Although the overwhelming consensus from recent studies that have followed women through the experience of hysterectomy is of a clear reduction in the disabling symptoms that lead to surgery, many women continue to have concerns about the effects of hysterectomy on sexuality and sexual function. The picture is complex because at around the age when most women have a hysterectomy they may also be starting or passing through menopause. The changes associated with this transition may themselves have an impact on sexuality and sexual function and these may be incorrectly blamed on the hysterectomy.

Doctors have been aware of sexual difficulties in a minority of women who have had a hysterectomy and have sometimes attributed it to post-surgical depression or concerns about self-image. These conclusions have been questioned in recent years, with an increasing number of medical practitioners and sex therapists suggesting that the procedure itself contributes to post-surgical difficulties in some women. Our ignorance of the role of the uterus and cervix in sexual response may be partly responsible for the occurrence of these difficulties.

A generation ago, it was believed that a woman’s major sexual response was centred in her clitoris and vagina. Recent research suggests, however, that for some women there are sexual sensations associated with the uterus itself. In the process of performing a hysterectomy, major arteries, veins and nerves that flow to and from the uterus are inevitably cut. It is possible that this interference may play a role in the sexual dysfunction reported by some women after hysterectomy. For some men, too, sexual satisfaction and response may be influenced by the presence of the cervix, against which the penis taps during intercourse.

There are several main ways in which hysterectomy can change sexual response. These changes may be either positive or negative.

• Removal of the fear of pregnancy may allow women and their partners to engage in sex with fewer inhibitions.

• Reduction or elimination of heavy and prolonged menstrual bleeding may enhance the experience of orgasm and intercourse.

• This same positive outcome may occur as a result of removing adhesions, fibroids and other causes of chronic pelvic pain when the uterus is taken.

• Alteration of the size and shape of the vagina during the surgery may make the sensations associated with sex more or less pleasurable for one or both partners.

• Removal of the main part of the uterus may eliminate pleasurable sensations associated with its contraction and movement. These sensations may occur during sexual foreplay, for example when the clitoris, breasts, vulva and vagina are touched, as well as during intercourse.

• Removal of the cervix may reduce sexual satisfaction. This is because of the pleasure that a woman and her partner may derive from the tapping of the penis on the cervix during intercourse.

• Creation of new scar tissue in the pelvis or vagina as a result of a hysterectomy may cause intercourse to become more painful.

• Changes in hormone production, particularly marked if the ovaries are removed at the time of the hysterectomy, may lead to intercourse becoming less pleasurable. These hormone changes — which tend to be more acute than when menopause occurs without surgical intervention — may result in several ill-effects. Decreased oestrogen levels may be associated with a general drying and thinning of the vagina. This may in turn result in painful intercourse, and severe night sweats and insomnia leading to feelings of fatigue. A decreased output of androgen hormones, including testosterone, by the ovaries may also reduce sexual interest (libido) in women. ‘Psychological effects on either partner, related to feelings of loss of the uterus, may lead to decreased pleasure in intercourse. This is more likely to occur if intercourse has been valued mainly for the children that may result from it.

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Who Should Have It?

IVF may be used as a last resort by couples who have had unexplained fertility for a number of years. It is often chosen if the woman has damaged fallopian tubes or other specific problems which mean that normal fertilisation cannot take place.

IVF is also an option if there are any other problems and you are over the age of 35.

What Happens?

In order to prepare you and your body for this procedure, GnRH analogues are given, either as a nasal spray or daily injection, in order to work as an anti-hormone to put you into a temporary menopausal state. This is called down-regulation and stops your own hormones interfering with the IVF treatment. Another fertility drug, FSH or hMG, is then given in the form of injections to stimulate several follicles to develop.

Once there are enough follicles of the correct size (as monitored by ultrasound), you are given an injection of hCG which primes the eggs before they are collected.

Around 34-38 hours later the eggs are collected through the vagina, using an aspiration needle guided by ultrasound. You may be sedated for this procedure or have a general anesthetic.

Your partner provides a fresh semen sample, which is treated as in IUI (above), and up to 100,000 sperm are mixed with each egg. The aim is to collect about 20 eggs. The ones that are fertilised, and start to divide well, will be chosen to go back inside the womb. This takes place two or three days later and the embryos are transferred into the womb via the cervix, using a soft catheter.

