Dorothy’s ‘decision’ to have a hysterectomy followed her admission to hospital to have bladder repair surgery. The night before the operation her doctor visited her and, as he was leaving, said casually, ‘We might as well take your womb out while we’re in there, because you don’t have any need for it now.’ When asked how she felt about this, Dorothy said she accepted it without question because she believed her doctor knew what was best.

There is no doubt that some women prefer to leave decisions about their health care entirely to their doctors, even to the extent of preferring the doctor to decide whether or not they should have major surgery. But it is becoming increasingly common for doctors and women to work together, exchanging information and ideas and, in the end, coming to a mutual agreement about the best course of action.

Psychologists have identified five basic patterns of behaviour used by individuals when faced with choices about things like health investigations and treatments.

• Complacently continuing whatever has been familiar until then, which may involve discounting new and relevant information.

• Uncritically adopting whichever new course of action is most strongly recommended or is considered to be ‘the fashion’.

• Escaping the conflict by delaying decision making, shifting the responsibility to someone else, or making wishful excuses to bolster a particular alternative, meanwhile refusing to consider pertinent information.

• Searching frantically for a way out of the dilemma and impulsively seizing upon a hasty solution that seems to promise immediate relief. This type of decision making means that the full range of consequences of a particular choice are never considered.

• Searching painstakingly for relevant information, thinking carefully about it in as unbiased a way as possible, and weighing the alternatives carefully before making a choice.

Although the first two patterns may save time, effort and emotional turmoil, they often lead to decision making that is less than ideal and has unfortunate consequences. The third and fourth patterns likewise tend to be associated with undesirable results. The fifth pattern, termed the Vigilant approach’, usually leads to high-quality decision making. Its major features include identifying the feasible options; sorting out personal values, objectives, barriers to particular actions and incentives to others; assessing the consequences of a particular choice; planning how best to put the decision into effect; and anticipating what will happen as a result of that decision.

Today, many women are participating actively and responsibly in making decisions about their health and are having a major say about investigations and treatments. Your consent should always be sought before a procedure is carried out, except in the most unusual of circumstances, such as an emergency during major surgery when your life would be threatened if a particular action was not taken. In addition, your consent should always be sought for participation in medical research. Remember also that it is your right to withdraw from treatment by a particular practitioner at any time.

For most women, a decision for or against a hysterectomy involves the following considerations:

• an assessment of the impact of the existing medical condition and its symptoms on quality of life

• a comparison of physical risks and effectiveness of various forms of treatment

• a personal assessment of the importance of the uterus and of emotional reactions to the current situation and to removal of the uterus

• careful consideration of any relevant social and cultural factors

• the views of a doctor or doctors, a partner and close friends

• an assessment of the skill and care of medical personnel available to you.

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Toxoplasmosis is an infection of the parasite Toxoplasma gondii which is found in most animals but the only reproductive host is the cat, which acquires the cysts by eating infected birds and mice. It can be transmitted to humans by contact with cat litter, eating raw or partially cooked meat, drinking contaminated water and in unpasteurized dairy products.

If a woman acquires toxoplasmosis during pregnancy, the baby is usually infected in 45 per cent of cases and it is a very serious disease for the foetus. The risk to the baby is greater in the first trimester (first 12 weeks) of pregnancy, when an infection of toxoplasma can cause hydrocephalus (accumulation of fluid on the brain), eye problems, convulsions, blindness and brain damage. Toxoplasmosis can also increase the risk of an early or late miscarriage.

In France pregnant women are routinely tested for toxoplasmosis, sometimes as often as once a month. If a pregnant woman becomes infected then, depending on the stage of pregnancy, advice is given as to the course of action. In this country, the Royal College of Obstetricians and Gynecologists have concluded that routine screening of toxoplasmosis for pregnant women is not ‘appropriate’, perhaps due to financial constraints. Once infected with toxoplasmosis, the person acquires life-long immunity.

Prevention is the best approach and that means that, up to four months before pregnancy and during pregnancy, the woman must not handle cat litter. If this is impossible then disposable gloves should be worn. Gloves should also be worn while gardening and hands should be washed thoroughly after changing cat litter, gardening and handling raw meat. If you eat meat only eat it when it is well cooked, wash all fruit and vegetables thoroughly to remove soil, avoid unpasteurised dairy foods such as milk and cheese, and wash your hands before eating.

