There is a list of relative contraindications to HRT, that is those conditions in which you and your doctor will need to consider the balance between the risks and the benefits:

• Angina, or if you have a family history of heart disease, was previously thought to be an absolute contraindication, but with research now showing that HRT can offer positive protection against heart disease, medical opinion is changing about this. Your doctor will be able to advise you according to your particular condition, and may suggest a non-oral type, such as the patch or implant.

• The risk if you have had deep vein thrombosis depends on how any previous thrombosis occurred. If it first occurred after you had been bedridden for a long time because of illness or a major operation, such as a hip replacement, and especially if it happened long before the menopause, then your doctor may feel it is unlikely to happen again in normal circumstances, so HRT would probably be possible. However, if the thrombosis occurred for no apparent reason, then your doctor would probably want to investigate it, and may then decide against HRT in your case. If the thrombosis occurred while you used the contraceptive pill, he will probably advise against HRT.

• Diabetics can usually take HRT safely, but as it can affect the way carbohydrates are broken down in the body, very careful monitoring would be necessary, and the diabetes would need to be stabilised before a course of HRT was started.

*57\42\4*

For most women, hysterectomy does not adversely affect sexuality. In studies of the effects of the operation on sexual interest and response, a minority of women — between 7 and 20% depending on the study — report some decrease in sexual function after hysterectomy. About the same proportion report an improvement, and more than half report no change. When partners of women who have had the operation are asked about its impact on sexuality, many have no comment, over a third say they are happy their partners had the operation for reasons such as removal of the fear of an unwanted pregnancy. A small minority express dissatisfaction saying things like the vagina is ‘too tight’ or ‘too dry’.

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.

*71\198\4*

According to The Oxford Dictionary, hygiene is the principles of maintaining health, such as by cleanliness. There is one part of hygiene which maintains good health at night and promotes sleep. This is ‘sleep hygiene’, and this has become standard terminology among sleep experts. There are five important items that are relevant to sleep hygiene and which are essential for the problem sleeper to consider: Drinks, Bedroom, Clocks, Biological clocks and Regular exercise.

Practising good sleep hygiene is an important alternative to taking sleeping pills.

People who do not work or take any exercise during the day will have too much time on their hands. They will tend to have frequent naps during the day and will not need as much sleep at night. For them there is not much difference between the activities during the day and those at night. These people do not accept the fact that they have already had too much sleep in the day and do not need much more sleep at night. They believe they are suffering from insomnia. A good day is normally a busy active day, so that in the evening you feel tired, as if you have achieved a lot and have earned a good night’s rest Regular exercise will keep your body healthy, keep your muscles strong, your heart and circulation in good shape, and also let off any tension that has accumulated in your body. It has been shown that exercise increases the amount of NREM sleep. However, if strenuous exercise is undertaken too close to sleep time, it may delay sleep onset. Exercise should be finished at least three hours before bedtime. Exercise and activities like aerobics, jogging, tennis, swimming, golf, gardening, and fishing are all very good for health. After all, sleeping well is a sign of good health, and good health starts with good hygiene.

*73\174\4*

Like writer’s cramp, spasmodic torticollis or wryneck is a condition which is widely considered to be uninfluenced by any form of treatment. In fact, the most recently advocated treatment involves a destructive operation on the brain.

A seventeen-year-old schoolboy had this condition in quite advanced form so that his head was held twisted to one side with his chin over his shoulder. When for a moment he was able to bring his head to the front, there would be a sudden spasm of the muscles, and his head would be jerked to the side again.

I believe that this strange symptom had an unconscious symbolic meaning for the patient; and in fact it seemed that this lad was turning away from his father and the principles for which he stood,

I taught him to relax the rest of his body and to experience this relaxation in his mind. In doing this we had to ignore the spasm of the muscles in his neck. Then when he had mastered the exercises he was gradually able to bring his neck muscles to relax for a few moments, then for longer periods; until after several weeks of practice the condition completely cleared.

An interesting point was that the muscles on one side of his neck had grown to an unusual thickness as a result of the spasm. Some weeks after the spasm was relieved these returned to normal size.

