Ишемическая болезнь сердца-Ischemic heart disease

В настоящее время в основе первичной профилактики (предупреждение развития заболевания) ИБС лежит концепция о факторах риска. Под этим термином врачи понимают привычки, связанные с образом жизни, или какие-либо врождённые признаки, увеличивающие риск развития заболевания. Чем больше у человека совокупности факторов риска, тем больше вероятность заболеть, и наоборот. Путём изучения обширных контингентов лиц в странах, отличающихся природными условиями, степенью индустриализации, образом жизни, питанием, были выделены факторы риска для ИБС. Их можно разделить на две группы:

- факторы, которые изменить невозможно;

- факторы, на которые можно повлиять.

К факторам риска ИБС, которые изменить невозможно, относят – пол, возраст и наследственность. Установлено, что мужчины болеют ИБС чаще и заболевание у них развивается в более молодом возрасте, чем у женщин. В последние годы наблюдается увеличение заболеваемости ИБС среди женщин, что в основном связывают с изменением образа жизни и приобретением вредных привычек: курение, низкая физическая активность, избыточная масса тела, однако, всё же женщины болеют ИБС реже, чем мужчины.

Всем хорошо известно, что риск заболеть ИБС увеличивается с возрастом и для мужчин, и для женщин. Если ближайшие родственники страдают ИБС, особенно если перенесли инфаркт в возрасте до 60 лет, то имеется неблагоприятная наследственность и эти лица должны быть особенно внимательны к своему здоровью и стремиться избежать других факторов риска.

Среди факторов риска, которые можно изменить, наибольшее значение имеют повышенный уровень холестерина в крови (гиперхолестеринемия), курение сигарет и повышенное артериальное давление (артериальная гипертония). Их называют основными факторами риска. Имеется много научных данных, позволяющих считать, что между этими факторами риска и ИБС имеется причинная связь. Выделяют ещё целый ряд факторов риска, влияние которых на развитие ИБС менее отчетливо, чем трёх вышеуказанных факторов. Это сахарный диабет, низкая физическая активность, избыточная масса тела, повышенный уровень в крови мочевой кислоты.

Рассмотрим основной фактор риска более подробно.

Повышенный уровень холестерина в крови.

Холестерин относится к группе жиров, он абсолютно необходим для нормальной жизнедеятельности организма, однако его очень высокий уровень в крови способствует развитию атеросклероза (сужению сосудов). Холестерин циркулирует в крови в составе жиробелковых частиц – липопротеинов. Определённый уровень холестерина в крови поддерживается за счёт холестерина, поступающего с пищевыми продуктами, и синтеза его в организме.

В настоящее время накоплено большое количество неоспоримых доказательств связи, между повышенным уровнем холестерина в крови и риском развития ишемической болезни сердца (ИБС). Их можно суммировать следующим образом:

1) эксперименты на животных показали, что кормление их пищей с высоким содержанием холестерина приводит к развитию атеросклероза;

2) исследования групп населения, отличающихся по уровню холестерина в крови, выявили различную степень распространённости в них ИБС;

3) у лиц, страдающих ИБС, чаще встречается повышение уровня холестерина в крови;

4) у лиц с генетически обусловленным высоким уровнем холестерина в крови (семейная гиперхолестеринемия) почти всегда преждевременно развивается ИБС, т.е. в подобной ситуации имеется пример в природе.

Между уровнем холестерина в крови и развитием ИБС наблюдается тесная, линейная связь, т.е. чем выше уровень холестерина, тем больше риск заболевания.

Выделяемая в практической деятельности граница нормального уровня холестерина в крови является условной. Нормальным считается содержание в крови холестерина до 6,72 ммоль/л (260 мг%). Менее опасны для развития ИБС, видимо, более низкие показатели уровня холестерина в крови, 5,17 ммоль/л (200 мг%) и ниже. Крупные международные исследования показывают, что среди групп населения с подобным уровнем холестерина в крови ИБС встречается относительно редко (например, в странах средиземноморского бассейна).

