Home remedies for Acne treatment
It is most frustrating thing to go through to have an acne on your face. It seems embarrassing whether you are going to class, walking to road way, or having a meeting you are more conscious about your face.
Essentials while using Home remedies for Acne.
It is found that scar treatments such as collagen injections or dermabrasion and acne removal treatments like use of cylisic acid are too irritating and intense. So people prefer to use home remedies to get rid of Acne.
Use treatment according to your skin type
every one has unique skin type so before using any treatment test your skin type. One ingredient which suits one person may not suit other. So it is better to test any ingredient on you arm or back of your ear before applying it on your face.
Be patient while using home remedies for Acne
it should be keep in mind that home remedies takes time to show result. It does not matter what ingredient you are using. Wait for week or month to see the results. If your skin does not improve or cause irritation then try another one.
Moisturize your skin regularly
Always remember any kind of skin, dry, oily medium or combination needs moisturizing. Acne starts when skin lacks moisturizer so daily Cleanse, Tone and Moisturize even when you have breakouts.
Pay special attention to your diet.
Acne is more closely connected to your non healthy diet then bacterial causes. Avoid excess carbohydrates, processed food, dairy products, nuts, caffeine, red Meat etc. Add fresh vegetables, eggs, juices, and fish, and salads, raw and green foods to your diet.
Drink lot plain water regularly
Take a 12 to 16 glass of water daily. Water purifies your system and helps in excreting toxins form your body which causes acne.
Home remedies treatment for Acne
This isn’t always the easiest thing to do, and so there are some
remedies treatment to get rid of cystic acne by using Alovera Gel and Green Tea.
Using Alovera as a Home Remedy for Acne.
Due to benefits of aloe Vera in medicines it is called the plant of immortality. This miraculous plant is being used to treat everything from stomach ailments to cancers
Alovera is used directly without being processed for skin and beauty treatments. By drinking half cup of Alovera juice improve skin condition, regulate your digestion system, cleans your internal system and stops constipations which is the root of Acne. It balances hormonal changes in your body. Prepare Alovera juice by plucking one big leaf form plant, washes out all dirt and debris out of the leave. Cut it into two sections and extract all juice and process this jells into your blender. You can also mix Alovera juice with carrot juice and orange juice to get more effective results. It clears body acne as well as facial acne and improves skin condition dramatically.
If acne appears on your face apply Alovera gel on breakouts. At first it will appear as worst and extract all white matter on your face. If therapy continues it will help in neutralizing your skin while functioning as a killer bacteria P. acne cause of acne and helps in making new cells on your skin. It gives natural glow to your skin and keep it moisturized.
90% of breakouts and pimples are healed by using Alovera gel.
It has anti-inflammatory and antibacterial properties, Aloe acts as a natural antiseptic as well, possessing the ability to penetrate deep into all three layers of the skin and extract puss form pores it also promote healing and generate new skin cells.
Using Green Tea as a Home Remedy for Acne
Green tea is used by Chinese to cure different ailments as well as in curing
cystic acne. Cystic Acne appears on face, chest, shoulders, back and on upper portion of arms. Green tea with honey is known as pimple tea and it is widely used in many china towns after meal. It naturally detoxifies system and underlies the toxins which can cause acne.
Taking green tea for acne is a win-win solution. It promotes your over all health having no side effects and is low in price as well. Green tea balances overacting hormones and reduces inflammation which causes acne.
If you want get rid of acne from its root then you have to take 2 to 3 cup of green tea a day. Do not add sugar in it as it neutralizes the effect of green tea. Take one cup of plain green tea in morning and one in evening detoxify your system.
If you are suffering form bad acne then take green tea facials. To take green tea facials simple boil water with green tea leaves and take it as regular facial steam. It reduces blemishes, redness and dries out pus inside zits. Do it once in a week. You will notice gradual improvement in your skin condition. You can do green tea facials for your face and for other body parts as well. To get effective results do it regularly for 4 to 5 months. It completely stops acne.
Different green tea cream and tablets are also available in market. It can also be used. But it always good to use natural things instead processed form. You can make green tea toner and green tea moisturizers in home.Just boil green tea in plain water add some rose water . When it cools down save it in a jar and use it as a toner and moisturizer daily after washing your face. Take cotton balls and soak it in green tea and keep it in refrigerator and use these green tea cotton balls on your pimple it reduces redness and helps in healing acne scars.
These balls are also effective to lighten dark circles of your eyes and reduce eye bags. Green tea gives natural glow to your skin and makes you younger.
If any of these home remedies for acne do not work for you after consistent use then you need to consult a dermatologist.
How the System Operates
The electronic computer used universally in business offices is a relatively modern invention. Each year they are becoming smaller, cheaper, more efficient, and requiring less sophisticated electronics. Indeed, today hardly a high school student is without at least a calculator, and they have long since become as much a part of the daily human scene as transistor radios and television sets.
However, the idea of the computer is nothing new. Indeed, the basic ingredients have been around for as long as mankind.
In fact. Every human possesses one of the world’s finest computers. It is quick, reliable, requires minimum servicing, and flashes out the answers in record time. What’s more, the cost has been virtually nothing.
We refer, of course, to the human brain, and the intricate apparatus known as the Central Nervous System. This is basically a complex communications network and, fortunately for the human race, because it is so specialised and so efficient, it makes living a relatively easy pastime.
Housed in the protective bony vault of the cranium is the nerve-centre of this computer system. From here, branches radiate. Some nerves go directly to certain specialised areas providing specific functions—such as the optic nerve caring for vision that goes to the eye, and the auditory nerve attached to the ear structure that cares for the sense of hearing. There are 12 so-called “cranial nerves” leading directly from the brain itself.
A massive ropelike structure of nervous material then leaves the brain via the stem, and courses through a canal made up of a central hole in the vertebral bones of the spine.
Depending on their location, the vertebrae have been given different names, purely for descriptive purposes. Those in the neck are referred to as the cervical vertebrae. Those in the chest region are the dorsal or thoracic vertebrae. In the lower part of the trunk, they are large, having to support the body, and these are the big lumbar vertebrae. Then comes a series of fused vertebrae located in the pelvic region, called the sacrum. Finally, at the very tip, there is a series of tiny, apparently unimportant bones collectively called the coccyx (or tail). In animals, the coccygeal bones are for the tail structure.
How the System Operates
As the spinal column of nervous tissue descends through this strongly protected (but movable) canal, nerves are given off at each side, between successive vertebrae. These supply structures on each side of the body.
In the lower cervical upper dorsal region, several major roots (as they are called) are given off, and these join, divide and redivide in a maze of nervous tissue called the brachial plexus. In turn this gives rise to the major nerves of the upper limbs. In this manner each part of the arms, hands and fingers is supplied with nerve fibres. They are all part of the total nervous network.
Further down, in the lumbar region, massive nerve roots are given off on either side to form the giant sciatic nerve. This supplies the lower limbs, including feet and toes. The large nerve gradually divides into smaller and smaller branches until every part. Skin, blood vessel walls, muscles etc, receives a nervous supply.
There are many functions of the nervous system, but only the chief ones will be pointed out.
Motor function. This part of the brain controls the action (or motor function) of the various parts of the body. It acts by producing electrical contraction of the muscle fibres that make up muscles. Contraction causes a shortening of the muscles. In turn this produces active movement.
If we desire to move the upper limb, the conscious idea goes to the part of the brain (called the cerebral hemisphere) governing limb movement. Electrical impulses are channelled along the correct nerve that goes to the muscle groups involving the upper limbs. A fraction of a moment later and the nerve fibres contract. The limb moves, or bends, or does whatever activity is required.
Similarly, if we desire to bend it in the opposite direction, impulses are sent to the opposite muscle groups. The first set of muscles relax as no more impulses are sent, and the opposite ones then carry out a similar function, so enabling an opposite movement.
This all happens in a fraction of a second. In an incredible manner, our computerised system knows which messages to send to which muscle fibres, merely by a conscious thought. It surely represents the finest coordination and smoothest working ever devised.
Sensory function. Apart from the strictly motor activity, the nerves have a sensory function as well. Most parts of the body have receptors to the various sensations. For example, we are able to appreciate heat (or lack of heat, which equals cold), pressure, pain, the awareness of space. The hands and fingers are plentifully endowed with sense end- organs (as they are called), for this all forms a part of nature’s inbuilt protection system of the body.
The cranial nerves also have specialised senses, such as being able to appreciate vision, hearing, the sense of smell, taste etc.
When stimulated, similar electrical impulses are conveyed through the nervous system back to the brain, and an awareness of these different sensations is possible.
When the two systems are coordinated, it will be seen that they are basically operational for our own welfare. We may see, hear, feel and sense danger. This will immediately give us the message consciously to set our motor system into action and take appropriate steps.
If we are exposed to excessive heat, we swiftly move from the spot. We immediately remove any part of the body from a source of pain. If we see danger approaching (whatever the form), our legs immediately work and bodily remove us from this threat.
The gradations may be on a small scale (pulling the finger from a hot stove), or a more major one when we run across the road to escape an oncoming vehicle. Or we flee for our lives in the event of a more ominous life-endangering threat from hostile foes. There are many degrees. But the essential basic principles are the same. The nervous system is geared to keep the body protected and in first-class working order at all times.
Just to make the total operation more effective, there are certain actions that are governed by so-called “reflex” movements. This circumvents the brain, and acts at the same level as the activity. For example, if the knee is tapped just below the knee cap, a “reflex” movement occurs and the foot jumps forward.
Many such reflex circuits occur in the body. They are automatic protective devices geared to preserve the body.
Another silently working system is also operating at all times. This is termed the sympathetic nervous system. It is basically geared to carry out many unconscious functions necessary to the normal everyday well-being of the body.
For example, the sweat glands of the skin are under the control of this system. Nobody consciously tells the sweat glands to start to work when the weather becomes hot, and the body desires to lose fluid. It just happens. This is because the sympathetic system automatically operates when stimulated by certain situations (e.g temperatures rising). Sweat is produced, and pours onto the skin surface. Here it dries, and in so doing, takes a lot of heat from the body. The result is that the body cools down, and so does not reach dangerously high levels that could have an adverse effect on the general function. As the temperatures (internally and externally) reduce, so the need for sweating is reduced, and we perspire less. Once more this is an entirely automatic, computerised function and result. It occurs in the specialised tissues of the brain cells.
This simple example is multiplied thousands of times so that every activity and possible function is covered. Fortunately, this is quite out of conscious control, for if we had to think each time we needed the assistance of one of these functions, we would be hard pressed.
The circulation of the blood, the production of hormones and chemicals by the internal glands, the beating of the heart, and in fact nearly every part of the system is, to a greater or lesser extent, under this automatic nervous system control.
Disorders May Occur
However, effective though it may be, there are many things that can go wrong with this intricate machinery. In fact, the way it is abused by so many, it is miraculous that it operates so effectively and so efficiently for so many years.
But, abused, taxed, and overburdened though it is, it will still make every effort to carry out its duties in a faithful, unremitting manner for a lifetime. All it asks is reasonable servicing, usually in the form of adequate nutritional requirements and sleep, and it will give faithful service.
However, as with any other part of the body (which is a living organism after all), disease processes are possible. The central nervous system is subject to a large number of diseases and disorders. In fact there is a terrifying list of them.
Computerised tomography, the high-tech, non-invasive method of investigating the brain, can very accurately locate many of the defects that develop.
It is not possible to discuss them all. But a selected number of the more commonly occurring ones will be described in the following chapters. Some disorders, such as headaches, migraine, epilepsy, are extremely common.
Some mention will be made of the less common ones, but the rare problems that may never be seen (even by doctors in a professional lifetime) will not be mentioned.
Apart from the simple disorders that may be treated at home, most of the more serious nervous system diseases will be under the attention of the doctor; and this information is provided to try to make your particular disorder more understandable to you, rather than to tell you how to treat it yourself.
The special study of the nervous system today is carried out by doctors who have undergone comprehensive training in this particular field.
The doctors are referred to as neurologists or neurophysicians. Those who actively perform surgery of the brain are termed neurosurgeons.
In recent years, this speciality has flourished as more and more seem attracted to it.
Also, there has been a rash of ‘television doctors,’ stars in televised entertainment dramas involving the human brain. This all indicates the enormous interest this particular part of the body currently has for everybody.
New High-tech Devices: CT Scanner
Careful history-taking and examinations accompany a check of the nervous system. However, apart from the routines that have been used for many years, newcomers have been added to the field in recent times.
The most significant has been the advent of Computerised Tomography (CT).
In this amazing development, produced originally in Great Britain, the patient’s brain is subjected to thousands of X-ray pictures taken from a variety of angles. These are automatically fed into a computer, and a final picture is produced.
This very accurately locates many of the defects that can develop in the brain. It can tell if there are brain haemorrhages, or thromboses (clots), cysts, abscesses, growths. In fact, the volume of data that it can produce in a short time is incredible.
Its value is extremely high, for it represents what is called non-invasive investigation. In the past, so many brain investigations involved the injection of radio-opaque dyes, or air, into the brain substance, and only after this was done were X-ray pictures taken. These were “invasive” measures, for the actual brain substance was invaded by foreign materials, and side effects were common.
The computerised tomogram has been one of the most advanced pieces of equipment seen in medicine in the past several decades, and has already proved its worth.
Magnetic Resonance Imaging (M1I)
However, no sooner had the CT been installed in most major hospitals and X-ray consulting rooms than another high-tech development came hurtling over the horizon. This is called Magnetic Resonance Imaging, or MRI for short. It works differently from the CT scanner, but the end product is similar, although claimed to be much more detailed. In this way, it can pick
Two scans of the human brain: Above, a side view and below, the brain as seen from above.
up refinements missed by CT, for example, the destruction of the outer nerve covering in such disorders as multiple sclerosis. MRI is now available in various large radiological units.
Positron Emission Tomography (PET)
But events still move on rapidly, and a further development called Positron Emission Tomography (PET) is now available in certain major centres. This is darned to be an improvement on CT and MRI in giving better, clearer pictures for certain parts of the body. It seems that development and research will continue to produce newer and allegedly better, and certainly more expensive units for diagnosis and treatment of patients with disease.
The cost to purchase, install and operate these machines is enormous, and they represent a major drain on national health resources. For this reason, there is some restraint by governments before their wholesale use is advised. On the other hand, some doctors view them with scepticism, and ask: “Has the patient materially benefited in terms of symptom reduction by all this expensive high-tech gear?” Often the answer, sad to say, is No. An accurate diagnosis maybe, but treatment has not necessarily kept up with diagnostic devices, and the end point is not much different, in many cases, to the days before all this amazing equipment.
Other Forms of Investigation
However, other investigatory methods are still widely used
Ultrasound Scans (using sound reflection) may be carried out. And often give valuable added information not readily obtained by other means.
X-rays of the skull are widely used. Although these show only shadows on an X-ray film, abnormalities can be detected and often successful diagnoses made.
A progression from this is arteriography. Radio-opaque dye is injected into the bloodstream that courses throughout the brain substance. This is X-rayed. A picture of the vessels shows up on the film. Certain abnormalities can thus be detected (such as growths from abnormal configuration of the vessels).
