• Oestrogen is effective in relieving hot flushes and night sweats, vaginal dryness and some urinary symptoms.

• Hormone therapy is particularly helpful to women who have had a premature menopause, whether it has been natural, or medically or surgically induced. They are likely to benefit most from it because they tend to suffer more extreme symptoms of menopause and are at an increased risk of osteoporosis and diseases of the heart and blood vessels, and because in many cases they no longer have a uterus and so the hormone therapy tends to be simpler (oestrogen only is usually prescribed, but sometimes progestogen or testosterone are added).

There is some evidence that oestrogen used on its own may offer protection against heart and blood vessel disease. This benefit is heightened for women who have had an early menopause. The decision about which hormone preparation is suitable for women who have not had a hysterectomy depends on the balance between several potential benefits and hazards. There are gaps in information on both sides that research will start to fill during the rest of this decade.

In deciding whether to undertake hormone therapy for prolonged periods in the absence of worrisome symptoms, women should take account of both the anticipated benefits and the possible risks. One of the benefits of oestrogen use is that it postpones bone thinning and reduces the likelihood of heart disease. When combined with a progestogen, there are still significant benefits for bones, but progestogen appears to negate some of the protective effect that oestrogen has on the heart and blood vessel system. In regard to the risks, the biggest concerns lie with cancers of the breast and endometrium. Breast cancer is the most common cancer of the reproductive organs and the one most feared by women, so consideration of the link between oestrogen and breast cancer is sometimes tremendously important in helping women decide about hormone therapy. If, for a particular woman, the avoidance of an increased cancer risk is more important than the benefit in terms of osteoporosis or cardiovascular disease, this is clearly the basis on which her treatment should be decided. In making a decision, it is important that women take account of their family history of breast cancer, strokes, heart disease and osteoporosis and that they try to identify the cause of death of all close female relatives.

For many women, drawbacks to combined oestrogen and progestogen include withdrawal bleeding, breakthrough bleeding and PMS-like side-effects, and the possibility that hormone therapy may increase the risk of breast cancer, especially in women with a family history of this cancer. For women who use oestrogen on its own and who still have a uterus, an important consideration is the need for regular and extended monitoring to detect any early changes suggestive of cancer of the uterus.

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This could be a one-off situation where the mother has caught a severe infection during the early part of pregnancy and it is unlikely to recur in a subsequent pregnancy. Or the miscarriage could be due to a genito-urinary infection which needs to be treated before conceiving again to prevent another miscarriage. Mr. Ronnie Lamont, consultant obstetrician and gynecologist at Northwick Park Hospital, believes that bacterial vaginosis may trigger miscarriage or premature birth. A study he conducted with 800 women found that those with bacterial vaginosis had five times the risk of late miscarriage (16-24 weeks), and those who delivered early (24-37 weeks) also had the infection.

Some infections do not cause a miscarriage but a congenital abnormality (where the baby is born with a defect or malformation). For example, German measles (rubella), contracted in early pregnancy, can lead to babies born with congenital blindness, deafness and mental retardation. A simple blood test can tell you whether you are rubella immune, meaning that you have had German measles or have been vaccinated in the past and so have rubella antibodies in your blood to prevent you from getting it again.

Fertility Drugs

One of the most commonly prescribed medicines for fertility problems is clomiphene citrate which is used to induce ovulation. Ironically, though it may increase a woman’s chances of conceiving, it also increases the chance of a miscarriage by 20-30 per cent. It is thought that the clomiphene can interfere with the womb lining, preventing the fertilised egg from implanting. Other techniques used to induce ovulation, like gonadotrophin treatment, can also increase the miscarriage rate.

Weight Problems

It is important not to be underweight or overweight when trying to conceive. Girls don’t begin to menstruate until their bodies are composed of at least 17 per cent fat. Studies have shown that 50 per cent of women who have a Body Mass Index (BMI) below 20.7 are infertile. A BMI of approximately 23-24 would be ideal for conception.

Women with anorexia and girls who exercise to the extreme (such as athletes and gymnasts) can lose their menstrual cycle because of the reduction of fat and therefore become technically infertile temporarily.

At the other extreme, it is known that obesity increases the risk of miscarriage.

Problems with excess weight can also be linked with polycystic ovaries (PCO) which can make conception more difficult. Miscarriages are more likely to occur in women with this condition. However, in a study of women with PCO “who were asked to change their diet, the rate of miscarriages dropped from 75 per cent to 18 per cent for the same women once they had lost weight.

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Starting from scratch to find a specialist that will suit both your needs and expectations is not easy. Where do you start?

It is best to shop around by talking to friends and relatives – in particular those who have either been diagnosed as having endometriosis or those who suffer from menstrual problems. These women are more likely to have had previous contact with a specialist and can perhaps make recommendations for you. Think about whether you are likely to feel more comfortable with a female or a male specialist.

Once you have decided on a doctor you would like to consult, you need to visit your GP to obtain a referral. It is helpful if your GP is familiar with the specialist you plan to visit as the pair should be in constant communication about your treatment and progress over the coming months.

