Medsarticles. Medical Weblog

Helen’s story

After seven months on Duphaston I returned to my doctor and told her how miserable I felt and that I wanted to try some of the alternative treatments. She suggested laser surgery and referred me to a surgeon experienced in the procedure.

I was a little apprehensive after my interview with this surgeon for he rather casually mentioned dividing the utero-sacral ligament as a way of relieving pain. My initial reaction was distrust as I imagined that the uterus would be unsupported. However this isn’t so and he carefully described the procedure explaining that as there were a lot of nerve fibres in the ligament it would give me relief from the pain experienced every time the uterus contracted.

I went home and looked up all the books and articles I owned. I telephoned the Endometriosis Association and received all their latest information as well as the opinions of a few professionals. I then spent a day in the Health Department Library but didn’t find much material. It appeared that there was very little information available because very few surgeons were doing the procedure here in Australia. I hoped that maybe zapping off my spots of endometriosis was all that was necessary to relieve the pain.

I recontacted my original doctor and told her of my concerns and asked her to speak to the surgeon. She relayed the message that he would be conservative but couldn’t really be sure of the best treatment until the laparoscopy. This made sense to me and I decided to trust them.

I awoke from the anaesthetic to hear the good news that all the endometriosis seen had been removed with the argon laser and that one of my utero-sacral ligaments had been cut (a utero-sacral neurectomy). I would not need to follow this surgery up with drug treatment.

Two menstrual cycles were pain free. It is hard to describe the feeling of liberation when you realise that the quality of life you had previously experienced was so compromised.

I hasten to add that I am quite realistic about the nature of endometriosis and know this current euphoria can only be guaranteed for twelve months. But as I am only experiencing a slightly rotten day on the second day of my cycle it all seems worth it. Most importantly I am getting on with my life.

Cathy’s story

One of the most difficult decisions of my life was deciding whether or not to have a hysterectomy. I had been seeing a gynaecologist who was treating me with Duphaston which wasn’t working. I was in severe pain, had no control of my bladder and I had bowel problems. He seemed to think there was not much wrong with me. He had performed a laparotomy on me seven months previously and diagnosed and cleaned up mild endometriosis. He was now suggesting that my only option was Danazol — mainly, to calm me down, I think, as he didn’t feel the endometriosis could have grown back so quickly.

I felt upset and humiliated by his attitude towards me and I felt there must be other alternatives. I knew I was in trouble — I was living on Panadeine Forte every day. Sometimes I couldn’t pass urine and other times I couldn’t retain it. The pain became so severe I couldn’t even drive a car. My family was suffering terribly with me also — I was always irritable and unable to function. Taking Danazol as was suggested worried me as I have a severe allergy condition to the extent that my husband and I had to build a new chemical free house in the hills. I had suffered bad side effects with both Provera and Duphaston.

I decided to get a second opinion a month later. The next gynaecologist said that the disease can grow back quickly and be very aggressive. He said that laser therapy via a laparoscope can control the endometriosis if it was mild and perhaps no drugs would be needed. However, when he gave me a gentle examination he thought he could feel a large cyst and sent me off for an ultrasound which showed a large cyst of four centimetres plus.

I now had to have another laparotomy and lose the right ovary. Drugs would not work on an endometrioma of that size. As I was 37 years old and had two children and didn’t want any more, he suggested I think about having a hysterectomy as my side effects were so severe — by this stage I was also bleeding from the rectum. After two months of agony, both physical and mental (my husband listened patiently for hours and supported me — I felt a failure for needing a hysterectomy), I decided I wanted my life back. I could no longer function — I had given up my work, my study and my social life. I was trapped by endometriosis in all my waking hours and sometimes in my sleep — it never left my thoughts.

So, in July 1990,1 had a hysterectomy during which a bowel surgeon was also present and needed. My right ovary was stuck to the uterus and was enlarged to the size of a tennis ball with endometriosis. There were also other cysts and spots of endometriosis. As I had agreed to a hysterectomy, the surgeon was able to remove the ovary and cyst with the uterus, without spilling the contents of the cyst.

