Ишемическая болезнь сердца-Ischemic heart disease

Many people find tranquility and joy in their later years, relieved of responsibilities such as bringing up children and maintaining a career. They are glad to have more time to devote to their partners, the rest of the family, friends, hobbies and other interests. People who plan for their later years usually manage best.

Others find it very difficult to adjust to social and family changes at this time of life. Particular problems may arise.

• If after retirement you move to a new community, you may find it hard to make new friends, and you may miss the family and friends you left behind more than you anticipated. Distance and finances can restrict how much contact you keep with the people who are dear to you. Continuity of old associations is very important.

• Loneliness and grief can be profound if your partner or someone very close to you dies. This, together with chronic illness of self or partner, is the most common trigger of depression among older people. Loving support from family and friends will help, but even so it takes months or years to be able to enjoy life again after bereavement. Don’t hesitate to approach your doctor or community health worker if you feel you can’t cope with grief or loneliness.

• You may miss the position of authority you attained in your career and the organization of your time imposed by a job. Even when you’ve longed for extra time to devote to travelling, sorting out your photographs, replanning the garden, getting into craft, playing more tennis or bridge and suchlike, you may find it hard to use your time for yourself. Women who’ve spent most of their adult lives caring for others may find it particularly hard to take time for themselves.

• Some relationships break down in middle age or later. Couples without a strong bond who’ve stayed together for years because of the children, or because they don’t want to upset their parents, or because they can’t afford to live separately, or because their careers let them get away from each other most of the time, may find that they can’t tolerate living together in retirement. Deciding to separate can be difficult and distressing, and living alone can be hard to adjust to. • Passing beyond middle age can bring disappointments, as we realize that some of our life’s hopes and dreams won’t be fulfilled. Most of us won’t write the great novel, make the great scientific discovery, achieve eternal fame, though it’s surprising how many great achievements have been in later life – read The Book of Ages, by Desmond Morris (Jonathon Cape, London 1983). No life is empty: we can always look back with pride on many achievements, and who knows what unexpected joys lie ahead.

There’s heaps of advice going around for older people: keep your mind and body active; take up new interests; join a club or group; do a course; become a community volunteer, and so on. All excellent suggestions to help you fill your life happily at any time, and when you’re older you may at last have the time to take them up. Whatever you choose to do in later life, enjoy it!

It’s also good to remember that older people have a special role to play in giving a view of life’s journey to others. Having seen it all in one’s life and survived is an important contribution to the young. You can be honest about the things in life that have been important to you: what you value and what you regret. This is a precious gift to those younger than you who are looking for their own path. Old people who can enjoy themselves or face difficulties with courage give hope and meaning to all around them.

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Who’s at risk of catching these infections?

Anyone who’s at risk of catching any other sexually transmitted disease. Infection is more likely in those who have more than one sexual partner or whose partners have other partners. Women whose partners are infected but don’t develop symptoms of urethritis are at particular risk because both go untreated. All women with a diagnosis of PID should make sure that their partners are checked to avoid reinfection.

Infection of newborn babies

Babies can be infected from their mothers during birth. Studies of pregnant women in the USA have found that from one in twenty up to one in five (in some districts) have chlamydial infections of the cervix. About one in four babies born to infected mothers will develop chlamydial conjunctivitis (eye infection) within two weeks of birth, and some of these babies will go on to develop pneumonia. Gonorrhoea transmitted from mother to baby during birth can cause serious eye infection in newborn infants, and occasionally throat infection and vaginal discharge.

How are these infections diagnosed?

The symptoms may be suspicious, but the diagnosis can only be confirmed for certain by laboratory tests and even that isn’t always easy. Your doctor will take a swab from any areas that could be infected, including rectum and throat if these have been in contact with your partner’s penis. The swab is wiped onto a glass slide to be examined under the microscope, and is then used to try to grow (culture) any germs that could be causing the infection. A urine test for chlamydia is proving to be a very reliable method of identifying the infection.

If you go to an STD or sexual health clinic, your doctor may examine the microscope slide straight away. Something may be found to strengthen suspicion enough for treatment to be started without waiting for the results of cultures, which can take from two days to two weeks to be ready. However, growing the bacteria is the only way to be certain about an infection, and the germs that have been grown can be tested for sensitivity to various antibiotics to make sure that whatever treatment you’re given will work. You will always be asked to contact your doctor when all the results are back from the laboratory, to confirm that you’re having the right treatment and in case further tests are needed.

When your partner has a proven infection, you will be given treatment even if it has not been possible to grow the bacteria from your swabs.

If you need tests for gonorrhoea or chlamydia you may also be offered tests for other STDs such as syphilis, hepatitis В and HIV. These may need to be repeated at a later date because it can take up to three months after they are acquired for these infections to show up in tests. The possibility that your sexual partner(s) may be infected will also be discussed.

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By examining your breasts regularly you increase your chances of noticing any change that should be examined by your doctor to rule out breast cancer.

Your doctor or nurse will teach you how to examine your breasts and provide you with an illustrated pamphlet describing the technique. These pamphlets are also available from women’s health centers, family planning centers, baby health centers, community nurses and many other public health outlets.

You should start BSE around the age of 20 years. It is best done about a week after your period starts, when there are least hormonal changes in the breasts. After the menopause, it could be done on the 1st of each month or, if you’re using HRT, before you start the progestogen supplement. With regular practice, you’ll get to know the normal feeling of your breasts and be able to recognize any change. This is what you’re looking for during BSE – something that wasn’t there last time: a lump; any area that feels thicker than surrounding tissue; any change in breast size or shape; nipple discharge; roughening of nipple skin; turning in of a nipple that previously turned out; puckering, dimpling, redness or any other change in the skin of the breast.

