THE DISADVANTAGES OF HYSTERECTOMY

Although a safer procedure than, for example, removal of the appendix, hysterectomy is not without risk. For every 2000 abdominal hysterectomies performed, between one and four women die within a month of surgery (the variation in figures depends on which study is consulted). Death rates may be less for vaginal and laparoscopically assisted hysterectomies.

In addition, reports suggest that between 25 and 50% of all women who have a hysterectomy encounter one or more complications. In the case of abdominal hysterectomy, 1-3% of women experience a major complication such as significant post-operative bleeding, the formation of a blood clot in the lungs, or damage to the ureter, the bowel or the bladder, all of which may require further surgery. Vaginal prolapse and sexual problems may also occur with any type of hysterectomy because there is reduced support for the upper part of the vagina from other pelvic structures. To minimise this risk, the ligaments supporting the bladder, bowel and vagina are stitched together after the uterus is removed.

Other complications include infections of the surgical wound and urinary tract, weight gain, abdominal or back pain, constipation, fatigue and frequent urination. Some of these, for example urinary tract infections, usually clear quickly provided antibiotic therapy is administered promptly. In some women, however, they become a persistent source of unsettling symptoms requiring treatment. For Rita, the biggest surprise following her hysterectomy was the kilos she suddenly gained. An enthusiast for keeping in shape, she couldn’t understand why she had put on weight, given that she was just as careful about what she ate after her hysterectomy as before. ‘My doctor thought it might have something to do with changes in my sex hormones, but when I asked about hormone replacement therapy he said this might cause even more weight gain/ Rita embarked on a vigorous schedule of physical activity which, at last report, had helped her weight to plateau. She is not alone in experiencing this complication of hysterectomy. Some studies report that weight problems occur in nearly a quarter of women after the operation. It seems that women who want to maintain their weight at pre-hysterectomy levels need to be prepared to reduce their calorie intake somewhat in the two to six weeks after surgery in line with their reduced activity levels.

Psychological disturbances have been widely reported in women who have had hysterectomies, with depression, mood change, anxiety and irritability often cited. Other studies have, however, raised the possibility that it is not hysterectomy itself that triggers these disturbances. Rather, they may reflect psychological states which developed during the period of stress and ill-health preceding the operation.

For pre-menopausal women, hysterectomy may lead to an early menopause and distressing menopausal symptoms such as hot flushes and vaginal dryness if the ovaries are removed along with the uterus. This may also occur in women whose ovaries are saved, but less frequently, particularly if the surgeon who does the operation is skilful and experienced. An uncertain factor in all this is the state of the ovaries before surgery. It may be that women who resort to hysterectomy have a higher incidence of problems with their ovaries than women who do not, and that even if they were able to avoid surgery, their ovaries might not function particularly well. What can now be said with some certainty is that women who have had a hysterectomy are much more likely than average to embark on hormone therapy. The Melbourne Women’s Midlife Health Project, which questioned 2000 randomly selected women aged forty-five to fifty-five years, found that half the women who had both ovaries removed at the time of hysterectomy were on hormone therapy, as were a third who had a hysterectomy but retained their ovaries. In contrast about one in six women who had not had a hysterectomy was on hormone therapy. In a comparable group of US women, the rate was about the same in the surgical menopause group and significantly lower in the natural menopause group. Rates seem to vary widely across Western Europe, but there is not enough information to enable a valid comparison.

Other long-term complications, which stem in part from the early menopause that sometimes occurs after hysterectomy, are an increased risk of heart disease and of the bone thinning disorder, osteoporosis. In order to reduce these risks, as well as to resolve menopausal symptoms, hormone therapy containing oestrogen is often prescribed after a hysterectomy.

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SOLUTIONS TO INFERTILITY: PROTECTING YOURSELF AGAINST OCCUPATIONAL HAZARDS AT WORK

You or your partner may be in a job that regularly exposes you to hazards and you will need to think about whether the risk can be minimized or whether you may have to change your occupation.

For example, working with lead (used to make storage batteries), radiation, pesticides and solvents can be a problem. If you work in a dry cleaners or hairdressers you are likely to come into contact with many different chemicals.

Visual Display Units

Research on the risks of radiation from VDUs is still in its early stages. However, you can reduce the risk if you:

• Keep the time spent on the VDU to a minimum, with the most being four hours per day.

• Ask your employer if it’s possible to give you other, non-computer work for at least the first three months of pregnancy.

