Directory of health resources for healthcare professionals.

For most women and men, the hardest thing is telling a new partner you’ve had herpes. It’s certainly a difficult matter to bring up, but think of it both ways. If you’ve never been infected and your partner has, I’m sure you’d prefer that he told you. And if you really loved someone, would you be frightened off if he told you he’d had herpes, especially if he promised to do everything possible to avoid infecting you? With herpes so common, when you confess he may breathe a sigh of relief and say ‘I’ve had it too; I was just about to tell you’.

If only one of you is infected, the best way to prevent sharing HSV is to avoid any contact with the affected area from the first suspicion that a recurrence might develop until you’re quite sure that it’s completely cleared up. I know a couple who followed this advice and managed to avoid the husband infecting the wife over 14 years: then she caught it when they knowingly took a chance. They said it was almost a relief after they’d shared it!

Condoms may be useful in reducing the risk of spreading infection from lesions on the penis.

Finally, let me repeat that if you do catch genital herpes, don’t let it get you down.

Try to regard it in the same way as you would oral herpes – as a nasty, unfortunate infection but one that won’t harm your health or happiness in the long run as long as you take reasonable care not to infect anyone else. Don’t let HSV ruin your life: conquer it!

*303/31/5*

This can produce good cosmetic results after mastectomy. The support services or your plastic surgeon will show you photographs of what can be achieved by breast reconstruction. Discuss the matter with your surgeon, who will advise about its suitability and whether it may be done at the time of mastectomy or later.

Follow-up

After treatment you’ll need annual mammography for at least the first 10 years after surgery and careful regular follow-up for the rest of your life, though the interval between visits will increase with time. If you’re concerned about any change in your condition before your follow-up is due, contact your doctor.

The future

Improved methods of early detection are on the horizon. Researchers are working on a blood test that will identify cancerous breast changes earlier than ever. New techniques, new drugs, plus the results of studies in different parts of the world all contribute to an ever-changing scenario in the detection and treatment of breast cancer. Identification of the gene that makes women susceptible to breast cancer may pave the way to prevention.

At present it’s up to you. Examine your own breasts once a month. Ask your doctor for a breast examination as part of regular health checks and whether regular screening mammograms are advisable. Regular BSE is very important between screening mammograms.

Breast cancer support services

Information can be obtained from the following.

Australian Capital Territory

ACT Cancer Society 15 Theodore Street

Curtin ACT 2605

Tel. (06) 285 3070

New South Wales

NSW Cancer Council

153 Dowling Street

Woolloomooloo NSW 2011

Tel. (02) 9334 1900

Northern Territory

NT Anti-Cancer Foundation

Unit 2, 23 Vanderlin Drive

Casuarina NT 0810

Tel. (08) 8927 4888

Queensland

Queensland Cancer Fund

553 Gregory Terrace Fortitude Valley QLD 4006

Tel. (07) 3258 2200

South Australia

Anti-Cancer Foundation

202 Greenhill Road

Eastwood SA 5063

Tel. (08) 8291 4111

Tasmania

Tasmanian Cancer Council

13 Liverpool Street Hobart TAS. 7000

Tel. (03) 6233 2030

Victoria

Anti-Cancer Council of Victoria

1 Rathdowne Street

Carlton South VIC. 3053 Tel. (03) 9279

1111 Fax. (03) 9279 1240

Western Australia

Cancer Foundation

334 Rokeby Road

Subiaco WA 6008

Tel. (09) 381 4515

*274/31/5*

During recent years there have been many alarming and sensational media reports linking the human papilloma virus (HPV) with cancer of the cervix and calling it a new epidemic and a sexually transmissible disease. None of these claims have been proved, but they have caused much anguish among people (both women and men) whose lives are affected when HPV is reported in a Pap smear. What does it all mean?

The wart virus is all around us. There are many different types: almost 50 have been identified and there are probably more. Some types cause skin warts; others cause genital warts; others live in the vagina and on the cervix, some types causing typical warty outgrowths, and some just causing a change in the microscopic appearance of the cells covering the ectocervix.

HPV isn’t new. It has probably always been around, but modem technology has now produced tests that demonstrate its presence more sensitively. These tests have even shown evidence of HPV in Egyptian mummies. What is now described as HPV effect in Pap smears used to be called something else (so common that it was considered a normal variation) 30 years ago before we knew much as we now do about viruses.

If the wart viruses are so widespread, why aren’t we all affected? We probably all carry many types of HPV on our skin and some lining membranes (it only lives in stratified squamous epithelium) but t is not known why the virus invades cells and causes changes in only some people. It’s suspected that there must be a change in our immune state plus one or more other factors (still not known) before the virus can invade and express its presence by causing cell changes. Studies using the new sensitive tests have found evidence of HPV on the cervix of up to 80 per cent of women, most of whom have normal Pap smears.

The suggestion that HPV changes in the cervix are due to sexual transmission of the virus has caused great anxiety and un-happiness. It makes women feel tainted, diseased and often judged as being promiscuous. A woman wonders who gave her the infection. She may have her suspicions, but if she has had only one partner she may doubt his sexual fidelity. A man whose only sexual partner develops HPV in a Pap smear may have similar doubts about her sexual behaviour. All the misery and distrust that arises because HPV changes in Pap smears are branded as a ‘sexually transmissible disease’ is, I believe, unjustified and unnecessary. HPV can certainly be transmitted through sex (and the more partners, the more likely the transmission), but is probably more often picked up in other ways, as suggested by the following facts.