Pneumo-encephalography is also used. In this process air is pumped into the brain and X-rays taken. Certain suspect disorders of brain structure (altered by disease) may become evident. This produces pain and cerebral discomfort.
Electroencephalogram. This has been in use for some years, and is the brain equivalent of the electrocardiogram in heart investigations. Electrodes are placed at ceftain points on the scalp. Tracings (on graph paper like a long streamer) are obtained. Typical patterns occur in normal subjects. But certain disease states produce abnormal tracings, which are often diagnostic.
Blood Vessel Disorders of the Brain
An enormous number of blood vessel disorders regularly occur in the brain. Just as the heart and coronary blood flow may be adversely affected by the nature of the walls of the blood vessels, so the brain may be similarly affected.
However, the cardiac picture is repeated and extended in the brain, for the circumstances are somewhat different.
Strokes and Cerebro-Vascular Accidents
Almost all cases of serious brain damage (many of which lead to sudden death) are associated with damage to the blood vessel walls, and nearly always there is associated elevated blood pressure.
Sudden disasters affecting the brain are usually referred to as “cerebrovascular accidents” (CVA for short). This means accidents in the blood vessel system of the brain.
These often involve a series of events, which may be separate, or occur in combination.
Nearly always the vessel walls are adversely affected by atheroma, which was discussed fully in the cardiovascular system. With the increased content of blood fats (essentially cholesterol and triglycerides), this material is laid down in the walls of the vessels. This leads to their thickening and hardening. Other elements are also laid down, and together these produce atheroma, or hardening of the walls.
Collectively this is called arteriosclerosis, or atherosclerosis. It can occur slowly, over a period of many years, and gradually affect the blood vessel system throughout the whole body. But the vessels of the heart and the brain seem to be particularly susceptible to these pathological changes.
As this advances, and it is very common in the second half of life when the risks increase with advancing years, the blood flow through the cerebral system is impeded. The vessel becomes narrowed as its walls thicken. Certain parts may become narrower than others, impeding still further blood supplies (and food and oxygenation) to particular areas, ultimately causing damage there.
MAJOR DIVISIONS OF THE BRAIN
Blood Vessel Disorders of the Brain
Atheromatous plaques form on the walls, and these may become craggy outposts in the central vessel blood stream. Blood clots may commence at these points. Later on, part of the clot, or the entire mass, may break off and become part of the cerebral circulation. Suddenly, this may block a major or minor vessel, and an abrupt cessation of blood to a given area will ensue. Depending on the area this nerve centre supplies, symptoms will follow.
Embolus formation, as it is called, and its subsequent blocking of a vital area is common.
Smaller arteries may steadily narrow, and these may gradually become filled with clot. This is termed a thrombosis.
Again, brain areas affected by clot formation may soften and undergo liquidation. Often the vessels around them are weakened by atheroma. If the patient also suffers from an increased blood pressure, the combination may lead to a sudden break down in the arterial walls. Blood spurts out into the surrounding tissues. As it sears into the vascular brain substance, inevitably more and more vessels are exposed and broken, so that a small rupture may become a major one.
Of course, it may be a large vessel that originally ruptures, destroying a large area of brain tissue.
Brain haemorrhages of this nature are usually of major impact. Often death occurs, usually not instantly (as with the dramatic heart attacks), but generally within hours.
The cerebral haemorrhage is often referred to as an “apoplexy of sudden onset,” and usually the outlook in these cases is grave.
The brain is a very vascular organ. If smaller vessels are interfered with over a period of time, blood will be channeled from other areas through the so-called collateral circulation” to provide nutritional elements to the part involved.
In recent years, with more investigation of the brain possible with newer forms of scrutiny (particularly with angiography, cerebral scans and more recently with the computerised tomogram, MRJ and PET), information is accumulating about these forms of brain disorder.
Although certain disorders occur in the brain itself, others may be locaed in the blood vessels supplying it. For example, they may have become pathologically narrowed by disease, preventing adequate blood from reaching the nerve cells. In some cases, this may be helped by surgery.
Symptoms. The symptoms of a stroke (as these conditions are collectively referred to) vary with the site of the lesion.
A common outcome is for one half of the body to be involved. A paralysis of that half can occur rapidly. This is called hemiplegia. There may also be loss of speech. The essential feature is weakness and complete lopseness of the muscles on the affected side of the body.
Hemiplegia is the most common sequel to vascular accidents of the brain.
After the initial cerebral ischaemic (lack of blood to the part) attacks if death does not follow (and this may take anything from hours to days following the stroke), then restoration of function may take place.
If this does occur, it is usually in a particular fashion. The deviation of the tongue to one side and the lack of facial symmetry clear up first. Then the lower limb begins to recover. Finally (and often very incompletely) the upper limb improves. The joints recover first proximally (ie the ones closest to the trunk). The result is that the patient can often stand after a period, but is not able to walk properly, for the feet may not be able to function adequately.
INTERNAL STRUCTURES OF THE BRAIN
INTERNAL STRUCTURES OF THE BRAIN
However, often the patient suddenly develops a coma with a CVA. If this is deep, with the patient showing no response to stimulation, and with respiratory irregularity, the outlook is increasingly poor. Often a sudden rise in temperature will herald death.
TREATMENT
Almost invariably the patient has other underlying disorders precipitating the onset of the CVA. However, there has often been no treatment beforehand, and the patient merely presents in a coma, the accident already having taken place.
Treatment is minimal at this stage, and supportive therapy in hospital is all that can be given in the hope that the patient will regain consciousness and be amenable to recovery to some degree.
If elevated blood fat levels (cholesterol and triglycerides) are a measurable entity in blood samples. Efforts to reduce them must be made, for there is a greater risk of cardiovascular accident.
If a patient is seen for the first time in a coma, the best form of therapy that can be instituted by an onlooker is to place the patient in a supine position (on the back) and endeavour to make certain the airway is clear, then check for cardiac and respiratory function. If these are not present, artificial respiration (mouth-to- mouth resuscitation) and external cardiac massage may assist in restoring these vital functions until either expert medical attention arrives or the patient can be transported to the emergency unit of a hospital.
Anticoagulants have been tried by the doctors but this is currently not favoured as being of much help in these cases.
If the patient shows signs of improving, the doctors might carry out investigations (eg angiography, CT Scan, MRI etc) to see if the patient is a suitable candidate for neurosurgery. Sometimes narrowings are discovered in the arteries in the neck or thorax that may be assisted by surgery. Whatever line of action is taken, often the hemiplegia is not greatly assisted by such measures. Many patients do not improve significantly.
Prevention. The best advice that can be given is similar to that for preventing heart attacks. Regular checking can show if the blood vessel system is likely to be attracted by disease. Elevated blood- fat levels (cholesterol and triglycerides) are a measurable entity. If they are raised, efforts to reduce them must be made as early as practical. This has been clearly outlined in the section on the heart, and reference to this is recommended.
If the blood pressure is raised, this too must be reduced to acceptable levels. Cigarette smoking and alcohol intake must be curtailed or stopped.
Taking sensible measures before it is too late is the wisest approach to what may be a sudden and lethal disease.
Cerebral Arteriosclerosis
This has largely been dealt with as a cause of cerebrovascular accidents in the last subsection.
However, a process of continuous, increasing thickening of the blood vessel walls of the brain can take place over a period of years and not necessarily give rise to a CVA.
This is more likely in males, is most common in the 60s, and becomes more and more accentuated with advancing years. The cause has already been discussed—the laying down of progressive layers of atheroma and blood fats on the inner part of the vessel wall. This reduces the normal flow of blood through the vessels, both in volume and speed.
Symptoms. The onset is invariably insidious and steadily progressive. Mental and physical changes take place, and there may be abrupt progressions, as small, multiple vascular lesions continue to occur. These are insufficient to produce the disasters of a major CVA. However, they impair mental alertness and acuity, and the brain gradually becomes scarred.
The patient’s general intellectual perceptiveness is impaired. His range of interests is limited, and many activities he once followed are no longer pursued. Memory for recent events reduces, yet the memory of long-standing incidents remains remarkably fresh.
Confusion may occur. The patient finds he cannot readily adapt to new circumstances, accommodation and surroundings. He becomes obstinate and conservative, hating and fearing change of any order. His emotional control becomes impaired, and his response to situations alters remarkably and is often unpredictable. Whatever tendencies he had to worry, with tension, stress and anxiety, are usually aggravated and exaggerated. Confusion and lack of alertness usually follow.
Physically he gradually deteriorates. Gradual muscular rigidity may take place, and his facial expression set, a little like Parkinson’s disease.
TREATMENT
This must be in one direction only. There is no adequate treatment that can wind back the clock and undo what the ravages of time have brought about. Efforts are usually made to keep the patient as happy as possible, in congenial surroundings, and to supply his needs and nutritional requirements. Life must be regulated and simplified to his capacity.
He will gradually, inevitably slide downhill. Finally a major CVA will bring it to an end. Often the patient will be bedridden for the remaining part of his life, probably in a nursing home or institution.
Frequently patients live on for many years, to be finally victim of an intercurrent disease such as pneumonia. Modern antibiotics (plus adequate nutrition) tend to keep these people alive for years longer than was once the case. It is sad to see these ageing people languishing in rest homes, deserted by relatives and friends, to eke out their last days on earth as lonely, deserted, unwanted human beings, bereft of their mental capacity, which a few years before may have been of a very high level. Such possibilities offer salutary warning to people at risk.
An ageing population seems to predict an increase in the incidence of Alzheimer’s disease, a type of cerebral arteriosclerosis.
Alzheimer’s disease
The symptoms of cerebral arteriosclerosis, as they advance, are referred to as “Senile Dementia” by doctors. It is not a very attractive term, and other more euphonious ones are often used. Nobody likes to think of a parent as being “demented.”
In recent years, another term has come into popular use. It is called Alzheimer’s disease. Some doctors describe it as the same as senile dementia, with similar causes. Others claim it is a separate, unrelated disease, even though symptoms are often similar or identical. It is not new, having first been described by Dr Alois Alzheimer, a neurologist born inPolandin 1864. He was the first to accurately describe the disorder.
Like dementia, it afflicts ageing persons, often in their 60s. In fact, figures indicate that with the advancing age of the population in general, vast numbers of patients with this diagnosis will keep occurring well into the foreseeable future.
Symptoms often come on suddenly, in persons who may have been very mentally alert. It seems to afflict anybody. Gradual or fairly sudden memory loss, inability to recall events, even recent ones, unable to utter certain words and phrases, seeing things, but unable to describe them, becoming annoyed easily and irritable, bad-tempered and even violent, are common symptoms. There is often rapid deterioration, lack of care for oneself and personal appearance, forgetting most things in life, and withdrawing into oneself, are common. This usually requires total nursing care in bed or hospital.
The cause of the disease is unknown. It may be related to reduced cerebral circulation. Aluminium poisoning of the cerebral cells has been cited often. Others claim an infection, for at autopsy certain particles have been discovered in the brain cells of these patients. It is claimed it may be genetically predetermined, and seeking a certain chromosome in developing babies could foretell if the disease will occur—all a bit late for the patient and immediate offspring.
One day we will probably have the complete picture, as to cause, and likewise the cure. At present neither is known. It is a progressive downhill disorder that usually ends up in a nursing home for incurables. Total attention to the patient’s needs, nutrition and encouragement are essential.
Alzheimer support units abound and relatives are recommended to contact the nearest one for support, advice and general cooperation, with a difficult disease and usually a difficult patient.
Transient Ischaemic Attacks (TIA)
Another disorder related to reduced blood going to the brain is called TIA, short for “Transient Ischaemic Attack.” It means there is a temporary impairment of oxygen in the cerebral cells, causing momentary symptoms. These may commonly occur on the face, such as a twitching of the lip or cheek muscle fibres, or temporary loss of sensation in some area. Or it may occur in any other part of the body, depending on the area of the brain suffering from the momentary oxygen deprivation. TIA is probably caused by a temporary and rapid spasm of a small vessel supplying a group of brain cells. The significance lies in the fact that it may be the forerunner of a stroke, so medical attention and treatment are recommended.
TREATMENT
A careful medical appraisal is necessary, and attention is given to blood pressure, the heart, blood vessels and nutrition, sleep, smoking and alcoholic habits. If no other major problem can be found, then simple aspirin 1 x 300 mg tablet a day is the current treatment of choice. This may be taken after the evening meal, probably a soluble tablet being dissolved in water. Taken on an empty stomach it may cause nausea. Aspirin helps reduce the way in which the blood platelets clump together (so forming clots), and minimises the risk of a clot forming. Reduced or preferably cessation of smoking, reduction of alcoholic intake, more exercise and plenty of deep breathing probably play a significant part also. Patients should keep in touch with the doctor.
Subarachnoid Haemorrhage
This form of haemorrhage is slightly different in causation, although the results are as disastrous as other forms of CVA.
Near the base of the brain is an arterial ring called the “Circle of Willis.” Frequently, a small bulge may occur on this particular artery, called a “berry aneurysm.” It is relatively common for this to rupture suddenly (for similar reasons as with any rupturing, weakened vessel wall). But instead of rupturing into the brain substance, being on the outer part of the brain it may rupture into the space outside the actual brain substance. Alternatively, it may gradually exude blood and “leak” over a period of time, thus releasing irritating blood into the cerebrospinal fluid that bathes the brain substance.
Symptoms. The patient may have suffered from recurring headaches. Or the person may have been entirely free from them, the incident heralding the first sign that all is not well. Intense headache is rapidly followed by coma.
About 30 per cent of patients die in the first attack, and death may ensue within 24 to 36 hours, or even later on during the first fortnight if fresh bleeding occurs from the rupture.
However, the patient may regain consciousness and start to improve. Severe headaches may persist for two to three weeks. Slow physical and intellectual recovery may gradually follow.
As with any coma, the patient is treated as a medical emergency, although there are certain features indicating this type of disorder (after investigatory tests). If this is suspected, then the patient may be considered to be a neuro-surgical emergency, for surgical intervention may save the patient from further attacks and may prolong life and bring it back to reasonable normality. However, experience shows that a high proportion of survivors have another attack (from a fresh site) within two years.
External Bleeding (Subdural Haematoma)
This is caused usually by injury to the front or back of the head. It produces a tear of the lining of the brain, or of the vessels as they enter the brain substance. Blood accumulates between the brains it self and the bony cranium. It occurs mainly in older people in the 50-andover age group, but may also occur in younger persons. The blood clots, and later the internal part liquefies and may absorb additional fluid from the brain fluids. The mechanical pressure of this mass on the brain will ultimately produce symptoms.
Symptoms. There is nearly always a history of injury, but it is emphasised that this is often trivial. Considerable time may elapse, with varying symptoms often difficult to interpret, before the suspicion of a haematoma occurs.
It may take days to weeks or months before symptoms occur. The time lapse is shorter in younger people and the symptoms are often more dramatic. Usually there is a definite history of accident, often in sport or falls.
Headaches are the most common initial symptom, often severe, on wakening in the morning or after exertion. Other symptoms develop, such as lapsing into stupor or coma, to awaken with almost normal feelings. Mental confusion may occur. Gradually the symptoms increase in intensity.
New diagnostic techniques may quickly identify the trouble. Brain scans, ultrasonograms and the computerised tomogram or MRI can quickly and accurately give a diagnosis and localise the lesion.
