Antidepressants Blog

A very distressing—and far too typical—letter came us recently from a woman in Ohio, written on the eve of her twenty-sixth birthday. Karen described her tangled history with endometriosis, beginning with her final decision: the prior week, she wrote, she had signed a document giving her doctor the right to perform surgery to “clean up the endometriosis and save as much of my organs as possible.” Her letter went on to detail her story:

For two years she had suffered from cramps, bleeding, and intense abdominal pain. One afternoon a cyst ruptured as she was driving to work. Miraculously, she got herself out of the car and Ragged down a good Samaritan who took her to a hospital, where she was given emergency surgery.

At this point, Karen did not know she had endometriosis. After surgery, her doctor put her on tranquilizers for her continuing pain; then he followed up with hormone treatments to quell her menstrual cramps. She subsequently had two miscarriages and her doctor ran some tests on her, including a laparoscopy (the surgical procedure that enables doctors to see into the pelvic area). It was then finally that he discovered endometriosis!

“My doctor was very comforting.” Karen said in her letter, “and I’ve always trusted him. He said there was a slim chance that I’d need a hysterectomy, but he’d try to save what he could. Of course, I heard the words I wanted to hear: he’d save me. I woke up from surgery and he told me the news. He hadn’t saved anything and he’d given me a hysterectomy. That ended it for my ever having children and I wasn’t yet twenty-six years old! I felt as if I’d been butchered, like a human sacrifice! But if he said I needed a hysterectomy, who should I believe? He also said that, in another month, I would have to go on estrogen supplements since he had removed both my ovaries, too. Was he wrong? What would you do?”

This woman’s castration was presented to her after the fact as the only answer to her problem. Her surgery was needless. Had she seen a specialist in endometriosis, we feel certain that she could have had a chance at recovery. Touting her doctor may have given her a measure of comfort, but this was not enough. As we see it, when her doctor operated, he did not have the expertise to understand that the internal bleeding was caused by endometrial masses. Doctors who do not have a trained eye can miss the condition in its earliest stages, even when it is literally at their fingertips. They may mistake it for something else—an infection or even cancer. This doctor’s choice of treatment – complete hysterectomy—harks back to what was common practice over a decade ago for such “far-gone” cases. That this physician subsequently prescribed hormones in the form of estrogen replacement so soon after surgery indicates another gap in his knowledge.

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Tai Chi was developed in China generations ago and consists of a series of slow, dance-like steps.

Using correct breathing, controlled stretching and gentle artistic movements, and it is a graceful way of keeping fit without much effort.

According to the Chinese this art of gentle relaxation and controlled body movements increases the body’s tolerance against disease and illness and helps rejuvenate the whole person.

It claims to relax the mind and body, improve circulation, loosen stiff joints and tone up muscles.

If you find vigorous exercise difficult or painful then you may like to try this gentle form of exercise.

Yoga

There are many different varieties of yoga, the most familiar in western countries being Hatha which involves physical postures that balance and harmonise the body systems. It is believed that yoga stimulates your natural powers and therefore gives you greater control over your well-being.

Yoga postures — known as asanas — flex the joints, stretch and tone the muscles and improve the body’s circulation.

The maintenance of slow and rhythmic breathing while the postures are being performed helps relieve body tension and therefore increases the effectiveness of the body positions.

Asanas should never be strained but should be practised slowly and gracefully.

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Dysmenorrhoea means painful periods. It is the most common symptom of endometriosis. In a recent survey of women with endometriosis by the Endometriosis Association, 81% of the women had experienced dysmenorrhoea.

According to medical textbooks there are two types of dysmenorrhoea: primary and secondary.

Primary dysmenorrhoea is said to be the ‘cramping’ type of dysmenorrhoea that typically affects teenagers. It usually begins a year or two after the onset of menstruation and tends to lessen by the age of 2 5, or after childbirth. The pain usually begins with the menstrual flow and lasts for only one or two days. It is often accompanied by nausea, vomiting, diarrhoea, dizziness and fainting. This type of dysmenorrhoea is generally believed by the medical profession to have no relationship to endometriosis.