His mother wrote, “I wish to take this opportunity of thanking you for the treatment you gave . . . earlier in the year. Without your help, I am quite sure he would not have recovered as he has done, and we are all very grateful to you. So far as … himself is concerned, he seems to be completely recovered, and his approach to life and its problems has, generally speaking, become much calmer and more reasonable than it was for some time past.” At Christmas the boy sent a card, “It is wonderful to be able to do things normally again.”

The mother spoke of the treatment I gave him. But remember that I merely showed him how to do it himself, just in the same way that I have set down here.

I have been a little doubtful of the wisdom of including these two cases—the writer’s cramp and the wryneck—because it is so easy for people to say to themselves, “It is impossible that such a simple approach could cure such difficult conditions.” Please do not be put off by the

simplicity of this approach. Remember that the regression is an essential factor,

I have just recently seen a man with a wryneck condition, and I think I could have helped him. But he rejected the idea: “How could this help me, when all the other treatment has done me no good.” The simplicity of the treatment is indeed its greatest difficulty.

Furthermore, please do not let the apparent diversity of all these conditions confuse

you—nail-biting, blushing, writer’s cramp, wryneck and even smoking. There is no diversity. They are all motivated by the one factor, anxiety. Our exercises reduce our anxiety and so allow the symptoms to subside.

*95\57\2*

Constipation is one of the most common ailments of civilized man. It does not exist among primitive people. It is a result of sedentary life in combination with denatured, refined, and devitalized foods—conditions for which our body was not made.

It is a common observation that many people afflicted with arthritis have a long record of chronic constipation preceding the onset of the disease.

Constipation is the root of many evils. It causes great discomfort and can be a contributing or major cause of a great many diseases. It may lead to such disorders as hemorrhoids, varicose veins, hernia, upset digestion, nervous irritability, skin eruptions, eczema, muddy complexion, and headaches. “Bad breath”—a national disgrace on which mouthwash manufacturers are now making millions of dollars—is more often than not a direct result of constipation. (Needless to say, no mouthwash can correct bad breath caused by constipation, since foul odor comes from the stomach and the lungs, not from the mouth!)

But constipation can also lead to many more serious diseases, such as impaired function of liver, gall bladder, kidneys, and other vital organs, and can be one of the major contributing causes of arthritis.

Your intestines house billions of different bacteria which help your digestive system break down the food you eat and thus aid their housing organism in its metabolic processes. Some of these are what we call “friendly bacteria,” some are “unfriendly” or putrefactive bacteria. When the diet is unbalanced, as in the case of too much refined and overcooked carbohydrates and too much animal protein, the balance of the intestinal flora is disturbed, harmful bacteria take over, and the result is sluggish bowels, gas, putrefaction, and constipation. Toxins (poisons) created by bacterial metabolism and putrefaction remain in the intestines and, as a result of prolonged constipation, are absorbed by the bloodstream, poisoning the whole organism. Chronic constipation will eventually weaken the muscles of the large intestine so that they will not be able to function properly and expel waste matter from the colon. Chronically constipated and sluggish intestines lead to chronic autointoxication or self-poisoning.

As was pointed out in Chapter 6, the impaired elimination of metabolic wastes and toxins from the system, and resultant autointoxication, is one of the most prominent syndromes or characteristics of arthritis. Therefore, those afflicted with arthritis should make a special effort to overcome constipation— this largely ignored and neglected but very dangerous ailment. Even if you do not suffer from arthritis as yet, but are badly constipated, make sure you correct this trouble before it leads to more serious complications.

*53\176\2*

The aims of treatment of febrile convulsion are three-fold:

• to stop the convulsion;

• to treat any underlying infection (e.g. urinary tract infection, otitis media) which might have caused fever;

• to prevent further febrile convulsions.

Febrile convulsions in most children stop of their own accord, usually after 4-5 minutes.

Short-lived febrile convulsions are not dangerous and do not cause brain damage. If a child convulses for more than 10 minutes then a doctor must be called immediately, or the child must be taken to the Accident and Emergency department of the nearest hospital. It is important to try and stop a convulsion, as there is a slight risk that prolonged febrile convulsions, lasting more than 30 minutes, may contribute to the later development of epilepsy (see p. 30). In order to stop a prolonged febrile convulsion, a doctor may give a medicine called diazepam (also called Valium or Stesolid), either by an injection into a vein or by a small tube inserted into the rectum, from which it is rapidly absorbed.

