Information on popular complementary and alternative medical topics

Complaints of pain from menstrual cramps were once considered a form of hysteria, not quite as counterfeit a condition as demonic possession, but close enough for disbelievers. The word hysteria is derived from the Greek word hystero, which means uterus. At one time, not long ago, it was common practice to ascribe metaphysical qualities to certain organs of the body, such as the heart representing love, the spleen connoting bad temper, and the uterus suggesting emotional problems.

Freud linked hysteria to sexual repression—a concept still revered by some medical doctors who mistakenly ascribe complaints of pain during a normal biological cycle to a woman’s month)y compulsion to deny her femininity and her sexuality. In fact, women in real pain from menstrual cramps may be assailed by far more than a few days of infirmity a month. They may be suffering from endometriosis and their cries for help arc being answered with outdated theories by physicians who do not understand the severity of their pain.

How do cramps occur and why do some women suffer from them over a lifetime while others never experience a single pang of monthly discomfort?

Physicians once pointed to a tight cervix as the probable and primary cause of menstrual cramps. They felt that this tightness obstructed the natural now of blood out of the body. The treatment for a tight cervix—nearly totally out of use today—was a stretching procedure, a so-called dilation of the cervix. A series of surgical rods of increasing diameters were inserted into the uterus through the cervix. This stretching by larger and larger rods was thought to ease the suffering from severe cramps. Unfortunately, when the stretching procedure was halted, the cervix either healed back to its original size or, as a result of the scar tissue created by the treatment, became even tighter? Clearly, cervical stretching was not the answer for relieving or curing menstrual cramps.

Today we are aware that a tightened cervix may be less a structural problem than a chemical one. Cervical tightening as well as menstrual cramps has been traced definitely to hormone levels, most specifically to a third hormone group involved in menstruation: prostaglandins. There is now an undisputed correlation between menstrual cramping and the presence of high levels of prostaglandins in the female body.

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I was diagnosed with severe and extensive endometriosis in January 1988.1 had two very large cysts, the size of melons, enveloping both ovaries and extensive adhesions throughout my pelvis. I have had numerous treatments since diagnosis. Following conservative surgery, including two laparotomies for removal of the original cysts and subsequent cysts, division of adhesions, numerous hormonal therapies, including Danazol and Duphaston, with all the side effects, I find I still have active endometriosis and complicating adhesions. Thus, I still have quite disabling pain at various times of the month.

After reading some literature on the use of transcutaneous electrical nerve stimulation (TENS) for dysmenorrhoea, I decided to speak to a physiotherapist friend and ask his opinion on the possibility of pain relief using the system.

He was unable to give me any specific help with regard to its use in endometriosis. However, he could not see any reason why in theory it should not work. I was given the name and address of a physiotherapist who could help and supply a unit for trial.

This physiotherapist was very positive and I hired the unit for a month’s trial, with a view to purchasing the unit. I was very sceptical as to whether this type of pain relief would work — I’m now sorry it took me so long to explore this avenue of pain relief!

From the very first time I used the TENS unit I received some relief — without the horrible feeling of being spaced out, which often occurs with analgesic drugs.

The TENS does not remove the pain completely but it does enable me to manage the pain more easily; it also enables me to lead a fairly active life, without having to pop pills all the time. During the first couple of months of using TENS I required it for the duration of my period but with continued use of the unit I now only need to use it for the first couple of days. It seems that with continued use, the effects of the unit builds up in the individual.

I only have one problem using TENS — a gel must be used on the electrodes to enable the electronic pulses to be conducted to the nerves and this gel can be a little messy. But it’s a small price to pay for such effective pain relief.

The cost of the unit was $230. Initially this might seem expensive but the resulting pain relief has made the cost well worthwhile.

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Because some of the symptoms of endometriosis such as pain and infertility can make the sufferer feel tired, miserable and out of control, women may also experience lethargy, malaise, depression, premenstrual syndrome (PMS), or insomnia.

Is endometriosis a progressive condition-No one really knows what happens to endometriosis if it is left untreated because there have been no comprehensive studies conducted to investigate this problem.

Most gynaecologists presume that endometriosis is usually a progressive condition. In other words, it is a condition which — if left untreated — progressively worsens in extent and severity for as long the woman menstruates.

The rate of progression is thought to vary. It is believed that in most women the rate of progression is fairly slow and that the disease gradually worsens over a period of years. In some women the rate of progression is thought to be so slow that their endometriosis does not progress significantly and so they have mild disease for many years. In contrast, it appears that in a few women the rate of progression is rapid and in some cases it may be so rapid that their endometriosis progresses from mild to severe in a matter of months. Some women seem to have spontaneous periods of remission.

It is impossible to predict the likely rate of progression in any particular woman.

Endometriosis recurs frequently following treatment and approximately 50% of women will have a recurrence of their symptoms, regardless of the type of treatment they undertake.