There are several points to consider when choosing the doctor who will manage your illness and its treatment and help you plan for the future. However, there is no such thing as the perfect doctor – or the perfect patient – so the material in this chapter is merely a guide.

What to look for

You and the specialist you select will be working together to improve your health and well-being, so it is important you feel comfortable and can talk openly. At your first visit, ask yourself the following questions:

•    Does the doctor appear interested in me as an individual and show concern with my general well-being?

•    Does she or he communicate and explain in a way I can understand?

•    Are all my problems taken seriously or do I feel patronized?

•    Has the doctor explained all the options of diagnosis, treatment, etc. thoroughly so that I understand?

•     Does the doctor encourage questions and then answer them completely and in easily understood language?

•     Has further reading been suggested, along with the names of self-help groups for further education and support?

•     Does the doctor show sympathy and understanding and provide some genuine comfort.

It is important to remember that your doctor should let you talk freely and should listen closely to your concerns. It is not unreasonable to expect your doctor to spend some time explaining and talking over concerns and problems with you. After all, you need to develop a relationship where you can feel confident in the doctor’s skills and where mutual respect exists.

There should be enough time during the appointment for you to ask questions. Do not feel intimidated. You may feel the doctor is rushing you and that your time is up but if you have questions you want answered and concerns that need to be cleared up, and then you have every right to continue the consultation.

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What we are about to say now will probably seem crazy to you right now, but someday you too will recognize that there has been a silver lining to this experience. Most of us truly believe that the most precious benefit of this entire ordeal is the relationships we have developed with the other women whom we have met. The community of women who have had breast cancer is enormous and remarkable. You now have friends, sisters beyond number, and each is waiting to help in any way she can. We mean it sincerely when we tell each other “Call me anytime.”

You have been through a lot already; you have found the strength you needed to confront difficult moments: mammograms, biopsies, X-rays, bone scans, and blood tests, and certainly the phone call from hell. You may feel devastated; you feel you can’t deal with one more decision; you may feel as though you want to snuggle under the covers and sleep so that you won’t have to address all the overwhelming questions that crowd into your mind. This is all normal and common. Of course you know that you will have to make decisions and choices; remember that it is okay not to like any of this. No one would choose to be in this predicament; none of us voluntarily made that choice, either. We are all reluctant, if not rebellious, members of a sorority we never wanted to join.

As you have already discovered, the time around the initial diagnosis is very difficult, painful, and stressful. You should know that you are at a very bad time emotionally; you may have heard from your doctors that this is the very worst time. Believe it. Once you have made the necessary decisions and once you have begun treatment, you will feel more settled, more in control. We are not suggesting that you will feel happy or carefree, not at all. But we are suggesting that you will experience some measure of relief. Before you arrive at this point, you will need to do your homework. It is very important that you make informed decisions about your treatment. Remember, it is your body and it is your life.

These first days are harder than anything yet to come. We know you don’t believe this now, but you will look back and see that this is true. Right now, however, it is normal to feel that your life is over, that your life is out of control, and even, perhaps, that you are crazy. Many women report, during the inevitable sleepless nights, that they are lying awake planning their funerals. Some of us stop eating. Some of us eat continuously. Most of us cry a lot. You will be impatient and short-tempered. You may either tell everyone you meet about your diagnosis, including the cashier in the market and the UPS deliveryman, or you may tell almost no one.

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However, there may be hints that something is amiss in the pelvis. The severity of symptoms will vary according to the site and degree of endometriosis, but it is not always the women with the most endometriotic tissue that end up with the most symptoms. Sometimes women with quite extensive disease will have few symptoms, and vice-versa.

The classic symptom of endometriosis is pain. This is usually in the lower abdomen and is generally related to the menstrual cycle. Severe period pain (dysmenorrhoea), particularly in someone who has not had this problem when younger, may give a clue that endometriosis may have developed. Pain during sex (dyspareunia) is another typical symptom. Doctors classify dyspareunia as being ‘superficial’ or ‘deep’. Deep, meaning felt in the pelvis rather than at the vagina, is the type of dyspareunia typical of endometriosis. It may be intermittent, or only in some positions.

The pain probably relates to the tethering of the uterus and ovaries by endometriotic tissue and scarring, and the swelling and activity of the tissue in response to the normal circulating hormones.

If the endometriosis is on or near other organs in the pelvis it may produce other changes. Needing to wee more often around the time of the period every cycle, and sometimes pain on passing wee may happen if the bladder is involved. These are also symptoms of bladder infection. If endometriosis is the cause the symptoms will tend to recur each period. If it is due to infection a urine test can diagnose this.

The bowel also lives in the pelvis, and can be affected. It may be that a woman notices looser, more frequent bowel actions around the time of her period, or possibly gets constipated. Just to confuse the issue (more), many women do get bowel changes cyclically from a cause other than endometriosis.