Since the operation I have been feeling significantly better and pain free. I can now enjoy my life again, my husband, my children, study and work. My sex life has also improved remarkably. I never knew one could have intercourse without pain — it is now a wonderful experience for me. I honestly believe I made the right decision to follow my instincts and seek a second opinion. My pain and my disease were very real and very debilitating.

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Endometriosis is the second most common gynaecological condition affecting women in their menstruating years and it is responsible for up to one-quarter of all the abdominal surgery performed by gynaecologists. It is also one of the leading causes of infertility in women over the age of 2 5 and it is thought to affect approximately 30% to 40% of infertile women. It is impossible to determine how common endometriosis is because some women do not have any symptoms and many women with the condition are undiagnosed. Gynaecologists believe that endometriosis probably affects approximately 10% to 15% of women at some stage during their menstruating years.

How does endometriosis develop-The full story of how endometriosis develops is not yet known. However, there are four main theories. Each theory explains how some, but not all, cases develop and it is likely that there is not one single cause of endometriosis, but rather a number.

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Vaginal spermicides (foams, jellies, creams, film)

These substances kill sperms on their way to meet an egg and must be put into the vagina before intercourse. They are unsafe as a sole method of contraception and should be used along with a sheath or a diaphragm. Follow the instructions for the brand you intend to use. Most are active for only 1-3 hours.

Advantages

• Easy to use.

• Can be bought without a prescription.

• Work well if used together with a barrier method.

Disadvantages

• Not reliable except when combined with a barrier method.

• Can be messy as they melt and run out of the vagina.

• Put some men off oral sex. If this is a problem insert the spermicide just before intercourse.

• May have medical side-effects.

Research shows that liver function is altered and blood pressure lowered in some women using spermicides. They are absorbed from the vagina, especially if left in place for long periods.

• You can’t bath or have a wash on a bidet for six hours after sex.

The cap (diaphragm)

This is a dome-shaped barrier made of latex rather like a sheath. It has to be used with a spermicide to be safe. It is a good method for many women but it has to be supplied by a doctor, who will measure the woman for the correct size. For best results it must be used properly.

Advantages

• It is cheap and easy to use.

• It is nearly as safe as the Pill.

• There are no medical or health side-effects.

• It can be used to hold back menstrual flow to make for more pleasant love-making during a period.

Disadvantages

• It is not suitable for the woman who dislikes handling her genitals.

• It interferes with sensation in some women, especially those who enjoy the front wall of their vagina (around the G-spot) being stimulated during intercourse.

• It has to be put in well before sex and this removes the spontaneity for many women who find such ‘premeditated’ preparation un-sexy.

• It is easy to forget that it is in place for a day or two.

• It has to be supplied by a trained person in the first place.

• It should ideally be checked every six months by a trained person to see that the fit has not changed. This is especially important soon after a baby.

• It is easy for small holes, invisible to the naked eye, to develop which render the barrier ineffective.

• It interferes with sensation in those men who like to feel their partner’s cervix hitting against the tip of the penis.

How to use it

Place 3 or 4 inches of spermicidal jelly on the inside of the cap and spread some around the rim too. Insert the cap in the way that you have been taught and do so well in advance of intercourse. If you don’t have sex within 3 hours use more spermicide in the vagina. Don’t remove the cap for at least six hours after intercourse. If you have sex more than once during this six hours use more spermicide without removing the cap.

Look after the cap well. Remove it gently after intercourse ensuring that you don’t damage the dome with your nails. Wash it with plain, warm water and leave it out to dry. Never use perfumed soap or detergent to wash it. Never use Vaseline or disinfectant or you will spoil it. Hold it up to a good light every month and look for obvious holes. If there is any sign of damage, get a new one. Never wear a cap for more than twenty-four hours without removing and washing it.

The sponge

This is a disc of spermicide-impregnated sponge that the woman places in the vagina before intercourse.

Advantages

• Fairly easy to use.

• A good, non-permanent, barrier method.

Disadvantages

• All the disadvantages of absorbing spermicides into the bloodstream.

• Must be left in place for six hours after intercourse.

• It has to be thrown away after a single use and so is expensive.

• It can be felt in the vagina by the man’s penis or fingers.

• It is rather unreliable (75-85 per cent effective only) and so is really only suitable for couples who want to space their children rather than those who want to be absolutely sure about fertility control.

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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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