Secondary dysmenorrhoea is the ‘grinding’ or ‘boring’ type of menstrual pain which is usually due to an underlying condition of the reproductive organs. According to the medical profession it typically appears in women who are in their 20s and 30s. This is the type of dysmenorrhoea that is generally believed to be associated with conditions such as pelvic inflammatory disease (PID), fibroids and endometriosis.

The pain of dysmenorrhoea due to endometriosis may be mild, moderate or severe and may be described as constant, deep inside, sharp, stabbing, knife-like, nagging, aching, burning, throbbing, dull, boring or cramping. It may be located in the centre or on one or both sides of the abdomen. The pain may radiate into the vulva, pubic bone, lower back, rectum, buttocks, groin or thighs. It may be more severe when using the bowels or passing urine, and may be accompanied by nausea, vomiting, and diarrhoea and/or constipation.

The pain may begin one to several days before the start of the period, gradually becoming more severe, particularly once the menstrual flow begins. The pain may last for the first one to two days or continue throughout the entire period. Usually the pain is most severe on the first or second day. It has been reported that the pain worsens and peaks at the end of the period although this pattern is not common.

It is not known precisely what causes the dysmenorrhoea associated with endometriosis but it is probably due to several reasons. One is that the bleeding from the endometrial implants causes irritation to the surrounding tissues. Another possibility is that the pressure resulting from the swelling of the implants and cysts causes pain in the immediate area in much the same way that a boil causes pain. It is also possible that the release by the endometrial implants of chemicals known as prostaglandins causes pain. Irritation to neighbouring organs, such as the bowel or bladder, by the implants of endometriosis can also lead to pain in those organs.

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Doctors are divided over the importance of stress in infertility and yet stud-have shown that it can affect a man’s fertility to the point where not only the count is reduced but also the quality of the sperm, with abnormal sperm and decreased motility.

Stress can also affect a man’s hormone balance, lowering his levels of testosterone and luteinising hormone.

The release of the stress hormone prolactin in response to a crisis can affect a woman’s ability to conceive and in extreme cases can stop her ovulating. It seems to be nature’s way of protecting women from getting pregnant at a time when they would find it hard to cope. Women going through a bereavement or other kind of trauma for instance can stop having periods altogether.

Couples trying for a baby often experience high levels of stress, particularly if medical intervention is required. The longer it takes, of course, the more anxious you may become – and the more chance there is of stress inhibiting your fertility. A number of studies show that if a woman becomes totally obsessed with having a baby she may release eggs which are not mature enough to be fertilised.

There are many anecdotes concerning couples who have given up fertility investigations, put their names down for adoption, and then found themselves pregnant. One lady I saw gave up work to have a baby and got so bored that she decided to find another job and then got pregnant. Other women may find that the stress of the job they are doing may be affecting their fertility. We are all so different and what affects one person may not trouble another – ‘one man’s meat is another man’s poison’.

Many couples find that they conceive on holiday when they are relaxed and have forgotten about all their domestic worries. Infertility is clearly a multi-factorial problem, which is why this book looks at all the possibilities, not only the physical aspects (such as hormones and nutrition) but also the psychological and emotional side.

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Women play an important role in educating their children about AIDS (and about other STDs of course, but AIDS is the most likely subject to come up because it has had so much publicity). Children will have heard of it from radio and television and from reading the news, and perhaps from school teachers or talking to other children. It’s important that parents ensure children have clear and accurate information and that they have no unjustified fears about how HIV can be caught. What you say depends on your child’s age and maturity and the circumstances in which the subject is brought up. Some of the pamphlets on AIDS contain information and illustrations suitable for teaching children of various ages.

Preschool children

Preschool children may be too young to grasp the concept of such an illness and are unlikely to ask questions. However, this is a good age to start teaching habits of hygiene that protect against the spread of infections in general (for example, avoidance of contact with other people’s blood, saliva, urine, faeces, discharges and wounds). Also, you can put in some good groundwork for future teaching about AIDS and other sexual matters by encouraging your small children to be as much at ease with and interested in their genitals (including talking and asking about them) as with other parts of the body. This may be hard if you grew up knowing that it was OK to talk about tonsils or lungs, but that mention of the vulva or penis resulted in embarrassment and avoidance (which lads sense and remember even before you’re aware of it yourself). If you want your children to feel free to ask you important sex-related questions when they’re older, you must let them know right from the start that you’re ‘askable’.

