 271 women could be followed for the 15-year observation period. The prevalence of BV declined from 15.6% in 1993 to 8.6% in 2008. The highest prevalence occurred among the age groups of 35 and 50 years. Among the 271 women who could be followed for the 15-year observation period, two-third showed normal/intermediate flora and one-third were infected with BV at least once. As this is a cross-sectional population study spanning 15 years, the prevalence of BV in the female adult population of the Aland Islands can be estimated. The prevalence has declined between 1993 and 2008 from 15.6% to 8.6%.

Since bacterial vaginosis (BV) is characterized by a lack of, or very few, lactobacilli and high numbers of small, mostly anaerobic bacteria, an obvious treatment modality would be eradication of the BV-associated bacterial flora followed by reintroduction of lactobacilli vaginally. As probiotic treatment with lactobacilli is one tool for improving the cure rate when treating BV, it is necessary to know the length of time after treatment that clindamycin can be found in the vagina and if this could interfere with the growth of the probiotic lactobacilli. We evaluated the vaginal concentration of clindamycin in 12 women for 8 days to obtain data on the concentration of clindamycin in the vagina after intravaginal treatment with the drug. The participants were examined five times between two menstrual periods: before treatment, the day after treatment was finished, and 3, 5 and 8 days post-treatment. The first day post-treatment clindamycin 0.46 x 10-3 to 8.4 x 10-3 g/g vaginal fluid (median 2.87 x 10-3) was found. Thereafter, the concentration of clindamycin decreased rapidly. In 10 patients clindamycin was found after 3 days. A very low concentration was still present 5 days after treatment in four patients. After 8 days no clindamycin was found. Clindamycin is rapidly eliminated from the vagina, within 3-8 days, after local administration. Our results indicate that treatment with probiotic lactobacilli could be problematic if carried out within 5 days after cessation of clindamycin treatment.

Diagnosing bacterial vaginosis (BV) has long been based on the clinical criteria of Amsel et al., whereby three of four defined criteria must be satisfied. Though there are other criteria and scoring methods which function well in comparison (i.e. Nugent scoring), it is not certain that they will always identify the same category of patients. Point-of-care methods based on various combinations of microbial products, presence of RNA, or more complex laboratory instrumentations such as sensor arrays, have also been introduced for the diagnosis of BV No method for diagnosing BV can at present be regarded as the best. It could be that - based partly on tacit knowledge on the part of the clinical investigators scoring in the clinic - various scoring systems have been chosen to fit a particular BV-related problem in a particular population. In this review we critically examine these pertinent issues influencing clinical scoring and laboratory diagnostics of BV. Copyright © APMIS 2005.

Background. The aim of this study was to evaluate how women experience the gynecologic examination and to assess possible factors associated with experiencing discomfort during the gynecologic examination. Methods. Consecutive patients visiting the Department of Obstetrics and Gynecology at Glostrup County Hospital, Denmark, were invited to participate in the study, and received a postal questionnaire that included questions about the index visit, obstetric and gynecologic history and sexual abuse history. The response rate was 80% (n = 798). The degree of discomfort during the gynecologic examination was indicated on a scale from 0 to 10. Experiencing discomfort was defined as a score of 6 or more, based on the 75th percentile. Results. Discomfort during the gynecologic examination was strongly associated with a negative emotional contact with the examiner and young age. Additionally, dissatisfaction with present sexual life, a history of sexual abuse and mental health problems such as depression, anxiety and insomnia were significantly associated with discomfort. Conclusion. The emotional contact between patient and examiner seemed to have great importance when focusing on discomfort during the gynecologic examination. Furthermore, we found that discomfort was associated with a number of factors that are seldom known to the gynecologists, such as sexual abuse history, mental health problems and patients' sexual life. Gynecologists need to focus on the emotional contact and to reevaluate issues for communication before the examination.