Согласно современным представлениям о механизмах развития ИБС имеет значение не только общее содержание холестерина в крови, но и с какой группой липопротеинов он связан. Риск развития ИБС находится в прямой зависимости от липопротеинов низкой плотности и в обратной зависимости от липопротеинов высокой плотности. Изменение индивидуальных уровней этих липопротеинов и их соотношение дают более точную информацию о возможном риске развития ИБС.

Уровень колсстерина в крови зависит, в основном, от состава пищи, хотя несомненное влияние оказывает и генетически обусловленная способность организма синтезировать холестерин. Обычно наблюдается чёткая связь между употреблением в пищу жиров и уровнем холестерина в крови. Изменение питания сопровождается и изменением уровня холестерина в крови. Разработан целый ряд формул, с помощью которых можно предсказать, как изменение содержания холестерина в пище повлияет на уровень его в крови. Так, изменение содержания в пище холестерина на 100 мг может изменить его содержание в крови на 0,129—0,165 ммоль/л (5-6 мг%). Однако, эти формулы учитывают только холестерин, поступающий с пищей, и не учитывают холестерин, синтезируемый в организме. Различные виды жиров по-разному влияют на уровень холестерина в крови. Наиболее выраженной способностью повышать уровень холестерина обладают насыщенные жирные кислоты, в то время как ненасыщенные жирные кислоты обладают обратным эффектом, т.е. способствуют снижению концентрации холестерина в крови.

Таким образом, холестерин и насыщенные жирные кислоты, поступающие с пищей, являются основными веществами, способствующими повышению уровня холестерина в крови. У каждого отдельного человека содержание холестерина в крови зависит от его количества, поступающего с пищей, и генетически обусловленной способности организма синтезировать холестерин.

Повышенный уровень холестерина в крови встречается довольно часто. Так, по наблюдениям сотрудников ВКНЦ АМН России, уровень холестерина в крови 6,72 ммоль/л (260 мг%) и выше у мужчин 40-59 лет встречается в Москве в 25,9% случаев, в Калинграде – в 24,3%, в Санкт-Петербурге – в 31,8% случаев. Наблюдения за мужчинами в возрасте 40-59 лет в одном из районов Москвы показали, что при наличии нарушений жирового обмена (высокий уровень холестерина и/или низкий уровень холестерина) увеличивается риск развития ИБС в 4 раза, а риск смерти от ИБС в 3,8 раза по сравнению с лицами, не имеющими факторов риска ИБС.

Тем не менее, хотя благоприятное влияние ненасыщенных жиров на уровень холестерина в крови научно обосновано, следует избегать их избыточного употребления. Содержание ненасыщенных жиров не должно превышать 10%, жиров в целом – 30% от энергетической ценности суточного рациона.

Для поддержания нормального уровня холестерина в крови следует следить за массой тела. Люди, ведущие малоподвижный образ жизни, должны уменьшить калорийность своей пищи или увеличить физическую активность. Имеются наблюдения, показывающие, что уменьшение массы тела с помощью физических упражнений на 3-4 кг у лиц с ожирением приводит к заметному снижению уровня холестерина в крови и благоприятному перераспределению типов липопротеинов (снижается уровень липопротеинов низкой плотности, способствующих развитию атеросклероза, и увеличивается уровень липопротеинов высокой плотности, предупреждающих развитие атеросклероза).

Необходимо обратить внимание на бесполезность, а нередко и вредность различных модных диет. Они обычно бывают несбалансированными, непривычными, их очень трудно выдержать длительное время, что, в конечном счёте, сводит на нет прилагаемые огромные нервно-психические усилия. Выбирая диету, не следует забывать, что приём пищи должен приносить удовольствие. Из обычных, традиционно используемых продуктов всегда можно составить такую диету, которая будет содержать все необходимые для организма вещества и, в то же время, будет малокалорийной, содержащей умеренное количество насыщенных жиров и холестерина.

В зависимости от уровня холестерина в крови комитет экспертов ВОЗ предлагает разделить население на три категории риска:

1. Содержание в крови холестерина менее 5,69 ммоль/л (220 мг) Этим лицам следует придерживаться рациональной диеты, чтобы предупредить обычный рост с возрастом уровня холестерина.

2. Содержание в крови холестерина 5,69-6,72 ммоль/л (220-260 мг) Этим лицам следует придерживаться уже более строгих диетических рекомендаций.

