“The war within”: psychological mediators of the relationship between cumulative stress exposure and self-reported changes in gynecological symptoms among women during wartime

Background Previous studies have tied stress exposure and psychological response, including posttraumatic stress symptoms (PTSS), to changes in gynecological symptoms (pain, urogenital symptoms and menstruation), however the multipartite relationship between these variables has been underexplored.Methods An online, cross sectional, survey was completed by 527 Israeli women during Israel–Gaza war. The questionnaires included demographics, gynecological symptoms before and after war onset, and validated scales for exposure to war-related stressors, exposure impact and PTSS. Serial mediation models were tested, with cumulative exposure to war related stressors as the predictor and the subjective impact of exposures and PTSS as serial mediators. Reported change in gynecological symptoms (pain, menstrual symptoms and urogenital symptoms) were outcomes.Results Indirect effects of cumulative exposure on changes in all gynecological symptoms were significantly mediated through PTSS alone and sequentially through the subjective impact of exposure and PTSS for all outcomes. Independent and direct effects varied between outcomes. PTSS correlated significantly with all the variables in the model.Conclusions The results support serial mediation of exposure effects for all three symptom change categories, emphasizing the importance of psychological factors in gynecological symptoms changes among women during times of crisis. Potential underlying mechanisms for future exploration and implications for clinicians are discussed.