Unfortunately, some women will have a recurrence within months of their treatment as the rate of recurrence is highest in the first twelve months after treatment. Others will have several years of remission.

Women with severe disease or large endometriomas are more likely to have a recurrence of their endometriosis and their length of remission will usually be shorter.

It is not known if recurrences are due to the presence of residual implants and cysts that were not eradicated by the treatment or whether they are due to the deposition of new implants — or a combination of both these factors. According to one researcher, the higher recurrence rates that are seen in the first year following treatment and in women with severe disease would indicate that recurrences are more likely to be due to the growth of residual implants and cysts.

Occasionally, a recurrence of endometriosis may be experienced following menopause if hormone replacement therapy (HRT) is being used, but usually this recurrence can be controlled by altering the dosages used in the HRT.

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Since the egg can only survive for up to 24 hours and the sperm can live for seven days in alkaline mucus, there is only a short window of time each month in which you can conceive.

Some women only produce fertile mucus for a day or two a month so it is vital to know when it is happening. It is all too easy to have intercourse at the wrong time of the month or not frequently enough at the right time. Here’s how you can identify your crucial fertile period for yourself:

Warning

Note that you will not be able to use this test if you have thrush or some other vaginal discharge because it will not be possible to see the changes in your cervical mucus. Any such problems should be treated before you try for a baby.

•     After passing urine, blot your vaginal mucus with white toilet paper.

•     Lightly apply a finger to the mucus on the toilet paper and then pull gently away to test its ability to stretch.

•     If it feels slippery, like raw egg white, and can stretch between your thumb and first finger up to several inches before it breaks, then it is fertile mucus. If it is sticky or crumbly (a bit like ‘school glue’) then it is the more acid, infertile mucus. As the mucus changes to fertile mucus, this is a sign that ovulation is about to take place.

•     Meanwhile, your cervix is also changing. To feel these changes, empty your bladder and wash your hands. Then place your right index finger in your vagina until you can feel your cervix.

•     As your period ends, your cervix is located low in your vaginal canal and the opening is closed, giving the feeling of touching the tip of a nose or a small rubber ball. As ovulation approaches and oestrogen levels increase, the cervix moves higher into the vaginal opening, making it more difficult to reach. It also begins to soften and opens, resembling parted lips. This opening and rising helps the sperm to travel into the womb. After ovulation, the cervix lowers again and closes and is blocked with mucus to stop sperm entering.

The best way to take advantage of this window of time is to have intercourse on the first day when you feel wet vaginally and notice that the discharge is stretchy. Intercourse should continue every other day while the mucus stays wet and stretchy. Taking a break of 48 hours between intercourses allows time to maximize sperm volume. This is very important.

However, it is also important that this method or the use of ovulation kits (described below) does not take over your lives. For example, I know of a man who was phoned at work by his wife because she had found fertile mucus and wanted him to come home straight away! In situations like this, spontaneity can be lost, the man can feel that he is just viewed as a breeding stud, and both partners can lose the enjoyment of love-making.

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What is a carrier?

The body’s immune system doesn’t always completely eliminate HBV: 5 per cent of infected adults still carry the virus in their blood six months after they first became ill, even though all symptoms have cleared up. These people are called hepatitis В carriers, and can pass on the infection to others. Half of them will get rid of the virus and become non-infectious over the next two years. The rest remain infected (and infectious) and are at risk of developing complications such as chronic liver disease, cirrhosis and cancer of the liver later in life. A person may become a carrier without having developed symptoms after becoming infected.

How common is hepatitis B?

It is estimated that, worldwide, there are around 300 million carriers of HBV. It is mainly the carriers, especially those who don’t know they’ve ever been infected, who keep spreading hepatitis B. The number of people infected by HBV varies in different parts of the world. The prevalence of hepatitis В also varies between different population groups within a country. In Australia, chronic carriers of the infection are most commonly found among homosexual men, intravenous drug users, Aborigines and migrants from Southeast Asia.

How is hepatitis В diagnosed?

Present and past infection and the carrier state can be diagnosed by a simple blood test that may be performed on request by any doctor, public hospital or sexual health clinic for anyone who thinks they may have ever been at risk.

If you develop jaundice and the other typical symptoms of hepatitis, you will be offered a test for hepatitis В along with other blood tests to try to find the cause of the symptoms and to see how much your liver function has been disturbed. You’ll be advised to have further blood tests after the jaundice has faded and until liver function is normal again, and, if your hepatitis is caused by HBV, to see whether you’ve become immune or a carrier.

The blood tests are very reliable. The diagnosis is only likely to be missed if hepatitis В causes mild symptoms or none.

How can hepatitis В be prevented? Spread can be prevented by avoiding contact with body fluids of infected persons or carriers, particularly blood and sexual secretions. Good hygiene and staying with one sexual partner make wise precautions.

