About twenty different types of prostaglandins are found in nearly every cell and are responsible for many functions. As with any other hormone in the body, there are adverse side effects when prostaglandins are produced in overabundance, we are most concerned with the prostaglandin involved with menstruation, the one that causes uterine contractions; F2 (or F2 Alpha). Normally, this hormone it kept in control by the “pregnancy” hormone, progesterone. If a woman conceives, she continues to secrete high levels of progesterone, and F2 Alpha is not released. The body supports conception by blocking prostaglandin production. What happens if conception does not occur?

Prostaglandins released prior to and during menstruation stimulate rhythmic contractions of the uterus. These contractions help shed the uterine lining, causing menstruation. If the level of prostaglandins is higher than normal, menstruation will be accompanied by cruelly disabling cramps and other problems, such as headache, nausea, vomiting, diarrhea, lowered blood pressure, and even fainting spells and fever.

When Dr. Pickles and his team isolated prostaglandins—their so-called menstrual stimulant found in menstrual fluid—they were unable to provide a scientific answer to the question of why one woman secretes a higher level of this substance than another, we still have no satisfactory answer to that question. We can only suppose that, as with other types of body chemistry, such as having oily skin or a proclivity to slenderness, the answer lies in heredity. Whatever the “X” factor, it is proved that certain women will secrete more prostaglandins than others and that those women with higher prostaglandin levels will suffer from menstrual cramps and a tightening of the cervix.

When the cervix tightens, somewhat like a clenched fist, the flow of menstrual blood out of the body is obstructed. The Wood, replete with prostaglandins, is trapped in the womb. The hormone is first absorbed by the uterine muscles, then released, reabsorbed, and released again, creating a destructive and vicious cycle.

Unchecked, the prostaglandins circulate throughout the body without losing their potency. The uterus responds by contracting and cramping until the menstrual blood finally flows out from the vagina, carrying the prostaglandins with it. This release and absorption of prostaglandins can cause uterine contractions far more intense than labor pains during childbirth. There is also the likelihood that the menstrual blood that doesn’t flow out of the body in a normal manner can back up into the fallopian tubes and then out into the abdominal cavity. This “backing up” eventually wreaks far greater havoc than excruciating menstrual cramps—it can lead to endometriosis.

Just as mere is a correlation between high levels of prostaglandins and menstrual cramps, a similar relation exists between regularly painful menstrual cramps and the possibility of the onset of endometriosis. The issue is not, however, quite so simple. Severe cramps may be blatant signals of hormonal fluctuations, but they are not necessarily blatant warning signals to every woman—or physician— that endometriosis may be developing and spreading. In fact, many women who are spared monthly cramps go through life blissfully unaware that they are victims of endometriosis. For these women, endometriosis is finally diagnosed either when they complain of painful symptoms other than menstrual cramps or when they discover that they cannot conceive—or they miscarry.

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If you don’t have access to organically grown fruit and vegetables (and being realistic, not too many of us do) then eat good, fresh fruit and vegetables daily and try to avoid processed foods.

Processed food may contain additives such as artificial colourings, flavourings and preservatives. Even storage can reduce the nutritional value of some foods, as can some cooking methods.

Many endometriosis sufferers have reported an improvement in symptoms simply by improving their diet and introducing regular exercise.

It is best to consult a specialist for advice but there are some simple steps you can introduce yourself to improve your diet.

Write down what you have eaten today. Be honest and examine the list carefully. Revise the list and in future try to eliminate any foods with additives or those that have been processed or refined.

Try to have a fresh salad or fresh fruit or vegetables daily. Organically grown produce is best but if this is not available then make sure you wash the fruit and vegetables thoroughly before use.

Drink lots of water. Spring or filtered water are better but, again, if this is not possible tap water is better than no water at all.

For those with bowel problems and constipation, your diet should also be high in fibre.

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The mistaken belief that pregnancy cures endometriosis appears to have arisen from the impressions and speculations of some of the early gynaecologists who had a special interest in endometriosis. In general, even those gynaecologists did not claim that pregnancy was a permanent cure. Rather, they said that their impression was that pregnancy usually led to an improvement in the condition and generally delayed its recurrence.

Such early speculations and subsequent assertions have never been proven in any scientific studies.