Some children who have had a first febrile convulsion will be admitted to hospital for observation and to find a cause of any underlying infection. Antibiotics may be given if an infection is found. A time in hospital may help to relieve parental anxiety. Interviews have revealed that the parents of at least half of the children who have their first febrile convulsion believe that their child is about to die, or has died. It is important to understand this concern and anxiety, to explain that this almost never happens, and reassure that children almost always make a full recovery following a febrile convulsion.

About one third of children will have a second or even third febrile convulsion. The risk of a child having a second or third febrile convulsion is greater if:

• the child is aged less than 12-15 months (and particularly if a girl);

• if the first febrile convulsion lasted more than 15-20 minutes or involved only one. side of the body (i.e. was a complex febrile convulsion);

• if the parents or brother or sister has had febrile convulsions, or has epilepsy.

There are some simple measures which can be taken to prevent further or recurrent febrile seizures. These measures include (whenever a child has an infection and is showing a rise in temperature):

• undressing the child;

• sponging him or her with tepid (lukewarm) water, and

• giving regular paracetamol (Calpol) (every 3-4 hours) which brings down the temperature. It is not a good idea to use aspirin for this purpose in very young children, as this drug may bring on further problems in the liver.

There are certain situations in which a parent might anticipate that a child’s temperature may well increase, and therefore that a febrile convulsion may occur. Such a situation might be after an immunization or vaccination (for example, the ‘triple’ vaccine, given three times in the first year of life, or the MMR (mumps, measles, rubella) vaccine given between 15 and 18 months of age). It is quite safe and sensible to give paracetamol at the time of vaccination and for 24-48 hours afterwards. With the MMR vaccine, there may be a very mild measles-like illness (with a high fever) 8-10 days after the vaccine has been given, and again, it would be wise to anticipate this and give paracetamol around that time.

In the past, anti-epileptic drugs were used to try and prevent further febrile convulsions from happening. It was shown that sodium valproate (Epilim) and phenytoin (Epanutin) were unsuccessful in preventing further febrile convulsions, and also did not alter the occurrence of convulsions without fever—that is, epileptic seizures. Although phenobarbitone has been shown to be effective in certain cases, this drug may cause significant side-effects in young children. In those few children who have repeated or long febrile convulsions, diazepam (Valium, Stesolid) may be given rectally, by parents after brief training. This medicine is used to prevent or stop the convulsion from lasting more than 30 minutes, but is only rarely necessary.

In a large prospective study of over 50 000 children carried out by the National Institute of Neurological and Communicative Disorders and Strokes in the USA, the incidence of febrile convulsions was 3.1 per cent, and the recurrence rate 32 per cent. By the time that the children had reached the age of seven years, more than one non-febrile seizure (that is, epilepsy) had developed in 0.5 per cent of those who had never had a febrile convulsion, and in four times as many—2 per cent—of those who had had a febrile convulsion. Children who had had prolonged or focal febrile convulsions, with evidence of pre-existing impaired development, were eight times more likely to develop epilepsy by the age of seven years than children with simple febrile convulsions, and 18 times more likely than children who had never had a febrile convulsion at all.

These figures show that one cannot deny the relation between some febrile convulsions (the complex and prolonged) and epilepsy. However, the parents of a child with one uncomplicated convulsion who has developed normally can be assured that the chances of subsequent epilepsy developing are very low—that the child has about 98 chances out of 100 of reaching the age of seven years without the occurrence of non-febrile seizures.

*89\188\2*

Transient ischemic attacks (TIA) are disturbances of brain function, usually lasting from two minutes to two hours, but sometimes for as long as 24 hours, which leave no trace. During a TIA, the victim may be paralyzed, unable to talk, or experience tingling or other unusual feelings on one side of the face or in one side of the body. There may also be dizziness, or partial loss of vision and hearing. One or more of these phenomena can occur repeatedly, or they may appear in different combinations from time-to-time, ranging from momentary dimming of vision to severe but temporary strokelike attacks.

