I tried repeating the word to myself — ENDOMETRIOSIS. I drifted back to sleep, happy that at last a name had been given to the cause of my debilitating period pain.

The doctor’s voice roused me once again: ‘You’ll probably never have children’.

I wondered who the doctor was talking to. I knew it was not me because I had not even tried to get pregnant.

The truth dawned the next day when once again the doctor described the severity of the endometriosis and repeated that pregnancy looked very doubtful.

He told me that I was to take 400 milligrams of Danazol a day for three months and then he would perform major surgery including the removal of my diseased ovary.

As the endometriosis was so extensive, he felt the Danazol would only marginally improve my condition and he could not guarantee the success of surgery.

I was devastated. One day I was in hospital with a suspected ovarian cyst. The next I was told I had a disease that I could not even pronounce, I had to take male hormones, I had little prospect of ever having a baby and I was to have major surgery in the near future.

I knew very little about Danazol as it was then a relatively new drug in Australia and I asked my doctor about any side effects. He tried to assure me that I need not worry about little details and that he would look after me. I did not feel at all reassured.

The week after being diagnosed as having endometriosis, my husband’s firm transferred him interstate. I was in turmoil, life was caving in around me.

Once settled in our new home, I decided to seek a second opinion. The news about the endometriosis had been so shattering I did not want to believe it. I wanted to hear something positive, something encouraging.

My new doctor had received a letter from my first doctor giving details of the disease. The new doctor asked me if I had any questions. Did I have any questions!

For the next half an hour he quietly explained in detail all I wanted to know, including drawing some diagrams so that I understood more clearly. He felt it was essential that I knew all the possible side effects of Danazol.

After I had exhausted my list of questions, he told me that he wanted to change the dosage of my treatment. I was to increase the dosage of Danazol to 600 milligrams daily and take it for six months. He hoped he would not have to perform major surgery. At the end of six months I had a laparoscopy to see how effective the Danazol had been. Much to my doctor’s surprise there was no visible endometriosis. There were certainly signs where the disease had been, but everything appeared normal.

My doctor suggested I continue taking Danazol for another three months just to make absolutely sure the endometriosis had been completely eradicated.

A few weeks after finishing the Danazol tablets I discovered to my delight that I was pregnant.

I often wonder how my story would have ended if I had not decided to have a second opinion. Would the smaller dosage of Danazol have cleared my endometriosis? Would the major surgery have eradicated the endometriosis? Would I have been left with painful adhesions? Would I have lost an ovary? Would I ever have become pregnant?

Of course, I do not know the answers to these questions but I am grateful I decided to seek a second opinion as the outcome was more than I ever hoped for.

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The GnRH agonists are modified versions of a naturally occurring hormone, gonadotropin releasing hormone (usually abbreviated to GnRH), which helps to control the menstrual cycle.

Initially, it was drought that the GnRH agonists would not be suitable for the treatment of endometriosis as it was assumed that they would stimulate the production of oestrogen. However, it was discovered that prolonged use of the GnRH agonists actually suppressed the production of oestrogen and caused the oestrogen levels in most women to decrease to the levels found in women following the menopause. Consequently, researchers began to investigate their use for the treatment of endometriosis.

How GnRH agonists work

The GnRH agonists eradicate endometrial implants by suppressing ovulation and oestrogen secretion. The resulting low levels of oestrogen in the body mean that the endometrial implants are no longer stimulated to grow and breakdown each month so they gradually degenerate and waste away.

Most women stop ovulating and menstruating during treatment and resume ovulation and menstruation again within one to two months of completing their treatment.

Dosages of GnRH agonists generally used

Since 1971 more than 2,000 GnRH agonists have been developed by various pharmaceutical companies. Some of them are still being developed and tested while others have been released for use in some countries. At present none of them are available in Australia for the treatment of endometriosis, except under special circumstances.

Some of the more well known GnRH agonists are Buserelin (Superfact), Naferelin (Synarel), Leuprolide (Lupron), and Goserelin (Zoladex).