Some hormonal disturbances before birth can lead to abnormal genital development.

The most serious genital abnormalities are those that can lead to the wrong sex being diagnosed at birth. The most important event in the identification of sex of a newborn infant is inspection of the genitals, which may appear to be unmistakably male or female, regardless of whether the genetic sex or the sex of the gonads corresponds.

If there is any doubt, genetic sex can be confirmed quickly by examination through the microscope of cells wiped from the inside of the mouth (this is called the buccal smear test). Cells of females show a minute particle (called the Barr body) within the nucleus. This particle is absent in males. In cities, analyses of chromosomes and genes to confirm sex may be available, but these tests take longer.

Masculinisation of the female external genitals

This is caused by overexposure of the female foetus to male hormones formed by the foetal adrenal gland or passed to the foetus from the mother.

Congenital adrenal hyperplasia is an inherited condition wherein enzymes need, needed by the adrenal gland to make cortisone are lacking. Because there is no cortisone in the foetus’s blood, the pituitary stimulates the adrenal to overgrow (‘hyper-plasia’ means overgrowth) and work harder. The result is that it produces more and more of all its hormones – except cortisone. The overproduction of male hormones leads to masculinisation of the external genitals. The clitoris may be so enlarged as to resemble a penis, and the labia may be partly or wholly fused like a scrotal sac. If sexual identification is made only by looking at the genitals, mistake can be made, even though the infant has normal female chromosomes, ovaries and internal reproductive organs.

Infants with congenital adrenal hyperplasia also can’t conserve salt and usually become severely ill during the first few] days after birth. Early diagnosis and treatment is needed to save the baby’s life. Treatment with cortisone must commence at once and continue throughout life to suppress adrenal hyperactivity. Plastic surgery techniques are usually needed to restore the genitals to normal female appearance and function.

Masculinisation of the female foetus’s genitals can also result if the mother takes certain synthetic progestogens with androgenic effects during pregnancy or, very rarely, if the mother has an androgen-producing tumour. Some synthetic progestogens that were used in the 1950s and early ’60s to treat some types of repeated miscarriage occasionally resulted in overgrowth of the clitoris and incorrect diagnosis of male sex at birth. These progestogens are no longer used to prevent miscarriage. Their effects were never as pronounced as those of adrenal hyperplasia, and stopped as soon as maternal treatment finished. Surgical correction was rarely needed.

*216/31/5*

Recurrent miscarriage

This is defined as three or more miscarriages in a row. It used to be called ‘habitual abortion’ – what a terrible term! Repeated miscarriages are terribly distressing and can lead to sexual problems, marriage breakdown and psychiatric illness, especially depression. In most cases no cause can be found; in others there may be an explanation.

• One or both parents may carry a chromosomal abnormality that prevents foetal survival. All major women’s hospitals have genetic testing facilities and genetic counsellors who can advise about the risk of such an abnormality in future conceptions. Though there isn’t yet any specific treatment for such conditions, if another pregnancy is achieved, foetal chromosome tests can be done. If an abnormal foetus is detected, parents can decide whether or not to continue the pregnancy.

• Immune-system disorders can be associated with recurrent miscarriage. In women with systemic lupus erythematosus (SLE), the most common immune disorder in young women, there is a higher miscarriage rate. In recent years some women who have received treatment for immune disorders have since had a successful pregnancy.

• Uterine abnormalities, such as fibroids or abnormalities of the shape of its cavity, can often be corrected by surgery.

• Incompetent cervix is the most common reason for miscarriage in the second trimester of pregnancy. The cervix, sometimes for no apparent reason and sometimes following tearing during previous labour or surgery, is unable to remain closed to hold the foetus in the uterus. If this has been the reason for previous miscarriage, the cervix may be reinforced with surgical stitches early in the next pregnancy. The suture is removed just before delivery is due.

• Various hormonal problems in early pregnancy used to be considered causes of miscarriage. Recent research suggests that this is rarely the case, and that high levels of luteinising hormone (LH) before conception may be more important in miscarriage in early pregnancy. If too much LH proves a culprit, hormones that will reduce the excess can be given to decrease the risk of miscarriage. The role of hormones in miscarriage is being studied further.

After a miscarriage

Most doctors like to see you about six weeks after a miscarriage. This visit provides a good opportunity to bring up any further questions you may wish to ask. Contact your doctor if you have any unexpected bleeding or fever before your visit is due.

Most women feel low in spirits on arriving home from hospital. This ‘down’ mood may get worse over the next few days, and you may be uncontrollably miserable and weepy for a day or so. Sudden hormonal changes are aggravating your natural sadness after the miscarriage. If you know that your spirits will lift when your next menstrual cycle gets going (usually within a fortnight of the miscarriage), it will help you get through this difficult time. So will the support of your partner, family and friends, so tell them how you’re feeling: pretending you’re ‘taking it well’ to spare others’ feelings will do more harm than good.

You can resume sexual intercourse as soon as you feel like it. If you don’t want to conceive straight away, discuss contraception before leaving hospital. Many women are advised to delay the next pregnancy for several months after a miscarriage. There is no sound reason for this to be a hard and fast rule: it’s something to be decided by you and your doctor, considering the circumstances of your miscarriage.

The disappointment of miscarriage may make you think ‘Never again’, but remember that if it’s happened once you have more than a seven out of ten chance that the next pregnancy will continue, and even in recurrent miscarriage there is 60 per cent chance of a later successful pregnancy.

*186/31/5*