3. Содержание в крови холестерина более 6,72 ммоль/л (260 мг). Желательно более детальное обследование и соблюдение диетических рекомендаций.

Other studies examined lymphocyte activity among sufferers of endometriosis. In one such study, it was postulated that if an immune system misfunction were entirely the cause, women with endometriosis would show a higher incidence of infectious diseases and cancer. Increased illness, however, seems net to be a factor among the women who participated in this study. Newer experiments have focused on the effect of the cellular antigen CA-125, a cell that acts like a foreign substance in the body. How this antigen is produced by the body is unknown.

Two particular studies, one conducted by Dr. Donald Pittaway and colleagues at the Bowman Grey School of Medicine in Winston-Salem, North Carolina, and the other by Dr. Phillip Patron and colleagues at Minnesota’s Mayo Clinic, have both turned up evidence to show that women with advanced endometriosis had elevated levels of CA-125. as did women who had acute pelvic inflammatory disease (PID) and unexplained infertility. However, patients with less advanced stages of the disease, and women who did not have endometriosis, tended to have similar and lower CA-125 levels. Still, these investigators believe, this antigen bears further study because of marked elevated levels of kin women with endometriosis. They are also looking for a possible test for detecting endometriosis by analyzing CA-125 levels, and antigenic proteins like it, in blood samples.

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It is usual for the partner to have a sperm test before the woman undergoes any testing.

The reason for this is that a sperm test is a simple procedure and certainly the most convenient of all fertility tests.

A sperm analysis is carried out to see if sperm are present, how many there are, how many are moving (motility) and how many are normal (morphology). The analysis also establishes if there is an infection in the reproductive tract and whether there are any sperm antibodies present. The testing of these factors will give a guide to your partner’s potential for fertility.

The sperm sample must be taken to the testing laboratory within an hour of collection as a delay may harm the specimen. Most infertility experts advise that intercourse should be delayed for at least three days before the sample is taken as a shorter period may affect the volume and sperm numbers.

A recent illness can affect the quality of the sperm, so if your partner has had a cold or flu recently it may be advisable to repeat the sample if the results are not favourable. Your doctor will advise if this is necessary.

Some medications may also affect the quality of sperm so, again, advise your doctor if your partner is on any medication.

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CT scans (computerised tomography) and ordinary X-rays are of no value in the diagnosis and monitoring of endometriosis. Ultrasound can have a role in some situations.

Ultrasound involves the use of high frequency sound waves to create an image or picture of the body on a screen or film. Over the last decade it has been used increasingly in the diagnosis and management of a number of gynaecological and obstetrical conditions, including the detection of ovarian cysts and determining the age and size of a foetus in early pregnancy.

Ultrasound has a limited role in the diagnosis and monitoring of endometriosis. At present, the machines used are not sensitive enough to detect small implants and adhesions. They can only detect cysts greater than two centimetres in diameter and determine their size and location. Ultrasound cannot determine the nature of a cyst nor can it distinguish it from other types of cysts or conditions.

Ultrasound should not be used as a substitute for laparoscopy to diagnose endometriosis. Its use is limited to confirming the existence of a cyst felt during a pelvic examination and determining its size and location prior to surgery. In some circumstances ultrasound may be used to help monitor the change in the size of a cyst after a laparoscopic diagnosis has been made.

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A repeat laparoscopy, also sometimes known as a second-look laparoscopy, is performed some time after a diagnostic laparoscopy in order to monitor the progression of your endometriosis. It is most commonly performed for one of the following reasons:

• following a course of hormonal treatment

• continued infertility following surgery

• recurrence of symptoms

• persistence of symptoms following an apparently normal laparoscopy.

Following hormonal treatment

A repeat laparoscopy at the end of a course of hormonal treatment enables your gynecologist to see exactly how effectively the treatment has eradicated your endometriosis. The location and size of your implants and cysts can be charted and compared to the chart that was made during the laparoscopy performed before your hormonal treatment began.

If the repeat laparoscopy showed that the treatment had eradicated your endometriosis then nothing further needs to be done for the time being. If it showed that the treatment had only been partially effective then it might be worthwhile considering a continuation of the same treatment. If it showed that the treatment had been ineffective you will need to consider some other form of treatment.