None of the current GnRH agonists are effective when taken by mouth because they are broken down in the digestive system. Other methods of administering the drugs have been developed, including nasal sprays, daily injections and monthly injections.

Side effects GnRH agonists

The side effects experienced by most women are usually a result of low oestrogen levels. The majority of women experience hot flushes and some also experience other menopausal-type symptoms, including vaginal dryness, decreased libido, headaches and depression. The side effects usually disappear soon after the cessation of treatment.

The GnRH agonists appear to have no adverse effects on the levels of fats and cholesterol in the blood.

One possible long-term side effect of GnRH agonist therapy is osteoporosis (loss of bone density). In trials conducted so far some women have shown a decrease in the density of the bones in their spines; it appears that this effect is reversed and the bone density usually returns to normal within six months of ceasing treatment.

At present it seems that this loss of bone density is not likely to be a significant long-term problem if the treatment lasts only six to nine months but considerable further research is needed before the complete picture is known.

How effective are the GnRH agonists

The results of the clinical trials indicate that the GnRH agonists are effective in eradicating endometriosis and relieving its symptoms but, like all the other hormonal drugs, they have no significant effect on adhesions or endometriomas and they are not a permanent cure. Overall, the GnRH agonists appear to be as effective as Danazol. When they have been approved for use in Australia they will probably assume an important place in the hormonal treatment of endometriosis.

*60\83\2*

Uterus (womb)-The uterus is a hollow muscular organ which is about the size and shape of a flattened pear. It lies between the bladder and the lower end of the bowel and is approximately 7.5 centimetres in length and weighs about 40 grams.

The upper part of the uterus can move forwards and backwards to some degree within the pelvis. Usually, it is tilted forwards so that it lies against the back of the bladder. In this position it is said to be anteverted. However, it may be tilted backwards and when it lies in this position it is said to be retroverted.

The uterus is made up of three layers. The outer layer is known as the peritoneum. The middle layer consists of a thick layer of muscle known as the myometrium. The inner layer which forms the lining is known as the endometrium. When this endometrium is found outside the uterus it is known as endometriosis.

The main function of the uterus is to protect and nourish the growing foetus during pregnancy.

*1\83\2*

The syndrome has tended to appear a somewhat woolly collection of symptoms and signs (more than a hundred have been reported) and this has led many, mostly male, doctors to question its existence as a real entity. To the women who suffer from it, though, it is real enough, and although there is undoubtedly a psychological element to many cases it is by no means a problem that is ‘all in the mind’.

The most common complaints are of anxiety, nervous tension, mood swings, irritability, weight gain, breast tenderness and headaches.

Between 30 and 35 per cent of women of childbearing age suffer from it. Almost 5 per cent of women are severe sufferers and become suicidal, accident-prone or very difficult to live with when they have PMT.

Recent research has shown that there are several fairly clear-cut sub-fractions of the condition which respond to different treatments:

ÐÌÒ-Ë women complain mainly of nervous tension, anxiety, irritability and mood swings occurring as much as two weeks before the onset of their period. The symptoms get worse and are sometimes followed by mild to severe depression, improving with the onset of bleeding. These symptoms have been found to be caused by too much oestrogen-research indicates that oestrogens act as stressors to the nervous system. Progesterone, on the other hand, has a calming effect. Research shows that the liver is unable to de-activate these raised levels of oestrogens without adequate supplies of  vitamins.

PMT-C women find their appetite increases two weeks before a period and they crave sweet, sugary things. The craving is especially bad if the woman is under stress. An hour or two after eating the sugar-rich foods the woman feels low, tired and shaky. If you are under stress and eat a lot of refined sugar several things happen. Stress changes the levels of certain brain enzymes, which creates a relative deficiency of a substance called dopamine. The highly refined sugar eaten forces the amino-acid tryptophan into the brain cells where it is converted to serotonin. An excess of serotonin causes palpitation, nervous tension and drowsiness, among other things. The refined sugar triggers the release of too much insulin and this reduces blood-sugar levels. A deficiency of a hormone called prostaglandin E (PGE) may also be involved. PGE suppresses the insulin response to sugar and reduces the nervous system’s responses to a decreased blood sugar. The following nutrients are needed for the formation of PGE from cislinoleic acid, which is its dietary building block: magnesium, zinc, and vitamins B3, B6 and C. Perhaps the craving for chocolate so many PMT-C sufferers have is really for the magnesium and phenyl-ethylamine (related to dopamine) that chocolate contains.