Treatment
Unless diagnosis is made and treatment undertaken, the outcome is often fatal. Newet techniques, if available, may assist in the diagnosis. Treatment (and perhaps diagnosis) involves repeated tapping of the cranium with trephine holes through which the blood clot may be sucked out. Sometimes a flap of bone is lifted from the cranium and the clot removed in this manner.
Recognition and treatment of a subdural haematoma is usually dramatic and curative.
Other Conditions. A variety of other conditions may occur in this category, but in principle they are covered, and for practical purposes the chief ones have been described.
Hypertensive encephalopathy may take place. This happens when the blood pressure in a patient already suffering from high blood pressure rises still further. A stroke does not result, but headache, sickness, drowsiness and maybe coma could follow. A crisis lasting from hours to days may occur and then the patient may recover again. This is an emergency measure that must be treated in hospital.
The Sagging Womb and Bladder Problems
Because of the mobility of the pelvic organs, and the fact that they are subjected to pressure from above during such actions as sneezing, coughing, straining, or even breathing, certain mechanical results can take place that are peculiar to this particular area. This is accentuated by the presence of the vaginal canal, which really represents an opening in the pelvic floor.
Some doctors liken this situation to other parts of the body where apertures exist and internal contents can be forced through the lightly covered orifices. This is the basic pathology of hernias, whether they be about the navel region (as in babies), or lower down in the inguinal (groin) region in adults.
The more common uterine displacements will be discussed. After this, a short word will be given over to the urinary tract that forms part of the pelvic cavity, for this is very significant, and are a well-known cause of trouble to many women.
Retroversion
The uterus is normally positioned pointing upwards and forwards. The cervical (neck) portion forms the upper part of the vaginal canal. From here, the body of the womb wells up into the pelvic cavity, tilting toward the front of the body. This is referred to as the normal anteverted position.
It is held in this position by a variety of anatomical bands and ligaments. It tends to remain in this position throughout life. (See figures.)
It is often believed that this position is significant. Under conditions of normal copulation, with the female partner lying on her back, and with the male uppermost, the seminal pool following ejaculation will be placed automatically in such a way that the cervix is bathed in it while the female remains in this position. It is essential that the sperms have ready and prompt access to the cervical canal. The entire mechanics of a uterus located in the way described will ensure maximum possibility for a pregnancy to result, provided the timing of the menstrual cycle is correct.
The Female reproductive organs as shown by an X-ray.
In some cases of infertility, the uterus is in the opposite position. It tilts backwards, and is described as being retroverted. At this time, if a similar position is used during intercourse, the cervical canal could be some distance away from the vital seminal pool. Fertilisation may thus become difficult or even impossible.
This of course assumes that the male uppermost position is being used. If other positions are utilised at a time when pregnancy is desired, then other mechanical problems may arise.
In recent times, many gynaecologists have studied the problem of retroversion. Once it was claimed to play a significant part not only in infertility, but was blamed for many. other gynaecological symptoms. These ranged from backache, and pelvic pain, to abortion.
Many now believe that the uterus is a very mobile organ, and rarely plays much part in producing symptoms.
However, fairly simple tests can be carried out to see if the apparent misplacement is really producing the symptoms claimed. It may be necessary to make further investigations.
In years past, innumerable surgical operations were carried out to correct retroversion. Many complex arrangements were entered into. The uterus was dragged from its backward tilt and forced to point forwards. In retrospect, it is not known just how much good these operations accomplished. Undoubtedly they had their part and assisted many women. But, some modern-thinking gynaecologists now claim that the effect was probably more in their minds (both the patients’ as well as the doctors’) than in the pelvis.
Be that as it may, it still holds a place in gynaecological practice. Often when there is not much else to do, it seems to be a potent factor in assisting couples with infertility problems.
Prolapse
Prior to childbirth, the pelvic structure is a tightly knit organisation. The ligaments and bands holding the various organs in place are taut unstretched and do their job well.
The vaginal tract is likewise a compact and firm structure. The lining is corrugated, indicating a high degree of elasticity. The walls are in apposition, and the muscle fibres surrounding the tract are also firm.
In the early days of marriage, this can play an important part in providing a greatly enhanced degree of stimulation during intercourse. This is just another of the little quirks of nature. It is designed primarily to ensure reproduction of the species.
But the ability of the pelvic structures to alter suddenly is just as amazing. Soon after conception takes place, hormones pour forth into the general system. One of the side effects of this is to give all the pelvic structures a greatly increased ability to move and to stretch in all directions. The organs become more mobile as their supports stretch more.
Finally, the culmination of childbirth puts the greatest test on all these surrounding structures. The womb has increased to enormous proportions. The cervix finally opens, to allow the newborn infant to escape. The birth canal (into which the vagina is converted) dilates tremendously. It is an amazing phenomenon of nature that a narrow structure that will just accommodate a penis can stretch to such an extent that it allows the passage of a baby’s head.
These diagrams indicate the development of first, second and third degrees of prolapse. Note in Figure 1 that the bladder bulges into the vaginal tract (cystocele), and the bowel at the rear is similarly bulging into it (rectocele). Figure 3 shows complete propalpse (procidentia) where part of the uterus and vaginal walls are permanently outside the vaginal tract.
But there is a penalty for this. In variably the organs are stretched to their fullest capacity. As with a rubber band that is suddenly overstretched, often it fails to come back to its normal, original size. Some of the internal elasticity has gone forever. In a similar manner, enormous numbers of the stretch fibres of the pelvic organs lose their capacity to return to their normal taut state following parturition (childbirth).
The situation may not be very obvious for the first few years, and with younger women. But with the progression of time, it gradually becomes more obvious.
Finally, when the “change of life” years approach, the system is suddenly deprived of the normal circulating amounts of female hormone, for these are no longer manufactured by the ovaries.
This represents the final assault on the pelvic organs, structures and supports. No longer do they have any assistance to retain their normal appearance and function. It is much like a machine or a car that is suddenly deprived of its normal supply of oil. Rust sets in, parts become worn, and areas that had suffered in years past, but maintained some semblance of normality from the lubrication present, now suddenly fold up, and suffer the full impact of this deprivation.
The vaginal canal becomes atrophic. The lining thins out. What elasticity remains tends to reduce in capacity to stretch. The entry sags, the vulva are comes thin and shrinks. Deeper in, the uterine supports similarly continue to lose their suppleness. The full after-effects of the trauma of childbirth many years ago are now being fully appreciated by the tissues, devoid of the regular “oiling up” that the female hormone provided during the intervening years.
This means that the pelvic structures do not have the same degree of support as in former years. Also, with continual stress for any reason being exerted on them from above, there is a continual downward force acting upon them. As this increases, the only direction in which they can go is down. The only exit of any size is the vaginal outlet.
So, the bladder, located in front of the vagina, tends to push inwards and downwards. This can gradually become quite marked, until it forms a pathological condition in itself, clinically referred to as a cystocele.
As this presses in, a bulging sensation is often felt by the woman. Also, urinary symptoms frequently develop, as it becomes more difficult to empty the bladder completely during micturition. A small reservoir develops in the bladder, and infections rapidly become established here. Apart from this, there may be stretching and irritation on the urethra, the little tube conveying urine from the bladder to the exterior. So there is often an intense desire to pass urine frequently, even though the amount passed is small. It often gives little satisfaction. Also, as the bladder valve becomes weakened by all this, urinary incontinence may occur. Or there is loss of total control over the bladder valve. So, with a simple forceful action such as a sudden cough or sneeze, urine will suddenly be released quite out of control.
In a similar fashion, the back wall of the vagina can become so weakened that the rectum gradually presses in, and similarly bulges inwards and downwards to form what is referred to as a rectocele. This may gradually worsen, so that constipation may occur. In some cases, it is necessary to manually press the prolapsing parts back in order to achieve normal bowel actions. This causes much distress and inconvenience.
As these conditions occur, they often gradually become more accentuated. With the persistence of the pressures from above, and the mechanical pulling of the cystdcele and rectocele, the uterus itself may finally start to be forced down the vaginal passageway.
A first-degree prolapse occurs when this is only a slight progression. This becomes second degree when the cervix actually protrudes from the vaginal outlet. A third-degree prolapse (also known as a procidentia) is said to occur when the cervix and everted walls of the vagina permanently lie outside of the vaginal canal. If this is allowed to remain this way, the protruding part becomes roughened, dry, atrophic, often ulcerated, foul-smelling and infected. It is a pitiful sight to see, and any woman is foolish to allow mechanical problems to reach this stage before seeking medical guidance. However, many do, and large numbers are still seen by gynaecologists.
The accompanying diagram shows the stages of development of a prolapse through the various degrees.
Diagnosis is usually quite obvious. Smaller degrees may not be so apparent, but symptoms are often minimal. Often the woman feels as though “something is giving way,” or “it feels as if something is coming down my front passage.” These apt descriptions are entirely correct, for this is exactly what is taking place.
TREATMENT
Treatment of these conditions is essentially surgical. Vaginal repair operations are excellent when carried out by a surgeon skilled in these various procedures.
Basically, the loose tissues in the front and back walls of the vagina are removed, and the basic wall is reconstructed. If there is prolapse, the elongated cervix is partially amputated, and with the remaking of the walls of the vagina and repair of the supports, the uterus is replaced into its correct position. Sometimes it is justified to remove the uterus surgically, for by this time it has totally served its useful function and is of no further use.
All sorts of variations of this theme are carried out. The operations go by various complex-sounding names, which relate to the actual extent of the surgery.
These are the names the surgeons talk about, and which you will hear bandied about by women when describing “their” particular repair operation.
• Anterior colporrhaphy—this means the cystocele has been repaired. The front wall of the vagina is reduced in width, and bladder stitched back and a new wall created.
• Posterior colporrhaphy—this means the rectocele, or back wall of the vagina is narrowed, the rectum stitched back and the wall repaired.
• Manchester operation. This is a combination of the foregoing two operations. It is the cure for complete prolapse (procidentia), and in addition the cervix is partially shortened in length (for by now it has mechanically elongated). The uterus is stitched back by reinforcing various of its supports. The vaginal canal is now made more like it was many years before.
• Vaginal hysterectomy. Sometimes the uterus is removed via the vaginal route as part of the entire operation of repair, if the surgeon feels it has outlived its function and the patient would be better with this additional procedure.
Following these surgical endeavours, the wounds soon heal. Often oestrogen therapy is given (hormonal replacement therapy) in the form of tablets taken orally. This will help prevent a recurrence, and will also assist the parts to heal normally. Treatment may be given for a short period of time, or longer term.
Some women are fearful that their sex life comes to an end following operations of this nature. On the contrary, many experience a marked improvement. With the entire pelvic anatomy (including the vagina) brought back to a situation as near as possible to what it was prior to the birth of their first baby, some women claim they have actually experienced a second honeymoon. Many husbands have made the same ecstatic discovery!
Provided the husband is attuned to the need to be careful and gentle for the first several weeks or months, the majority of women rapidly swing back to a very enjoyable, fulfilling and satisfying sexual relationship. Gone completely is the fear of pregnancy (if the uterus is removed), gone is the laxity, the urgent desire to pass urine unexpectedly at any moment, gone are the recurring urinary infections.
Indeed, surgery at this time of life can be a very rewarding affair, as countless women have discovered to their immense joy and satisfaction.
Sometimes in women who are unable to undergo surgery, various medical techniques are used. These rely on mechanical support of the pelvic contents, and polythene rings and pessaries are used for this purpose. But these are only a second-best routine, to be used only if surgery is not possible or practical.
Urinary-tract Problems
The bladder is located in very close proximity to the vagina and uterus. The urethral outlet, the tiny external opening through which urine escapes from the body, is located just above the vaginal entry. This short canal, about 3 centimetres in length, is closely related to the front wall of the vagina, and it runs into the bladder, also closely related to the front vaginal wall.
As has been described in the previous part of this chapter, with a weakening of the overdistended vaginal walls during the passage of time, a cystocele can readily occur. As the vaginal walls weaken, the bladder presses into the vagina and tends to prolapse down its length. In this way, residual urine can collect in the bladder, and this often becomes a source of chronic infection.
Cystitis persists unless action to clear it up is taken. This can be by the use of the appropriate antibiotic, or more sensibly by surgical repair.
However, another situation can occur concurrently with this, giving rise to a condition called stress incontinence. The valve of the urethra becomes weakened, and any sudden forceful stress on the bladder can cause the sudden release of a small amount of urine, over which the person has little (if any) control. This may be difficult to differentiate from a bladder infection.
It is most important that bladder infections be treated promptly. If they are not, the infection may spread up the canals that lead to the kidneys (called the left and right ureter), and produce kidney disease that may become serious. It can produce its own set of symptoms, such as loin pain, an elevated temperature, nausea, vomiting, rigors etc.
Enormous numbers of women suffer from urinary-tract disorders, particularly infection. In recent years much work and research has been devoted in major centres to this problem. It seems that many women suffer from urinary- tract infections (UTI) without knowing, and without symptoms being produced. If major infections occur, then the typical burning, scalding, frequency, malaise and urgency occur. But with minor infections (which are serious, just the same, due to their implications), symptoms are often entirely absent.
It is well-known that urinary infections can readily be cleared up with the use of suitable antibiotics. But there is a tendency for recurrences. These days, long- term treatment with antibiotics and certain sulpha compounds is widely used.
The lower part of the urethra (the canal leading from the bladder to the exterior) normally has bacteria in its lower third. It is well-known that these can be pushed into the bladder following sexual intercourse. Many women complain of cystitis the following day.
A simple and effective way to overcome this is to get out of bed and pass the urine as soon as possible after intercourse, on every occasion. This may present a nuisance problem, but those taking the trouble to do it regularly find the beneficial results well worth the small amount of effort and inconvenience involved. This immediately gets rid of the urinary reservoir and sweeps out the germs that may have recently penetrated there, and so denies them the opportunity for multiplying, which they will surely do otherwise.
Hysterectomy
Hysterectomy means removal of the uterus (womb). This is a common operation, especially in older women, and in many cases it can transform their lives from one of misery, into the way it was when in the heyday of one’s health and vitality. Although some claim too many hysterectomies are done these days, such reports usually come from chauvinist males, and rarely from women, especially those who have successfully undergone this surgery and had a return to normal living.
The uterus is subject to a vast number of disorders, many of which have already been discussed iii preceding chapters. Growths, either benign (non-cancerous) or cancerous ones, are notorious for producing uterine problems. Bleeding anomalies and many other disorders frequently mean the uterus should be removed. Sometimes there is associated disease of the tubes or ovaries, one or both. Depending on the state of these organs, various parts may be removed at the same time.
Surgery is very straightforward. It is usually carried out under a general anaesthetic (the patient fully asleep). An incision is made above the pubic bones, the uterus located, and removed. The entire organ is taken away, including the cervix. In years past, the cervix was sometimes left, making it a less difficult operation, but as cancer of the cervix could still occur, it is now the universal recommendation that it be removed with the body of the womb. Sometimes the operation is carried out via the vaginal approach. This gives similar results. In younger women, every effort is made to preserve the ovaries, either fully or partially, for they will continue to produce essential female hormones up until the age of 50 or beyond.