Only a maximum of three embryos can be implanted back, according to UK law, and it is hoped that they will implant in the womb. Because the embryos are put directly into the womb, they end up there three or four days earlier than they would do normally. It takes an embryo (fertilised egg) approximately seven days to travel down the fallopian tube before it ends up in the womb.

In order to increase the chances of implantation, the hormone progesterone is given either as pessaries or injections.

Success Rate

Respite all the hype, the IVF success rate is relatively low – only 15-20 per cent.

IVF treatment most commonly fails at the implantation stage. Many couples tell me that everything went really well until they reached this point.

Sometimes the IVF cycle is abandoned because the drugs either failed to stimulate egg production or, at the other extreme, caused hyper-stimulation which is potentially dangerous. Sometimes no eggs can be retrieved from the follicles or the quality of the eggs is poor and fertilisation with the sperm is unsuccessful.

Assisted Hatching

In normal pregnancy, a hole is made naturally in the casing of the embryo and the embryo hatches and attaches itself to the lining of the womb. The enzymes present in the fallopian tube that usually soften the casing are not present in IVF because in IVF the embryos are put back straight into the womb. So, if there have been a number of failed attempts at IVF, a technique called assisted hatching may be used, whereby a needle or chemical is used to make a tiny hole in the casing of the embryo.

Frozen Embryos

Extra embryos resulting from the IVF treatment can be frozen if their quality is good. However, under the HFEA Act of 1990, these embryos can only be kept in storage for five years. They do not thaw out well and many have to be discarded. The embryos are stored in liquid nitrogen and, in order to prevent what is called ‘cooling injury’, as the embryos are thawed out, cryoprotectant chemicals are used. Of course, there are also moral and ethical issues, which have to be considered when deciding to freeze embryos, because it is not eggs that are being frozen but a potential baby.

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When a doctor finally puts a name to all that pain and suffering you feel relieved. At last someone has recognized that you do have something wrong with you and it is not all in your head. No, you are not neurotic and your symptoms have a name. Endometriosis. You do not have cancer and you can at last do something about your problem.

Denial

Some women cannot accept that they have a disease. They will not accept the fact that it may cause infertility, may interrupt their lives, relationships and careers. They believe that if they ignore it the symptoms and disease will just go away. They turn a blind eye to it all and bury their head in the sand.

Confusion

For others, the relief of finally knowing what is wrong is clouded by fear and confusion, particularly if they have never heard of endometriosis or know only a little about the disease.

Many women are told the best ‘cure’ is to have a baby. For teenagers, those not in a relationship, or those who had decided not to have children, this can be a confusing and annoying ‘solution’.

It is normal to want to know the answers to several questions. The most common questions are:

• what causes endometriosis can I have children

• what treatment is available

• will the treatment I choose get rid of the pain

• can I be cured

• is it hereditary

• is it a sexually transmitted disease

• where do I go from here.

The more accurate information and support that you receive soon after you have been diagnosed, the less likely you will be confused and unsure of the next steps in dealing with this disease.

Overwhelmed

• You may feel overwhelmed by the various options of treatment that are presented to you. These options may include having no treatment at all – adopting a wait and see approach. This may be the case especially if your endometriosis is mild with few symptoms and you are planning to get pregnant.

Perhaps you were trying to get pregnant before your endometriosis was discovered and the prospect of a six to nine month course of drugs which will prevent you from getting pregnant during that time will be exasperating.

You may have to consider going on a course of fertility drugs if you want to get pregnant – something you may never have considered before.

Having to make a decision about which hormonal or surgical treatment is best for you will almost certainly be overwhelming.

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By far the majority of infections are transmitted through sexual contact, so things which increase your chances of getting PID include:

• having unprotected sex

• having unprotected sex with several different partners

• having unprotected sex with someone who has had sex with several different partners.

Another (less common) way infections can get into the pelvis is through surgical procedures. Even if they are carried out in a sterile operating theatre, with squeaky clean techniques, there is a small chance that any surgical jiggling around in the pelvis may promote an infection. The procedures which can be

associated with developing PID include:

• dilatation and curettage—D and C

• insertion of an intrauterine device—IUD

• abortion

• endometrial sampling/hysteroscopy

• general surgical procedures, like appendicectomy for appendicitis.

How is it investigated?