Primary schoolers

The appropriate age to explain more about AIDS is somewhere between 6 and 12 years. It is recommended that parents should bring up the subject rather than waiting to be asked: children may be uneasy about raising a topic that involves such difficult things as sex and death. A newspaper headline or television programme may provide a good opening.

Teenagers

Your teenage children will have read and heard as much as you have, but may not have a mature understanding of this information. Discussion of AIDS with teenagers must be frank and accurate, and provides a good opportunity to reinforce teaching about personal hygiene, safe sex and the use of condoms (which also provide contraception), and the potential dangers of drugs. Many parents find these subjects very difficult, but there is plenty of evidence that teenagers are less likely to run into problems with sex and drugs if these matters are discussed at home.

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This describes urinary frequency and pail on urination, usually related to sex, but with no bacteria in the urine. There’s usually no temperature, no pain in the lower abdomen and often little or no urgency. Attacks are often recurrent and may begin after having a catheter in the bladder, after childbirth or surgery, or after a bacterial infection.

The symptoms are probably the result of mechanical trauma to the urethra by the thrusting of the penis during intercourse. Chronic inflammation around the bladder base, where the urethra starts, may also flare up and cause symptoms after sex. Urethral symptoms occasionally arise from the pressure of the rim of a diaphragm. They are also more likely at certain times such as during a viral infection, emotional upsets, when overtired or under any circumstances that reduce sexual arousal and increase the likelihood of frictional trauma to the urethra during intercourse.

Women who get urethral syndrome aren’t helped by antibiotics unless infection is also present, though often these are prescribed over and over again. The inflamed urethra settles down of its own accord after a couple of days without sex or whatever else is irritating the urethra. The antibiotics usually get the credit. But if further intercourse brings back the symptoms while you’re still finishing your course of antibiotics, you can be pretty sure that infection isn’t the cause.

The best way to conquer the after-sex urethral syndrome is to make sure you’re always properly aroused and lubricated before penetration. This won’t be easy if you’re worried about the outcome or if the problem has put you right off sex. It can help to use a lubricating jelly until you gain confidence in knowing that you can enjoy sex without developing urinary symptoms. Postmenopausal women who are not on hormone replacement will mostly need to use extra lubrication.

Other things can irritate the urethra and lead to symptoms. Your urethra can become inflamed, even if not infected, if you have vaginal and genital inflammations and infections.

Other irritants include soap, bath salts and foams, talcum powder, ‘feminine hygiene’ products (which we can all do without), pressure from a tampon in the wrong position, or synthetic underpants. Some people get urethral irritation a few hours after a spicy meal or other foods and drinks (including vitamin C) that make urine acid. (Always wash your hands thoroughly before going to the toilet after handling chillis. The slightest trace transferred when you’re drying your bottom can leave you stinging for hours! As you’ve guessed, this advice comes from an uncomfortable personal experience!)

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Uterine adenomyosis

Adenomyosis means ‘gland within the muscle’. In this condition fragments of endometrium penetrate and grow between the muscle fibres of the uterine wall. It is really endometriosis of the uterine wall,
and may accompany endometriosis elsewhere in the pelvis. Adenomyosis is most common in women who are over 35 years of age.

Symptoms occur because the endometrium within the muscle undergoes the same changes during the menstrual cycle as that lining the uterine cavity. Periods become heavier and more prolonged, and are often associated with a dull ache and a feeling of pressure in the pelvis. The uterus becomes enlarged and softer, and may be tender.

Treatment of adenomyosis is the same as for endometriosis elsewhere in the pelvis, but unfortunately the response to hormones is not generally as good. In women who want no more children, hysterectomy is usually the best solution.

Endometrial hyperplasia

This is overgrowth of the endometrium resulting from prolonged stimulation by oestrogen without the balancing effect of progesterone. Endometrial hyperplasia occurs in women who don’t ovulate for a long time, and is most common in the years preceding the menopause.

There are two exceptions in which the connection between this condition and failure to ovulate does not apply.

• Young women often don’t ovulate for some months or years after the menarche. Periods may be heavier during this time, but as soon as ovulation begins, progesterone from the corpus luteum corrects the endometrial overgrowth.