When the operation is over, the layers of the pelvic wall are stitched together and soon the patient is up and around. Her problems are usually over, recuperation is generally rapid, and her health thereafter is usually markedly improved. Gone is the chance of ever reproducing again, but the operation is often carried out after the full family numbers have been achieved, so this is usually no big deal. In my view, hysterectomy is a valuable aid to making the woman feel better, have a greater level of self-esteem, and be filled with more energy and vitality.
Some women fear that it will detract from their love-life, and make them a “neuter gender.” This is totally incorrect. In most cases, many women have an appreciated lovemaking capacity, for the causes of their previous pelvic ill health have been removed, and they feel so much better. Pain, discomfort, for whatever reason, also goes. They are still very feminine, still very much a woman. Sensations are frequently improved.
Do not let anyone dissuade you from this surgery, if it is indicated, on account of reduced libido. In most cases, it is simply not true. Most likely you will perform better than ever.
Lovemaking and Some of Its Problems
There are many important facets to married life. In the overall picture, it should represent a happy blending of all avenues of communication. Total happiness is possible only if both partners are alive to this realisation.
Many of the factors that will help to achieve this have already been outlined in the first section of this book.
An important part of the physical side that causes much heartache and dissension will be covered in this Article.
The great majority of couples are perfectly capable of achieving the delights of physical union intercourse, but this is not always the case.
Although it may seem strange to many readers, the facts of the situation are that a significant number of marriages are never consummated. In others, normal, regular intercourse does not occur. In others again, while sexual activity may have been at a satisfactory level at one stage, for a variety of reasons this has lapsed.
In a large gynaecological clinic that specialised in treating couples for infertility, it was found that of the total number treated, about 3 per cent had never consummated their marriage. In other words, normal sexual union had not taken place. Under such circumstances there was little wonder the female partner had failed to conceive.
The chief reason for all this is put down to a symptom complex that is referred to as dyspareunia.
Dyspareunia simply means that there is pain with intercourse. Another related term, apareirnia, means that intercourse has not taken place. Of the two situations, the former is by far the more common.
This condition can be highly frustrating for both partners. Generally, the position arises not through any lack of desire on the part of the woman, for she is invariably only too happy and eager to take part in sexual activity. But if she experiences pain or discomfort whenever an attempt at penetration occurs, she gradually develops a mental overlay to the whole problem, making the solution doubly difficult.
The entire situation is one that can readily and rapidly snowball. As nearly everybody knows, in lovemaking, success breeds success. Conversely, failure unfortunately tends to breed failure. This situation is nowhere better illustrated than in women with dyspareunia.
Varied Descriptions
An enormous range of possibilities exists, and the descriptions given are as varied as the women who pour out their sad stories to the doctor.
Many women put up with their situation and say nothing, probably for many years. They accept it as being part of the hard lot of the wife, as “one of those things that happen,” as a penalty for being married. Some believe that it is the usual thing to happen, for women with this problem seldom discuss it with others, believing it is a highly personal matter that should not be talked about, even to their doctor.
Many women, out of sheer devotion and loyalty to their husbands, will not even discuss the matter openly with him. They are afraid of upsetting him, of spoiling his marital rights, or of creating domestic rifts.
Under these circumstances the situation rolls on in a never-ending manner, with little hope of relief in sight.
On the other hand, other women will loudly and openly voice their disapproval, and will certainly not “suffer in silence.” If they find the whole experience uncomfortable, they will not tolerate it, but will let their partner know in no uncertain way. These women, often forceful personalities in their own right, will tend to reject intercourse, and shun all sexual activities.
Other women will happily go along to their family doctor and pour out their problem. Unfortunately, many busy doctors are a little blinded to the psychological importance of this symptom, and have neither the time nor the interest to lend much support. Many believe that saving women from the rigours of cancer and correcting major symptoms is far more important than endeavouring to remedy an unsatisfactory love-life.
With this fear in mind, lots of other women will not openly admit their problem to their medical adviser.
Whatever the nature of the symptom complex, the fact remains that it is a very real problem. What is more, it demands action, for many marriages have foundered and split because of this.
A husband can be kind and understanding for just so long. But with the in- built sexual drive being so strong, few will put up with this deprivation of their sexual urges and needs indefinitely.
Women need sexual fulfilment also, and it is in their own interest to have the problem rectified if at all possible.
There are varying degrees of difficulty among women with this complaint. Some find that even minimum penile penetration evokes considerable discomfort. Others find that penetration can proceed without much discomfort, but with complete vaginal containment, the pain commences and increases. With the natural thrusting motions of sexual activity, this can become rapidly more uncomfortable.
Doctors recognise that there are two chief reasons for this problem. In many cases there are definite physical reasons, and these can often be corrected, either with medication or some type of surgical approach. But in other instances, no physical or pathological cause can be discovered. In these cases, the reason is essentially a psychological one; it is “all in the mind.” Because these factors are both very important, they will be discussed separately under two headings.
Physical Causes of Dyspareunia
There are many genuine physical causes that make normal sexual activity painful. Here are some of the main reasons, although the list is certainly not complete.
• Malformations of the lower female genital tract can occur. These may physically make the insertion of the erect penis nearly impossible.
• Previous surgery. Much surgery is carried out in the pelvic region. After this, because of the scarring or other related reasons, discomfort can take place. In younger women, childbirth with tears or an episiotomy (where the entrance is surgically widened to allow the baby’s head to come through) may heal, but leave an acutely tender area over the scar, which can remain this way for many months and years. Older women often suffer discomfort following a “repair operation.” Here the vaginal walls, having lost elasticity, tend to cave in, and they must be tightened and the lax tissue removed. Discomfort after these operations is well-known.
• Infections. Vaginal infections of any kind can make the lining very tender. Trichomonal and monilial infections are notorious for this, and can destroy the delights that were previously experienced with normal intercourse. Any vaginitis, whatever the cause, can have a similar effect.
• Tumours. Growths of the pelvic area, particularly the rectum or vagina, may make normal penetration difficult and give rise to discomfort.
Most of these conditions will produce discomfort when an attempt at insertion is made. Some women find that it is only with deep penetration that pain takes place. Some of the more likely reasons for this include:
• Chronic pelvic infections. Any infection anywhere in the pelvic organs is a possible cause of this problem. Infection can occur in the cervix or the body of the uterus. It may take place in the tubes, or in the ovaries themselves. Or the overlying pelvic lining may be involved. With the use of the IUD as a contraceptive reasure in recent years, uterine infecti ns may be silently persisting in cou’ntless instances. These must have an effect in many women, and gradually lead to the production of pain with intercourse.
• Adhesions. Sometimes adhesions from previous pelvic or low abdominal infections can be a precipitating cause. This means that thin bands have grown from one organ to another. For instance, the womb, ovary or tube may be adherent to part of the bowel or to the front wall of the abdomen. When in certain positions, these may pull, and this can readily be aggravated by intercourse. Many such cases have been reported, and relief has been rapid when the adhesions have been severed by surgery.
• Advancing years. Women who have passed the menopause often notice a thinning of the vulva and vaginal tissues, and a drying out. This is due to the lack of circulating female hormone, and an atrophic vaginitis commonly occurs that makes intercourse more difficult and uncomfortable. It is an age-related problem, but fortunately it is very amenable to treatment.
• Partner problems. Coming toward the end of the list of probabilities, the fault may lie essentially with the husband. Some have a gross ignorance of the normal female anatomy, and have little appreciation of the basic techniques of lovemaking. Selfishness, clumsiness, the desire for personal sexual gratification at the expense of all else, inadequate ability or knowledge about pre-sex foreplay, are just some of the male-orientated reasons why the female partner may suffer as a result.
• Other reasons. Many other potential reasons exist. A tender prolapsed ovary may be pressed on with deep penetration. This may elicit pain. Retroversion, not a common cause, but often present in women with dyspareunia, may be a precipitating feature.
• Non-reasons. Hardly ever is the old myth of “disproportion” a reason. This assumes that the wife is “too small” and the husband is “too big.” Clinical trials have established that practically any penis will fit any vagina. Neither is the hymen a common or valid reason. Usually what fragments of this remain are quickly stretched, and rarely act as a mechanical barrier to penetration. Very rarely a rigid remnant may be present, but this invariably responds to gentle stretching, and an erect penis is by far the best instrument for accomplishing this purpose.
Sometimes a husband’s ignorance of lovemaking techniques and of his wife’s sexual needs can cause tensions in the marriage.
Psychological Reasons for Dyspareunia
Now that many of the basic physical reasons have been checked, there still remains a massive aspect that some doctors believe is larger than all the others put together.
These are in effect, mentally orientated reasons. To be sure, the problem is basically a physical one, but the underlying reason is attributed to what is occurring in the mental processes.
This usually presents in the form of a condition called vaginismus. This condition is due to a sudden tightening of the muscle fibres surrounding the vaginal entrance. Often the muscle spasm is so vigorous that penetration is utterly impossible. Even an experienced and understanding physician trying to carry out a vaginal examination in the surgery will evoke a similar response, and it may be entirely impossible to conduct an examination.
In some cases not only are the muscle fibres surrounding the vagina involved, but the muscles of the whole pelvic floor and even the muscles of the thighs that involuntarily cause them to close may contract vigorously. (This is so well- known that these muscles have often been referred to in semi-jest as “the pillars of virginity.” Certainly, when in action, they would seal a woman’s chastity.)
Almost always this condition arises from impulses being sent down from the brain. The girl’s basic upbringing and her early training invariably play a major part. Those with very severe, religious upbringings tend to fare worse. The inherent idea with which a former generation was deluded by well-meaning but completely out-of-touch parents that sex is dirty, that intercourse is not for nice people, that God abhors the things that go on in marriage, all play a major part when it comes to this problem.
In rarer instances, a sexual assault in a girl’s early life may have permanently scarred her subconscious. Or the clumsy attempts made by the husband on the nuptial bed may have created such emotional havoc that the memory lingers on. In all these instances, an inherent fear is the basic cause.
Treatment of Dyspareunia
Any woman suffering from dyspareunia should consult her own family doctor. Or she may be referred to a competent gynaecologist who may be more expert in this field and more attuned to the complexity of the situation and the wide range of causes.
Often a brief physical examination will take place, and this will be followed by a more detailed pelvic check.
The gynaecologist will make every effort to find if there is any physical or pathological reason for the symptoms.
If one or more can be found, then so much the better. Treatment will then be directed to therapy aimed at lessening that particular complaint.
Often infections can be treated with specific medication, already outlined in this section. Deeper infections may require antibiotics, possibly for a longtime. If an IUD has been in place for many years, it should be removed. It is incredible how infection can continue to smoulder silently on for years with these devices in place. Most doctors have stopped inserting IUDs.
If there appears to be some internal disorder that cannot be accurately pinpointed, such as adhesions or misplaced pelvic organs, a surgical investigation may be recommended.
Today, with the ready availability and widespread use of the laparoscope, it is possible for the doctor to gain an amazing internal view of the total pelvic and abdominal contents. So, instead of the hapless patient being subjected to the trauma (mental and physical) of the old-time laparotomy (investigation operation where a large incision was made into the pelvis), the laparoscope via a tiny incision about 1 centimetre long can gain very useful and valuable information about any possible defect inside. Certain abnormalities may be treated at the same time via the laparoscope. The entire operation may last less than half an hour, and the patient (who has an anaesthetic) may be allowed to leave hospital all in less than one day.
Older women who are experiencing problems due to their age and obvious lack of hormones often benefit from the insertion of oestrogen suppositories or creams into the vaginal tract on a regular basis. If the outer parts are uncomfortable, steroid creams can often assist. Simple, surgical lubricating jellies make penetration much easier. Oestrogens orally in small doses for short periods of time also assist tremendously. This simple treatment often brings excellent results.
Discussion Can Help
If no pathological basis can be found to account for the problem, a discussion into the whole aspect and attitude to sexual relationships will often produce beneficial results.
This is often carried out with the male partner present at the same time. Specific attention is paid to lovemaking techniques. Often a husband will become a little wide-eyed when he discovers that the basic cause could lie with him, and his total ignorance or at best inadequate knowledge on how to go about satisfying his wife’s sexual needs unfolds.
Some women who have a so-called “low sex drive” need special attention, and unless a husband is attuned to these needs, adequate sexual satisfaction will never come her way.
Often the use of simple lubricants can assist. The wife may be instructed on how to manually dilate her vagina; sometimes dilators are used, not so much for their dilating benefit, but for the psychological reason of showing her that her vagina is quite capable of penile containment.
Sometimes surgical correction of a scarred and contracted vagina is required, but this is not often necessary.
Many couples see the entire sex fields in a new light after time and effort have been taken to explain to them many of these fundamentals. Once the thinking has been corrected, and the sub- conscious mind has been retrained (but it may take a long time for this to be done completely), a new form of thinking can take over. No longer is sex a dirty word. No longer is penile penetration something that God forbids in the marital unit. No longer is it unchristian to have sexual desires. This is all part of the normal pattern of life, or living, or the desire to copulate and reproduce. It is all part of the planned system of having and rearing a family.
Once these attitudes win mental acceptance, a couple is then well on the way to success. Once the delights of uninhibited sexual joy have been experienced, a new world suddenly bursts forth, and the couple will find they have discovered a unity and fulfilment they never believed possible.
Frequently prescription drugs, elevated blood pressure medication in particular, will have an adverse effect on male potency.
Male Problems
Although the woman is often involved with sexual problems, her partner may also have several difficulties that adversely affect the lovemaking process. While his hormonal system would normally give him the desire for intercourse any time from the early to mid-teens onwards, a variety of events may occur to drastically reduce this desire. The result is either lack of desire, or more likely the inability to gain or maintain an erection adequate for penetration and ejaculation.
Some illnesses probably head the list, with diabetes the major culprit. Many diabetics suffer from reduced libido, and difficulty in gaining and holding a reasonable erection. Ideally, these people should be under treatment, and as their diabetes comes under control, there may be a return (full or partial, often partial) of their libido and sexual capacity. On the other hand, in some the problem seems permanent.
A considerable amount of research has been carried out in recent years, and two forms of therapy are now widely used. The first one is the silver wire. This is a special device, stitched into the penis, allowing the penis to be kept in any desired position, eg erect, limp, pointing up or down. As the wire is manipulated, a pseudo-erection is possible, providing a certain amount of sexual gratification.
Another method is insertion of small, fluid-filled wells into the groin, with a tube going to another tube located in the penis. By pressing the wells, fluid goes to the penis, and causes an artificial erection, enabling intercourse. Afterwards, the procedure is reversed, the fluid returns to the wells until next time. This too is often successful. The operations are carried out by specialist urologists in major capital-city hospitals.
Other illnesses can similarly reduce libido and the male’s capacity. In fact, any illness will reduce libido, although on recuperation, it will often spring back to normal. A large number of modern medications are known to reduce libido. Drugs given for elevated blood pressure probably head the list. Many of the newer families of drugs are notorious for this, and males refuse to take them due to this adverse side effect. Some of the newer drugs to reduce acid production in the stomach (for ulcers, dyspepsia and similar problems) have a similar effect and can be downright “disastrous,” in the words of patients so afflicted. Sedatives and tranquillisers similarly reduce libido.