After seeking any clues from the history, a doctor should examine a woman carefully to look for any signs of infection. This will involve looking for a fever, abdominal tenderness, a vaginal or cervical discharge, or pain on specific vaginal examination. The doctor should take swabs from the cervix, specifically testing for chlamydia as well as other bugs.

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Working out where all of this is going to take place, and who is to be involved is usually the next step after a positive pregnancy test.

“There are now many ‘birthing options’ from which women can choose. Australia, like many developed countries, has included pregnancy care in medical care. At this point in time, the majority of pregnant women in Australia will have a doctor involved to some degree in their care, and deliver their baby in a hospital.

Historically it was midwives (specially trained nurses, or experienced women without formal nursing training), who looked after women in pregnancy, and deliveries took place in the home. There was little organized antenatal care, and doctors became involved only if there was a problem. Problems were not that uncommon, and the death rates of mothers and babies were fairly high. Over many years, in an attempt to make pregnancy and childbirth safer for women and babies, doctors started monitoring pregnancies, looking out for problems which could be avoided or treated. Deliveries were sometimes assisted, with instruments, or operations.

The trend continued, and doctors became much more involved with not only problem pregnancies, but also routine, normal ones, which were also delivered in hospitals. With that came also a move against the interventions and medical treatment of women, most of whom were going to have normal pregnancies. The debate still rages, and out of it all we may be heading towards a situation where women have much greater choice than ever before, and the security of very low death rates for mothers and babies.

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The problem (or one of them) with sexually transmitted diseases, is that they are not fussy. They will infect anyone who gives them the chance. The clean-cut, respectable looking, even my mother would like him/her type may have a bug. Every time you have unprotected (unsafe) sex with someone, you are inviting their sexual past to infect you.

‘Brad’, who seems like a perfectly nice young man, with no obvious vices, may have had sex with a girl in the past, who had sex with a man, who had had sex with a woman, who a few years ago, at a party, tried shooting up speed. She didn’t like it, and never did it again. That woman would probably not consider herself an intravenous drug user, a member of a ‘high-risk group’ for catching AIDS, and Brad is unlikely to know about it. So if you are thinking of having sex with Brad (or anyone new), it would be a good idea to have ‘safe sex’ (see below), at least until you have both been tested for any diseases.

There are a few suggestions that may be useful to you if you are working out for yourself how you want to deal with the spectre of sexually transmitted diseases.

Things which may lessen your risk of catching something:

• Practise ‘safe sex’.

• Use condoms (properly and every time).

• Honesty and trust between sexual partners.

• Have regular check ups (perhaps each time you have a new partner, or every few months, or yearly, whatever you feel comfortable with).

If you don’t feel comfortable going to your regular doctor about this, try a clinic specifically set up to deal with sexually transmitted diseases, or a different doctor. The clinics are friendly, non-threatening places. They are staffed by people who deal with STDs every day.

If you do find that you have a sexually transmitted disease, don’t panic. Find out what the correct treatment is and whether your sexual partner(s) require treatment. What sometimes happens is that person A has a current partner, B, but A doesn’t get the bug from B, but from a different person, C. That means that A needs to let both B and C know that they need to see a doctor for treatment. This can get tricky.

Telling someone that they may have a sexually transmitted disease is rarely fun, or easy, but is extremely important. Each person needs to decide how to do it for themselves. Pointing the finger and blaming rarely helps a calm discussion. The STD clinics or your local doctor may be able to help you if you are not sure how to go about it. Some clinics have cards or letters which can be sent or given to the ‘contacts’, and this may be useful. Some clinics have staff who can assist with contact tracing. The important thing is to make sure that all potentially infected people are informed of the risk, and have the chance to get treatment (before spreading it to someone else or back to you).

Make sure you are adequately treated, including getting checked out for other possible STDs. Specialists in the area suggest that a full check for STDs is advisable for both partners before the start of any new sexual relationship. Keep in mind the ‘window period’ in testing for infections like HIV and hepatitis, so using condoms for the first three to six months is recommended as well. If you are having casual sex with different partners it would be wise always to use condoms, and have regular STD checks every three months or so.

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The procedure is done under a general anaesthetic, and is usually performed using a laparoscope, or less frequently now a laparotomy. The fallopian tubes are identified and either blocked with special little clips, or cut, a piece removed, and the ends tied off.

The whole business is not without potential problems, for example the risks associated with having a general anaesthetic, or the clips not working, or bleeding, etc. The risks of these things happening are very small. The failure rate of the procedure as a contraceptive is about one in 1,000.