The reality is that pregnancy seldom ‘cures’ endometriosis and the effect of pregnancy on endometriosis varies widely.

Is endometriosis cancerous-Endometriosis is definitely not a form of cancer, nor is it a

pre-cancerous condition.

Endometriosis is sometimes referred to as a benign cancer because it behaves like cancer in some ways. Like cancer, it is able to grow and expand, to implant itself in a distant part of the body after having been transported there by the bloodstream or the lymph vessels and to invade or penetrate organs and tissues in the body.

But unlike cancer, endometriosis does not destroy the organ or tissue on which it implants itself.

Any tissue in the body can develop into cancer. Therefore, theoretically, any endometrial implants and endometriomas have the potential to become cancerous. But it is extremely rare for endometriosis to become cancerous.

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If your cycle is regular there should be a temperature rise between days 14 and 16. It is on the days just before this point that you should be at your most fertile. Count the days from the beginning of your last period when you are estimating this. Using this method, you should have intercourse every other day from about day 11 to day 16 even if you are unsure about the mucus changes.

Because the temperature reading has to be the basal body temperature it needs to be measured first thing in the morning. Our normal body temperature rises as the day goes on, so it is important to take it at the same time each day, in order to distinguish between a routine rise and the rise that occurs after ovulation. To use this method:

• Take your temperature first thing in the morning while you are lying in bed, before you have a drink or go to the toilet. You should wake up and immediately put the thermometer under your tongue.

• The easiest type of thermometer to use is an electronic digital thermometer, now available from most chemists (B-D is a good make), as it registers the temperature within one minute and often has a memory. This can be convenient if you like a lie-in at the weekend. Then you can just set your alarm, take your temperature at 7am, turn the thermometer off when it ‘bleeps’, and the temperature reading will be stored for later when you can write it down.

• If you are using a mercury thermometer then it must be a special ‘ovulation thermometer’, as it needs to have an expanded scale. If you can get a Fahrenheit thermometer (either digital or electronic) it will be easier to see the rise in temperature at ovulation.

•You will need to plot the temperatures on a graph to see the changes over the cycle. Use a different graph for each cycle, counting the first day of your period as day 1. Since most (but by no means all) women have a 28-day cycle, you have to count the actual days and not rely on calendar dates to pinpoint the vital days in the month ahead when you should be at your most fertile.

Remember, however, that many factors can affect your temperature – illness (fever), disturbed nights, travelling across time zones, shift work, alcohol and drugs. So there are now a number of other ways of charting ovulation.

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This used to be called delta hepatitis. It is spread mainly by needle and syringe sharing, rarely by sex, and can only infect people who already have hepatitis B. Infection with both hepatitis В and D often causes more severe liver inflammation than HBV infection alone. Though there is no cure for hepatitis D, it can be prevented by a hepatitis В vaccination or by immunity after complete recovery from HBV infection.

Hepatitis С
and G

The hepatitis С virus was identified in the 1980s, and hepatitis G is the most recently recognized. In the past, when people developed typical hepatitis and no evidence of hepatitis A or HBV infection could be found, the illness was called post-transfusion or non-A, non-B hepatitis.

The incubation period for hepatitis С and G can be from 15 to 160 days. Symptoms are usually moderate to severe. More than half of those infected become carriers and may develop chronic liver disease.

The hepatitis С and D viruses are spread mainly by contaminated blood, usually by sharing needles and syringes. In countries where all blood donors are tested for these viruses, transfusion will become a less common means of spread. Sexual transmission is possible, but uncommon. Until we know more about the sexual transmission of hepatitis С and D, chronic carriers are advised to use condoms for sex.

Hepatitis A and E

The viruses that cause these infections live in the faeces of infected people, and must be transferred to the mouth for others to catch them. Infection spreads through contaminated food and water or by anal/oral sexual practices, particularly among homosexually active men.

The hepatitis A virus (HAV) causes epidemics from time to time in Australia. After infection, it takes from 10 to 50 days for symptoms to appear. Recovery is usually complete within a week or two. Complications and chronic liver problems are rare. After recovery, you are immune for life from further infection with HAV. Hepatitis E (enteric hepatitis) appears to spread in epidemics like hepatitis A, and causes similar effects. It is unknown in Australia, and has only been found in India, Asia, Africa and Central America.

Can hepatitis A and E be prevented?