Alcohol, although it may increase sexual desire, is a poor performer, and is a common cause of reduced libido, and erectile and ejaculation failure. Many young men fail to realise that their enormous capacity for alcohol will often have a very adverse effect when they try to turn words and desires into action.
Overwork, long hours of operating under stress and duress also have an adverse mental effect, which in turn seems to shut off libido and performance. Often a break from work, a vacation, a change of scenery will work wonders for men in this category.
Smoking is also bad news. It is claimed that the effect sexually is often the first and earliest indication that the blood vessels are being adversely affected. By narrowing down the diameter of the vessels to the penis (called vaso- constriction), less blood goes to the area. A large volume of blood is required for erection. If the supply tubes are obstructed, problems arise. This is an indication that vessels to other parts of the body are probably. being similarly adversely affected, for example to the heart and brain. It augurs poorly for the person’s sex life. But it also offers a poor outlook for his heart and brain, and such persons may be prime candidates for later heart attacks and strokes.
Advancing years also cause problems. Whereas women are often at the height of their libido and sexual desire in their 30s and 40s, in males it tends to be the reverse. Their peak is in their 20s. Although hormonal production keeps on for many years, often into their 60s, 70s and even 80s, libido often sags at a relatively early age compared to women. Large numbers of men have difficulty in maintaining a good erection in their late 50s and 60s. Many equate this with “bad luck,”“one of those things,”“old age.”
On the other hand, many men suffer from enlargement of the prostate gland (situated just below the bladder). This may cause difficulties in passing urine, and can cause nocturnal frequency. This may lead to surgery being required on the prostate. Often, the nerve supply to the prostate is interfered with (as part of the operation, not by intent). Later, they may have considerable difficulty in gaining and maintaining a normal erection. However, the assistance and cooperation of a loving, attentive, understanding partner can often help overcome this to a certain extent. Both must understand the situation, and try to help one another. This is true in every aspect of the lovemaking game.
Often some younger men suffer from “premature ejaculation.” This means that ejaculation comes within seconds of penile insertion, often with one or two thrusts. The male has no control over it, and the woman is left in a state of mental and physical expectation with nothing to follow. It is a devastating disorder, and requires advice, recommendations and treatment by a competent sexual counsellor (usually a doctor who specialises in this field). Help is often available, with methods such as the “Squeeze Technique,” and other forms of treatment.
Incidentally, overweight is another bit of bad news. The sheer mechanics of lovemaking are much more difficult if one (or worse, two) partners are over weight. Give all these matters some consideration, for many are either partially or completely curable. Discuss them with your doctor, who may offer appropriate lines of action, and refer you to the appropriate consultant.
Although there are many causes, these represent some of the more common ones.
Breast Cancer
Nothing has captured the imagination more in the so-called civilised Western world than the human female breast.
Everybody admires a shapely figure. But the female bosom has been exalted more than any other obvious part of her anatomy. The social awarenes of an attractive shape seems to know no bounds. It is used to extol anything, and advertising men are loud in their praise for this, the greatest product-selling device yet encountered!
Such is its impact upon the spectrum of society—the rich and the poor, the exalted and the humble, the perfect gentleman and the ruffian—that women will go to no end of trouble, pain, suffering, humiliation and deprivation to achieve a shape that is claimed to be attractive by the world’s yardsticks of comparison. Great sums of money are spent annually on bosom-bolstering devices. Probably even more is spent in endeavouring to surgically improve what nature has provided free of charge.
Reconstruction surgery (tagged as augmentation mammaplasty in the name of science) is not particularly comfortable, and carries with it the risks of operative surgery, anaesthesia and hospitalization. Yet women queue up by the thousands to have this physical assault made on their frames. All this is done in the name of “better health,” but really is a valiant, vain effort to reach the physical dimensions of their female competitors.
Not that this is altogether to be decried. It is often astonishing to witness firsthand the enormous psychological benefits that many women achieve when made as attractive-looking as their contemporaries.
Self-esteem may suddenly skyrocket. Confidence returns (or may come for the first time in a person’s life); a positive mental approach may suddenly replace a faltering, introspective psychologically warped outlook. Much is to be said for the efforts womankind makes to impress her man.
But the ironical twist to the story is that in spite of all this adulation and glamorous form-worshipping, the breast is the target for a far more important attack.
As the site for the most ominous type of disease possible, it virtually holds the top record.
The most disastrous of all is breast cancer. This is enormously common in women living in the Western world, and the rate is increasing.
Large sums of money have been spent and endless research into this subject has been carried out for decades past. But the sad situation is that despite all this effort, despite the variety of systems devised, the surgical procedures and other techniques advocated, the mortality rates of breast cancer haven’t improved much over the past 50 years! In an age of vast scientific accomplishment, when they can place living men on the moon, and bring them back home again, science still cannot cure breast cancer.
From all parts of the Western world the story is identical. Just to emphasise the enormity of the situation, here are a few statistics gleaned from recent medical journals:
• InAustraliaandNew Zealand, one woman in 13 will contract breast cancer.
• At least 250,000 women die annually (worldwide) from breast cancer.
• Breast cancer kills one female in each 25—there has been no improvement in mortality in the past 50 years, a recent 50-year review indicates.
• 10,000 women die annually in the United Kingdom from breast cancer.
• About 5 per cent of women in theUnited States develop breast cancer at some time during their lives.
• About 1,200 Australian women die annually from the disease.
• In Western Europe and the United States the figures are increasing. In Asia and Japan, the figures are low, and are reducing!
• Cancer of the breast is among the most common malignant tumours, and is a major cause of death in women. The peak incidence is between. The ages of 40 and 50 years.
The reports go on and on. Hardly a medical journal comes off the press, but it contains somewhere an article or report on this horrible disease.
Left untreated, the average person will live for about three years. However, the disease is sometimes capricious. Some patients who do not receive any treatment may die within three months; others have survived for as long as five to 30 years! No doubt some of the latter would be included in wild and usually ill- founded claims for new “cures” for cancer.
There seems to be a family tendency for breast cancer. Those who have such a history tend to contract the active disease at least twice as commonly as others, and they seem to be affected at an earlier age. However, on the worldwide scene, it appears to be affecting more women at a progressively younger age level. Some women who have suffered from cystic disease of the breast appear more prone to develop the disease, and for this reason it is essential that they take greater care, and have more frequent and thorough follow-up care than their contemporaries.
There is still uncertainty about the effects of a woman’s marital state, the number of children she has produced and breastfed, and cancer. However, many claim that the risks are reduced when breast feeding has been actively pursued.
Contrary to popular belief, it seems that local injury, inflammation and non- cancerous tumours of the breast do not play any part in the subsequent later development of cancer.
A lot has been written about the contraceptive pill and the possible production of cancer. Many surveys have been carried out. A massive long-term appraisal in the United Kingdom claims that there is positively no relationship. Indeed, if anything, the hormones of the pill might exert a mildly protective benefit on breast tissue and make it more likely to withstand the development of carcinoma.
The New Breast Self-Examination Technique
Breast Cancer
Why some nations seem almost exempt from breast cancer is unknown. A strange situation is that if people from these countries (notablyJapan) migrate to Western countries (such as the United States) and live there permanently, with the progression of time, their breast- cancer rate slowly equates to that of the local population. This seems to indicate the presence of some local factor as a causative or aggravating agent.
It is very well established that the best hope for survival lies in early detection and prompt surgical treatment. Many methods have been used to endeavour to make diagnosis earlier and earlier. Some methods have succeeded in part.
“Regular self-examination of the breasts after each menstrual period should be practised by all women over the age of 30,” a team of American experts have emphasised.
Many women find this difficult, and claim they can feel all sorts of lumps in the breast. They believe it is difficult to know what is abnormal and what represents normal breast tissue.
Various cancer-prevention societies also advocate regular self-palpation (feeling) of the breasts. Printed in this chapter is a guide as to how this may be carried out, step by methodical step. Regularity and thoroughness are two essential ingredients for success in any self screening system.
Fortunately, with the wide use of the contraceptive pill, many women must reattend their physician (probably six to 12-monthly) for a repeat prescription. Many doctors take this opportunity to carry out a complete breast examination. Also, a pelvic check is done at the same time, for uterine cancer is a serious disease, and may be detected by such screening procedures.
Breast Cancer
In recent times, more use is being made of special investigations used to detect breast cancer early. These are mammography, ultrasound, needle biopsy and thermography.
Mammography means that the breasts are subjected to special X-rays. When interpreted by skilled experts, a relatively clear diagnosis is often possible. The results are not 100 per cent, but cases can be detected that may have otherwise been missed. In some regions inBritainandAmerica, there is talk of carrying these tests out on a wide scale (especially with women in the at-risk age bracket). The cost to the country would be enormous, but it seems it may be worthwhile on a selected scale.
Mammography is either in the form of an ordinary black and white X-ray ifim, or as a blue and white “print” called a xero-gram, and which some claim gives a clearer picture of a possible cancer or any abnormal growths.
Ultrasound means breast examination by shooting special soundwaves through the tissue, and recording the picture on a televisionlike monitor. Hard copies are also made for the records. This tends to pick up breast irregularities, cysts, lumps and early cancers. It is used with the other forms of investigation.
Fine Needle Biopsy: This waxes and wanes in popularity, and means the insertion of a fine needle into the lump of the breast and withdrawing fluid or cells. These are examined microscopically to detect the presence of cancer cells. Some claim there is a risk of spreading if cancer is present, as the needle is withdrawn. Other doctors disagree. Nevertheless, in expert hands, it is often useful as an additional method of diagnosis.
Thermography has had its ups and downs. For a while it enjoyed popularity. But then it fell into decline, for it was believed to be too insensitive. But with newer, ultra-sensitive equipment it has again come into prominence. This depends on the fact that cancer cells are warmer than surrounding normal tissue. Once more, as with mammography, certain cases may be picked up that may have escaped detection by normal palpation or radiography.
In the past couple of years, a greater attempt has been made by researchers to discover a blood factor that may be specific for certain cancers. Although various enzymes have been detected, using the highly sensitive radioimmunoassay and other sophisticated techniques, to date none has appeared that is breast-cancer specific. Maybe the future will yield a chemical in the blood that will ultimately make diagnosis simple by routine screening procedures.
Breast cancer seems to have certain areas of predilection. Here are the chances of it occurring in the various quarters or quadrants of the breast:
Breast Cancer
• Upper outer quadrant: 45%.
• Lower outer quadrant: 10%.
• Upper inner quadrant: l5%.
• Lower inner quadrant: 5%.
• Central (about the nipple): 25%.
The key problem is that the cancer spreads with terrifying speed. Often before diagnosis has been made, it has spread to the lymph glands in the armpits. Once this has taken place it is entirely unknown to what other distant parts it has journeyed. At this stage, even if massive surgery is carried out, the patient’s doom has often been irrevocably sealed.
In patients undergoing initial surgery, microscopic study of the lymph glands of the armpit (axilla) indicate in about 60 per cent of cases that these are involved by this time.
Mammography, a special blue and white X-ray print called a Xero-gram, is said to give a clearer picture of possible cancers or abnormal growths.
But besides spreading by the lymph system, spreading via the bloodstream is also common. For this reason, the disease can rapidly spread to other organs, and cancer cell nests (called metastases) may commonly be detected (by X-rays) in the pelvis, spine, ribs, long bone of the thigh, the femur, skull and arm bones. Spread to the lungs and liver is also common.
Symptoms. In the majority of patients (about 80 per cent) the chance discovery of a painless lump in the breast is the first sign.
Less frequently, there may be other telltale symptoms, such as discomfort in the breast. Or there may be nipple symptoms such as erosion of the nipple, itching, redness, retraction or discharge. The breast itself may show signs of redness, or generalised hardness, enlargement or shrinkage.
Often lumps are difficult to feel by the examiner. But patients have reported
Thermography, a procedure that has gained popularity in recent times with the arrival of ultrasensitive equipment, relies for diagnosis on cancer cells being warmer than surrounding tissue.
tumours less than one centimetre in diameter that have escaped the skilled examination of the physician.
The patient is usually examined lying on her back, with the arms at the side and overhead; sitting with them by the side and then overhead. This procedure is usually meticulously followed by the examining doctor. Unless it is very strictly followed, it may be possible to miss small lesions. As it is, about 5 to 10 per cent of cancers are detected during routine examination for some other disorder, and chance has played a part.
The cancer usually consists of a non- tender firm or hard lump with poorly delineated margins. There may be slight skin or nipple retraction, and this may be an important early sign. There may be a minor degree of asymmetry between the two breasts when examined side by side.
When breast cancer is advanced, the signs are painfully obvious. The tissue is red, ulcerated, swollen and the cancer may be clearly in view. The breast may be fixed firmly to the chest wall by the cancer, the breast itself swollen or shrunken in size.
Even in these modern days, when knowledge of at least some aspects of breast cancer seems to be widespread, women still come along for the first time with massive fungating sores on the breast that have obviously been there for years.
Why does this happen? Fear is perhaps the chief reason. The “It can’t happen to me” attitude is probably another. When questioned, no answer that makes sense is proffered in many cases. It seems one of the phenomena of these modern times.
TREATMENT
Sometimes “needle biopsy” is carried out first to help pinpoint diagnosis. But apart from this, immediate surgery is indicated. Usually a biopsy section is removed at first, and this is subjected to an on-the-spot “frozen section” pathological examination. Within a few minutes an accurate answer can be given as to whether the lump is cancerous or not.
If cancer is found, surgical removal of the breast is carried out. Often this is a radical mastectomy procedure. Not only is the breast taken away, but the surrounding tissue and glands of the armpit are meticulously removed.
These are all subjected to pathological examination. From the degree to which the glands are affected, a more accurate picture for the future prospects may be offered.
With heavy infiltration with cancer cells, the outlook is grave. By this time, it is highly suspect that the cancer cells have already traversed the body far and wide.
Following on from surgery, various forms of therapy are then followed. Radiation therapy has been popularly used for many years. But relatively recent reports from various worldwide centres have incriminated radiotherapy as possibly lessening rather than increasing the chances of survival following surgery.
About the same time as these occurred, major advances have been taking place indicating the possible benefit of anticancer chemotherapy. Several trials indicate this may be the treatment for the future. Time will tell. At the time of writing, drugs such as L-Pam, cyclophosphamide, methotrexate and fluorouracil were among the favourites. Maybe these will prove to be of even greater value, used alone or in combination, or with other more potent as yet undiscovered and untried treatment. For the first time some sort of progress in improving the situation appears imminent.
It is to be hoped so, for at the present moment the total picture is still far from rosy.
As a point of interest, and reverting to the theme expressed at the commencement of this chapter, many surgeons are taking a more humane attitude toward their breast-cancer patients.
In a major hospital in Birmingham,Britain, patients are being offered immediate reconstruction surgery with the introduction of an artificial prosthesis at the same time as their cancerous breast is removed.
This would seem the ideal situation for this type of surgery. At least the woman would have the mental appreciation of still looking like a woman when she awakes from her major and traumatising operation—a chest that looked fairly normal, and not too different from that of her contemporaries.
Maybe this idea will soon spread to other hospitals. It is to be hoped that it will. It could ease the mental burden of many unfortunate women otherwise doomed for a dismal future.