• Use houseplants to stop the air becoming too dry. (Some plants are able to absorb a certain amount of radiation and to act as air purifiers, according to a NASA space project, which showed that the plants could remove toxic substances like carbon monoxide from the air. The most beneficial plants are the tropical ones such as lady palm (Rhapis), bamboo, parlour palm (Chaemaedorea), ficus, peace lily (Spathiphyllum) and spider plants.)

Occupational Hazards for Your Partner

The male organs are on the outside of the body for a good reason. The testes need to be several degrees cooler than body temperature because sperm production can only take place at 32°C (89°F). And our normal body temperature is 37°C (98.4°F). Anything that brings the testes closer to the body, and so raises their temperature, may affect the sperm count. An increased temperature of only 1°C has been shown to decrease the sperm count by about 14 per cent.

A number of studies on drivers have found that men who spend more than three hours a day in a car or lorry are less fertile. When men drive they are not only sitting for a long time but are getting the vibrations from the vehicle. So they are literally ‘in the hot seat’.

The same research showed that men who are exposed to heat during their work are four times less likely to make their partner pregnant within three months. This might apply to a range of occupations – including anyone working with boilers or welding. One man I saw, who is a baker, was getting great blasts of heat directly on his genital area every time he opened an oven door.

What He Can Do

• Avoid crossing his legs when sitting down.

• Take regular breaks to move around.

• Avoid wearing tight trousers or underpants which constrict the testes.

• Avoid hot baths – he should shower instead.

• Shower his genitals with cold water to lower their temperature and improve circulation.

• Avoid using electric blankets – particularly once he is in bed.

Exercise

It is important to have a good level of physical activity because it improves heart function, controls cholesterol, reduces blood pressure, reduces excess weight and generally optimizes health. But it is also important to keep a balance and some sports may compromise male fertility.

If a man exercises excessively it can lower his sperm count. Long hours of training for a marathon, for instance, could therefore be a problem.

Very vigorous sports, like squash or running, may not be advisable because of the knocking effect of the testes against the thighs as the man runs.

Likewise tight-fitting nylon shorts, either worn on their own for running or under shorts in the gym, may contribute to male fertility problems.

Finally, men who regularly go for long bike trips, especially on a racing bike, may spend a lot of time bent over, bringing the testes quite close to the body and crushing them against the seat of the bike, causing overheating and constriction.

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EXPLAINING ENDOMETRIOSIS: PAIN MANAGEMENT

Pain is a message which tells us that a part of the body has been damaged or injured in some way. The message is transmitted by a network of nerves from the site of the damage or injury to the brain – where it is perceived as pain.

Pain is the dominant symptom for many women with endometriosis. Until recently, the management of pain was largely ignored by the medical profession, and even now there is little written about which pain management techniques are the most beneficial for the relief of the pain associated with endometriosis.

It is thought that much of the pain of endometriosis, especially that experienced during menstruation, occurs when the implants bleed on to the tissues surrounding them, causing inflammation and the release of chemicals known as prostaglandins which in turn causes pain.

The endometrial implants and cysts may also cause pain as they grow and swell during the second half of the menstrual cycle, particularly if they are embedded in the ovary.

Adhesions can cause pain because they pull and stretch the organs in the pelvic cavity into abnormal positions.

The rupture of an endometrioma may also cause pain because the spillage of its contents severely irritates the surrounding tissues, causing inflammation and the release of prostaglandins.

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REACTIONS TO THE MENOPAUSE

We all react differently to problems at any time in our lives; there is an old saying that at the menopause we are what we are only more so, but this really only describes our reaction to any change or phase in our lives. For example some women notice pain more than others. It also depends on what else is going on at the same time.

It is suggested that women who have interesting and fulfilled lives notice the menopause less, but I do not find this in our clinic. I have patients who say they cannot carry on their busy involved lives with their hot flushes and emotional disturbances. Among these are a top accountant, an opera singer, and an executive in a business organisation. Some women, on the other hand, cannot do housework because of their menopausal symptoms. It all depends on your make up. There is no need to feel ashamed or apologetic, and there is no sense in not seeking help.

You may find that generally tidying up your physical habits is all that is needed. It is well known that tension, excess weight and alcohol consumption, to mention just a few examples, all increase the severity of some symptoms. Maybe you can adjust this yourself. Some believe in natural foods and increases in vitamins; others in hormone replacement. Find a sympathetic doctor you can talk to. I feel that if you know the facts, you can sort it out with him or her and in any case will be more relaxed about approaching and experiencing this phase in your life.