PMT-H women mainly complain of weight gain during the last few premenstrual days. Their body weight goes up, their breasts, hands, feet, faces and ankles swell. Rings become tight, shoes and skirts are tighter than normal, contact lenses feel less comfortable or even cannot be worn, and the breasts and lower abdomen are tender. Most women in this group gain only 3 lb or less in weight but it seems to be all in sensitive places. Some gain as much as a stone.

Such women often have normal oestrogen levels but have elevated levels of hormones produced by the adrenal glands that control salt and water retention by the kidneys. High brain levels of serotonin stimulate the release of ACTH-a brain hormone that makes the kidneys retain salt and water. Excess carbohydrate consumption makes the body produce too much insulin, as we saw above, and insulin is known to make the kidneys retain more salt than they should. Stress also makes the kidneys retain salt and water.

PMT-D women have premenstrual depression, are withdrawn and confused, cry easily, can’t sleep, are forgetful, and may even be suicidal. Many such women, if they have no other signs, are not diagnosed as PMT sufferers and end up with psychiatrists. Some of these women improve with oestrogen supplements.

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• which bacteria was causing the infection

• which antibiotics are effective against the bacteria

• whether you are allergic or have had previous bad reactions to any antibiotic

• whether you are pregnant

• where the infection is and how far it has spread.

Many types of gonorrhoea can be treated by penicillin, but some strains (particularly those prevalent in Southeast Asia) have developed resistance to penicillins. Chlamydia is not eradicated by penicillin.

Many STD specialists will advise you to begin treatment as soon as infection is suspected (while waiting for culture and sensitivity results) with a combination of antibiotics that is likely to be effective against both gonorrhoea and chlamydia as well as most other bacteria that cause serious genital tract infections. However, it is important to contact your doctor when the results are available, in case different or additional antibiotics are needed. If gonorrhoea has spread into the blood or if any infection has spread to cause complicated PID, epidymitis or Fitz-Hugh-Curtis syndrome, treatment in hospital will usually be advised.

Your doctor should explain why a particular treatment is chosen and the importance of regular dosage and completing the course. If you have any reaction to the antibiotics (this is uncommon), contact your doctor so that alternative treatment can be given if necessary. You’ll be asked to return when you’ve finished the course to make sure that the infection has cleared up and your partner has been properly checked. This check is very important. Partners should always be examined and tested prior to being given any treatment. You’ll be advised not to have sexual intercourse until both you and your partner have finished treatment.

What happens if the infection isn’t treated?

The greatest danger for women is that infection might spread to the tubes, causing PID and scarring that increases the risk of ectopic pregnancy or loss of fertility from blocked tubes. This is particularly risky with chlamydial infections, which can cause tubal damage before any symptoms are noticed. Women with untreated chlamydial infections also risk passing the infection on to their babies during birth.

In men the infection can spread to the epididymis, though this is not nearly as common as PID. If the epididymis on both sides is affected, scarring may lead to infertility.

These infections can have dire consequences for your health, fertility and happiness, so never risk letting one go undetected and untreated. If you have any suspicion that your partner may be infected, see your doctor for a test and ask your partner to do the same. In some areas doctors now advise testing all pregnant women. No matter how unlikely your chance of infection may be, this test is a wise precaution to protect you and your infant.