Genital Herpes

This virus is sexually transmitted. Once acquired, it can come and go, with attacks varying from slight red bumps to blisters. If a woman gets herpes for the first time during the early part of pregnancy it can increase the risk of miscarriage by up to 25 per cent. If herpes is active when the woman gets to term then she is usually offered a Caesarean. This is because, if delivered vaginally, the baby could contract herpes during the delivery and there is a possibility of brain damage, blindness or death.

Gardnerella

This vaginal infection, gardnerella vaginalis, needs to be cleared up before conception. It can cause a burning sensation and also a grey or yellow discharge with a fishy smell.

Group  Haemolytic Streptococci

This is a very common bacteria, but it has links with premature rupture of the membranes and premature birth. If this infection is present during birth the mother needs to have antibiotics to prevent the infection spreading to her baby.

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There are 101 different symptoms you can put under the endometriosis umbrella. Most common is pain.

Some women complain of pain and feeling bad, usually for the two weeks preceding menstruation. Other common symptoms include fatigue, bloating, irregular and abnormal bleeding, rectal bleeding, pain in cycle, pain in bowel, pain in bladder, a general feeling of pressure within the pelvic cavity, painful intercourse, infertility, depression, lethargy, insomnia, diarrhea – sometimes alternating between constipation and diarrhea – and a general feeling of being ‘nervy’.

Other symptoms include blood pressure changes, leg cramps,

palpitations, changes in body temperature, mood swings, changes in weight – most often an increase although some people seem to lose a lot of weight – skin rashes, flushing, loss of libido and sugar cravings.

Other associated symptoms include some tendency towards showing a hormone imbalance.

What happens at the first visit

An hour is allowed for each consultation – possibly longer for the first. A detailed list of symptoms is taken, together with answers to relevant questions defying such things as sleep patterns, moods, traumas etc. This can take some time as the woman has the opportunity to ‘divulge all’, and there is usually quite a deal of bottled-up anguish in endometriosis cases.

A medical history is taken – past illnesses, operations, traumas, etc. A list is made of past and current medications and a family medical history is taken. An inspection is made of the woman’s hands, nails, hair, tongue, palpation over liver/stomach/ spleen/ovaries/kidney area, examination of any rashes, moles, lumps, etc.

After I arrive at any treatment programme, I discuss this with the woman, explaining the method and significance of the remedies and the anticipated healing path ahead.

What is your treatment regime

Bach flower essences: For the mental/emotional sphere – to help emotional blocks and negative beliefs.

Diet: Non-chemical foods. An emphasis on low fat, high fibre, low sugar foods. No processed or refined foods. Ideally, organically grown fruit, vegetables, cereals and grains, filtered water. Avoid coffee, tea and alcohol. If candida is present, a special anti-candida diet will be prescribed.

Pain management: If needed, acupuncture and visualization may be considered.

Stress management: Meditation, yoga, massage.

Exercise: Gentle, regular exercise such as walking, cycling, swimming. No jarring exercise such as jogging.

Usual length of a treatment cycle

Two to 18 months, most around the six to eight month span with intermittent visits over the longer period. It is sometimes hard to tell due to lack of compliance to treatment – after the pain has gone, the motivation to complete the healing programme can disappear.

Women being treated usually require a visit once every four weeks.

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• The woman—70 to 75 per cent of infertile couples have a female factor.

• The man—30 to 35 per cent have a male factor.

• The couple—40 per cent of infertile couples have more than one factor. In some couples no cause will be identified.

However, the most common causes of infertility are:

• Anovulation (not producing an egg)—about 30 to 40 per cent of infertile couples have this problem.

• Having blocked fallopian tubes—about 20 per cent.

• Sperm problems—about 20 to 30 per cent.

Rarer causes include problems with the uterus, cervix, chromosomes and male anatomy.

Sperm problems. Hormones controlling the production of sperm (similar to those controlling egg production in women) are circulated from the hypothalamus and pitiutary. They act on the sperm-making cells in the testes (balls), so if there is not enough of the right mix of hormones around, or the message is not getting through, there may not be many good quality sperm made.