The interview study described in this chapter was performed in cooperation with two Nepalese non government organizations called Community Action Nepal (CAC Nepal) and Shakti Samuha. Informants were eight trafficking survivors who were independently living in various parts of Kathmandu Valley and six trafficking survivors who were currently staying at a rehabilitation centre. After being rescued, five of the informants now earned their living as prostitutes, one was a housewife, one had her own shop, and five were at a rehab centre. Most of the informants had been tricked into being trafficked. The most commonly used bait was a nice job in Kathmandu or abroad with a good salary, which would allow the informant to buy 'nice clothes' and eat 'good food'. To this need to be added that the migration decision of the informants (which turns out to be trafficking) takes place in an interface between economic hardships, the informant’s own desire for better work and a better life, and pressure on her to assist sustaining her family.The trafficker was most often a known person, male or female, who had spent time and efforts in building a good relationship with the informant before taking off for the ‘good job’. Life at the brothel was described as a prison, where the informants instantly and at any time of the day and night had to obey the brothel owner (who often was a woman, and sometimes Nepalese), and her 'guards' (male or female). If they refused or did not act accordingly they were severely punished often by physical means. The informant’s life was reduced into one purpose ‘how to satisfy brothel’s customers’. The owners of the brothels were usually sitting at the main entrance and other guards were always around. The doors were always locked when the informants had some time off. Most informants had not been allowed to leave the house, and a few of them did not understand where they were until they later on could ask someone.The relief of finally returning home to Nepal was often clouded by difficulties. Only one of the informants could go directly back home to her family. She was well accepted by her husband and in-laws, but she had to face a lot of resistance from other community members. Later on she decided to leave her husband, as she realized that he was also to blame for her being trafficked.The informants revealed that their experiences while being trafficked were usually kept a secret during and after trafficking. According to several studies, the trauma of having been trafficked is often complicated by societal refusal upon return from the brothels. Survivors know who the traffickers are, but their reputation for cruelty and the failure of the police and legal system to enforce the law, contribute to creating an attitude that there is no point in making official reports.A puzzling fact is finally presented: during the last two decades Nepal has made great improvements in designing anti-trafficking programmes and implementing new anti-trafficking laws. Yet, trafficking seems to have become an increasing problem in Nepal during the same period. This poses an urgent challenge on both researchers and society.

The interview study described in this chapter was performed in cooperation with two Nepalese non government organizations called Community Action Nepal (CAC Nepal) and Shakti Samuha. Informants were eight trafficking survivors who were independently living in various parts of Kathmandu Valley and six trafficking survivors who were currently staying at a rehabilitation centre. After being rescued, five of the informants now earned their living as prostitutes, one was a housewife, one had her own shop, and five were at a rehab centre. Most of the informants had been tricked into being trafficked. The most commonly used bait was a nice job in Kathmandu or abroad with a good salary, which would allow the informant to buy 'nice clothes' and eat 'good food'. To this need to be added that the migration decision of the informants (which turns out to be trafficking) takes place in an interface between economic hardships, the informant’s own desire for better work and a better life, and pressure on her to assist sustaining her family.The trafficker was most often a known person, male or female, who had spent time and efforts in building a good relationship with the informant before taking off for the ‘good job’. Life at the brothel was described as a prison, where the informants instantly and at any time of the day and night had to obey the brothel owner (who often was a woman, and sometimes Nepalese), and her 'guards' (male or female). If they refused or did not act accordingly they were severely punished often by physical means. The informant’s life was reduced into one purpose ‘how to satisfy brothel’s customers’. The owners of the brothels were usually sitting at the main entrance and other guards were always around. The doors were always locked when the informants had some time off. Most informants had not been allowed to leave the house, and a few of them did not understand where they were until they later on could ask someone.The relief of finally returning home to Nepal was often clouded by difficulties. Only one of the informants could go directly back home to her family. She was well accepted by her husband and in-laws, but she had to face a lot of resistance from other community members. Later on she decided to leave her husband, as she realized that he was also to blame for her being trafficked.The informants revealed that their experiences while being trafficked were usually kept a secret during and after trafficking. According to several studies, the trauma of having been trafficked is often complicated by societal refusal upon return from the brothels. Survivors know who the traffickers are, but their reputation for cruelty and the failure of the police and legal system to enforce the law, contribute to creating an attitude that there is no point in making official reports.A puzzling fact is finally presented: during the last two decades Nepal has made great improvements in designing anti-trafficking programmes and implementing new anti-trafficking laws. Yet, trafficking seems to have become an increasing problem in Nepal during the same period. This poses an urgent challenge on both researchers and society.