A
permanent vaccine against hepatitis A is available. If you haven’t been immunized and someone you’re close to gets hepatitis A, or you’re travelling in a country where it’s common, your doctor can give you an injection of immunoglobulin that provides antibodies that will fight off infection for up to three months.

Good hygiene helps to protect against hepatitis A and E infection. If you’re visiting places where sanitation is poor, it’s wise to avoid unboiled water and ice and stick to foods that can be peeled or have recently been cooked.

Treatment of viral hepatitis There is no specific treatment for acute viral hepatitis. You’ll usually be advised to rest at home until your liver function returns to normal and you feel well again, and to avoid anything (such as alcohol and certain drags) that might put extra strain on your liver. During the acute phase you’ll be advised against foods containing a lot of oils or fats (meat, milk and so on), which need bile from your liver to be digested. Hospital treatment is only necessary if vomiting or other symptoms are so severe that the patient must be fed intravenously, or if any other complications develop. Recently interferons (which stimulate immune function against viruses) and some antiviral drugs have been used to inhibit the progress of liver damage in chronic hepatitis В, С and G.

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Anything that increases the pressure in the abdomen, such as coughing, sneezing, lifting or pushing things, jumping or bursting out laughing, can also increase the pressure on the bladder. Just before you start these activities you unconsciously tighten your pelvic-floor muscles around your urethra to prevent urine from leaking.

If your sphincter muscles aren’t strong enough to keep your urethra closed, urine can leak through it when you do anything that increases pressure in the abdomen. This leakage is called stress incontinence, and it affects about 20 per cent of adult women. Whether the leak is just a few drops or a lot depends on how much your pelvic floor is weakened and how active you are (for example, jogging or playing tennis) when it happens.

Many things, in addition to damage during childbirth, can take their toll on the strength of the pelvic-floor muscles.

• After the menopause lack of oestrogen causes further weakening of the pelvic floor.

• All our muscles lose some tone and strength with age. The pelvic floor is no exception.

• Obesity puts more pressure on the bladder through increased weight of organs and tissues within the abdomen, making the symptoms of stress incontinence much worse.

• Chronic constipation and constant ‘straining at stool’ (the term for having to bear down hard when trying to empty the bowel) weakens the pelvic floor and may damage its nerves.

• During pregnancy lots of the hormone relaxin is produced. This hormone relaxes muscles and softens ligaments and other tissues of the pelvic floor in preparation for delivery. This makes bladder control more difficult during pregnancy and soon after delivery.

• Our bodies prepare for the possibility of pregnancy by starting to release some relaxin towards the end of each menstrual cycle. This, plus the added muscle-relaxing effect of progesterone, is why bladder control can be a bit more difficult just before periods.

• During breast-feeding, oestrogen levels are very low, making it harder to regain good bladder control after childbirth. It’s very important to keep up pelvic-floor exercises while you’re lactating.

• Some drugs used to control high blood pressure can paralyze part of the sphincter muscle.

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Two types of drugs are used to treat hirsutism:

• drugs that reduce hormone production such as the contraceptive Pill and similar hormone combinations. These reduce ovarian production of hormones (including androgens) but supply oestrogen and progesterone. They are sometimes used to treat simple hirsutism, with good results. The Pill that contains the anti-androgenic progestogen cyproterone acetate in low dose is most useful (also for acne).

• drugs such as spironolactone and higher-dose cyproterone acetate, which reduce the effect of androgens in the body. These drugs can cause some side-effects such as breast tenderness, lethargy, irregular periods and occasionally depression, though these are rarely serious and are often minimized if either oestrogen or the Pill is added to the treatment. Anti-androgens can’t be used if there is any possibility of pregnancy because of the risk of interfering with the sexual differentiation of a male’ foetus.

It is important for women having these treatments to realise that the life cycle of terminal hairs is measured in months (from when the hair begins to grow until when it falls out), so no apparent improvement may be seen until up to six months after starting. Treatment curbs androgen-stimulated growth of hair in ‘male’ sites, and prevents the conversion of more vellus hairs to terminal hairs. But once hair follicles have been stimulated to grow terminal hairs, they resume this growth when anti-androgen treatment is stopped. Those terminal hairs that develop before treatment can be removed by permanent cosmetic methods; then no new terminal hairs will form when excess male hormones have been eliminated.