• Hormonal contraception stops ovulation, but the progesterone it contains prevents endometrial overgrowth. In fact, the combined Pill or contraceptive progestogens are often used to correct endometrial hyperplasia.

The symptom of endometrial hyperplasia is increasingly heavy and prolonged menstrual bleeding, often quite irregular. Diagnosis is by examination under the microscope of endometrium removed by curettage. D&C often stops the heavy bleeding for a few months, but as long as the ovaries continue to produce oestrogen without ovulation, the condition will recur.

The treatment for endometrial hyperplasia is usually to give progestogens. In young women, taking the contraceptive Pill for several months may correct the condition. Endometrial hyperplasia is a benign condition but if it isn’t controlled, it’s possible that prolonged stimulation by oestrogen could lead to endometrial cancer. For this reason, hysterectomy is often advised for women over the age of 40 who want no more children.

Cancer of the uterus

This usually means cancer of the endometrium (lining of the uterus), which is the second most common pelvic cancer in women (after cervical cancer).

Endometrial cancer is much I treacherous than either ovarian or cervical cancer. It develops slowly and can usually be detected early because it almost causes symptoms of irregular or post menopausal bleeding before it spreads.

The cause of endometrial cancer a clear, but it seems to be connected with oestrogen. It is more common among women over the age of 50 who have been exposed to high levels of oestrogen and lack of progesterone, such as those who’ve had endometrial hyperplasia, polycystic ovarian syndrome, or hormone replacement with oestrogen alone. But not all women with a history of these conditions develop endometrial cancer. It’s suspected that the endometrium of those who do is more sensitive to oestrogen stimulation and overgrowth.

The treatment is primarily removal of the uterus, tubes and ovaries by surgery, and may be curative if there’s been no spread. The ovaries are removed because they might contain minute spots of cancer, and because any oestrogen produced might stimulate tiny groups of cancer that have spread elsewhere. If there’s obvious spread when the cancer is nosed, surgery is usually followed by radiation therapy and sometimes treatment with progestogens.

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Primary amenorrhoea is the failure to start menstruating during puberty. When a woman stops menstruating at any time between the menarche and the menopause, it’s called secondary amenonhoea.

Primary amenorrhoea

Ninety-five per cent of girls have had their first period by the age of 16 years. Those who haven’t started menstruating by this age (earlier if there’ve been no other signs of puberty by the age of 14) should see their doctor to discover if there is any particular problem that needs correcting. Many will just be ‘late starters’, but it’s important to treat the following causes of primary amenorrhoea.

Underweight Sometimes failure to start menstruating is an important clue to anorexia nervosa, and this should always be suspected if menstruation hasn’t started or has stopped in a young woman who is extremely thin.

Imperforate hymen

Congenital abnormalities of internal reproductive organs Very rarely, the ovaries, uterus or vagina may not develop properly before birth.

Hormonal disturbances Many hormonal disturbances can lead to primary amenorrhoea.

• If the hypothalamus or pituitary glands are underactive, all the developments of puberty will be delayed or disturbed

• If the ovaries can’t respond to pituitary hormones, there may be a growl spurt but secondary sexual characteristics won’t develop without ovarian hormones.

• Underactivity of the thyroid gland (hypothyroidism) usually results in disturbed puberty and delayed menarche

• Overactivity of the adrenal glands (adrenal hyperplasia) can lead to an over production of male hormones that counteract ovarian hormones.

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If something can be done to treat any cause found, the treatment and reason for it will be explained to you so that you can decide whether you want to go ahead. Such treatments include measures to improve the sperm count or reduce sperm antibodies, drug therapy to stimulate ovulation and procedures to correct blocked tubes.

Improving sperm count First, reducing excessive smoking and drinking is advised; any general health problems are given attention and if drugs or occupational factors are suspected, these should be eliminated if possible. If there is a problem with the hormones that control sperm production (rare), in many cases this can be corrected. Surgery may be attempted to open up any block in the tubes that carry the sperm into the semen, though the success rate of these procedures is low. A varicocele can be removed surgically; this results in increased sperm production in some but not all cases.

Reducing sperm antibodies To suppress the immune system and formation of antibodies, medication with cord steroids may be offered.