In conclusion. Once more, as a concluding comment, the advice proffered earlier is reiterated. Cancer of the breast is a sinister, deadly disease. The earlier it is diagnosed, the greater are the chances for long-term survival. But this can only occur through constant vigilance by all women at all times. Never let this be forgotten.
Those Ugly, Unwanted Hairs . . . and What to Do
As a strictly feminine problem, unwanted facial hair is a particularly personal one.
Great numbers of women suffer from this complaint. In most cases, the symptom is not a disease, nor is it related to any internal disorder. But as a symptom in it, it can produce much heart burning and soul searching.
Beauty is the eternal goal of every woman, and in our society hairiness is equated with masculinity. Despite the legal arrival of equality of the sexes, the sexual distinctions in regards to appearances are still poles apart. However, men like their women to be feminine. The age of chivalry has virtually died, but the mental concept lingers on.
Therefore, the suggestion that a woman should have whiskers like a man is appalling. It strikes at the very essence of her womanhood.
Indeed, many women develop mental hang-ups and anxiety states, and every doctor has seen frank cases of depression over this seemingly simple symptom.
Doctors talk about hirsutism. This usually means there is an excessive growth of hair on the face, breasts, limbs or abdomen.
Most women have a greater or lesser amount of hair growing on the limbs, but this seems more acceptable for reasons that seem on the surface totally unrealistic. Moreover, scalp and pubic hair seem all right too, but maybe women equate this with some protective function that is designed to retain their modesty.
Whatever the primordial reasons (and it is unlikely that these will ever be fathomed), the stark fact remains that hirsutism with the distribution noted will remain a controversial female talking- point for many decades to come. It will also be a fighting-point, and one for which a suitable answer is being eternally sought.
In the vast majority of cases, unwanted facial, breast, abdominal hair, or heavy growths on the limbs, is entirely harmless. There are some rare pathological causes that will be discussed briefly later on; but most women with excessive hair growth have no sinister, hidden internal disease.
The condition is clinically referred to by doctors as constitutional or physiological hirsutism. A very close and detailed physical examination will not reveal any other signs of virilisation (mannishness).
There is nothing to worry about; just as some women have long, pointed noses with a bump in the middle, and others have short, stubby ones with no bump, or some have big, prominent ears, and others small ones, or some are endowed with very feminine chest contours, and others are unhappily given no shape at all, so some women have hair here and there where they wish it wasn’t.
Often there is a family tendency to the unwanted hair situation. A parent with excessive hair will often produce a daughter with the identical problem. But this does not always hold true.
If physical and investigatory examinations do not indicate the presence of any untoward physical pathology, the patient is usually reassured of this. At least this often removes a mental burden that some serious disease, or a cancer, may be lurking in the internal depths. Many brighten perceptibly when told the good news.
TREATMENT
In recent years, an increasing amount of research has been carried out to try to discover some universally suitable product that will selectively remove facial, breast and abdominal hair (and probably excessive hair from the limbs), but at the same time not interfere with the normal hair distributions of the scalp, eyebrows and other parts where its presence is acceptable. Herein, of course, lies the major problem.
However, by chance, a form of medication that has been used by doctors for many years for other purposes was found to have a favourable effect on women with facial hair. It is called spironolactone (“Aldactone”). When given in an oral dose of 100 mg a day for
Many months, it appears to reduce facial hair growth. It should be given under medical supervision. It usually takes nine months or maybe longer for its full maximum beneficial effect to be reflected on the face. It may be necessary to increase the daily dosage. This is tailored to the woman’s response. Usually there are no adverse side effects. Sometimes it is noted that there is an improvement in skin appearance, especially if the woman had been prone to facial pimples. These also tend to diminish. It is believed it works by blocking testosterone uptake by the hair follicle. Each sex has some hormones of the opposite sex (ie women have some testosterone circulating in their blood). This may be the reason why masculine- type traits occur (facial hair). By blocking the uptake of this chemical there is no further stimulation to hair growth which thence stops. Medication is continued more or less indefinitely. The treatment is not effective for everybody, but many consider it worth a try. It seems to be less effective for women past the menopause.
There are still other methods available, especially in those with small growth, or in circumscribed specific regions.
• Facial hair. For relatively small amounts, electrolysis by an experienced operator is by far the best and most permanent method. In this manner, the hair root is destroyed, and further growth from each treated follicle is impossible. Some women claim that as the follicles are destroyed, hair grows from new ones. But this is more in their imagination than real. As a precautionary note, always attend a person who is an expert in this field. Otherwise it is possible to have a series of tiny scars that protrude above the skin surface. Long-term, these may become a greater problem and more obvious than the hairs that preceded them. A good operator will usually leave a smooth, scar-free result.
For larger areas, depilatory creams may be used. However, this is a temporary measure, and the hairs will grow again. But a few weeks’ respite may be obtained. For special occasions, this can assist. But the creams will remove hairs completely, including the fine, soft, downy hair that gives the face some of its characteristic charm and softness. So, think well before resorting to this as a regular method. Depilatory waxes are not for the face.
Larger areas and hair growing on the upper lip may be treated with peroxide bleaches if the colour is dark and prominent. This will lighten the shade and make the hair much less noticeable.
Some women foolishly resort to shaving with a razor. This is a bad routine for the face. It tends to make the skin coarse, tough and masculine-looking and accentuates the very feature that is the problem.
• Breasts and abdomen. Very often the amount of hair in these areas is minimal. Frequently a few solitary hairs grow from the general breast area, or the nipple or surrounding areolar region. (This is the pinkish-brown circular area surrounding the nipple.)
Electrolysis is generally the method of choice for these hairs, many of which grow quite long.
A recurring problem, especially in summer months when bikinis and brief beachwear are worn, is hair peeping from underneath the clothing. Admittedly beach wear is extremely scanty these days, and one might say, “Serve them right!”
However, electrolysis is often the most suitable method. If the growth is too profuse for this, depilatory creams are suitable. Or even shaving can be used, for the skin is not under such close scrutiny as facial skin.
• Arms and legs. Often heavy growth of hair occurring on the upper or lower limbs is best removed by depilatory waxes. This often gives results that can last for some weeks. Electrolysis is quite unsuitable for such extensive areas, and the skin is not under close scrutiny by others. Depilatory wax use is rather uncomfortable, but it is quite successful for large areas. It also removes the very fine
Hairs that cover the skin in general, but this is not so important to appearance in these regions.
All methods of hair removal may be facilitated by the application twice daily of an oestrogen (female hormone) cream, such as dienoestrol 0.01 per cent.
Pathological Causes
In a very small minority of women, a pathological basis for the unwanted hair actually exists. This is often associated with other forms of virilisation also, such
as deepening of the voice, facial pimples, reduction in size of the breasts, an increase in the size of the body muscle structure, thinning of the hair of the scalp and with a recession of the normal hairline. The clitoris tends to enlarge in size; the menstrual blood-flow is often reduced and comes at more widely spaced intervals.
When hirsuties is associated with symptoms of this nature, then it is time that full medical investigation takes place.
Special investigations are undertaken at large, well-equipped clinics, usually at major hospitals. The urine is checked for the presence of special products called 17-keto-steroids, and the blood checked for testosterone levels.
If present, these could indicate the presence of internal growths that are producing excessive hormonal levels. Surgical removal may be followed by a recession of the symptoms.
Latrogenic Hirsuties. There is another form of hirsuties worth mentioning. Certain forms of drug medication may contain hormones (especially male hormone) that produce male-type symptoms, including hirsuties. When the medication is stopped, the hair disappears and a return to normal occurs.
Sometimes steroid drugs are given to pregnant women, and these may contain progesterone. It has been found that this may result in virilisation of the foetus. However, these days most doctors are extremely cautious in prescribing any form of drug medication during pregnancy.
Things That Go Wrong in the Pelvis
The female pelvis contains only a small number of organs. But these are complex, despite their seemingly simple outer appearance.
The pelvis really represents an entire manufacturing plant, complete with machinery, built-in computing apparatus, self-starting regulatory devices, and the ability to produce the total, complete product. It is capable of handling this all alone, as a composite package deal. This amazing feat has not been emulated by man in the physical world in which he lives.
However, with such a sophisticated set-up, it is inevitable that calamities happen. It is remarkable that they occur with such infrequency. For, judging by the number of infants produced, the number of abortions naturally carried out by nature her (to maintain quality control of the species), the relatively few maternal and infant deaths and disasters seen on the way and the ratio is extremely low. Once more, contrasted to man-made efforts in the commercial sphere, his efforts are puny indeed. Maybe there is a lesson to be learned here somewhere. It seems that more reliance should be placed on nature (or perhaps the real Creator of all life) than there is in the everyday sphere.
But, there can be no denying the fact, problems do arise, and they can frequently increase quickly if left unchecked.
The total numbers would in themselves fill a book. However, apart from those already discussed (and those that will be dealt with in subsequent chapters of this section), a few chief ones will be described here. This is by no means an attempt to cover the entire picture. Cancers of the uterus, a potent and serious disease, have been dealt with. A discussion will be given over to the other common swelling that frequently takes place in the uterus, the myoma. This will be followed by a brief run-down on the various major abnormalities that occur in the ovaries. Both disorders are fairly widespread, and every woman must be alert to the possibilities, their
The development of myomas in the wall of the uterus.
seriousness (and otherwise), and the line of action that is required.
The Myoma (Fibromyoma, Fibroma, Fibroid)
These structures (which are basically the same) are non-cancerous growths that occur in the wall of the uterus. They are composed of muscle fibres intermingled with fibrous strands, hence the variety of names.
They are the most commonly occurring tumour in the female. The size varies enormously. Fibroids may be the size of a pea or less. At the other extreme, they may grow to enormous dimensions, the size of a football or larger. Some have been removed weighing as much as 10 kg.
Nobody is certain how many women suffer from these, but a very conservative estimate would be at least five in every 100. However, they develop very slowly from microscopic seedlings occurring in the uterine walls. They are most commonly manifest in the fourth decade of life, when symptoms occur and of necessity demand treatment. At this stage, about 20 per cent of women probably have the disease.
These growths appear to be more common in women who have never been pregnant, or have produced only one infant.
It seems that the female hormone oestrogen plays a part in helping myomas develop. After reaching a maximum size in the fourth decade, they rapidly reduce in size after the change of life when hormonal levels suddenly peter out.
Although the tumour originates in the wall of the uterus, as it grows it may direct itself toward the interior or the exterior. This can produce all manner of resultant complications with the increase in size and the passage of time.
The accompanying figure shows the range of positions. They are often given technical names that relate to their anatomical position. By sheer mechanical presence, complications can take place. If it develops a stalk (pedurzculated), the tumour may become twisted, and so produce a surgical emergency. It may press on surrounding structures and produce irritations to those organs (constipation by pressure on the bowel; a desire to pass urine often if the bladder is being compressed).
Symptoms. These depend to a large degree on the size and position of the tumour. Small growths frequently produce no symptoms at all. A common symptom is heavy menstrual bleeding, particularly on the second or third day of the normal period. This can often be associated with “flooding,” with pain and the passage of clots. Serious anaemias can develop as a result. Usually a pelvic examination will indicate the presence of the tumour.
Sometimes surgery is necessary before a correct diagnosis is made.
TREATMENT
The course of action depends on the nature and severity of the symptoms being produced. If severe bleeding is occurring, particularly in an older woman, surgical removal of the uterus is often undertaken. If troublesome pressure symptoms are encountered, a similar approach is frequently made.
In younger women (especially those under the age of 40), and those still desirous of maintaining their reproductive function, myomectomy may be advised.
One important flow-on benefit is that a substantial number of women who appeared to be infertile (presumably due to the presence of the tumour) subsequently become pregnant after this operation. The figure has been claimed to be as high as 40 per cent.
Ovarian Tumours
The ovaries are a fairly common site for the development of tumours. They are most frequently detected in women aged 35 years or more. They tend to grow slowly, and are often not discovered until they have grown to a relatively large size.
Often a lump welling up from the pelvic cavity (sometimes believed to be a pregnancy, even though menstruation may still be occurring) is the first indication. But in an obese woman, it may just appear that she is putting on even more weight in the abdominal region, and may be overlooked for a long time.
Many are discovered in the course of routine pelvic examination for some other reason. (This is another reason in favour of having regular pelvic checks when returning for a repeat prescription of the contraceptive pill. If this is not carried out routinely by your own doctor, it is well worth asking for.) Many tumours are discovered during a laparoscopic examination of the pelvis.
Fortunately, about 95 per cent of ovarian tumours are benign (ie non- cancerous.) Benign tumours are usually cystic, so that if a cystic swelling is discovered, it usually means that it is a simple, non-cancerous one.
However, the remaining 5 per cent still equals a lot, and malignancy in this area is fraught with problems. For cancer tends to grow at a steady rate, silently, and almost symptom-free in the early stages. Often, by the time adequate symptoms have occurred to make the patient seek medical assistance, the cancer has advanced to an incurable state. Once more this indicates the supreme value of regular medical examinations and pelvic checks throughout life. Discovering these disorders early (before symptoms set in) offers about the only chance of a successful outcome.
Benign tumours never cause pain, unless some sort of complication occurs, and rarely do they affect menstrual function. Symptoms can take place if the tumour is on a lengthy stalk (pedicle), and it becomes twisted on itself. If the cystic swelling suddenly bursts, symptoms may also take place.
Princess Anne ofBritainwas in the news some years ago when it appeared that she had an ovarian cyst that had suddenly developed this complication. Sometimes a surgical emergency may arise. But with small cysts, a slight discomfort may be all that is experienced.
Very large tumours may produce symptoms from pressure on surrounding structures. Abdominal discomfort, lack of appetite and/or nausea may occur when the abdominal contents are squeezed by mechanical pressure.
Malignant tumours of the ovaries are often associated with pain, particularly in the later stages when surrounding structures have become involved. Fluid in the pelvic cavity and weight loss are also other ominous signs.
Diagnosis of ovarian tumours may be simple, or they may be extremely difficult. Sometimes radiology and ultrasound aids are needed to help in distinguishing it from other possible diagnoses.
TREATMENT
Treatment of most ovarian tumours is surgical. In young women, every effort is made to preserve as much of the normal ovary (if there is any left) as possible. This will help ensure continuation of the system’s hormonal supply, and so help maintain a feeling of normality.
As there is a high risk of benign cysts becoming cancerous, their removal is usually imperative. Besides, it is often difficult to know if a tumour is in fact cancerous or not until it has been thoroughly examined by the pathologist under the microscope. Any parts that are removed must always be scrutinised by the experts for a full report.
In older women, frequently a greater amount of tissue is removed, for there is often an increased risk of cancer.
The main point in this section is the need to recognise that ovarian tumours are relatively common. While most are non-cancerous, there is a real risk that malignancy may develop.
The sooner diagnosis is made and treatment undertaken, the better. There is also a case for regular pelvic examinations throughout life in order to detect any such abnormality as early as possible.
Menstrual Irregularities
From the age of the menarche, when secondary sexual development takes place in the female, the normal menstrual period commences.
The age at which this starts is variable, but it usually occurs anywhere between the ages of 10 and 16 years. In some women it is even later, but this is rare, being about one in every 100 women.