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There are many theories, often contradictory, but none has been proved. The most widely held theory is that PMS is due to hormone imbalances. But of which hormones? Many believe that the ovarian hormones oestrogen and progesterone are the culprits. Other hormones named as suspects are prostaglandins (widely distributed in the body to aid control of many unconscious functions), prolactin (controls milk production and possibly other reproductive functions), antidiuretic hormone (helps control fluid balance), adrenal hormones (important in stress and fluid balance) and gonadotrophins from the pituitary.

Many women who complain mainly of premenstrual depression have a history of postnatal depression or depression during puberty – other times when there are significant hormonal changes.

Recent research suggests that cyclic changes in ovarian activity are linked to changes in the rate of production and/or release of endorphins (opium-like substances) in the hypothalamus: a part of the brain of paramount importance in the regulation of mood, behaviour, appetite, temperature and fluid balance. If this theory holds true, it should offer some interesting new means of combating PMS.

Among the non-hormonal causes suggested for PMS are vitamin deficiencies, mineral deficiencies, bad diet, faulty posture and negative attitudes to menstruation.

How common is PMS?

It’s hard to know exactly. It’s usually said that about nine out of ten women experience premenstrual changes, but not all changes are considered symptoms of ill health. Many women view breast changes as evidence (as menstruation is) of the cyclic ebb and flow of ovarian hormones. Around 15 per cent of women say that they feel better before periods. However, 5-10 per cent of women experience some disturbance of health premenstrually, and for a small number the syndrome can be regularly debilitating.

How is PMS diagnosed?

The clue to diagnosis is the regular recurrence of symptoms during the second half of the menstrual cycle, usually becoming worse as menstruation approaches. There is a symptom-free interval of at least a week after the period. Diagnosis can be helped by keeping a diary of symptoms over several months, which usually shows clearly the cyclic nature of PMS.

Another feature of PMS is its variability over the reproductive life span. There may be months or years when there are no premenstrual changes or changes so slight that they’re not considered worth mentioning. Symptoms often appear or become worse after a pregnancy, after stopping the Pill or after gynaecological surgery, and as with any other symptoms of ill health, are often worse during physical or emotional stress.

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Hormone replacement therapy

Studies on many hundreds of thousands of women have proved that HRT relieves oestrogen deficiency symptoms and can prevent or greatly reduce adverse effects on health due to a lack of oestrogen. Its benefits include the following.

• HRT eliminates physical symptoms due to a lack of oestrogen.

• Women feel psychologically better on HRT: they have more energy and vitality to enjoy life and cope with its ups and downs; less depression mood disturbances.

• HRT maintains healthy genital skill vaginal lining, making these tissues less liable to inflammation and infection. Lack of oestrogen causes the genital] vaginal membranes to become thinner, drier and less elastic. During sex, lubrication is slower and penetration may hurt. This may put you off sex, a time when you and your partner have more time to enjoy this part of your relationship. Your partner may feel rejected if you avoid sex because it is painful: many a relationship has foundered due to such misunderstandings and quite unnecessarily.

• By helping to maintain the tone of the pelvic muscles, HRT can help to prevent bladder control from worsening after the menopause.

• Oestrogen reduces the risk of cardiovascular disease and severe osteoporosis.

What HRT won’t do HRT won’t (alas!) prevent grey hairs and wrinkles. It also won’t solve emotional upsets due to marital, family and other interpersonal conflicts, or the many other worries and disappointments that invade our lives. But it may help you to muster more emotional and physical energy to deal with these problems.

Are there any health risks
HRT? For most women the advantages of HRT outweigh any possible disadvantages. There are a few women, including those with a history of breast cancer, some types of thrombosis, a rare type of migraine, severe liver disease and some gall bladder diseases, for whom hormonal treatment is inadvisable. Other measures can help relieve menopausal symptoms for these women. It used to be suspected that HRT might cause problems with blood pressure and blood fats such as cholesterol. More recent studies have shown that the reverse is true — HRT is of real benefit to women who have risk factors for heart disease such as high blood pressure and increased blood cholesterol.

Can HRT cause cancer? When HRT first introduced, it was found that women who took oestrogen alone for a long time developed cancer of the lining of the uterus more often than women who took no hormones. A vast amount of research has now shown that if oestrogen is combined with regular supplements of progestogen, there is no increased risk of uterine cancer.

