Some STDs are caused by viruses. They include herpes simplex, hepatitis, genital warts and AIDS.

Herpes simplex    

The herpes simplex virus (HSV) causes blistery sores (herpes simplex lesions) that most often occur near where moist lining membranes meet the skin around the mouth, the genitals and the anus.

There are two types of HSV: type I and type II. Type I mainly causes cold sores around the mouth. Most people who get oral herpes have been infected during childhood, mostly before 5 years of age. Type II usually affects the genital region, and is most often sexually transmitted. However, either type of HSV can infect any part of the body covered with stratified squamous epithelium. I have seen it on the skin of the buttocks, thighs and neck, and even on the hand of a laboratory technician who accidently pricked her finger while culturing the virus.

HSV belongs to the herpes virus family, which has over 50 members. Only a few are known to cause disease in humans. Once you pick up any herpes virus, it stays in your body for the rest of your life. Though there are often symptoms soon after you first become infected, after recovery these viruses remain in a latent (inactive) state most of the time. However, in some circumstances they can become reactivated to cause symptoms and possibly make you infectious again.

I should mention here that among health workers, the word ‘tumour’ is used to describe any abnormal lump anywhere in the body. Tumours may be benign (non-cancerous) or malignant. If you hear your lump described as a tumour, don’t be frightened and assume that you have cancer.

Cysts are the most common cause of breast lumps for women between the ages of 35 and 55, but rarely occur in younger women. They result from fluid being trapped by a blocked duct. A cyst may develop suddenly or slowly and may reach up to several centimeters in diameter. It will feel smooth and round, soft or tense, and is often tender. Cysts usually can be moved around easily within the breast tissue. Some cysts disappear slowly as the fluid in them is absorbed, but usually they need to be emptied by needle aspiration (drawing out the fluid with a fine needle), which makes them disappear immediately. If the cyst refills or if the fluid withdrawn is bloodstained or if a lump can still be felt after the cyst is emptied, further investigation is needed.

The most common solid breast lump in young women is an overgrowth of fibrous and gland tissue (fibroadenoma). These lumps feel smooth and firm, and move around so easily within breast tissue that when you try to feel them they seem to dart away from your fingers. For this reason they’re often called ‘breast mice’. Fibroadenomas are benign and removal is unnecessary unless you’re worried by the presence of the lump, but examination of a fragment of the lump under the microscope is necessary if you decide not to have it removed.

Other lumps and thickenings, such as those caused by hormonal changes or by scar tissue, are more difficult to identify as benign. These days just about all breast lumps are investigated further to rule out the possibility of cancer. Following are the tests commonly used.

Diagnostic mammography

This is a special X-ray technique for examining abnormalities felt in the breasts, and is usually the first test offered to women aged over 25 years. Most women who think they have a lump can be reassured that they don’t have cancer after negative results from a specialist examination, a mammogram, and often an ultrasound.

Previously it was feared that the dose of radiation from mammography might itself increase the risk of cancer. However, the special equipment and techniques used now give such a small dose of radiation that it is no longer considered any risk.

Ultrasound

This test is generally the first performed for women aged under 25 years. It is also used for any woman who has a lump that can be felt but doesn’t show up on mammography, or to look at a change seen in the mammogram but not felt. It involves passing sound waves into the breast. These waves are reflected back differently by tissues of different density, for example cysts and solid lumps. The reflections are analyzed by a computer screen to give a ‘picture’ of the breast tissue. Ultrasound should be used when there is any doubt about a change found by feeling the breast or by mammogram.

Biopsy

This involves removal of some of the suspicious breast tissue so that it can be examined under the microscope. It is done when there is any uncertainty after mammography or ultrasound. Biopsy may be done in two ways.

Fine-needle aspiration A fine needle is inserted into the tissue and a fragment drawn out. The same procedure is used to empty the fluid from cysts. This can be done in your doctor’s rooms. Surgical biopsy Some tissue is removed through a small incision. This may be done in hospital or a day centre under general anaesthetic. The sample removed by either type of biopsy must be examined by an expert in microscopic examination of breast tissue.

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Most things that can go wrong with the cervix involve the membranes that line its canal or cover its vaginal surface.

The canal that runs through the cervix opens into the cavity of the uterus at the internal os and into the vagina at the external os (os is Latin for mouth). It is lined by a single layer of columnar epithelial cells that dips down into its wall to form glands. These cells are influenced by oestrogen and progesterone to form varying amounts and types of the cervical mucus that fills the canal. Where the cervix projects into the vagina, its outer wall (called the ectocervix) is covered by a tough stratified squamous epithelium many cells thick, the same as the vaginal lining. The point where the columnar epithelium that lines the canal meets the squamous epithelium covering the ectocervix is called the squamo-columnar (S-C) junction and is very important in cervical health.

At puberty, ovarian hormones stimulate growth of the cervix to its adult size and mucus production by the lining cells and glands of the cervical canal. From puberty on, the cervix undergoes constant changes with the rise and fall of hormones during each menstrual cycle and with the altered hormonal conditions of pregnancy and lactation. Its wall becomes slightly enlarged and softer at the time of ovulation due to an increase in tissue fluid between its cells, and the external os becomes more lax and open.

Throughout the reproductive years there are changes in the position of the S-C junction. At birth and before puberty the junction may be inside the canal, at the external os or on the ectocervix. Its position is thought not to change much during the first 10 years of life. At puberty, pregnancy and other times during the reproductive years the junction may move further out onto the vaginal surface of the cervix. This is called cervical eversion, because the canal lining appears to be ‘turned out’ onto the ectocervix.

