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!

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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

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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.

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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.

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Physical problems after the abortion are uncommon. Most women will be warned to expect very little bleeding for the first few days, after which bleeding like a period (often with cramps) begins. This may be bright red for a couple of days, and then dwindle away with small amounts of dark spotting over the next week or so. This delayed bleeding is the result of hormonal changes after the abortion. Before this was understood, it was often thought to mean complications, and many women had to go through admission to hospital and curettage, which almost always showed nothing wrong. We know better now.

Most clinics like to arrange a visit (or a check with your own doctor) about two weeks after the abortion. This is a good time to check that everything’s back to normal in your pelvis, to make sure that all’s well with the contraception you’ve chosen, and to see how you’re coping emotionally.

The emotional response after abortion is more complex. Immediately afterwards many women feel great relief, sometimes tinged with sadness. A few days later most women experience a sudden downturn in mood, feeling depressed, listless and uncontrollably weepy. This is also due to hormonal changes. It usually begins about the same time as the bleeding and cramp, so you feel physically as well as emotionally miserable for a day or so. You’ve probably also been warned that these ‘blues’ are likely to occur and will only last for about 36 hours, but that doesn’t make it easier to cope. It’s a time when you need good friends around you.

You may feel upset about the abortion from time to time long after it’s done. If sadness or regrets continue to make you miserable, it’s wise to go back to your clinic or hospital and speak to a counsellor.

Effect of abortion on future pregnancies

When large groups of women who have had abortions are compared, those who have had a lawful abortion are no different to those who haven’t, and have the same chance of having a healthy pregnancy and
baby in the future. Having three or more abortions puts a woman at a slightly
increased risk of miscarriage or prematurity in future pregnancies. For individual women anything that results in reproductive tract infection can be a threat to future fertility. This is why it is so important, follow carefully all advice aimed at preventing infection.

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The condom, also called sheath, rubber or French letter (and in France chapeau anglais – English hat), works simply by catching the semen so that it doesn’t get into the vagina.

History of condoms

Condoms have a colourful history. Penile sheaths have been worn since the remote past, thousands of years before the discovery of rubber. These early sheaths were worn to protect the penis against frostbite, injury in battle and insect bites. They also served as magic charms, or were worn as a decoration and to distinguish men (by their colour and splendour of embroidery) according to their rank. In the sixteenth century, linen condoms were recommended in an attempt to prevent the spread of syphilis. Legend has it that Casanova employed 20 women to sew silk condoms for this purpose.

It was not until the eighteenth century that sheaths made from animal intestine were used to prevent pregnancy (Casanova also used these, asking his partners to tie them on with coloured ribbons!). When Dunlop discovered how to vulcanize rubber last century, rubber condoms began to be manufactured. The early rubbers were thick, hard to put on and uncomfortable to wear. Since 1930 thin condoms made from liquid latex have been produced.

Attitudes to condoms

In the days when the sale of contraceptives was banned, USA law also forbade them being sent through the mail (this is how the ‘plain brown wrapper’ originated) and required that their labels state that they were for the prevention of disease only. The association with prostitution, promiscuity, venereal disease and breaking the law gave condoms a rather squalid reputation, and made them the butt of sordid jokes and innuendo. They were loudly denounced by those who believed that sex should only be for the purpose of begetting children. These attitudes made people embarrassed about buying condoms. People also didn’t like using them. Both men and women felt that they cut down sensation – ‘like having a shower in your raincoat’ (before latex this was probably true), and putting a condom on an erect penis was too explicitly confronting for many couples. Rumours such as ‘there’s a dud in every packet’ and ‘it’s like playing Russian roulette’ did little to make people feel confident about their contraceptive efficacy.

Public health education to prevent the spread of the AIDS epidemic and other STDs has changed attitudes to condoms. They are now widely promoted as ‘good’ (though as this is mainly for their role in disease prevention, I wonder how it will affect their future as contraceptives) and they have come out from under the pharmacy counter. They can now be advertised (illegal in Australia until the 1970s) and are openly displayed for sale.

Some years ago my colleagues and I used to dream that if condoms were easier to buy, so many unplanned pregnancies and abortions could be prevented. Now you can pick them up at the supermarket with the weekly groceries: there they are at the check-out with the razor blades, matches and Lifesavers. They are discussed openly in print and broadcast media (previously unmentionable), and are promoted freely by vendors and health authorities (for example, the first government-supported ‘State Condom Week’ in South Australia in 1977 was aimed at reducing the spread of STD and requests for abortion. Health workers gave out information and samples in the streets of Adelaide – something that would have been unthinkable five years earlier). The first National Condom Day, featuring distribution of educational kits and free samples, was held in August 1993.