*297/31/5*

Inflammation, thickening, cracking or flaking of the skin

Nipple and areola skin can be affected by any conditions that affect the skin of the rest of the body, and nipples are prone to skin conditions such as eczema. Because nipple skin is more delicate and has a greater nerve supply, it tends to become redder, more swollen and more painful than other skin. There is an uncommon type of cancer called Paget’s disease of the breast in which cancer in a duct beneath spreads to the outside through the nipple. This occurs mainly in postmenopausal women. At first one nipple and areola become itchy or sore. Later the skin may become cracked, weeping and crusted. Treatment is the same as for other types of breast cancer.

Lumps

There are many sebaceous glands near the edge of the areola and at the base of the nipple. Occasionally the duct of one of these glands becomes blocked, resulting in a pimple-like lump that will usually discharge spontaneously and settle down within a few days. If not, or if inflammation spreads around the base of the lump, see your doctor.

Nipple discharge

You may notice a yellowish, grey, brown or green discharge on your bra. Most causes are benign, and include overgrowth of the lining cells or cystic dilatation of the ducts beneath the nipple.

Milk discharge in a woman who isn’t breast-feeding can result from stimulation or sucking of nipples during sexual activity. Rarely is it the result of overproduction of prolactin by the pituitary gland, which often goes with menstrual irregularities or amenorrhoea. Consult your doctor about any sort of nipple discharge to see whether further tests or treatments are needed.

Inversion of a previously everted nipple

This may be due to benign inflammation of ducts behind the nipple, resulting in scar tissue that contracts and pulls the nipple inwards. In some types of breast cancer the nipple may be pulled in or up, or a dimple may form in the areola. Full investigation is necessary in all new nipple inversions to rule out the possibility of cancer.

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There is now no doubt that there is increased risk of a rare type of vaginal and cervical cancer in the daughters of women who took diethylstilbestrol (DES) during pregnancy.

During the 1940s and early ’50s it was believed that DES could save some pregnancies at risk of miscarriage. By the mid-1950s the usefulness of DES in preventing miscarriage was in doubt, but some doctors continued to use it in the hope that it might help.

At the time it was used nobody had any suspicion of the problems DES might cause. Suspicion was aroused in the late 1960s when reports of vaginal cancer occurring in women in their late teens and early twenties began to appear. The majority of these women had been exposed to DES while their mothers were pregnant.

As soon as the alarm was raised the drug was withdrawn. Records were examined and all young women whose mothers had DES treatment were asked to have regular examinations. Though the risk of developing vaginal cancer was only three in ten thousand, other abnormalities of the uterus, cervix and vagina were found in young women who had been exposed to DES before birth.

The most common abnormality found has been vaginal adenosis, which is the replacement of the normal lining of the vagina with glandular epithelium. Vaginal adenosis is not a malignant condition, but it is suspected that it could become so. Though so far no women who have been exposed to DES and have vaginal adenosis have developed vaginal cancer, all are advised to be checked at least once a year. In some cases the adenosis has disappeared spontaneously.

In good hands it is quite safe: the overall risks are among the lowest for any major surgery. Complications are possible but uncommon. They include wound infection, haemorrhage from the vaginal wound, damage to bladder or ureters, thrombosis (the formation of blood clots) or chest infection. Complications are more likely when hysterectomy is performed on a badly diseased uterus or when chronic pelvic infection exists. Most occur during the first week. You’ll be regularly checked while in hospital so that any complication can be dealt with promptly.

Rarely, hysterectomy without oöphorectomy before the menopause can lead to cessation of ovarian function if the ovarian blood supply is damaged during surgery.

This results in symptoms of oestrogen deficiency, which must be treated by oestrogen replacement.

Sex after hysterectomy

You’ll be advised not to have sex for about six weeks after surgery. This means penis-in-vagina sex: you can start any other sort of sexual activity as soon as you feel like it, as long as it causes you no discomfort. After healing of the vaginal wound has been confirmed at your post-operative check, you can begin sexual intercourse. Take it gently at first: it may take a few weeks before full activity is comfortable.