Infertility

If you have had surgery in order to improve your chances of conceiving, a repeat laparoscopy may be recommended if you have not conceived within six to twelve months of the surgery. In this situation the laparoscopy will be performed to determine whether or not any adhesions have developed that may be reducing your chances of pregnancy.

Recurrence

A repeat laparoscopy is advisable if you have a recurrence of your symptoms following a period of remission, particularly if you are contemplating any treatment. You really need to know that the symptoms are due to endometriosis and not some other condition. In addition, it is advisable not to undertake any hormonal treatment unless you know that you definitely have endometriosis.

Normal laparoscopy

A repeat laparoscopy may be advisable if you have had persistence or worsening of symptoms that may be due to endometriosis, despite the fact that you have previously had an apparently normal diagnostic laparoscopy. It is now recognized that, in the past, a proportion of women with endometriosis were incorrectly diagnosed as not having endometriosis because their gynecologists did not recognize their atypical implants or because they had microscopic endometriosis.

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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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Who needs an episiotomy?

Episiotomy is a cut made towards the back of the vaginal opening (the perineum) to enlarge the outlet for delivery. Recent increased use of this procedure has caused much controversy. In the 1950s 20-30 per cent of women an episiotomy at childbirth. In the 1980s the rate (in labour wards) was 75 per or more; some obstetricians do episiotomy routinely.

Those in favour of routine episiotomy believe that it prevents perineal tears (which occur in half of all deliveries without it), damage to pelvic-floor muscles and injuries to the baby’s head. Opponents claim that it shouldn’t be done to the 50 per cent who wouldn’t tear.

When is it wise to do an episiotomy? When it’s obvious that the vaginal opening is stretched to its limit, it’s better to make a clean cut than to allow on more uncontrolled tears. Episiotomy can prevent much of the pelvic-floor damage and prolapse that we used to see before it was introduced. The cut heals better and sooner than a ragged tear.

Episiotomy is necessary for most hi and posterior (head facing frontwards) liveries, whenever forceps must be and to protect the soft head of a pre-term baby from too much compression during birth.

Whether the perineum is opened by tear or cut, it must be repaired by stitching. This is done soon after the placenta delivered and before the anaesthetic wears off. Stitches that are absorbed and don’t
need to be removed are generally used.

Pain from a perineal wound mars the postnatal period for many women. Symptoms are usually worse after tearing, when there is more bruising and swelling than after episiotomy.

The longer-term psychological consciences of perineal wounds on mother -child and partner relationships have been largely ignored until recently. One study has shown that three months after delivery 20 per cent of women who had stitched perineal wounds still had disturbing pain, one in three had diminished lido and one in five found sex painful or avoided sex.

What about the use of forceps?

The use of obstetric forceps, which are designed so that they can’t crush the baby’s head and in fact protect the skull by acting like a crash helmet, has saved the lives of many babies when labour is held up in the second stage, or when the second stage must be hurried because of maternal or foetal complications. The forceps draw the head through the vagina and over the perineum with the help of mother’s pushing. Babies delivered with the aid of forceps often have red marks on their faces: these disappear within a few days of birth.

Forceps are also used in pre-term and breech deliveries to protect the baby’s head. They may be needed to deliver the head when epidural block has been used, if the mother can’t feel to push with each contraction (though this doesn’t often happen).

Another method that helps deliver the foetal head during the second stage of labour is vacuum extraction, which uses a device called a ventouse. This consists of a flat cup attached to a vacuum apparatus. The cup is pressed onto the head, and a vacuum is created to hold it firmly in place. The obstetrician pulls on the handle of the ventouse to draw the head through the vagina and over the perineum. A baby delivered with the aid of a ventouse usually has a swelling on the crown of its head: this disappears within a few days. In Australia the ventouse is less commonly used than forceps.

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History of abortion

Abortion has been practised throughout history in almost all communities. Often it was sanctioned or even enforced by the community in times of famine and during treks, or if the pregnancy had been conceived with the ‘wrong’ man or was the result of incest or rape. Means of trying to induce abortion included a variety of drugs and magic rituals, introducing objects into the uterus and physical interventions such as lifting and carrying heavy loads and constricting or pummelling the pregnant woman’s belly.