Tubal ligation has also been in the news because of suggestions that it can cause problems with the ovary. The truth, or otherwise, of these claims is still the subject of further research.

Some women report that their periods are heavier and more painful following tubal ligation. This may in part be due to the fact that they cease the oral contraceptive pill after the procedure, and the effect of the pill on the periods is lost, and more ‘normal’ periods return.

However, it is a relatively safe, effective form of permanent contraception. The big word is ‘permanent’. Embarking on sterilisation thinking that it is a reversible procedure is not a good idea. Yes, it is true that many women and men have reversals of their sterilisation procedures, but it is a tricky business. Technically it involves a major operation, and there are no guarantees that it will work. The success rate varies, averaging between 30 to 60 per cent. If a woman does get pregnant following a reversal of sterilisation, she runs an increased chance of that pregnancy being ectopic, which is a life-threatening condition.

Doctors will often want to be sure that the person undergoing tubal ligation understands the permanent nature of the procedure. It is unusual for doctors to offer it to young women, as there is a higher rate of requests for reversal in women under the age of 27. It is not recommended that women should have this procedure done at the time of either a caesarean delivery or termination of pregnancy for the same reasons, as women are often in a state of emotional vulnerability at these times. However all cases are judged on individual circumstances.

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If you leave blood to sit for a while it will turn to a jelly-like consistency called a blood clot. Blood should form clots; it is the way our bodies avoid bleeding to death every time we cut ourselves, ft blood has a chance to sit for a while in the uterus or vagina before it comes out, it may form clots. If the bleeding is heavy, the tendency for blood to sit around is greater, so clots are more likely to form. Passing clots in a period is a regular occurrence for some women, and frightens the life out of others, especially if it has never happened before. It simply means that there is a moderately heavy flow. If a woman is passing a lot of dots, she probably has menorrhagia, and should be assessed regarding this.

Very rare causes of heavy bleeding, like blood-clotting problems and Weeding diseases usually show evidence of a generalised bleeding tendency, like bleeding gums and easy bruising. These tendencies may run in families, so there may he a history of a relative having a bleeding problem.

Not only is heavy bleeding inconvenient, but it can also be associated with the development of anaemia. The type of anaemia which happens as a result of blood loss is called iron deficiency anaemia. One of the important ingredients in blood ceils is haemoglobin. It is the stuff to which oxygen molecules attach themselves. Blood cells transport oxygen molecules from the lungs to the test of the body, drop the oxygen off at some point, for example at a muscle cell and collect the waste products, like carbon dioxide, and take that back to the lungs to get rid of it. It is like the milkman dropping off the fresh milk and picking up the empties (or how it was when milk was actually delivered).

Anyway, one of the important ingredients of haemoglobin is iron. To successfully transport oxygen around your body you need enough iron to make enough haemoglobin. Blood contains iron, and if you arc losing more iron (in periods) than you can eat ( in food) you may have to rely on your iron stores, which are stowed away for a rainy day (or a few heavy days, at least). If you

continue to lose iron at a relatively rapid rate, your iron stores will become low, and the iron content in your blood will become low. There will be less haemoglobin made, so the oxygen -carrying capacity of your blood will be less, so the cells around the body, which need oxygen to function, will start to suffer.

When someone is anaemic they may feel that they have less energy, because they are in fact missing, out on their usual dose of oxygen. Their blood is slightly paler, so the places which are usually dark pink, like inside the eyelids, and the tongue, may even look slightly paler. Even the fingernails may show changes with long terra anaemia, and the general condition of many systems may be impaired. If anaemia becomes more severe it can lead to breathlessness, and in people who have heart conditions can add further strain to the heart.

These changes take rime to develop in women who have very heavy periods. Most of us who have the occasional heavier period are able to make up for the loss with no problem, but persistent heavy periods, particularly in someone whose diet is low in iron, may result in that person becoming anaemic. The most common causes of heavy bleeding are hormonal, and physical. Heavier bleeding is more common at the beginning and end of the reproductive years (menarche and menopause), when anovulatory cycles arc more likely to occur, but may occur at any stage. It is also more common for a couple of cycles following a pregnancy of miscarriage or curette. Heavier bleeding may be due to a uterine polyp or fibroids which are usually diagnosed at either a curette or hysteroscopy.

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