Stimulating ovulation If you’re not ovulating, you’ll be advised to have further tests to find out exactly how the hormonal control of ovulation is disturbed. Until quite recently there wasn’t much hope for women who didn’t ovulate. Today the so-called ‘fertility drugs’ will produce ovulation in almost all women who use them. These drugs include clomiphene, gonadotrophins, bromocriptine and gonadotrophin-releasing hormone (Gn RH). Clomiphene and GnRH stimulate the pituitary gland to produce more FSH and LH. Gonadotrophins are tried when pituitary can’t be made to produce its own. Bromocriptine is used when ovulation stops because there is too much prolactin in the circulation.

The use of drugs that stimulate ovulation is very complicated; they are usually prescribed and monitored by fertility specialists in centres with close access special laboratories, as regular (sometimes daily) blood tests must be done on the patient to check progress and work out the next dose. You should have explain to you what this treatment entails, such as the frequency of specialist visits required, chances of success, the possible side-effects, the risk of multiple pregnancy and the cost. Ask about these things.

If you’re very underweight, you may encouraged to eat up and gain some weight before starting the treatment stimulate ovulation. On the other hand, if you’re very overweight you may need to lose some.

Surgery for blocked tubes What can be done depends on the cause and extent of the blockage. This is delicate, painstaking surgery (called tuboplasty) and as the canal through the tube is only 1 mm or so wide in some parts, microsurgery techniques are used.

Even if the tube can be opened, fertility can’t be guaranteed. Scar tissue may form after surgery and re-block the tube. The tubal lining, which has an important role in the safe passage of the fertilised egg through the tube, may have been damaged by whatever caused the blockage in the first place. No matter how skilful the surgeon, it may be impossible to restore the function of a badly damaged tube.

Your surgeon, after looking at the outside of your tubes through the laparoscope and maybe inside by falloposcopy, will give you a realistic opinion about whether it’s worth trying to repair the canal through your tubes and the chance of pregnancy afterwards.

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During your first pregnancy you may be surprised at how different your body feels, and how it changes as the months go by. With subsequent pregnancies you’ll know what to expect, though some changes may be different each time. Most of the feelings of pregnancy are wonderful, but some symptoms are not so welcome.

The early months

Many women notice changes in their bodies as early as the time of the first missed period. The earliest changes are in your breasts, which become larger, firmer and often tender due to growth of breast glands and increased blood supply. Veins under the breast skin become more conspicuous. Nipples may tingle or itch. From about the eighth week, your nipples and their surrounding areolae begin to enlarge and darken.

Feeling sick

More than half of all pregnant women experience nausea alone or nausea and vomiting in the early months. These symptoms are usually mild, occasionally severe. It’s a strange feeling, not quite like the nausea you’ve felt with any illness. It often goes with unusual food cravings and aversion to the taste and smell of some foods. Contrary to popular belief, nausea can happen at any time of the day, but because it’s usually aggravated by an empty stomach, it’s often worse before breakfast. Having a small snack before you get up helps, as does having small meals more often during the day.

The cause of pregnancy sickness isn’t clear, but it’s probably connected with the hormonal changes of early pregnancy. It generally settles after 12 weeks as your body adjusts to the higher hormone levels. If it continues into the middle months, or if at any time you can’t keep anything down, see your doctor.

Your bladder

Your kidneys work overtime in early pregnancy, producing more urine. You’ll probably develop a huge thirst to keep up with this. Also, the increased blood fl and enlarging uterus in your pelvis reduce the capacity of your bladder. This adds to a bladder that rarely feels empty long. A frequent need to urinate can disrupt your daytime routine and disturb your sleep at night. It can be hard to through a movie or last the distance during long bus trips.

Tiredness

It’s normal to tire more easily and г sleepy more often during pregnancy. This is nature’s way of ensuring you get extra rest you need. You’re more likely feel daytime sleepiness if your bladder disturbs your rest at night. Take a nap if you can.

Dizziness and faintness

During early pregnancy there are m changes in the circulation and composition of the blood. If you’re hot and flush (and a lot of your blood is in your skin)
or if you suddenly stand up (which causes a brief fall in blood pressure), the blood flow to your brain may be momentarily too low, resulting in dizziness and faintness. Avoid becoming overheated, stand up more slowly. If dizziness fainting happen often or without re see your doctor.

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