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MENOPAUSE: OESTROGEN REPLACEMENT THERAPY

Treatment of uncomfortable intercourse is to my mind one of the most important uses for oestrogen replacement. Women must be given oestrogen replacement long-term after the menopause if they are having painful intercourse and discomfort so severe it cannot be relieved by other measures. These women, from then on, will only get drier and drier if the discomfort is due to oestrogen lack, and the process will not be reversed unless treatment is given. Marriages have been ruined and family life disrupted when this simple treatment has been withheld. There is no doubt that this symptom is interrelated with libido after the menopause, but as explained later, other factors are also important.

In all the discussion about increased desire, or loss of it, there are two main points, that libido is maintained by regular sexual activity, and that sexual activity actually keeps the vagina more flexible. There is no doubt that sexual activity within a relationship gives a new meaning to it, and in most instances it is well worth maintaining. It is a fact that in both men and women, regular sexual activity in later life not only improves the performance but also the desire.

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MENOPAUSAL SYMPTOMS AND HYSTERECTOMY AND OOPHORECTOMY

As I have said already, if the uterus is removed periods cease, but, if the ovaries are left, hormones are still produced and menopausal symptoms should not occur. However, in patients attending our clinics, and it is reported elsewhere as well, a large number of hysterectomised patients do have menopausal symptoms earlier than expected. This is thought to be due to the fact that the blood supply to the ovaries is interfered with, and they atrophy or shrink following operation.

Oestrogen replacement after oophorectomy Unless it is con-traindicated, oestrogen therapy should be given after an oophorectomy. It is routinely done in most cases, particularly with younger women. Oestrogen replacement should be continued at least until after the woman would have normally had her menopause in her fifties as this prevents thinning of the bones or osteoporosis (see chapter 5).

7 thought I could not become menopausal if I had had a hysterectomy’ This is a common statement. If ovaries are present menopause will, in many cases, occur at about the same age as you would have it normally. If ovaries are removed it follows soon after operation.

Hysterectomies do not affect your sex life at all. If ovarian production is also interfered with but the symptoms are removed with replacement therapy, this should not affect your sexual life either.

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DO YOU OR DON’T YOU REQUIRE TREATMENT WITH OESTROGENS?

This is up to you, and may depend on the severity of your symptoms. As far as I am concerned I am neither of the group that says ‘It is best for everyone’ nor am I against it. I prescribe oestrogens for those whom, after full examination, I feel it will benefit, and for whom I believe it is safe. Oestrogen therapy should not be refused, nor should women worry about taking it, but like any therapy it should be used with caution and administered in the safest possible way. After all, this applies to any therapy.

If you are in doubt If you have symptoms, try replacement therapy. You can stop at any time; you will know in a short time if the symptoms are relieved and you feel better for it.

What is the safest possible way?

The safest course of replacement therapy is the method outlined in the guidelines of our clinic. We see patients six to twelve months after they are stabilised on treatment, examining their blood pressure and their breasts and looking for any untoward side-effects. We give them a full examination and pelvic examination yearly, and we do a smear test yearly for two normal smears, then every alternate year.

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QUESTIONS AND ANSWERS:

SHOULD UNUSUAL BLEEDING BE REPORTED?

It is important to know about bleeding, when it is abnormal, and when to report to your doctor.

Heavy periods Around the menopause, women often experience heavy bleeding. This should not be ignored. In almost all cases it is due to hormonal changes, but, in a small number of cases, there may be something abnormal producing this, and a dilatation and curettage should be performed. This is not only for diagnosis, but is often curative.

Prolonged periods Any period that lasts longer than seven or eight days, or, if your periods are usually long, if there is a pronounced increase in length, should be reported.

Bleeding between periods This should be investigated; it may be due to a polyp or local build-up of tissues in the uterus or cervix, but it may be due to something more severe. It may also be due to oestrogen lack, due to an atrophic vagina, and in these cases it may also occur after intercourse. This should also be reported. Other bleeding that should be reported is bleeding that is more frequent, and bleeding that occurs twelve months after the last menstrual period.

Missed periods Although missed periods are very common during the menopause, you will probably want to consult your doctor to ensure you are not pregnant. If you are pregnant, and wish to carry on with the pregnancy, tests can be done to determine whether the baby has abnormalities. This should be considered as there is a relatively high degree of abnormality in babies of older women.

With oestrogen therapy, what bleeding should be reported?

1 Bleeding while the tablets are being taken unless progestogen tablets have been taken in the preceding week.

2 Any bleeding which is heavy or prolonged at any time, even if it is at an expected time, that is following progestogens.

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