There has been some uncertainty about whether HRT may be associated with the risk of breast cancer in susceptible women. There is growing evidence that use of HRT for more than 10 years slightly increases the risk of breast cancer, but that women who are on HRT at the time breast cancer is diagnosed have a better chance of surviving longer than those who aren’t.

The important thing is to balance up the risks and benefits for each individual, for example, if a woman has increased risk of coronary heart disease or osteoporosis, the preventive health benefits of HRT far outweigh any increased risk of breast cancer. Women who have no oestrogen deficiency symptoms and who are not at increased risk of heart disease or osteoporosis should consider the slight increase in risk of breast cancer when deciding whether or not to take HRT.

There is no known link between HRT and increased risk of any other type of cancer. There is evidence that HRT may reduce the risk of colon (large bowel) cancer and ovarian cancer.

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You’ll be asked many questions at your first visit. First, you will be asked about the present pregnancy: LMP date and details; probable date of conception, if known; recent contraceptive use; when pregnancy symptoms started. Then there’ll be questions about your general health history; operations; any significant family history; your gynaecological history; details of any previous pregnancies.

You will be given a full general physical examination to exclude the possibility of health disorders that could affect the pregnancy. Weight, height and blood pressure are measured. Neck, lungs, heart and breasts are examined next; then the abdomen, spine, legs and feet. Armpits and groin are checked for swollen glands.

Finally, a careful pelvic examination is performed with the following aims:

• to assess the size of the uterus; is it consistent with the enlargement that could be expected since the time of LMP?

• to check the condition of the external genitals, vagina, pelvic floor, cervix, uterine wall, tubes, ovaries and other organs and tissues in the pelvis.

A Pap smear will be done, if due.

Routine tests

These tests are an important part of antenatal supervision. Urine is tested for protein (to exclude the possibility of abnormal kidney function) and sugar (to check for diabetes).

A blood sample is taken for the following tests (some won’t be repeated if they’ve been done before):

• blood group and screening for blood group antibodies that may have developed in previous pregnancies or other circumstances. If you’re Rh (Rhesus) negative you may need more tests later in pregnancy to see if Rh antibodies have developed

• blood count to make sure that you’re
not anaemic and that all blood cells normal

• rubella (German measles) antibody level. Occasionally rubella immunization doesn’t result in sufficient immunity, immunity decreases with time. If your
immunity is low you’ll be advised how best to avoid infection during pregnancy. If you develop a fever and changes in rubella antibody levels confirm the diagnosis. Rubella dif the first three months of pregnancy ties a high risk of serious foetal malformation. If you’re infected with rubella
at the critical time, you may request termination of your pregnancy. Ideally you should be checked for rubella antibodies before your first pregnancy that your immunity can be boosted necessary.

The following tests aren’t always recommended. Some doctors doubt usefulness as a routine but may suggest them in some circumstances, or you request them.

Alpha-fetoprotein This protein passes from foetal to maternal blood. Raised levels in the mother’s blood may be found when there is multiple pregnancy, in some instances where there are uncommon foetal abnormalities such as spina bifida (though the test doesn’t always detect these conditions), and sometimes when everything is quite normal. If a repeat test is also high, other tests such as ultrasound and amniocentesis may be need to search for the cause.

VDRL (Venereal Diseases Reference Laboratory) This is a screening test for syphilis. Maternal infection with syphilis can be passed on to the foetus, causing malformations and serious illness, though fortunately not until the second trimester so action can be taken immediately to cure the mother and protect the foetus from harm. Though syphilis is uncommon in Australia now, the odd unexpected positive result turns up. Because some other conditions can cause a positive VDRL, further tests are always done to see whether the cause is really syphilis. No matter how unlikely your risk of syphilis, VDRL screening is a wise precaution, and it’s reassuring to know that you’re negative.

Pelvic ultrasound This test is very useful if the length of pregnancy is in doubt; to detect multiple pregnancy; if ectopic pregnancy is suspected; to detect some (not all) foetal abnormalities; and to detect abnormal positions of the placenta. Ultrasound isn’t done routinely because it hasn’t been shown to improve the pregnancy outcome for mothers and babies unless it is used for a specific purpose.

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