Early Christian teaching permitted abortion before the ‘soul had entered the body of the foetus’, 40 days after conception for’ males and 80 days after conception for females (how the sex of the foetus was determined isn’t stated!). Later, abortion was allowed until quickening (movement) was felt by the mother during the fifth month of pregnancy.

The Church’s condemnation of abortion of an ‘animated’ foetus is based on a passage in the Bible (Exodus 21:22-3) dealing with assault on a pregnant woman leading to miscarriage. If no other harm was done to the woman, the attacker was fined to compensate her for the lost child. If the woman died, the attacker was executed, paying ‘a life for a life’. The (inaccurate) interpretation of this resulted in abortion being held as a crime against God.

Most civil laws making abortion criminal offence were not passed until nineteenth century. In 1869 Pope Pius decreed that any abortion was murder, and around the same time new legislation in Britain (and subsequently Australia) outlawed all abortions except those done preserve the life of the mother.

History shows that women in need seek abortion whether or not it is legal, even at considerable risk to their safety.
The anti-abortion laws resulted in the development of underground or ‘bасk-street’ abortion rackets. Clandestine, unsanitary abortions were performed by unscrupulous, often unqualified practitioners. Outrageously high fees were charged including large sums for police ‘protection’. Anaesthetic wasn’t used for painful procedures because recovery would have been too slow: abortionists didn’t want patients hanging around their premises No aftercare was provided.

The illegal abortion racket discriminated against the poor. Women who were well connected and well off could usually find and afford a doctor to perform abortion: poor women had to accept the less expensive services of unqualified people or try to induce their own abort using overpriced (and harmful or useless)
drugs or devices.

Many women died or suffered haemorrhage or infection and became chronic ill or infertile after illegal procedure their own attempts to abort. Women needing treatment of complications from abortion filled about half the hospital gynaecological beds (and still do where abortion remains illegal). They were treated as criminals. As one woman, now in her sixties, said: ‘The doctor said it served me right to be so ill’. The whole story of the illegal abortion racket is a disgrace to humanity.

Abortion law reform

Agitation for abortion law reform began in the UK in 1936, but it wasn’t until 1967 that the British parliament passed the Abortion Act which, though it didn’t repeal the previous criminal law, broadened the circumstances in which abortion could be lawfully performed. Abortion was regarded as lawful when the risk to the life, physical and mental health of the mother and of her existing family was greater if the pregnancy continued than if it were terminated. Abortion was also permitted when there was a risk that if the child were born it would suffer serious mental or physical handicap. To comply with this law, two doctors had to certify ‘in good faith’ that the conditions of the Act had been satisfied, and the operation had to be performed in registered premises. The decision was entirely in the hands of doctors and depended on their beliefs and trades.

In Australia criminal law is a State matter, and each State’s Crimes Act includes unlawful abortion as a criminal offence. In 1969 South Australia amended its criminal law on abortion in line with the 1967 UK Act. The changes made in South Australia also applied in the Northern Territory. No other State has amended or repealed its abortion laws, but rulings by judges in Victoria and New South Wales about 20 years ago have been used as precedents to extend the circumstances in which abortion is lawful. These can be broadly stated as a sincere belief, on reasonable grounds, that it is in the best interests for the welfare of the woman and her existing family to terminate the pregnancy. Social and economic factors, both present and future, could be taken into account in reaching this belief.

Since these rulings, abortion has become widely available in New South Wales and Victoria, and is now performed in Queensland, Tasmania and Western Australia in the hope that the rulings of New South Wales and Victoria would be taken into account if criminal charges were laid. However there is always the risk that the rulings could be overturned and the present criminal law strictly enforced.

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Intrauterine devices (IUDs) are inserted into and retained within the uterine cavity to prevent conception. The IUD was the first reversible contraceptive method that required just one action – its insertion -to provide long-term contraception.

History of the IUD

The first story (unverified!) concerns nomadic tribes in North Africa thousands of years ago, who are said to have placed stones in the uteri of camels to prevent pregnancy during long treks. Over 2000 years ago Hippocrates, the father of medicine, is reported to have recommended inserting objects into the uterus for contraception.