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The basic physiological response is the same as women’s: engorgement of pelvic and genital blood vessels and increased muscular activity. However some manifestations of these changes are different in men.

• The first sign of arousal is erection of the penis, which becomes longer, wider and harder due to engorgement with blood. The erect penis rises to make an acute angle with the abdomen.

• As arousal proceeds the testes move upwards in the scrotum into a position close to the perineum. Muscle strands under the scrotal skin contract, making the sac smaller and wrinkling its skin.

• Increases in pulse and breathing rates, blood pressure and overall muscle tension are much the same as for women.

• Breast changes and skin flush are generally less than they are in women. During the plateau phase, erection of the penis becomes complete. The glans becomes deep purple and a tense ridge develops around its base. Semen collects in the seminal vesicles. The testes swell and are pulled closer to the perineum. The latter sign means that orgasm is imminent.

Orgasm in men, as in women, is a series of rhythmic contractions of the pubococcygeus muscles and the muscles in the walls of the internal reproductive organs. The big difference is that contraction in the seminal vesicles, prostate and urethra (resembling women’s uterine contractions) pushes the collected semen onwards and outwards. This is ejaculation. Semen is ejaculated as a series of spurts with enough force to carry it into the cervical canal or, if outside the vagina, as far as 50 cm from the tip of the penis.

I’m sure you all know how much and what you should and shouldn’t eat if you want to lose weight, but I’d like to make a few points.

• You can’t lose weight quickly. Fat accumulates slowly and steadily, and that’s the way it will go. If you lose weight rapidly by fasting, it will come back just as quickly.

• Fat can’t be rubbed, melted or pummelled off. There’s no way to lose it from any particular part of the body: the parts you want to reduce most (breasts, hips) are often the last to go.

• Don’t believe anyone who claims to be able to remove the dimpled fat they call ‘cellulite’. This is a normal type of fat.

• Fad diets and food replacement diets are a waste of effort and money. Most cause loss of body water but don’t decrease your fat stores. Some are dangerous.

• Appetite-suppressing drugs are risky at any time of life, but especially in adolescence. They’re habit-forming, cause side-effects, and any weight you lose comes back after you stop them.

• Snacking between meals is often the culprit. Most snack foods contain lots of kilojoules. I know it’s hard to break the snack habit, but it’s one of the best ways to start losing weight.

Two important decisions we must make when worried about our health are when to seek the help of a professional health-carer, and whom to consult.

Most of the time we have no doubts about when we need to consult a health professional. When the need arises, we all want to be sure that, for instance, someone with adequate knowledge and training prescribes our spectacles, fills our dental cavities, takes out our inflamed appendix and delivers our babies (though untrained taxi-drivers have been known to make quite a good job of the latter!).

Severe injuries or acute, very worrying symptoms prompt you to call the family doctor or hurry to the nearest hospital casualty or emergency medical service. Less severe symptoms will lead you to visit the family doctor or nearest medical clinic, dentist, optometrist and so on. Minor injuries and symptoms can often be treated from the home first-aid kit or with over-the-counter remedies, or with well-known, tried-and-proven measures such as applying ice-packs to a sprain and elevating the injured joint. It’s usually easy to tell when things aren’t improving as they should be and you need professional help.

Professional health care falls into two broad divisions: orthodox and alternative. Alternative therapies and health practices have become increasingly popular in the past few decades. You may want to consult an alternative health professional for some problems. This may be because you’ve had bad experiences with conventional medical services, or because you’ve tried orthodox practitioners without getting relief or satisfaction.

Orthodox health care

Orthodox health care is based on the sciences of anatomy, physiology, biochemistry, pharmacology, microbiology and pathology. Orthodox health professions include medicine, dentistry, nursing, audiology, dietetics and nutrition, occupational therapy, optometry, orthoptics, pharmacy, physiotherapy, podiatry, psychotherapy and speech pathology.

The practitioners of these professions are trained in government-approved tertiary education centres and must satisfy standards of knowledge and competence before being granted license to practice. Their professional behaviour is monitored within their profession and, to a certain extent, by State law.

Orthodox health care has been criticized for being too disease-orientated. This is a bit unfair, because until recently people only sought health care when something went wrong, so the training of practitioners focused mainly on health disorders.

The public image of the medical profession has taken a great dive during my lifetime. When I was a child, I got the impression that all doctors were kindly, caring, ‘clever’ (they made sick people better), and had wonderful bedside manners. They lived in nice houses and had jars of jelly beans on their desks. What a role model! No wonder I chose to study medicine.

By the time I entered practice, doctors were being accused of being authoritarian, judgemental, arrogant, poor listeners, poor communicators, careless of their patients’ feelings and time, and too interested in having the biggest house and flashest car in town. Today the complaints are louder than ever. What went wrong?

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