The prevalence of troublesome fear of childbirth (FOC) in Western countries is about 20%, of which approximately 6–10% suffer from severe FOC that impacts daily life. The countries of Sweden and Denmark are quite alike as far as childbirth culture is concerned. However, to some extent they differ in the organisation of midwifery care during the antenatal and labour period, respectively, and this may influence women's FOC. The aims of this study were to compare FOC among Danish and Swedish nulliparous women and to investigate a possible difference in FOC between women who, during pregnancy, had met the midwife who they were subsequently coincidentally allocated to receive labour care from and women who had not previously met the midwife. In total 165 women participated, comprising 55 Swedes and 110 Danes, of whom 55 among the latter group had met the midwife during pregnancy. Severe FOC was found in 10%. There were no differences between the Swedish women and the Danish women who had or had not met the midwife. Fear of childbirth measured in gestational week 37 correlated positively with fear at admission to the labour ward.

Objective To evaluate the effect of stress coping capacity in combination with mode of anaesthesia on postoperative recovery in fast-track abdominal hysterectomy. Design Prospective longitudinal study. Setting Five hospitals in the south-east of Sweden. Population A cohort of 162 women undergoing fast-track abdominal hysterectomy for benign conditions. Methods Self-administered questionnaires, the Stress Coping Inventory (SCI) and the Swedish Postoperative Symptom Questionnaire (SPSQ), and clinical information were collected prospectively. Stress coping capacity was categorised as high or low according to the summed score of the SCI. Comparisons of effect variables were adjusted using a propensity score-matching model. Main outcome measures Associations between stress coping capacity and hospital stay, sick leave, use of analgesic and self-reported postoperative symptoms. Results Women with high stress coping capacity had a significantly shorter sick leave, experienced postoperative symptoms significantly less often, and with lower intensity, than women with low stress coping capacity. With the exception of symptom intensity, these findings were related to having had the operation under spinal anaesthesia as opposed to general anaesthesia. Hospital stay, use of analgesics and abdominal pain were not related to stress coping capacity. Conclusions In patients for whom spinal anaesthesia was applied, high stress coping seems to be a quality that helps patients manage the burden of surgery. It is desirable for the individual, as well as for the healthcare system, to enhance recovery by using intervention programmes designed to improve or manage stress coping, particularly for individuals with low stress coping capacity. This recommendation merits further investigation.

Whether bacterial vaginosis (BV) is acquired from an endogenous or an exogenous source is subject to controversy. Despite findings of an association between sexual behaviour and BV, some data indicate that BV is not a sexually transmitted infection in the traditional sense, while other data indicate that BV is an exogenous infection. A third aspect of BV is its tendency to go unnoticed by affected women. All of this will have a strong impact on how physicians view the risks of asymptomatic BV This review focuses on whether or not BV should be regarded as a sexually transmitted infection (STI), its role in postoperative infections and pelvic inflammatory disease (PID), and on whether or not treatment of BV during pregnancy to reduce preterm delivery should be recommended. The reviewed studies do not lend unequivocal support to an endogenous or exogenous transmission of the bacteria present in BV For women undergoing gynaecological surgery such as therapeutic abortion, the relative risk of postoperative infection is clearly elevated (approx. 2.3-2.8). A weaker association exists between BV and pelvic inflammatory disease. Data on treatment of BV as a way of reducing preterm delivery are inconclusive and do not support recommendations for general treatment of BV during pregnancy. The discrepant associations between BV and preterm birth found in recent studies may be explained by variations in immunological response to BV. Genetic polymorphism in the cytokine response - both regarding the TNF alleles and in interleukin production - could make women more or less susceptible to BV, causing different risks of preterm birth. Thus, studies on the vaginal inflammatory response to microbial colonization should be given priority. Copyright © APMIS 2005.