The first modern IUD dates from 1909, with descriptions of coils of silkworm gut used in Europe. The first widely used IUD was the Gräfenberg ring, developed in Germany in the 1920s. It was made of coiled silver-copper alloy wire. The ring gained a bad reputation at the time because of the high rate of infection and other complications when it was inserted by untrained operators, and also perhaps because contraception was strongly condemned by political authorities in Germany at the time. It has since been shown that, with proper insertion and care, the Grafenberg ring can be as safe as any other IUD and it remains the most commonly used device worldwide (because it’s so popular in China).

The first plastic device was introduced in 1962, the first copper-carrying device in 1969, and the first hormone-releasing device in the mid-1970s. Today it’s estimated that more than 60 million women worldwide used IUDs, over 40 million of them in China.

Because IUDs must pass through the narrow cervical canal to be placed in the uterine cavity, ingenious designers have come up with a variety of forms that may be folded, straightened or compressed in some way for insertion but are able to regain their shape within the uterus. The effects of adding copper or hormones to IUDs is described below.

How do IUDs work?

Nobody’s quite sure, but IUDs are believed to prevent pregnancy in the following ways.

• Their presence as a foreign body causes a reaction in the lining of the uterus that makes it unsuitable for implantation of a fertilised ovum.

• Recent studies suggest that the changes in the uterus – both in the fluid contained in it and in its lining – prevent sperm from swimming through its cavity to fertilise the ovum.

• Copper causes a foreign-body reaction together with other changes in the endometrium, making it even less suitable for implantation. Copper is also toxic to sperm.

• Progestogen-releasing IUDs alter the growth and development of the endometrium in each cycle. Progestogen also affects cervical mucus so that sperm are less able to pass through the cervical canal.

The contraceptive efficacy of plain plastic IUDs depends on the surface area of the device that is in contact with the endometrium. With the added effects of copper or hormones, smaller devices are as effective as larger plain devices.

How effective are IUDs?

For all devices used now, failure rates are 0.3-6 pregnancies per hundred woman-years. Copper and hormone-releasing devices are generally more effective. About one-third of failures are due to undetected expulsion of the IUD. The most important factor that influences efficacy (and other problems) is the degree of skill used in inserting the device.

Side-effects and j complications

The most common side-effects are heavier periods, longer periods, menstrual cramps and spotting between periods. These menstrual side-effects tend to be worse soon after insertion and usually, but not always, settle down after a few months. About 15 per cent of users have the device removed within two years because of its effects on menstruation.

Less common side-effects are cramps between periods and cramps or pain after orgasm. IUDs have no side-effects on the rest of the body.

There can be complications: the main worries are pregnancy and pelvic infection.

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Anyone writing about sex is confronted by the problem of what words to use. In spite of the wonderful diversity of English, I find it frustratingly difficult to find satisfactory terms for many of the organs, processes, sensations and emotions associated with sex.

Sex is a loaded subject in our culture, and this is reflected in our language. There’s no shortage of words to describe sex organs and actions, but the majority of terms are evasive, ambiguous, sexist, derogatory, guilt-ridden, or (especially in vulgar slang) violent, punitive or deliberately offensive. When it comes to the sensations and emotions of sex, our language is barren.

As a medical writer, I feel at ease using anatomical terms like ‘vulva’ and ‘penis’ and I shall do this throughout. I feel OK about ‘womb’ as an alternative for ‘uterus’ but most other commonly used terms are so ambiguous or offensive that I can’t bring myself to use them. (One must be so careful with the vernacular: words mean different things to different people. ‘Fanny’ is slang for buttocks in the USA but in Australian slang means ‘vulva’. To speak of giving someone ‘a pat on the fanny’ may be quite acceptable in the States: not in Australia!)

But how do my readers feel? Do they understand and feel at ease with anatomical terms? Some women still don’t know the difference between ‘vulva’ and ‘vagina’ and are uncomfortable with these words, preferring less explicit terms such as ‘down below’. Many still blush at the mention of ‘clitoris’: such is the power of guilt and shame attached to female sexual arousal and this erotic organ. How can we find a happy medium?

Finding suitable words for sexual intercourse is the most difficult task. My Macquarie Thesaurus gives 33 alternatives for sexual intercourse, all unsatisfactory in some way. They fall into categories of technical, evasive and coarse slang.