What if you find something?

Imagine you’re examining your breasts. Suddenly your heart skips a beat. You cautiously feel your breast again. Is that a lump? You nervously prod around the suspicious spot. You’re not sure. You compare it with the same spot on the other breast. Yes, there’s definitely something different. It wasn’t there when you checked your breasts last month. Could it be cancer? You break out into a cold sweat!

Try not to panic. Even if you’re in the highest risk age group for breast cancer (over 50), more than eight times out of ten the lump will be benign. The chances that any lump or change will be cancer are:

Retained tampon

Part or all of a tampon may be unwittingly left in the vagina after a period. It may be that a bit separated from the tampon during withdrawal, or that the string became tucked inside the vagina and the tampon was forgotten, or that a second tampon has been inserted without remembering to take out one that’s already there.

Chemical changes in the blood held in the tampon give a particularly unpleasant ‘bad-meat’ smell to the vaginal discharge, which may be slightly increased in amount and brownish in colour. When the tampon is removed, the smell goes away almost immediately and no further treatment is necessary.

Most women feel quite foolish when a medical visit about a smelly discharge reveals a retained tampon as the cause. But it’s an easy mistake to make and will happen to most of us at least once during our reproductive lives. If you develop that particular meaty smell soon after a period ends, it’s worth checking in your vagina for a retained tampon. It will feel rough and spongy, and you can pull it out with your fingers and ‘cure’ yourself.

Vaginal fistulas

A fistula is an abnormal, tunnel-like passage connecting two hollow organs or an internal organ and the skin surface. A fistula between the bladder and the vagina called a vesico-vaginal fistula) results in constant leakage of urine from the vagina. If the fistula is small there may be just a slight trickle of urine as the bladder fills, but if it is large, there will be total urinate incontinence. Fistulas between the urethra and the vagina only cause leakage oil urine during voiding, which may not be noticed. Fistulas between the rectum and the vagina result in leakage of faeces.

Most fistulas opening into the vagina are caused by tearing during prolonged, obstructed delivery, and are rare in countries where good obstetric services prevent such injuries. However, there are many parts of the world where fistulas still result from childbirth. Other less common causes include accidents during difficult pelvic surgery, and extensive radiation for pelvic cancer.

Treatment is by surgical repair, usually with good result.

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Surgical removal of the uterus is the second most common gynaecological operation after D&C. The word ‘hysterectomy’ comes from the Greek hysterikos meaning suffering in the womb’. There are several types of hysterectomy.

Total hysterectomy The entire uterus (body plus cervix) is removed.

Subtotal hysterectomy

The body of the uterus is removed, leaving the cervix. This operation was popular in the past; the cervix was believed to be important in sexual function and the enjoyment of sex. We still don’t know the function of the cervix in sexual pleasure, but because most women who’ve had total hysterectomies notice no change in the sensations of sexual arousal and orgasm, total hysterectomy is recommended these days because it is a less difficult and safer operation.

Radical hysterectomy

The uterus and associated lymph glands in the pelvis are removed.

Hysterosalpingo-oöphorectomy

This is also called hysterectomy and bilateral salpingo-oöphorectomy. The uterus, the ovaries and tubes on both sides are moved. The vault (uterine end) of the vagina may also need to be removed. If a woman needs a hysterectomy before the menopause, the ovaries are preserved unless they are damaged or diseased beyond salvage. If no ovarian tissue can be saved, hormone replacement must be started at once.

After the menopause, when ovarian production of oestrogen has ceased, saving the ovaries is not so important. However, there is no justification for removing healthy ovaries as a routine when hysterectomy is performed in postmenopausal women. As far as we know, postmenopausal ovaries continue to produce androgens that may be important in maintaining libido in older women. Perhaps they have ‘ other undiscovered functions.

When is hysterectomy necessary?

Reasons for hysterectomy include:

• cancer of the body or cervix of the uterus, or cancer of the ovaries

• benign tumours (such as large fibroids) that cause symptoms and can’t be removed without removing the uterus

• endometriosis that can’t be controlled by other means and is causing severe symptoms

• excessive menstrual blood loss and pain that hasn’t improved with other treatment

• severe prolapse that can’t be corrected otherwise

• rarely, to relieve symptoms due to severe chronic pelvic infection that can’t be controlled by antibiotics

• very rarely, as a life-saving emergency if the uterus is severely injured during childbirth or other gynaecological surgery.

The operation

Hysterectomy involves cutting the uterus away from the ligaments that hold it in the pelvis and separating the cervix from the inner end of the vagina. The uterus can be removed through the vagina or through an incision in the lower abdominal wall.

Vaginal hysterectomy is usually performed with laparoscopic assistance. It has the advantage of less post-operative pain and a shorter average hospital stay (two to three days) and convalescence (about the weeks), and is now the most common method of hysterectomy for benign (non-cancerous) uterine disease. However, vaginal hysterectomy is unsuitable if the uterus is very enlarged or if adhesions or other disease have attached the uterus to other organs and tissues in the pelvis. Abdominal hysterectomy surgery, so you’ll be in hospital for about a week. As with any abdominal surgery, you’ll have some abdominal pain and pain around the wound, for which you’ll be given painkillers as required. The pain rarely lasts more than a few days. You’ll be encouraged to be up and moving a little more each day – early movement reduces the risk of some complications. Convalescence after abdominal hysterectomy is usually complete within six weeks.

After either type of hysterectomy there will be a decreasing amount of bloodstained discharge from the vaginal wound for about two weeks. Any bright red vaginal bleeding should be reported to your doctor without delay. For the first couple of weeks after you get home you’ll need to take things easily. Aim to do a little more each day.

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