Caused by temporary blockage of arteries supplying the brain, TIAs often result from blood clots carried there from elsewhere in the body. A failing heart or a damaged heart valve is the usual site of the clot formation, but other conditions (including atherosclerosis, diabetes, or early tumors) may provide the stimulus for clotting. For this reason, anyone who begins having TIAs needs to be examined by a physician to determine whether medical or surgical treatment is required for an underlying disease.

Even when no underlying cause is found, TIA victims can benefit from continuous anticoagulant drug treatment to slow the clotting process. This treatment should be carefully monitored and changed at intervals to match the patient’s varying needs. Regular follow-up visits to the doctor are therefore essential, even though one may feel perfectly well.

*204\143\2*

Signs and symptoms

The symptoms of sinusitis include fever (sometimes as high as 40.6°C), pain, stuffy nose, and cough. Depending on the location of the infection, headache may occur in the back of the head (infection of a sphenoid sinus), at the temples and over the eyes (infection of the ethmoid and frontal sinuses), or above and below the eyes (infection of the maxillary sinuses). Small children who have an infection in the ethmoid sinus develop red and swollen eyelids. However, the key to diagnosing sinusitis is the discharge from the nose.

With sinusitis, discharge from the nose is yellow, milky, or opaque. Pus in the sinuses can be revealed through an X ray, but it’s easily confused with a thickening of the lining of the sinuses because of a common cold or an allergy.

Home care

You can promote sinus drainage and protect against sinus infection by treating a cold with decongestants (taken by mouth) and nose drops, or by treating an allergy with antihistamines taken by mouth. These measures also encourage drainage after sinusitis has developed. To relieve pain and fever, heat may be applied to the affected sinuses, and aspirin or paracetamol given to the child.

Precautions

• A high fever (39.4°C to 40°C) plus signs of sinusitis indicate a potentially serious infection. See your doctor.

• A pus-like discharge or signs of sinusitis on one side of the nose suggest that a foreign object may be lodged in the nose or that the inside of the nose may be deformed. See your doctor.

Medical treatment

After identifying the infecting bacteria the doctor may prescribe antibiotics for the child to take by mouth. Suction may be used to drain the sinuses of older children with sinusitis. Surgical drainage is rarely indicated in children.

*191/84/5*

Characteristics of the Grasses That Cause Allergy

Grasses cause three times as many allergies as trees because they grow almost anywhere in the world (from the frozen North to the equator), even though they thrive best in moderate climates. There are many kinds of grasses, some of which, like sugar cane, wheat, rye, corn, bamboo, and rice, are planted so far from human habitations that they rarely cause allergies. Timothy, Johnson orchard, Bermuda, blue, and June are the names of grasses which can cause allergies. They grow in meadows and lawns in and around densely populated areas and pollinate in the United States from May to August.

Allergy to grasses is easily diagnosed because the pollen of all grasses looks the same when seen under a microscope; as a result, the pollen of any kind of grass can be used for testing or desensitization. (There are two exceptions to this rule: Bermuda and Johnson grasses, which have importance only in limited localities.)

In subtropical countries like Israel, grasses pollinate all year around and are the main cause of pollen allergy.

Characteristics of the Weeds That Cause Allergies

The most common cause of pollen allergy in the United States is weeds.

Some weeds, like English plantain, pollinate in June and July, while ragweed pollinates from the middle of August to the first frost. There is a short variety of ragweed, a tall variety, and a giant one. The short variety reaches a height of one to five feet and has hairy green stems, parted leaves, and long green-to-yellow spikes. The giant variety may reach a height of fifteen feet and has either three-lobed or simple leaves.

Both plants can live in the poorest of soils and can resist all severe weather conditions but snow. About mid-August, a photochemical reaction (which depends upon the balance between daylight and darkness) causes all ragweed plants to produce flower spikes which contain pollen. After a day or two, pressure builds up in the spikes, they burst open, and the pollen is thrown out into the air. It lands on the plant’s leaves, dries up, and is then carried away by the wind for hundreds of miles. All ragweed pollen looks and acts very much alike, no matter what variety of ragweed plant originated it.

*17/99/5*

IVF is a technique for fertilising your eggs with your partner’s sperm outside your body – hence the use of the phrase ‘test tube babies’. The fertilised egg is then implanted back into your womb.

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.

*93/73/5*