The study also found much lower rates of adverse effects of hysterectomy than expected. Earlier studies had reported problems with passing urine in 20-30% of women after hysterectomy, but the Maine study found this occurred in only 4%. Other studies have reported diminished sexual function in 15-30%, but although 7% of the Maine women reported being bothered by less interest in sex after their hysterectomy, only 1% reported less enjoyment of sexual activity, and the majority reported increased interest in, and enjoyment of, sex. Persistence of pelvic pain after hysterectomy has been reported to occur in 22% of women, but in Maine the figure was 5%. Importantly, 82% of women in the Maine study felt they had a choice about having the hysterectomy and, for most, six or more months elapsed between the decision to have surgery and the actual operation.

As a check on possible biases that might explain these sorts of findings, the Maine study authors looked at eligible patients who were not referred by their doctors to participate in the trial. They found that patients not in the study were more likely to feel that they had no choice about having a hysterectomy, and their mental health assessments were less positive than those of the women who had participated. It is possible that doctors selectively referred patients to the trial who were more involved in the treatment strategy and in a better state of mental health. It is also possible that improvements in surgical techniques and post-operative care are responsible for the more positive results that seem to be occurring. In the light of these uncertainties, the authors recommended that their study be repeated in other parts of the US.

Recent Australian research on the outcomes of hysterectomy has also found high levels of satisfaction among women having the operation, although this was tempered by the belief that some new symptoms had arisen which were caused by the surgery itself. Research by an Australian team from the University of Newcastle and Macquarie University, published in the British Journal of Obstetrics and Gynaecology in 1991, asked women who had had a hysterectomy between two and ten years earlier to describe the impact of their experience. Of 175 women interviewed, 97% said the hysterectomy was worth the trouble and 88% said they would recommend a hysterectomy to others with similar problems, given their experience of it. The single most important benefit for 32% of the women was relief from heavy periods; for 25% it was relief from pain or painful periods; and for 4% it was improved emotional well-being.

An earlier Australian study, in which over 800 women who had had a hysterectomy (abdominal or vaginal) in New South Wales in 1976 or 1977 responded to a questionnaire, found that only about half were enthusiastic or very pleased that they had undergone the procedure. About 11% were not satisfied with the outcome of the operation and almost 12% complained of poor doctor or nurse communication. Post-operative recovery was frequently longer than expected, with 70% requiring up to three months for a return to normal activities and 16% more than six months. One impact that favourably impressed many women was sexual function, one-third indicating that this had improved after hysterectomy, while 3% reported a deterioration.

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Aluminum has been linked to dementia because it has been found in patches of cell damage in the brains of people with Alzheimer’s. The results are not conclusive but we should perhaps be wary of it anyway.

The main sources of aluminum are indigestion tablets (antacids), deodorants and anti-perspirants, anti-caking agents found in some dried milk, aluminum cookware, soft drink cans and foil. High levels of aluminum can be seen from the analysis of a hair sample.

What You Can Do

• Buy aluminum-free deodorants at health food shops, where the ingredients will be listed on the containers.

• If you are taking indigestion tablets, have the cause of the problem investigated either medically or with a good nutritional therapist.

• Get rid of all your aluminum pans and buy cast iron, enamel, glass and stainless steel. (People used to cook rhubarb (a very acidic fruit) in an aluminum pan to ‘clean’ up the pan, which it did very nicely, as the aluminum was neatly absorbed into the rhubarb.)

•The same applies to acid drinks like colas in aluminum cans. They should be avoided for a number of reasons, including the leaching of aluminum into the drink.

Cadmium

This is an inorganic poison present in tobacco smoke and is a well-known mutagen. It interferes with your zinc levels which are crucial for both male and female fertility. The main answer is for both of you to stop smoking.

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Who is suitable for combined treatment?

Combined treatment is sometimes used for women with the more severe forms of endometriosis in association with a conservative laparotomy though it may also be used in combination with a hysterectomy. Laparoscopic surgery is often followed by a course of hormonal treatment regardless of the severity of the condition.

What does combined treatment involve?

Gynecologists vary in the way that they use combined treatment. Some believe that the hormonal treatment is best used before surgery and some believe that it is best used after surgery, while others believe that it can be used both before and after surgery.

Those who recommend that the hormonal treatment be taken before surgery believe that it makes the surgery easier to perform by reducing the size and number of the implants that need to be removed and makes them easier to remove. They also believe that it reduces the development of adhesions following surgery.