Menstruation normally proceeds fairly regularly until the age of 45 to 50 years, when the change of life sets in, and normal menstruation finally ceases. Some women may continue with regular periods well into their 50s, but this is not usual.
There are many factors that play a part in ensuring this regular cycle. Some are physical, but emotional overtones and external stresses, tensions and related psychological events can all play their part via the higher cerebral centres.
For this reason, although periods are traditionally normal and regular, and the level of loss is about the same, great variations can take place.
In fact, some females do not start their periods as anticipated. Others commence very late. Some bleed very heavily for no outward obvious reason. Others have a scanty flow. Some women have a cycle of 21 days; in others it is prolonged, and successive periods may be separated by as many as 35 to 40 days.
Many women tend to develop a menstrual pattern, and this may persist for many years. What seems normal to one person may seem totally abnormal and unacceptable to another. The natural variations are wide.
For many years some women will accept their particular pattern as being satisfactory to them. The chief reason may be that this is how it has always been, and they know no different way of life.
But then they may read a magazine article (probably about the possibility of cancer being related to a particular bleeding pattern). This gets hold of their imagination, and they quickly seek medical opinion, probably for the first time in many years, with the fear that they may be so afflicted, or may face some real dangers.
This is not a bad effect. Anything that will drive women to the doctor for a cancer check is to be applauded, for the rate of cancer deaths, worldwide, ranks it as number two cause of death. Apathy and lethargy and perhaps absolute ignorance, are some reasons for this. Fortunately, a great many cancers of the genital tract (and the breast) are accessible, and can be diagnosed fairly early. Abnormal bleeding habits may be an early sign that all is not well.
Many different classifications of bleeding abnormalities in women exist. But for practical purposes, these will be discussed under two main headings:
(1) Absence of Menstruation.
(2) Abnormal Uterine Bleeding.
Absence of Menstruation
This is called amenorrhoea. It may be a state of affairs that is present up to a given point of time. The girl has never menstruated, even though most of her contemporaries commenced in the traditional 10 to 16 year segment. Doctors call this primary amenorrhoea. There are various causes, most of which are uncommon.
Some girls are born with an imperforate hymen. This means the thin membrane that often partially covers the vaginal opening does not contain any opening in it. When menstruation occurs, the blood becomes dammed up in the vagina behind the hymen, and is not allowed to escape, due to the mechanical barrier. An examination by the doctor will reveal a bluish bulging hymen with no point of entry. Fortunately, the simple expedient of making an incision will be followed by the escape of the dammed-up blood, and menstruation may proceed normally after this.
On rarer occasions, some females are born with a congenital absence of the vagina. This may be associated with other congenital developmental problems, most likely in the urinary tract. Plastic surgery can assist these women regain a greater degree of normal reconstruction.
Others may be afflicted with chromosomal abnormalities. In place of the usual two XX female chromosomes there is only one, and there may be poor or deficient secondary sexual development. Diagnosis is a specialised procedure; chromosomal analyses are carried out, and if deficiency exists, hormonal therapy can yield very good results.
In other women, menstrual periods may suddenly cease, even though they may have been relatively normal up till that time. This is termed secondary amenorrhoea.
Women engaging in vigorous sport, or ballet training involving a strict diet, a thin figure and a great deal of physical activity, often do not menstruate, due to a low level of female hormone and an increased amount of male hormone in their systems.
The most common cause is a purely normal and physiological one, and is due to pregnancy. Sudden cessation of normal menstrual periods in a woman enjoying regular intercourse and not taking any contraceptive action is usually considered due to pregnancy until proved otherwise. Today, with rapid and accurate radioimmunoassay tests for pregnancy identification, a diagnosis can often be made before the first missed period! Certainly they can give a positive answer within a day or two of conception.
Another fairly common cause for missed periods is the person’s age. During the first two to three years following the menarche (the start of menstruation) it is common for young women to miss a period here and there, or to miss several consecutively. This is merely due to a fairly low level of hormones in the system and usually corrects itself without any treatment. Of course, this can often lead to much heartburning (the mental kind) and anguish, especially if the young lady has been “playing around,” as they say.
The contraceptive pill is notorious for producing period disorders. Those who regularly take the pill have a complete inhibition of ovulation. This means that the egg is not released from the ovary each menstrual month. The pill is usually taken for 21 consecutive days, then discontinued for the next seven days. During this break, an artificial menstruation, or more correctly withdrawal bleeding, commonly occurs, but to a limited extent. It may last for only an hour or so or half a day. In some, there is no bleeding at all, and this situation may persist indefinitely.
More serious, however, is what occurs when the pill is stopped, and a return to normal fertility is desired. In a certain proportion of women, post-pill amenorrhoea occurs. This means that the ovary fails to produce the egg each month. This can persist for several months or even up to several years. It is a most frustrating situation, particularly in the case of young marrieds who had hoped to plan their family in an intelligent manner, only to find that when they wanted to reproduce, this was denied to them. It is food for thought for those contemplating this sort of thing. Fortunately today with modern treatment, this can be rectified.
Other reasons also exist. It seems that they are mediated via the higher centres in the brain, and this produces a temporary shutdown of the hormone- stimulating mechanism that prods the ovaries into action. For, without activity in the ovaries, if an egg is not released, then menstruation simply cannot follow. Crash diets in young women provide a well-known cause. Sometimes this has led on to the more problematical condition of anorexia nervosa in which failure to eat is tied in with emotional crises, major weight loss and ill health. Other severe emotional strains are well documented for interfering with regular menstrual functioning. Sometimes, in rare situations, the ovary just prematurely ceases to operate.
Women engaging in sport, strenuous athletics, vigorous excercises, and those who do ballet training (where a strict diet, thin figure and a great deal of physical activity is involved) often do not menstruate. Hormonal checking indicates a low level of female hormone, and an increased amount of male hormone in their system, all of which tend to reduce the chance of regular ovulation, and normal periods. Generally, when these women cease• these activities later on, they quickly return to normal, and periods
often start automatically.
All of these situations require the attention of the doctor. They are not amenable to self-treatment, and the sooner a visit to your own understanding physician or gynaecologist is made for full examination and apptaisal, the better. Be guided by the advice of the expert in these matters. Psychologically, the sooner a move for a proper diagnosis is made, the better.
Abnormal Uterine Bleeding
The volume and frequency of menstrual bleeding can be as capricious as it is varied. A dazzling array of technical definitions is used to describe the possible variations. Here are the main ones, and you may find yourself among the number.
• Polymenorrhoea. This means that bleeding lasts for the normal number of days (four, five, or six or whatever is usual for a particular woman), but that it occurs more often. For instance, the total cycle is less than 24 days—it may mean a period comes on each 22 days or even less. It is caused by a variation in the regular rhythmic release of hormones that initiate the egg-release mechanism.
• Menorrhagia. Here the cycle is normal, but the duration and volume of bleeding is increased. Instead of lasting for the usual four to five days, it may persist for eight days or more. It usually means there is some hormonal imbalance present.
• Polymenorrhagia. In these cases, the bleeding is excessive, and the length of the cycle is reduced. Often this occurs when there is chronic inflammation occurring in the pelvic organs. But it is also often present in people suffering from emotional disorders, anxiety states and similar psychosomatic disorders.
• Metrorrhagia. This means bleeding is quite irregular, both in volume and duration. It is usually excessive, and is often associated with disease of the uterus.
• Dysfunctional Uterine Bleeding. When investigation fails to indicate any disease, this name tag is often applied.
Frequently it is related to psychological or psychosomatic causes.
The Greeks held the view that the womb (hysteros in their language) controlled female emotions, and that any disorder of the uterus could produce hysterical and other abnormal mental states. Of course, this is not true, but rather the reverse is nearer the mark.
Emotional problems can often be transmitted through the higher cerebral centres to produce uterine abnormalities.
It is well documented that emotional upsets, tensions, anxieties, sexual frustrations, marital disharmony, work pressures, family disputes, submerged fears, can all lead to either complete failure of menstruation, or to uterine bleeding abnormalities. These are capable of working on the part of the brain called the hypothalamus, and in turn the cyclical release of hormones that stimulates ovulation is prevented, or disturbed. In turn this leads to menstrual irregularities.
Days from the start of the Menstrual Cycle
However, there are many other causes of menstrual irregularities. Each part of the pelvic system can play a possible role. Disorders of the ovary itself can occur from tumours and cysts of this organ. Or the uterus itself may be at fault. Non- cancerous growths called fibroids are notorious for producing heavy bleeding. But more important, cancer of the womb can also produce irregularities.
Heavy bleeding is common with the IUD (intra-uterine contraceptive device), although it is rarely used today.
Pregnancy is the most common cause of abnormal bleeding, and its presence denotes a disturbance of the normal progress. It usually indicates an impending abortion (or miscarriage).
TREATMENT
It is essential that any sudden deviation from a person’s normal menstrual habits be investigated promptly by the doctor or gynaecologist.
A full pelvic examination usually takes place at once after a thorough check history has been taken.
It is imperative that the cause be discovered. Once this has occurred, then therapy can be instituted if this is warranted.
In many cases, the cause is quite apparent. Injuries (an increasingly common situation, especially with female participation in many erstwhile male sports, such as water skiing) are usually obvious.
The bleeding of a pregnant woman is often (but not always) fairly self-evident.
But often a diagnostic D & C (short for dilatation of the cervical canal and curettage of the walls of the uterus) is ordered promptly. This can be accompanied by a request for blood tests or pregnancy tests. Certain blood disorders may be present. Prolonged bleeding, even though it may not have been heavy but persistent, can produce anaemia in women, and this is quite common. Tests will quickly indicate any of these abnormalities.
The operation is preceded by a general anaesthetic. Then the gynaecologist manually examines the patient’s pelvic organs to determine any obvious abnormalities. When the patient is at complete rest and fully relaxed, a better examination may be carried out.
After this, the walls of the uterus are curetted or scraped clean. The “scrapings” are examined, and then sent to the pathologist for examination under the microscope.
This total exercise will often produce an answer if a physical cause exists. Blood tests may indicate a correctable abnormality. The physical examination may indicate the presence of cysts or solid tumours in the ovary or uterine wall. If a miscarriage is imminent, this may also be treated and the diagnostic routine then has become the therapy at the same time. Any abnormality in the uterine wall (such as meaty growths called polyps, a well-known troublemaker) will be swept away to be examined by the pathologist. Serious lesions such as cancer, if present, will show up in the microscopic study.
This is often carried out in conjunction with a laparoscopy. Here, a thin stainless steel tube with a light and magnifying light at one end is inserted through a small incision (about 1 cm long) just below the navel, and directed downward to the pelvic cavity. At the free end. the gynaecologist peers into a specially magnified eyepiece, and is able to obtain a complete bird’s eye visualisation of the pelvic cavity and its contents. The doctor can therefore see if there is any obvious pathology present. Whereas the D and C gives information of the internal part of the womb, this is an outside appraisal. What is more, it is often possible to actually treat any obvious disorder, such as piercing small cysts, cutting through adhesions, and caring for other anomalies that may be playing a part in the symptoms. The laparoscope has revolutionised gynaecological diagnosis and treatment and is now extensively used worldwide. Doctors in Australiaand New Zealand have been using them regularly for many years now.
From this point on, treatment will depend on what eventuated at the operation and subsequent investigations. Whatever is amiss must then be corrected, if this has not automatically occurred with the D & C.
If no abnormality is detected, the patient may be subsequently placed on oral hormonal therapy.
Indeed, this has revolutionised the lot of the hapless bleeding woman. In old time (and that is not so very long ago), removal of the uterus was a common subsequent operation for cases in which persistent, heavy blood loss was taking place. There was no other simple remedy. But removal. Of the entire organ of course automatically solved the problem.
But today with the universal availability of the contraceptive pill, which is really a combination of normally occurring oestrogens and progestogens, a check to ovulation, and hence to uterine blood loss can often quickly take place.
This is of even greater importance in younger women, particularly those under the age of 35 years who may still wish to reproduce.
Once the uterus is removed, it is entirely impossible to reproduce ever again.
However, in women over the age of 40, the full family complement has usually been acquired. These days, further pregnancies over this age are certainly discouraged, and the removal of the uterus for medical reasons is no great loss. Many women would prefer to take oral medication, rather than suffer the thoughts of a surgical operation, for it is a major one and there is always a slight risk factor. (However, crossing the busy highway in front of your home is probably a far riskier event than a straightforward hysterectomy carried out by experts today.)
Hysterectomy, surgical removal of the uterus, is probably the most common female operation next to the diagnostic D & C procedure. There is often criticism that too many are carried out, and that surgeons sometimes perform it unnecessarily and without giving other routines a fair trial.
In the long run, it is often up to the patient and doctor to fully discuss the alternatives. In any discussion of this nature, it is better to have a three-way talk, with the husband being present at the same time. He often likes to know the reasons for procedures of this magnitude (it is always a once-only event in any woman’s life, and is quite important to her and her partner).
Before the operation is the time to ask all the questions. It is not much use leaving these until afterwards. The surgeon usually will be happy to point out the pros and the cons for the recommended line of action. Take advantage of this, and listen and ask questions.
Final Caution
Before this chapter is concluded, a final note of caution is offered. The warning will be repeated many times.
Abnormal or irregular uterine bleeding may indicate the presence of cancer, not only of the uterus itself, but possibly of other pelvic organs.
This is most likely in women who have passed the change of life, or the so-called menopause.
Post-menopausal bleeding is usually defined as bleeding that occurs six months or more after the menopause— that means when normal periods appear to have finished.
“One-fifth of these cases are due to malignancy,” the British Medical Journal recently stated. Under no circumstances should this be neglected. You must see the doctor promptly, even if you are scared stiff of what might be found. Only early diagnosis and prompt treatment offer hope of survival from cancers in this region. Do not put it off until tomorrow. Then it may be too late . . . forever.
Whether the flow is frank blood, a watery fluid or a smelly, offensive material, the same rule applies. Get along to the doctor.
If you are in this age group and you are trying to retain your good looks and youthful appearance by taking hormonal tablets, irregular vaginal bleeding can occur. This is often of no serious consequence. But the same rule applies, for it is impossible to tell the difference until adequate investigation takes place. This usually means that a diagnostic D & C, preceded by a full pelvic examination, is essential.
But never put it off until tomorrow (or next week, next month or next year— unfortunately it is happening all the time). The life in peril could be yours, and you have total control over what you do.
Besides, your family needs you for as long as possible. Why neglect them at this stage of life, even if you don’t particularly care about yourself?
All About the Change of Life
What! No menstrual period? A woman suddenly realises that her normal monthly flow has not occurred. Or the thought may not occur to her until she has actually missed more than one.
If she is in the 45 plus age range, then she has either reached, or is on the verge of a time in life commonly referred to as the menopause.
Menstruation most commonly ceases about the age of 50. This is also popularly known as the change of life or climacteric.
Happily, many women breeze through this particular event with perfect equanimity. Periods stop abruptly; there is little if any outward indication that marked and dynamic changes are occurring inside the body. Nervous stability remains normal, and life seems little different from the usual pattern.
But this is not always the case. Many other women are not so fortunately endowed. For them, the time is fraught with problems, and every day new hazards seem to occur and escalate.
It seems that about 50 per cent of women sustain symptoms that are sufficiently distressing to warrant medical attention.