It is thought that the increase in some of the hormonal messengers (prostaglandins in this instance) in the pelvis around the time of the period may be responsible. If a woman has endometriosis affecting her bowel (which is rare), she may have pain on passing poo, or notice blood in the bowel action.

Less often, actually incredibly rarely, endometriosis can give rise to very unusual symptoms. If the endometriotic tissue is in distant places, like the nose, brain, lung or liver, the woman may have weird cyclical symptoms. It is thought that the endometriotic cells can travel in the blood or lymph systems to get to more uncharacteristic locations, but this is very uncommon.

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There are some conditions which may be inherited, and early testing may identify affected pregnancies. Some inherited conditions affect only one sex, so testing to identify the sex of the foetus may be offered.

The particular condition, and the need for testing in an individual or couple, is usually discussed when the medical and family history is discussed with the doctor at the first visit.

There are tests available which can check specifically for chromosomal abnormalities and spina bifida, as well as for some rarer conditions. The two most commonly offered are chorionic villus sampling and amniocentesis.

Chorionic villus sampling (CVS). This test is usually performed at between nine and twelve weeks gestation. It involves identifying the developing placenta with ultrasound, and taking a tiny sample of it to check the chromosomes. (The chorionic villi are embryonic tissue which form part of the placenta.)

The technique may be performed by inserting a very fine needle either through the woman’s abdominal wall (using local anaesthetic), or via a fine probe inserted into the vagina and through the cervix. The procedure is done by experienced doctors, under vision with ultrasound, and only takes a few minutes.

The results of this test, which gives information about chromosomal abnormalities, the sex of the foetus, but not about spina bifida, are usually available to the doctor who ordered the test within three weeks or so. Depending on the result of the test, a woman may decide to terminate the pregnancy, and this procedure would involve a routine abortion.

The risk involved with this particular test is a very small chance of miscarriage. There is always a ‘background’ risk of miscarriage in every early pregnancy (about 2 per cent at ten weeks). Having a CVS may increase this by another 1 per cent.

The test is offered to women whose chance of an affected pregnancy is the same, or greater, than the risk of miscarrying as a result of the test (for example women who will be over 37 years of age when the baby is due to be born).

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Cervical cancer is the sixth most common cancer in Australian women, with about 360 women dying each year from the disease. About 1,000 new cases are diagnosed yearly. It is most common in women aged sixty and over (who are, unfortunately, a group who seem reluctant to have smears), but is still a significant killer of younger women, in their twenties and thirties. Screening well women for evidence of pre-cancerous changes is an effective means of reducing the death rate from cervical cancer. Unfortunately, the method is at present under-utilised, with only about 50 per cent of women being regularly screened, and that means there are still too many women dying unnecessarily from a treatable cancer. Older women, and women from non-English-speaking backgrounds in particular are missing our.

New methods of detecting pre-cancerous change, using blood tests and others, arc being investigated, and may be available at some time in the future. It seems that these are unlikely to replace the smear test, but may be useful as additional methods.

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Urinary tract infections are bacterial infections. The bugs can infect the lower reaches of the system, namely the bladder and urethra, and/or the upper tracts, the kidneys and the ureters.

Symptoms. The most common form of infection in women is cystitis, which is basically a bladder infection. There are classic symptoms:

• Frequency of urination, which means going more often than usual, and maybe feeling the need to go again straight away after a wee, but there is nothing there.

• Painful urination, often a burning feeling. It can be so bad that sometimes the muscles of the bladder involuntarily shut off, making it difficult to wee at all. There is often pain centrally in the lower abdomen, which may also be present at times other than passing urine.

• Blood in the urine, which may or may not be visible. It is sometimes seen as a red stain on wiping after urination, or if mixed with the rest of the urine it may appear quite red.

Other symptoms commonly experienced are nausea, vomiting, back pain, headache and fevers. These are more common, however, in infections of the upper urinary tract. Pyelonephritis, which is a bacterial infection in the kidney, is usually a more severe illness, and fevers and even rigors (involuntary shivering and shaking with a fever) are generally noted. Untreated, cystitis can progress to nephritis.

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Manual sex, or masturbation. Stimulation of the genitals using the hands. This may be done to another person, male or female, or to yourself. Most of us find our genitals as babies, and it feels nice. (Fortunately our arms are just long enough.) As we grow up we are discouraged from touching our genitals, because it is ‘not nice’. Despite that, just a hour everyone masturbates, as children and adults, even the people who told us we would go blind if we did it. It is a useful way of finding out what feels good, and is an outlet for sexual feelings. Manual stimulation between

partners is an extremely common form of sexual activity.

Oral sex. Stimulation of a person’s genitals using the mouth. As this is a bit tricky to do to yourself (unless you are a dog, when you can do it whenever you like), it is usually one person doing it to another. It can be either a male or female, doing it to either a male or female. If two people are doing it simultaneously to one another that is often called a ’69′. Orally stimulating a female is known (in the laboratory, if not on the street) as cunnilingus, and the same to a male is called fellatio. There are lots of slang names, some of which are in the glossary. It is very commonly practised.

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