If your ovaries are removed or if you’re past the menopause, treatment with vaginal or systemic oestrogen will maintain a healthy vaginal lining that lubricates easily during sexual arousal (and your vaginal wound will heal more quickly).

You may fear that hysterectomy will shorten your vagina and make sex difficult or impossible. This is not so. Neither you nor your partner should be aware of any difference. The vagina isn’t shortened at all unless it is also diseased and must be partly removed, but even in this case it can be dilated to make sex possible.

Another common fear is that sexual feeling will be reduced or lost after hysterectomy. This rarely happens. The lower end of the vagina, the vulva and the clitoris are the main sources of pleasurable sexual sensation. Contractions of the uterus are part of orgasm, but most women who’ve had a hysterectomy say that the quality of orgasm is no different. Surveys have shown that sex improves for the majority of women after hysterectomy. This isn’t surprising, because before the operation their sexual enjoyment may have been affected by symptoms.

About 15 per cent of women report that their sex life deteriorates after hysterectomy. This may be due to negative expectations and anxiety in the woman (and her partner) about the effect of hysterectomy on her sexuality and sexual response.

Fears about the possible effects of the operation can change a couple’s sexual interaction. If you fear that hysterectomy will make you less sexually attractive, you may be anxious to see how your partner responds. If, from genuine consideration of your convalescence, he makes fewer sexual approaches, you may jump to the conclusion that he finds you less appealing.

Good communication is the answer to settling back to normal sexual activity after hysterectomy (or any surgery). It helps if your partner takes part in discussions with your doctor before the operation, and if you can talk the matter over between yourselves both before and after.

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The most common reason for abnormally slow growth of the foetus (a ’small-for-dates’ foetus) is reduced blood flow to the placenta resulting in insufficient oxygen and nourishment reaching the foetus. This most often happens if the mother smokes and in women with pregnancy-induced hypertension. Less common reasons for slow foetal growth are other abnormalities of the placenta, congenital abnormalities of the foetus and maternal undernutrition. Identical twins share the same placenta, and one twin may grow more slowly because it receives less than its half-share of placental blood flow.

Foetal growth retardation is suspected when the uterus doesn’t enlarge at the expected rate and the mother’s weight gain is poor. It can be confirmed by ultrasound. Rest and observation in hospital are usually advised in an attempt to improve the placental blood flow. Delivery is induced when the obstetrician, in consultation with the parents and a pediatrician, decides that the baby would have a better chance in the nursery than in the uterus. The baby usually catches up quickly after birth.

Gestational diabetes

Sometimes diabetes appears for the first time during pregnancy, though usually not until towards the end of the second trimester. When this happens, blood sugar can usually be controlled by diet alone, but more frequent antenatal checkups will be advised. Pregnancy-induced diabetes disappears after delivery.

Rhesus iso-immunisation

The Rhesus (Rh) factor is an antigen found on the surface of red blood cells. It was first identified in the rhesus monkey, hence its name. Over 85 per cent of people have this factor in their blood and are said to be Rh-positive. People who don’t have the Rh antigen on their red blood cells are Rh-negative. If Rh-positive blood enters the circulation of an Rh-negative person (for instance by transfusion), an antibody to the RH factor develops because the RH factor is recognized by the immune system as foreign. This antibody destroys Rh-positive red cells.

The Rh factor is very important in pregnancy. If a woman with Rh-negative blood carries a foetus with Rh-positive blood, some of the foetus’s red blood cells may cross into the mother’s blood and stimulate the development of anti-Rh antibody in the mother’s serum. This is Rhesus iso-immunisation. In the same or a later pregnancy these antibodies can cross to the baby and if the baby is Rh-positive, can destroy some of its red cells, resulting in anaemia and jaundice.

Bleeding from the foetus to the mother can happen at any time during pregnancy, but is most likely in spontaneous or induced abortion, ectopic pregnancy, antepartum haemorrhage or during delivery.

