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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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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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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• 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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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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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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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:

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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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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