The job of the testes is to make sperm. The sperm are stored in the epididymis (attached to each testis) and the seminal vesicles (in the pelvis). When a man ejaculates during an orgasm, sperm, mixed with a liquid called seminal fluid, squirt out of the penis via the urethra (the tube which also carries urine from the bladder to the outside). Doesn’t sound particularly romantic, but in general it is effective. When it doesn’t work, it may be for a variety of reasons.

The cells of the testes may not be capable of responding to the signal sent by the hormones, and may not be producing any, or adequate sperm. This may be because the testes have developed that way (congenital infertility), or have had something happen to them at some time (acquired infertility). Having abnormal sperm or low sperm counts does not affect sexual performance; infertile and subfertile men usually have otherwise perfectly normal sexual function, and still ejaculate seminal fluid, often with no idea that something is wrong until their partner does not become pregnant.

Causes of congenital problems include undescended, or incompletely descended testes. The testes are meant to live in the scrotum (skin sac below the penis), where the temperature and conditions for sperm making are ideal. During the development of the foetus the testes migrate from the abdomen (near the kidneys) to the scrotum. If they don’t make it all the way to the scrotum the temperature around the testes is usually too high to make sperm. Little boy babies who have incompletely descended testes can have an operation to bring them down to the scrotum, to prevent them being infertile later in life.

Acquired fertility problems include damage to the testes. This may happen because of infections (mumps, gonorrhoea, chlamydia, syphilis and others), trauma (such as direct trauma from an accident, severe bruising), or torsion of the testis (which is where the testis twists on its attachment, and cuts off its own blood supply—a very painful condition. Prompt surgical correction is required to fix it). High-dose irradiation directly to the area, or some forms of chemotherapy, which are both treatments used in the treatment of certain cancers, may damage the sperm-making ability, and people are usually informed of this risk before undergoing such treatment.

Tests of semen performed for investigation of infertility look at several dip ferent factors. They measure the amount of semen, how many sperm there are, and the shape and appearance of the sperm. They look at how many of the sperm are moving in a normal way.

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Various words are used to describe the inhabitant of the uterus. Very early on it may be referred to as a fertilised egg, or conceptus. It is called an embryo during the first eight weeks of development, and after eight weeks it is called a foetus, until it is born and we know it as a baby.

When the egg is fertilised in the fallopian tube, and settles in the uterus six to eight days later, the ovary which has produced that egg has the responsibility of supporting the conceptus, hormonally, until it can make its own. The major hormones needed are oestrogen and progesterone, so the ovary churns them out of its ‘corpus luteum’, which is the sort of cyst which is left after the egg has popped out of the ovary.

So there is extra oestrogen and progesterone around, causing several changes in different parts of the woman’s body.

Meanwhile, back at the uterus, the conceptus is busy multiplying its cells, becoming an embryo, a sac and a placenta. The placenta is an incredibly clever and essential piece of equipment. It is made up from cells of the conceptus, as well as from the uterus lining (endometrium) to which it is attached. The placenta’s function is to transfer oxygen and nutrients to the embryo, and remove wastes. It does this by allowing the blood vessels of the embryo (via the umbilical cord) to come into contact with those of the woman, although the actual blood itself does not mix. As well as acting as an exchange plate for the woman and her embryo, the placenta also starts making oestrogen and progesterone to support the pregnancy.

The embryo grows at a predictable rate in early pregnancy. At six weeks from the last period it is about 0.4 centimetres long. By eight weeks it is about 2 centimetres long, and weighs 1 gram. At twelve weeks the foetus is over 6 centimetres long, and weighs about 15 grams. During this time development of various parts and systems is progressing. It is becoming more recognisable as human, with arms and legs, and a relatively large head.

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A vaccine has been developed which gives people protection against hepatitis B. It is being given to people at particular risk, such as family members of carriers, babies whose mothers are carriers, health professionals, people in institutions, and members of communities where the carrier rate is high. It is likely that it will eventually be offered as a routine immunisation, in the same way as are triple antigen and other immunisations.

If someone actually has an incident that places them at high risk (such as getting accidently jabbed with an infected needle), and they are not immune, there is another injection which can be given within seventy-two hours which will help to prevent infection. This is a short-acting immunity-boosting injection, which should last long enough to enable the person to be vaccinated properly.