Mothers with Rh-negative blood have their blood examined at the beginning of each pregnancy and at about 28 and 36 weeks. If antibodies are detected, it means that some foetal red cells have crossed to the mother and that the foetus may be anaemic. The degree of foetal anaemia can be measured by examining the amniotic fluid (by amniocentesis). If the foetus is mildly anaemic, labour may be induced around 38 weeks. If anaemia is severe, delivery may need to be earlier. In very severe cases, blood transfusion to the foetus in the uterus may be undertaken before delivery. The baby is checked immediately after birth to see if there has been so destruction of the baby’s red cells that change transfusion is needed, in which baby’s damaged blood is replaced with negative blood.

If jaundice is present, the baby nursed in a crib under a light that break down bilirubin, the pigment broken-down red cells that causes jaundice. If bilirubin is allowed to reach high levels in the baby’s blood, it can lead to brain damage.

Rh iso-immunisation used to cause many stillbirths and much severe illness in newborns. Since the introduction of anti-D gamma globulin (which acts anti-Rh antibody and destroys Rh-positive red cells) in the 1960s, these proplems have become rare. All women with negative blood are now given anti-D immediately after any pregnancy in the hope of destroying any foetal red cells that may have crossed from the foetus before Rh iso-immunisation can develop.

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Breast development

At around the age of 10 or 11 the nipple enlarges; the areola may darken and fat begins to accumulate under it, causing it to bulge. In boys this is all that happens, but in girls the breast continues to develop under the influence of hormones (oestrogen and progesterone) produced by the ovaries. Oestrogen stimulates the milk ducts to grow inwards into the tissue beneath and around the areola, where they divide into increasingly smaller ducts lined with special cells. These are the milk glands. At the same time fat is laid down around the developing glands and the breasts protrude more and more. The breast isn’t a symmetrical cone of tissue beneath the nipple; it has a tail that extends up into the armpit, which develops in the same way as the rest of the breast.

Breast size

A woman’s breasts continue to grow until about 17 or 18 years of age. It is the amount and arrangement of fat laid down in our breasts that determines their final shape and size. This, together with the size, shape and colour of the nipple and areola and the position of the breast on the chest wall, are inherited characteristics that account for every woman’s breasts being a bit different. Breasts may be large or small, conical or rounded, high or low and everything in between.

Nipples

Nipples can vary just as much. They may be flat-topped, divided into two or more lobes at the tip, pointed, knobby (thicker at the top than at the base); they may protrude a little or a lot, or they may be inturned (inverted) and look more like a dimple. The areola may range from very pale pink to dark brown, may be a small or wide circle or oval, and it may not be symmetrical. All these variations are normal and don’t affect the ability to breastfeed.

No doubt you’ve noticed that your nipples and areolae look and feel different from time to time. As well as having a rich nerve supply (that makes them very sensitive), they contain many small blood vessels and tiny bundles of muscle tissue arranged in circles around the areola and radiating from the tip of the nipple to the outer border of the areola. In response to touch, cold and sexual arousal, the muscle contracts so that at first the areola becomes smaller and wrinkled and the nipple protrudes further (and inverted nipples usually emerge). Then the blood vessels become engorged so that the nipple and areola become swollen and warmer. This response helps during breast feeding by enabling the baby to get a good grip on the source of milk.

Though the greatest changes in breasts happen during puberty, further changes continue throughout life. Our breasts may become larger before periods, during pregnancy and breast-feeding, and with weight gain. Breasts may become smaller with weight loss, after breast-feeding and after the menopause.

How you feel about your breasts

Many women don’t like their breasts -they’re too big or too small, not firm enough, the nipples are the wrong colour or shape. Because our society focuses so much on women’s breasts as sex symbols, women may think they are less attractive because of their breasts. But the ‘ideal’ varies depending on whether you’re reading Penthouse or a high-fashion magazine, or whether you see Elle Macpherson or Mia Farrow as the model of an attractive woman. Society’s (and our own) attitudes to women and our breasts can affect how we feel about our bodies and our confidence in how others see us, and perhaps explain why breast problems and breast disease are more frightening to most of us than other health disorders.

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