Background: The diagnosis of bacterial vaginosis (BV) is often made according to Nugent's classification, a scoring system based on bacterial counting of Gram stained slides of vaginal secretion. However as the image area of the microscope field will influence the number of morphotypes seen there is a need to standardise the area. Methods: A graph intended for recalculation of number of bacterial morphotypes seen by the observer using 1000 x magnification from various microscope set-ups was constructed and applied to data sets typical for scoring BV. The graph was used in recalculation of Nugent scores, which were also compared with the Ison/Hay scores to evaluate the consequences for the diagnosis of BV. Results: The observed image area differed by 300% among the investigated microscope set-ups. In two different data sets, one treatment study and one screening study, a considerable change in the number of women classified as intermediate was seen when the graph was used to standardise the image area. The recalculated numbers were also compared to the Ison/Hay classification. Weighted kappa indexes between the different methods were 0.84, 0.88, and 0.90, indicating that the methods are comparable. Conclusion: Because of the considerable differences among image areas covered by different microscope set-ups used in Nugent and Ison/Hay scoring, there is a need to standardise the area in order to reach comparable scores reflecting the diagnosis of BV in different laboratories. The differences in the intermediate group will have a considerable effect on the results from both treatment and prevalence studies, even though the kappa indexes indicate very good agreement between the methods used.

The syndrome bacterial vaginosis (BV) is characterized by a disturbed vaginal microflora in which the normally occurring lactobacilli yield quantitatively to an overgrowth of mainly anaerobic bacteria. As BV is a possible cause of obstetrics complications and gynaecological disease - as well as a nuisance to the affected women - there is a strong impetus to find a cure. In BV treatment studies, the diagnosis criteria for diagnosis of BV vary considerably and different methods are used for cure evaluation. The design of study protocols varies and there is no consensus respecting a suitable time for follow-up visits. For the purpose of this review, available data were recalculated for 4-week post treatment cure rates. For oral metronidazole the 4-week cure rate was found not to exceed 60-70%. Treatment regimens with topical clindamycin or topical metronidazole have the same cure rates. It can thus be said that no sound scientific basis exists for recommending any particular treatment. There is no evidence of beneficial effects on BV engendered by partner treatment, or by addition of probiotics or buffered gel. Long-term follow-up (longer than 4 weeks) shows a relapse rate of 70%. With a primary cure rate of 60-70%, and a similar relapse rate documented in the reviewed literature, clinicians simply do not have adequate data for determining treatment or designing clinical studies. This is unfortunate since - apart from the obvious patient benefits - clinical studies can often serve as a guide for more basic studies in the quest for underlying disease mechanisms. In the case of BV there is still a need for continued basic studies on the vaginal flora, local immunity to the flora and host-parasite interactions as an aid when designing informative clinical studies. Copyright © APMIS 2005.

Background. Bacterial vaginosis (BV) and intermediate flora is known risk-factor for post-operative infection after surgical termination of pregnancy. Vaginal application of 2% clindamycin cream is an efficacious treatment for BV, but it is not known whether preoperative administration of clindamycin cream might reduce the signs of post-abortion infection after surgical termination of pregnancy. Aim. To evaluate whether preoperative treatment with clindamycin cream might reduce the signs of post-abortion infection after legal abortion. Design. Prospective, double-blinded, placebo-controlled, multicenter study. Material and methods. Consecutive women attending for surgical termination prior to 11 + 4 gestational weeks were approached. We randomized participants to preoperative vaginal treatment with 2% clindamycin cream or placebo cream in a double-blinded fashion. At all visits vaginal smears were air dried on microscopy slides to be stored. The rate of postoperative pelvic infection according to our definition was the main outcome variable, the cure rates of BV and of intermediate flora were secondary outcome variables. Results. Of 1655 enrolled women, 1102 were evaluable for analyses. Fifty-eight women developed signs of post-abortion infection. Preoperative treatment with clindamycin cream significantly (RR: 4.2, 95% C.I. 1.2-15.9) reduced the risk of post-abortion infection among women with abnormal vaginal Bora (BV and intermediate flora). Treatment with clindamycin cream in women with normal lactobacilli flora did not demonstrate any difference compared to the non-treatment group. Conclusion. Preoperative treatment for at least three days with clindamycin cream significantly reduced the risk for developing signs of post-abortion infection only among women with preoperative abnormal vaginal flora (BV and intermediate flora).