The technical terms are terrible. ‘Copulation’ is from the Latin ‘to couple’, which is also something you do to railway lines. ‘Coitus’ is a sharp word that sounds like a piece of machinery. And these terms really only refer to the penis-in-vagina part of sex.

Acne is a very common disorder of the oil (sebaceous) glands of the skin. It affects about eight out of ten of us at some time during our lives, mostly between the ages of 15 and 30 years. Acne describes everything from the occasional blemish through the spectrum of whiteheads, blackheads and pimples to its severest form, which affects about one in twenty people.

Most adults don’t take acne seriously enough. It’s often dismissed as a harmless disorder of young people that they’ll ‘grow out of in their twenties, but there are few diseases that cause so much misery. It occurs at a time of life when you have enough adjustments to make to your body image and ego without having to worry’ about a spotty face. At any time of life, but especially during adolescence, acne can make you feel self-conscious, ugly, inferior, insecure, guilty (‘Is it punishment for something I’ve eaten or done?’) and unwanted. Severe acne can be psychologically devastating.

You’ll probably think your acne is worse than anyone else does. Most young people can’t keep away from peering at their faces in the mirror to see what new horror has broken out. With such close scrutiny, you’re bound to find things that other people don’t notice. This may make you think that your parents or others are making light of something that worries you terribly when in fact it’s the whole you they see, not just your spots.

All acne – from a few blackheads to most severe – can be helped by proper treatment. Don’t think that you have put up with it until you grow out of it. Do something! Here’s some informal to help you understand and conquer the demon.

What causes acne?

Every hair on our bodies has a sebaceous gland just above its root. These glands produce a pale, oily section (sebum) that keeps the hair and I rounding skin soft and supple. At puberty
the sebaceous glands on the face, ne and front and back of the upper chest stimulated by androgens: the male hormones that are produced in increasing amounts by both males and females fro around 10 years of age.

Androgens cause the glands to increase the amount and change the composition of the sebum they make. These hormones also make the skin that lines the sebaceous ducts thicken. Hence the duct rows so that it’s harder for the sebum get out. If the skin closes completely over the duct the sebum builds up behind, forming the lump known as a whitehead. The sebaceous duct can also be blocked by a plug of thickened sebum. The surface of this plug darkens on exposure to air, resulting in a blackhead. When a gland with a blocked duct continues to produce sebum, it can be forced through the natural boundary of the gland into the surrounding tissue. Then bacteria normally present in the skin (and harmless under other circumstances) cause the sebum to break down into irritant chemicals that will inflame nearby skin; the result is a tender red lump we call a pimple. The pus formed by the inflammation usually pushes towards the surface to form a ‘head’ that breaks through the blockage of the duct, and the pimple quickly drains and disappears, leaving no scar. If the duct is very tightly plugged, the inflammation can spread to deeper layers of the skin, forming a ‘blind’ pimple. In the most extreme cases of sebum overproduction, cysts may form deep in the skin and raise purplish lumps that can take months or years to heal. This cystic acne is the most severe form of acne, and almost always results in some pitting and scarring.

Why is acne worse for some than others?

We all produce these hormones, but some people’s sebaceous glands are more sensitive to hormones than are others. Acne in teenagers is rarely caused by an excess of male hormone: the skin is just overreacting to the normal amount. This sensitivity seems to be inherited. Also, males produce more androgens than females, which is why boys often have more acne than girls.

Excess male hormone is only likely to be a cause in women who develop acne (or worsening of it) when they are well past puberty. In such cases there are usually other signs of masculinisation.

What else aggravates acne?

• Hot, humid weather, which causes skin cells to swell and thus increases the chance of blocked ducts. This is why face-steaming treatments are useless or harmful.

• Anything that stimulates extra growth of skin cells, such as rough scrubs, can block ducts.

• Emotional or physical stress can provoke an outbreak by increasing the output of androgens from the adrenal gland. This might explain why ‘whoppers’ tend to break out when you’re upset, doing exams, excited about a special date, or ill.

• Some women notice a breakout before periods, probably due to female hormones being converted in the body to androgens.

• Oily applications to affected skin usu-¹ ally worsen the condition.

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