The problem of the menopause is a fairly recent phenomenon. The hard, cold facts are that in past ages, many women failed to reach these mature years that the majority now do.
In Roman days, average life expectancy was about 23 years. By the 14th century, it had risen to around 33 years. Even at the turn of this century, it was only 48 years. So, in those days, the problems of the change-of-life woman seldom occurred.
The reason why symptoms occur is that the ovaries, the small pelvic organs that have been active since the age of 10 to 16 years, producing hormones and eggs on a very regular basis, finally reduce operations.
Gradually the hormonal production winds down, until it finally stops completely. Similarly, the release of the egg each 28 days ceases.
The consequences of this reduction in activity are twofold. First, the chances of pregnancy reduce drastically. If there is no egg present, the chance of its becoming fertilised is nil. Also, no egg means no menstrual period, and these cease.
But more dramatically, the enormous reduction in circulating hormones also means that the chemical responsible for the general well-being and normal operation of the pelvic areas phases out.
Almost inevitably, this leads to the production of a new set of symptoms.
Symptoms, Usually the most apparent symptom is cessation of regular menstruation. This may occur abruptly. But more likely it is a gradual process. A period is missed intermittently. Or the time between successive periods may be longer than normal, until finally they cease altogether.
We would emphasise again that if bleeding at this time is heavier than normal, then investigation by the doctor is often essential. It may be due to simple hormonal withdrawal from the system. But in this special at-risk age group, uterine cancer must always be considered with bleeding irregularities, particularly heavy bleeding, or bleeding after total cessation of menstruation.
Another very common symptom is the appearance of hot flushes. These may be mild and transient. Or they may be marked and distressing. Often they commence in the face. From here they may spread to the neck, shoulders and probably the chest area. The upper part of the body is usually affected most markedly. There may also be a suffocating sensation, and the patient may fan herself and gasp for more air. In some, profuse sweating may occur.
The body appearance tends to alter. The breasts may become larger, due to an increase in their content of fat. But in some women, the reverse takes place and the breasts tend to become smaller less attractive pendulous and weary looking. Many women tend to become plump, as fat is deposited on the usual places, usually where it is desired least of all—the midriff, buttocks, thighs and upper arms. This is often associated with a reduction in the desire for activity and exercise.
Depression, Irritability
Often there is a very definite emotional overlay to the whole problem. Many women experience depression, bouts of irritability, feelings of anxiety and tension. Emotional conflicts often flare.
By this time in life, most children have grown up and have left home. The woman’s parents have usually died in recent years, or present a problem in a home or convalescent hospital.
Her husband has either failed in life or has made the grade. If he is a failure, there is not much chance of his extricating himself from it at this age. This fact, along with the economic and, social stigma this can present, in a vulnerable woman is an extra burden she feels forced to face each day. Maybe he neglects her, and is more at home with his friends. Perhaps he drinks, gambles or otherwise spends more time following his own social pursuits than in caring for his wife.
On the other hand, if the spouse has made a success of his life, this inevitably means he is away from home for many hours each day, and perhaps is involved in trips on account of the business. He has little time to spend listening to her sad story, and often less patience to help her solve her problems that may seem trivial to him when he spends most of his waking hours involved in major decision- making experiences.
None of this benefits his wife, who often feels more and more alone in the world, deserted by all those who mean the most to her.
Doctors hear these sad but very plausible stories on a never-ending basis each working day.
“Life holds no more meaning for me.’“Life has come to an end.”“Nobody cares about me any more.”“Life is a bore. a drudge; I often wish I would never wake up in the morning.” The sad phrases roll out regularly.
Because of the hormonal lack. The sex organs tend to be affected dramatically. With no oestrogen, the lining of the vulva and vagina thin out. They shrink in size.
Complex problems and difficulties mean that the menopausal woman must be treated with love and understanding if life is to be meaningful for her.
However, while some women find that intercourse has lost its desirability and attraction for them, many others discover that their libido is considerably increased.
Suddenly, many realise that their child-bearing days are over. The risk of pregnancy is totally removed, and the need to take precautions for contraceptive reasons vanishes. This can add new dimensions to the thought of sex and intercourse.
But when it comes to the physical act of lovemaking, the situations may be annoying and completely frustrating.
Penetration may be painful or difficult. The thin, atrophic, ageing lining tends to stretch less easily, and penile accommodation may be less readily achieved as in former times. Many women have found the demands of a thoughtless husband extremely trying. Considerable matrimonial disharmony can take place over this problem, arid marriage disasters are not uncommon during the menopausal years.
Conversely, some husbands show a markedly reduced libido and capacity and desire for intercourse. Kinsey showed many years ago that after the age of 40, the sexual desire and capacity of most males tended to reduce gradually. Conversely, that of the female counterpart went in the opposite direction. So, once more,- some women tend to accentuate their feelings of neglect. They believe their husbands no longer care, or are probably having an affair (usually imaginary) with a fictitious beauty.
So, the unhappy picture of marital discord and domestic stress continues.
Urinary Tract Problems
Often urinary tract problems arise also. The urinary system is closely related to the genital organs, and is frequently caught up in its gradual decline. Frequency in passing urine, and an urgency are common. Later on, as the vaginal walls further reduce their normal premenopause elasticity, sagging of the walls and prolapse can take place. This presents another set of symptoms that will be discussed later. But it all adds to the general unhappy picture.
Before the change, the incidence of coronary heart disease, the most common killer of people in the Western world, is far less than it is for males in the same age bracket. But after the menopause, this becomes more likely. With advancing years, it gradually equates with the male rate.
Osteoporosis, a condition in which the calcium is gradually withdrawn from the bones, making them soft and spongy and more liable to damage and pain, is a raised possibility.
The risk of pregnancy is definitely over. Most doctors now believe that contraceptive measures can be discontinued at the age of 50. The pill, or whatever system was used, can be discarded.
Happiness and well-adjusted lifestyle are possible in middle life with a minimum of therapy due to modern methods.
Certainly pregnancy over this age has been reported. Indeed, the celebrated Guizrness Book of Records (1972) claims:
Mrs. Ruth Kistler of Portland,Oregon,USA, gave birth to a daughter, Suzan, on October 18, 1956, at the age of 57 years, 129 days.”
But such events are indeed rare. Nearer the norm is the comment most doctors are guided by in a widely used medical text: “Pregnancy after 47 years of age is rare and parturition [birth] over the age of 52 has not been proved.” Not long ago, the widely read British Medical Journal gave 50 as the age women could safely discard the contraceptive pill.
Even if pregnancy did take place, the hormonal lack in the body generally, plus the very thin uterine lining would usually be incapable of sustaining foetal life to full-term.
Today, with the recognised increased risk to babies conceived to women over the age of 40, legal terminations are often carried out for women in this age segment if a pregnancy did inadvertently, occur.
TREATMENT
Fortunately, treatment of women suffering from symptoms in this age bracket is very successful. Today, therapy is well advanced, and the majority can benefit. Most women can again discover a full, happy, and well-adjusted life with minimum therapy.
Treatment is based on the artificial use of hormones. These are identical to the ones nature produces normally. The most widely used is called ethinyl oestradiol. This is given in minute amounts, from 10 to 20 mcg daily. Treatment is usually tailor-made to the woman’s apparent needs by the doctor. It is varied in accordance with her response.
Treatment is usually given for short courses. Special caution is needed if there has been any cancer history.
Many doctors prefer to use a variation of this medication called conjugated equine oestrogens, which is widely known by its trade name Premarin. A common satisfactory dose of 0.625 mg a day is prescribed. Many believe this gives a more normal type of reaction, and may be preferable, but it is usually much more expensive.
Today, there are definite guidelines laid down for the use of hormones for menopausal women. This follows some fears encountered in the mid 1970s that continual use might cause adverse repercussions, and there was talk of cancer.
However, this has been refuted, provided the oestrogen is taken for a set number of days per calendar month, and taken in conjunction with the other female hormone,
Progesterone (or “gestagen”), in small doses, for a certain number of days per calendar month. The progestogen pill is usually one of the brands used for contraceptive purposes, being norethisterone 350 mcg (“Micronor”) or levonorgestrel 30 mcg (“Microval”).
The method of taking the medication (which will be confirmed by your doctor) is as follows:
Take the oestrogen tablet daily from Day 1 to Day 24 of the calendar month, then discontinue until the first day of the following calendar month. In addition:
Take the progestogen tablet daily from Day 15 to Day 24, then discontinue until the 1 5th day of the following calendar month.
Usually this will cause a slight menstrual bleed about three days after the tablets have been discounted. But most women will accept this fact of life as small payment for the relief obtained from symptoms. Keep in close contact with your doctor, especially regarding this so- called “withdrawal bleeding,” which is not due to cancer despite your age. However, some doctors still believe investigation of the womb (probably before or after medication is started) is advisable as
By the use of these hormones, a general feeling of well-being often occurs. Depression and anxiety may vanish, the world smiles again, hot flushes disappear as if by magic, the old irritability wanes, nerves settle, sleep improves, and the outlook brightens.
In some women, the skin becomes less wrinkled; the fingernails and toenails grow more rapidly, and break and crack less easily.
Many cases have been reported where the hair becomes more attractive, wavy and shinier.
These hormones have often been called the youth pill. Women taking them and gaining these results are often apt to agree, but it is not the universal panacea for greater beauty, and it is not the eternal fountain of youth. But it certainly may help.
Male Hormone Prescribed
Sometimes, doctors add a minute amount of male hormone to the prescription. This seems to add greatly to the libido of women, and if a flagging sexual life is present, it can rapidly upgrade this.
Some women automatically continue with the contraceptive pill. The pill contains the female hormone, but in amounts far in excess of what is normally needed.
Women who are having difficulty with intercourse (and this represents a large number) can gain great benefit from the use of oestrogen suppositories and creams placed directly into the vagina. This rapidly brings back a thickening of the vaginal lining, improves the blood supply, improves sensitivity, and can make intercourse much more attractive. Steroid creams applied to the vulval area can frequently benefit this part too. The use of surgical lubricating jellies before intercourse can facilitate penile entry. In short, the entire act of intercourse can be greatly improved. This can have a beneficial physical and psychological effect on both partners. It can do much to overcome the unsatisfactory situation that often persisted prior to these innovations.
One lady who was treated in this manner said that intercourse had never been attractive or enjoyable in her more than 30 years of marriage. But since she used the measures suggested, she openly declared: “Life holds so much more meaning. I never envisaged it could all be so attractive, so beautiful. My marriage has now been fulfilled in a way I never believed possible.” Comments such as this are common.
Sometimes doctors prescribe mild sedation for a short period during the menopausal period if sleep disturbance takes place. Nitrazepam, Temazepam and other related medication of the benzodiazepene family have now replaced the barbiturates, but they should be taken for minimum periods of time. A patient is best sleeping naturally, and not having to rely on oral medication.
Drug Therapy Not Recommended
Occasionally “nerve pills” are used to reduce tensions and anxiety. The benzodiazepenes are widely prescribed, for they are safe, but unfortunately, like many tranquillising kinds of medication, may be habit-forming. The fewer of these that are taken, the better. Becoming totally dependent on drug therapy can become a way of life, and is not recommended apart from short spells when a genuine need exists.
The use of alcohol as a way out is to be condemned. This may give temporary relief, but it is of short duration, and can only lead to bad habits that will ultimately impair general health and mental acuity. Never become involved in the alcoholic merry-go-round as a way out. It is not worth it. If you already have, then get in touch with an organisation such as Alcoholics Anonymous, which has a commendable record in assisting those afflicted in this manner.
Becoming involved in time- and energy-consuming activities is an excellent idea. This provides less time to scrutinise your own problems. The art of feeling sorry for oneself is a one-way ticket to unhappiness. It snowballs. But getting energetically interested in other people, or their activities and problems can work wonders for you. Many opportunities are about on every hand.
Becoming involved in service organisations, or voluntary help clubs can yield mentally rewarding results. But the person who benefits most of all is the woman who involves herself.
Filling the mind with positive thoughts of success can also bring about wonders. Think success, and in most cases, with a bit of push, you will achieve the success you seek. History has repeated this fact too many times for it to be wrong.
This way you can make life so much happier, brighter and more fulfilling in every respect.
Special Caution
This has been mentioned several times before. But due to its importance, it is mentioned once again.
Irregular vaginal bleeding that comes on after the menopause must be considered to be cancer of the uterus until proved otherwise. Today, with the enormous level of cancer in the community, most doctors are fanatical about this.
Agoraphobia
There is a common condition suffered by many women, not necessarily those in the older age group, but in any age. What is more, it may affect men, too, but much less commonly. It is called agoraphobia, and simply means a fear of the wide open spaces. Although this is its literal meaning, in reality it involves a fear that embraces leaving the protection of the home and venturing forth into the wide world. There is an intense and inherent fear of the open, such as roads, footpaths and paddocks. But it also involves a fear of people, especially crowds, such as experienced in streets, shopping centres, theatres, churches, restaurants, or sporting venues.
The person prefers the safety of the home, where all is familiar and spells peace, security and protection. Here she is in command of the situation, knows every nook and crevice and feels safe. The experience of venturing outside, especially alone, will often bring on symptoms. “My legs turn to jelly,”“I feel like fainting,”“I am terrified,”“I feel like vomiting … running away … screaming. . .“ are some of the expressions used by patients. Therefore they tend to dwell in themselves, and their problems gradually worsen, even though many are otherwise normal, sensible, intelligent persons. Life becomes filled with fears, and as their social world shrinks down, so does enjoyment. If this comes on after marriage, serious problems may develop, and marital rifts are highly likely.
TREATMENT
Patients are not easily treated, for many are too fearful of venturing forth, or seeking help. Many feel their situation is misunderstood, and the doctor will laugh at them. It is true that many doctors are unfamiliar with these symptoms, and tend to prescribe tranquillisers, anti- depressants and similar nerve calmers, mostly with complete failure.
Doctors, counsellors, probably psychiatrists and psychologists who take an interest in this field, often obtain good results. Various forms of treatment, along psychological lines, are helpful. So-called “desensitising” the patient by gradual exposure to the precipitating circumstances appears to help some. Others use relaxation techniques, often with very good results.Australia’s Dr Claire Weekes has pioneered treating this condition, and with the use of recorded tapes and ex.
planatory books, has brought help to many. Her work is recognised worldwide.
An understanding partner and family can also assist the mother to regain her general confidence by helping wherever possible, and assisting the counsellor with this work.
Allied conditions are the “phobias” in general. Many are fearful of flying in aeroplanes, or travelling in tunnels, lifts or escalators. Others are scared of the water, the dark, certain animals (cats, dogs, frogs, snakes, rats, lizards), or being
a small room (claustrophobia)—the List is endless. Some are fearful of examinations, appearing on stage, or doing public work. The fear they harbour is in excess of what would be normally expected of a person in these circumstances, and is commonly referred to as a “phobia.” In a great number of these cases, relaxation therapy by a trained operator (usually a doctor or psychologist specially trained along these lines) is often successful. In using this kind of treatment, a Christian doctor will show the patients how to place their faith and confidence in a Higher Power, and often this is a major part of gaining success . . . inspiring confidence and safety in the patient’s mind that they are being cared for by a Supreme Being.