The chapter introduces the GEXcel research theme on Sexual Health, Embodiment and Empowerment.

Objectives: In Nepal, the change of the abortion law in 2002 extended the staff duties at family planning clinics to include performing induced abortions. This study investigated the experiences, opinions and attitudes of the staff about their work at safe abortion service centres in the Kathmandu Valley and identified areas in which the health care staff stated the need for improvement.

Study design: Fifteen qualitative semi-structured interviews were conducted with doctors and nurses working with induced abortion at one hospital and five clinics in the Kathmandu Valley. The interviews were transcribed verbatim and analysed using the constant comparative method.

Results: The core category ‘Proud, not yet satisfied’ comprised a strong perception of providing an important service that is beneficial for women’s health and a feeling of pride in providing quality service. Four related categories were identified: ‘Beneficial legal framework’, ‘A will to reach out to all women’, ‘Frustration about misuse’ and ‘Dilemma of sex-selective abortion’. The respondents emphasised that improvements are necessary to (1) ensure that all women have access to safe abortion services; (2) prevent abortions from being used instead of contraceptives; (3) stop illegal medical abortions; and (4) deal with the dilemma of sex-selective abortions.

Conclusions: Respondents were proud of and had psitive experiences from their work. They stated they have the opportunity to secure women’s rights and health; however, changes are needed to bring the quality of abortion care to a satisfactory level.

The aim of this study was to evaluate the effect of applied relaxation and electro-acupuncture (EA) on psychological well-being in breast cancer-treated women with vasomotor symptoms. Thirty-eight breast cancer-treated postmenopausal women with vasomotor symptoms were included in the study. They were randomized to either treatment with electro-acupuncture (EA) (N = 19, three of them with tamoxifen) or applied relaxation (AR) (n = 19, five of them with tamoxifen) over a 12-week study period with six months follow-up. Vasomotor symptoms were registered daily. A visual analog scale was used to assess climacteric symptom, estimation of general well-being was made using the Symptom Checklist, and mood using the Mood Scale. These were applied during treatment and at follow-up. In total 31 women completed 12 weeks of treatment and six months of follow-up. Hot flushes were reduced by more than 50%. Climacteric symptoms significantly decreased during treatment and remained so six months after treatment in both groups. Psychological well-being significantly improved during therapy and at follow-up visits in both groups. Mood improved significantly in the electro-acupuncture treated group. In conclusion psychological well-being improved in women with breast cancer randomized to treatment with either AR or EA for vasomotor symptoms and we therefore suggest that further studies should be performed in order to evaluate and develop these alternative therapies. © 2006 Informa UK Ltd.

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Purpose. To describe reasons for non-attendance at cervical screening, as reported by non-attendees, in Sweden. Methods. Four hundred women were randomized from a population-based register, of which 133 non-attendees answered the Cervical Screening Questionnaire (CSQ) in telephone interviews. Pearson's Chi² and Mann-Whitney U-test were used to analyze differences between groups. Logistic regression was used to study the relationship between explanatory variables and a binary response variable. Results. The most common reasons for non-attendance were: feeling healthy, lack of time, and feelings of discomfort with the gynecologic examination. Non-attendees, who reported non-attendance due to experiences of discomfort associated with the gynecologic examination, estimated great discomfort at their latest examination. A history of sexual abuse was reported by 16.5%, but there were no differences regarding non-attendance due to experiences of discomfort associated with the gynecologic examination, between non-attendees who had no history of sexual abuse and those who had. Conclusion. It seems as though non-attendees did not attend cervical screening as they felt healthy, and thereby did not give time to preventive efforts. Earlier negative experiences such as discomfort during earlier gynecologic examinations seem to guide their decision not to attend.