The practice of using the hormonal therapy after surgery is based on the thinking that surgery can only remove those implants which are visible and accessible. The hormonal therapy is used to eradicate any implants remaining after surgery, including any microscopic implants.

If the hormonal therapy is used before surgery, two to six months of treatment is usually prescribed, whereas if it is used after surgery up to nine months of treatment is generally used.

Effectiveness of combined treatment

There are few statistics on the benefits of combined treatment. Many gynecologists believe that combined treatment is probably more effective than hormonal or surgical treatment alone.

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In a survey at the Prince Henry’s Hospital clinic, 91 per cent of women complained of hot flushes, and gave them as a reason for attending the clinic. Even women who do not experience these find themselves reacting more to heat than they did before. Women in all kinds of work describe the difficulty of coping with flushes during their working day. They are obvious to other people; the neck and face become red; and they are known to be aggravated by stressful situations. Others describe a more severe phenomenon of underlying weakness following the flush; they feel quite exhausted. Hot flushes may occur hourly, by day or night, or they may be occasional.

What causes them?

The actual mechanism that causes hot flushes is not known in detail, but they are known to be aggravated by heat, alcohol, obesity, caffeine and hot, spicy foods and stressful situations.

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On the positive side, with no fear of pregnancy, more time on their hands and lack of distraction from constantly present young, libido may increase and sexual experience may have a widening place in people’s lives.

As people grow older, with increased business cares and tiredness, there may be a decrease in sexual activity. On the other hand, some people, in a frantic attempt to relive their youth before it is entirely lost, look elsewhere and, in some cases, take off permanently with a younger partner. To be aware of this is an important factor in managing this time of your life.

However, in the vast majority of people that I see, both partners want the company of people of their own age group, who are alert and in good health.

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Before the menopause, oestrogen acts on the lining of the uterus (the endometrium), causing it to build up to form a bed for the fertilised egg. If fertilisation does not occur another hormone (progesterone) causes shedding of this lining and thus a monthly period is produced.

Later, if oestrogen is administered continuously without a break, or without added progestogen (which causes a shedding of the uterine lining) the endometrium builds up further and further and may give rise to endometrial hyperplasia. This in some women may go on to form cancer. However, if oestrogen is given with progestogen, shedding of the endometrium occurs regularly and it does not proceed on to hyperplasia.

Work has now been done which shows that if progestogen is given for 10-14 days each month with the oestrogen therapy then the incidence of hyperplasia and cancer of the lining of the uterus comes back to less than that in the normal community. That is if oestrogen is to be given safely then progestogen must be given with it.

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They are usually lighter than in earlier years, particularly after the first period or clearing out. It varies very much from woman to woman, and the quantity of flow is related to age and the dose of oestrogen. The closer to your last periods, the heavier they usually are, but as you age the lining of your uterus reacts less to the oestrogen stimulation, and no period may occur at all. Progestogen must still be taken monthly.

Is there any premenstrual tension with progestogen?

This occurs in some patients but is not common and often settles with repeated doses. There are three progestogens used commonly, and one may suit one person better than the other in some instances. Simply try the other progestogens and fit whichever one suits you into your programme. You had to organize yourself with your hormones in your youth, and it is necessary to do so now if you want the benefits of oestrogen therapy. Progestogen is necessary in the programme of treatment.

Do these periods mean I can get pregnant?

The periods are purely a local effect due to a cleaning out of the lining of the uterus. They do not mean you are producing eggs and can become pregnant, provided you have had no periods for twelve months before starting treatment.

Is oestrogen replacement sometimes necessary before periods cease?

If true menopausal symptoms exist, then your oestrogen production may have decreased, particularly if your periods are more scanty and are longer spaced. Your symptoms may then be relieved by oestrogen therapy. This of course would never be given if bleeding was heavier or more frequent, as it would only aggravate this and might produce undesirable changes in the lining of the uterus.

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Fibroids are innocent tumours comprised of fibrous and muscular tissue; they are common, and cause heavy periods. They can produce pressure symptoms, if large enough, by pressing on adjacent organs such as the bladder. Bleeding and pressure symptoms are the reasons for their removal.

What is dilatation and curettage?

It is the usual method, in Australia, of examining the lining of the uterus. You will be in hospital, and the procedure will be carried out under a general anaesthetic. An instrument is introduced into the uterus and the lining scraped to remove any abnormal build-up. The build-up is then sent to a pathologist for diagnosis. Vabro curettage is another method used. This is done without an anaesthetic and without admission to hospital. An instrument is inserted into the uterus and cells from the lining are sucked out and examined.

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