It is important that carriers take extra care not to put other people at risk. This does not mean locking yourself away and never talking to anyone; there should be no shame or blame attached to being a hepatitis B carrier. It is important to be responsible, and this means telling any people who may be at risk of contracting the disease from you, so that they can protect themselves. This includes people who may have contact with any of your blood, vaginal fluid, and possibly your breast milk or great quantities of your saliva (for instance, sexual partners, treating doctors, nurses or dentists, tattooists, acupuncturists).

Now that immunisation is available the risk of catching hepatitis B should be decreasing. However, the number of immunised people in the community at the moment is small, and will be slow to grow, so the routine preventative measures will be important for quite a while.

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Not taking the tablet—If you miss a tablet, or are late (by more than twelve hours), you can’t maintain a high enough level of active hormone in your blood stream. This is a common cause of pill failure.

Not absorbing the hormone—The pill is designed to be swallowed, and absorbed from the gut at a certain rate. Different things can affect the rate and efficiency of that absorption, such as

• vomiting and diarrhoea

• some medications (prescribed and non-prescribed), including antibiotics, prednisolone, and vitamin C. These can change the types of bugs which live in the gut, and may also affect the rate at which the liver breaks down the hormones. If taking any medication ask if there are any interactions with the pill.

So what do you do? If you are beset by any of these potential pill-failing pitfalls you should keep

taking the pill, and either abstain from intercourse or use a barrier method, like condoms (properly) plus the pill, for the time of decreased absorption, and for at least SEVEN CONSECUTIVE HORMONE TABLET days after. If these days of being careful run into the sugar tablets (or the hormone-free time when you would normally expect to get your period), don’t bother with the sugar tablets that month. Don’t have a break, or a period, just go straight from the hormone tablets at the end of the packet straight on to the hormone tablets at the beginning of the next one. You may have a little spotting or bleeding during this next cycle if you have skipped a ‘period’, but that is preferable to giving your ovaries a chance to think about making an egg, if you don’t want them to. If you have any questions about what to do contact your doctor, or Family Planning Clinic.

When used properly the pill has a tiny failure rate—only about two pregnancies per 1,000 women years. How’s that, compared to up to three per 100 with an IUD and anywhere up to fifteen per 100 for the condom and twenty per 100 for the diaphragm?

However we are more likely to hear about the pill’s potential side-effects than it’s usefulness and efficacy as a pregnancy preventer. It is widely used with a high degree of safety. To put this in perspective, let’s look at the possible problems with the pill.

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There are several follicles each cycle which respond to the FSH. Usually one of these follicles grows faster, and will become the ‘Egg of the Month’, as it were.

The ovary produces more oestrogen, and then a surge of L.H from the pituitary gland acts to stimulate the release of the egg from the follicle it has been developing in. This is ovulation. After ovulation the ruptured follicle takes on a hormone-producing role, and is called the corpus luteum. It produces progesterone, as well as oestrogen, and the progesterone works on the lining of the uterus to make it ready in case the egg is fertilised, and needs a place to settle. The progesterone also affects the cervical mucus, making it friendlier to sperm, and it also tends to change the body temperature a little, making the resting ‘basal’ temperature rise by about 0.5°C.

The egg, meanwhile, has been grasped by the ‘fingers’ of the nearby fallopian tube, and is making its way along the tube towards the uterus. This trip takes a few days, and if there are any sperm in the area they will usually swim up the fallopian tube and meet the egg there. If the egg is fertilised by the sperm (in a process called conception), the newly formed conceptus travels along the fallopian rube towards the uterus, where it can find a suitable place to implant and grow.

The ovary has been churning out oestrogen and progesterone, and keeping the home fires burning, so to speak, in case conception takes place. If it does not, then the corpus luteum usually stops working after fourteen days, so there is a drop in the level of oestrogen and progesterone. This drop affects the lining of the uterus, which starts to disintegrate and come away. That is what a menstrual period is, and that is why it usually takes place fourteen days after ovulation. After the lining is shed, the FSH and oestrogen start up again, and the ovary repeats the whole cycle.

If a conception does occur, and the conceptus finds a place to settle and starts growing, it too can produce hormones. These hormones include human chorionic gonadotrophin (HCG), which is the hormone measured in pregnancy tests. This HCG tells the corpus luteum to keep working beyond its usual four-teen days, and it continues to produce progesterone to support the growing embryo until it can make its own, which it does after about eight weeks.

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