The delicate columnar epithelium that lines the canal cannot survive when it is exposed to the acidity of the vagina, so it becomes transformed into the stratified squamous epithelium that covers the ectocervix. The surface of the cervix over which everted canal epithelium has been or is being transformed is called the transformation zone (TZ). During the transformation process (which can happen more than once during our reproductive years) the cervix seems to be more susceptible to anything that might cause unusual or abnormal cell growth and division.

This outward movement of the canal lining seems to be influenced by hormones and possibly other factors not yet identified. It is considered to be a normal process, but we don’t know why it happens in some women and not others. When this is understood we may find the answers to many puzzling questions about abnormalities of the cervix.

The lining of the cervical canal is transparent. When it is everted onto the ectocervix the blood vessels in the tissue beneath show through, so that the eversion looks red. It also appears rather knobbly compared with the smooth surface of the membrane covering the ectocervix.

In the past doctors called this eversion an ‘erosion’ or ‘ulcer’, because that’s what it looked like with the naked eye. It was thought to be abnormal (we now know that it isn’t) and was treated by burning or freezing the area to transform it to ectocervical epithelium. Most of these treatments were unnecessary: given time almost all eversions will be replaced naturally by a transformation zone.

Occasionally an eversion that is slow to transform may lead to chronic inflammation of the cervix.

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About a quarter of hysterectomy patients need treatment for psychological problems after the operation. The most common are depression, anxiety, grief reaction and lack of libido. The highest risk is among women whose symptoms aren’t relieved by the operation and those who’ve previously been treated for emotional disorders. Also at risk of poor emotional outcome are younger women and those who would have preferred more children. Inadequate understanding of the womb’s role in health and sexuality can also contribute to post-operative psychological problems. On the other hand, the majority of women enjoy better emotional health after hysterectomy, as would be expected when the
source of distressing symptoms is removed and health is restored.

Many of the old fears about the consequences of hysterectomy arose from a widely held but quite incorrect belief that it was the same as castration. As explained, the ovaries are preserved unless it’s impossible to do so. If your ovaries must be removed at the time of hysterectomy, you’ll be told about it and encouraged to use oestrogen replacement to eliminate the effects of lack of oestrogen on health and sexual function.

Another myth about hysterectomy is that it makes women gain weight. There is no physiological reason for weight gain after hysterectomy unless you eat more and exercise less than before. Women who become overweight after any surgery may do so because during convalesce they develop a pattern of overeating underexercising that can be hard to break.

The controversy about hysterectomy

Few subjects in gynaecology have caused
as much debate as hysterectomy. The controversy reached its peak in the 1970s when health authorities became alarm at the high rate of hysterectomy in Australia. The flames of the debate were fanned by the press with such sensational headlines as ‘Shock Survey on Hysterectomy: Convenience a Key Reason’.

A survey of hysterectomy in the late 1970s showed that two out of five Australian women had their uterus removed before the menopause, and nearly half of the female population had hysterectomy by the age of 65 years. This was much higher than the rate of hysterectomy in the UK and European countries.

Why had so many Australian women had hysterectomies? Did almost half of all Australian women have serious disease of the uterus that couldn’t be corrected by non-surgical means? (The answer to this must certainly be ‘No’.) Were hysterectomies being performed unnecessarily? Were women pressuring surgeons into performing hysterectomies for ‘convenience’? Worst of all, were surgeons recommending hysterectomy for their own financial gain?

It’s difficult to answer these questions in retrospect, but it seems likely that in the past some hysterectomies were performed for reasons that would be considered invalid today, including sterilisation, to do away with the inconvenience of menstruation, and to prevent possible future disease.

Most women who’d had hysterectomies didn’t think that they were unnecessary. The majority of a survey of 823 women who had hysterectomies in New South Wales in 1977 were satisfied about the outcome of the operation and believed that it had been done for a good reason. Still, some were unsure whether the operation was necessary and a few regretted it.

The controversy in the late 1970s and early ’80s has resulted in both women and surgeons becoming more careful about the decision for hysterectomy. Less hysterectomies are now performed. Other changes since the 1970s have contributed to the fall in the rate of hysterectomies.

• Women are now better informed about their gynaecological health and are encouraged to take a greater part in decisions about their health care.

• Improved non-surgical treatments have been developed for many bleeding problems, menstrual pain and endometriosis.

There will be even fewer hysterectomies in the future. The new technique of removing or destroying the endometrium through the hysteroscope (endometrial ablation) can eliminate many problems of bleeding without removing the whole uterus. Recent studies on progestogen-releasing IUDs have shown them to be as good or better than endometrial ablation in controlling some bleeding problems caused by progesterone deficiency.

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This is labour that begins before the 3 week of pregnancy. It used to be called premature labour. Pregnancy problems that increase the risk of pre-term la include pregnancy-induced hypertension, multiple pregnancy, antepartum haemorrhage, incompetent cervix, abnormalities of the uterine cavity, and a rare condition called hydramnios in which too much amniotic fluid is produced. More often than not there is no apparent cause.

When there is no reason for pre-term labour, the mother is given medication to try to stop the uterine contractions. At the same time corticosteroid drugs are given. These cross the placenta and stimulate the foetal lungs to produce surfactant, the substance that is normally produced from around 34 weeks to allow the newborn’s lungs to expand and function properly.

When pre-term labour is the result of pregnancy-induced hypertension or antepartum haemorrhage, no attempt is made to stop it. Pre-term labour is often prolonged because the small baby dilates the cervix slowly. Episiotomy and the use of forceps to deliver the head are recommended so that head injury is prevented.