Sexual and other close contacts of people with hepatitis В should ask their doctor whether they need a vaccination for post-exposure or for permanent immunity.

If babies are exposed to HBV at birth, treatment can be given to help prevent them from becoming carriers.

Hepatitis В vaccination

Vaccination to give permanent immunity against hepatitis В is now available: three injections, two a month apart and the third six months later. It is advisable for all sexual and close contacts of carriers and for sex workers, health workers and others at risk of contact with other people’s body fluids.

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To understand incontinence we must know something of the normal control of urination. The bladder is a muscular t that drains to the outside through the urethra. Urine produced by the kidneys flows through the ureters into the bladder, where it is stored. Urine only escapes when pressure inside the bladder is greater than the pressure that keeps the urethra closed. Most of the time the urethra is compressed and kept closed by its sphincter and the pelvic-floor muscles that support it. A sphincter is a muscular cuff that acts like a rubber band or valve when it’s contracted to close off the tubular organ it surrounds.

When the amount of urine in the bladder reaches about 400 ml (though the amount varies from person to person and in certain circumstances), its muscle wall begins to stretch. Nerve endings in the muscle tell you that your bladder’s full and you feel the urge to pass urine. In childhood you slowly learn to consciously control this urge until it’s convenient to urinate. When you feel you want to go but must wait a while, your sphincter muscle and the pelvic-floor muscles tighten their hold around the urethra to help you hold on.

When you decide that it’s the right time to empty your bladder (which is usually when you’re seated on the toilet), you consciously release control and a series of muscle activities begins:

• the muscles that keep the urethra closed relax

• the muscles in the bladder wall contract so that urine is pushed out through the urethra

• when all the urine is passed, the pelvic-floor and sphincter muscles contract to close the bladder outlet.

The most common causes of incontinence in women are things that upset the balance or strength of the muscles that keep the bladder outlet closed, and the muscles that cause the bladder to empty. The two types that commonly affect women are stress incontinence and urge incontinence, or a combination of both.

Incontinence can also result from anything that affects the nerves controlling urination such as spinal injury and some other nerve disorders such as strokes, multiple sclerosis and Parkinson’s disease.

Myra’s story

Myra is 55 years of age. During a recent routine checkup, she mentioned that she had put on more weight than she liked since her menopause at the age of 51 years. ‘I suppose it’s because I’ve had to give up my tennis,’ she said. Knowing that she was a good player who really enjoyed a game with her friends, I asked ‘Why?’. ‘Oh, bladder problems,’ replied Myra, blushing. ‘I’ve had a bit of a weakness for ages, but until I was about 50 I could control it pretty well. In the last few years it’s really got the better of me. Now, every time I serve or run for a return, I wet my pants. It’s so embarrassing. I’ve heard about the operations but I’d prefer not to have surgery, so I guess I’ll just have to put up with it.’

Myra’s story is like that of many women who suffer some pelvic-floor damage during childbirth but don’t develop troublesome symptoms until after the menopause. If she had been doing pelvic-floor exercises since her first baby was born, it’s unlikely that she’d have had these problems. She commenced pelvic-floor exercises the next day and decided to start hormone replacement therapy. Three months later she was playing tennis twice each week without fear of accidents, and had lost 4 kg.

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There are two types: ‘simple’ hirsutism and hirsutism with virilisation (obvious evidence of masculinisation).

‘Simple’ hirsutism

This is growth of varying amounts of terminal hair on ‘male’ sites in women who] have no other signs of masculinisation. One or many sites may be affected, beginning around puberty.

Why does simple hirsutism occur in some women and not in others if all women produce some male hormones after puberty? Many factors may be responsible, including how much male hormone is produced, how it is circulated and used in the body, and increased sensitivity to androgens of the hair follicles id the sites affected. All of these factors ten to be controlled by our genes, which explains why the tendency to simple hirsutism runs in some families and races. It is
common in southern Mediterranean and Middle Eastern women, variable in Caucasians and rare in Asian women.

Hirsutism with virilisation

This is always associated with an excess of male hormones. The onset may be before (rarely), during or after puberty. Male-pattern hair growth is usually much more pronounced than in simple hirsutism (but a diamond-shaped or ‘male’ pattern of pubic hair growth is normal for many women and is not regarded as a sign of virilisation). Other symptoms and signs of virilisation include missed or scanty periods, subfertility, acne, deepening of the voice, altered body shape and increased masculinity, shrinkage of the breasts, male-type baldness and an enlarged clitoris. The excess hormone may come from overactivity or hormone-producing tumours of the ovaries, adrenal glands or pituitary gland, or from drugs (mainly anabolic steroids and the anticonvulsant phenytoin; less commonly synthetic progestogens with masculinising properties; rarely corticosteroids).

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The premenstrual syndrome describes a wide range of symptoms that trouble some women from one to ten days before menstruation. The symptoms vary from woman to woman and also in the same woman from one cycle to the next.

The most common symptoms are abdominal bloating, breast enlargement and tenderness, and mood changes. Other physical symptoms include fluid retention leading to weight gain and swelling of the feet, ankles and hands; skin disorders; hot flushes; headache; pelvic discomfort; backache; changes in bowel habit (often constipation); bladder irritability.

Nervous symptoms are often called premenstrual tension (PMT) and include irritability, aggression, anxiety, depression tearfulness, lethargy, insomnia, change in appetite, food cravings, thirst, change in libido, loss of concentration, and co-ordination leading to clumsiness and increased risk of accidents.

Even a single symptom can be distressing. Sore breasts can disturb walking running and can affect your game at sp they can hurt when you play the piano o| violin and when you brush your hair; can make you flinch when your toddler jumps onto your lap and when your partner embraces you. Mood changes make you respond to people and situations in a way that’s just not ‘you’ and that you’ll feel regretful or ashamed about, and it’s no comfort to blame PMS when you’ve offended someone. What is responsible for these unwanted changes in your body and mind?

Still a mystery

Many questions about PMS remain unanswered. What causes it? Why do some women suffer regularly while others notice symptoms only sometimes or never? How can it be treated? Since PMS first described in 1931, researchers have been trying to answer these questions.

After 60 years we’re not much wiser. The results of research have been mixed and conflicting.

Is PMS a real disease?

All women who have ever experienced any premenstrual changes (and is there anyone among us who has never noticed a few facial spots, some different breast sensations, or a tendency to drop plates?) know that their symptoms are real. But because there is no precise definition of PMS, and because it is rarely associated with changes that can be seen or measured, doctors have often been baffled and disconcerted when women consult them about premenstrual symptoms. The disorder has often been put in the ‘too hard’ basket: doctors are inclined to dismiss and ignore things they can’t understand. Women have often felt that their very real symptoms have been discounted or belittled.

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Long-term lack of oestrogen leads to changes in many systems of the body that make them more liable to degeneration and disease. After the age of about 60, most women who don’t have hormone replacement will have some signs of health deterioration due to a lack of oestrogen, though the degree of disability varies greatly.

Muscular aches, weakness and stiffness may be due to reduced muscle tone and joint ageing, which are accelerated without oestrogen. Osteoporosis can lead to crush fractures of spinal vertebrae resulting in dowager’s hump and increased risk of other fractures, especially of the hip and wrist. Deterioration in the cardiovascular system can lead to angina and heart attack.

Some symptoms that start around the menopause become worse with the years. Dryness and thinning of the vaginal lining and genital skin are progressive and sex may become painful or impossible.

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Since it was introduced early this century modern antenatal care has made a huge contribution to the health of mothers babies. Australia was one among the first countries to provide antenatal services. Few Australians today will have heard of any woman who has died as a result; pregnancy or childbirth, largely thank antenatal care plus improved management of labour, the availability of blood transfusion and antibiotics, and bet social conditions that ensure healthier pregnant women.

There are two broad divisions of antenatal care: education and pregnancy supervision.

Education

Today most maternity and district hospitals provide many opportunities for you to get the best out of pregnancy: talk, films and question sessions for parents; nutritional advice; tips on how to relieve pregnancy symptoms; exercise classes; preparation for childbirth; breastfeeding know-how; baby-care information. Most women attend as many sessions as they can during the first pregnancy, and just the exercise classes for subsequent pregnancies.

If you live in a remote area you may have to rely more on reading to learn how to look after yourself during pregnancy and prepare for delivery, with occasional visits to antenatal classes.

Pregnancy supervision

The purpose of pregnancy supervision is to discover any problems so that they can be corrected if and as soon as possible. Not every problem is preventable or treatable, but early detection usually improves the outcome for mother and baby. For most of this century pregnancy supervision has been provided mainly by doctors, though today you’re more likely to meet a team that also includes mid-wives, physiotherapists and nutritionists, as well as the many experts who perform the routine and other tests that have become part of pregnancy supervision.

Which doctor?

Most women see the family doctor for confirmation of pregnancy. If you live in the country, your doctor is likely to supervise your pregnancy and deliver your baby. If you live in the city, you’re likely to be referred to a hospital or a private obstetrician for antenatal care and delivery: few city GPs deliver babies these days. You can also go directly to a public hospital antenatal clinic for confirmation of pregnancy and antenatal care. You don’t need a referral, but it’s a good idea to ring for an appointment.

It’s very important that you feel happy with your doctor and other antenatal attendants. You must have faith in their competence, feel at ease with them and be able to ask questions freely. If you’re not satisfied, find someone else.

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