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.

*211/31/5*

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.

Women today have gynaecological examinations not only in consultation about gynaecological symptoms but when they’re quite well, as part of having regular Pap smears taken and as a routine measure in antenatal and postnatal care. Most women don’t like it, especially the internal (pelvic or bimanual) examination. Even women who’ve had several pregnancies and numerous examinations can’t suppress a grimace when they hear ‘Can I examine you now?’ or a sigh of relief when it’s finished.

It’s not that the examination hurts (though parts of it can be a bit uncomfortable). Modesty and embarrassment make women dislike this procedure. It’s hard enough to have to bare your genitals and have them scrutinised under a spotlight, but when someone (even someone who has professional licence to do so) touches your sensitive genitals and feels and puts things into your vagina – that really is going against the most powerful taboos of most women’s upbringing!

If you know your anatomy and know how and why each part of the examination is done, I’m sure it will be less intimidating and more comfortable for you, even if you’ve had examinations before. Whether it’s done by a women’s health or family-planning nurse, a midwife, your family doctor or a gynaecologist, the usual routine for a gynaecological check is as follows.

1 Your general and reproductive health history is taken if you’re a new client. If you’re known to the practitioner, you’ll just be asked what’s been happening since your last visit and the reason for the present visit.

2 Your blood pressure and weight are measured. Sometimes a urine sample is tested.

3 You’ll be asked to undress and climb onto an examination couch. You’re given a sheet to cover yourself (in winter a warmed blanket let’s hope).

4 Usually your abdomen is examined first by feeling for any tender spots or lumps. Then your breasts are inspected and examined.

5 You’re asked to bend your knees and move your bottom as close as possible to the end of the bed (some couches have leg rests or stirrups). Some doctors prefer you to lie on your side for the rest of the examination. Your nurse or doctor then inspects your external genitals. It is usually necessary to separate the labia so that the vestibule and the urethral and vaginal openings can be seen.

6 The interior of your vagina is inspected next. Because the vagina is usually collapsed like an empty balloon, a speculum is used to hold its walls apart so that your vaginal walls and cervix can be seen. If you’re due for a Pap smear, it’s taken now.

7 After the speculum is taken out, an internal (bimanual) pelvic examination is done. Your nurse or doctor puts two fingers into your vagina to lift up your cervix and hold it steady. With the other hand on your lower abdomen, the condition of your uterus and ovaries can be felt between the two hands, as well as any other swellings or tender spots in your pelvis. Don’t be alarmed if your doctor closes her eyes at times during this step: she’s concentrating on what she’s feeling. We call this ‘seeing with the tips of the fingers’.

That’s it – five to ten minutes at the most.

What if you’ve never had sex?

If it’s necessary, the examination can be done using a very narrow speculum and perhaps only one finger in the vagina. If the opening in the hymen is very small or the patient very nervous, the bimanual can be done with two fingers in the rectum (back passage). Rarely, it may be necessary to examine a woman or young girl under anaesthetic.

*11/31/5*

The obvious solution to stress is to do something about whatever is worrying you, but you’re not always equal to this when things are getting you down. You need help, such as taking any or all of the following steps.

Talking things over Discuss what is bothering you with someone you trust and who may be able to advise you about solving your problem: someone in the family, a friend or a professional counsellor who has your interests at heart and is a good listener. Sharing your problem takes the weight off your shoulders and often lets you think more clearly about solutions.

Relaxation This is a potent antidote to stress. It may not solve your problem but it will make you feel better and morel able to take a positive approach. You can learn relaxation techniques from books, audio- and videotapes and classes run by many community groups. Here are a couple of simple exercises to start with.

• Close your eyes and take several slow, deep breaths. Relax your shoulders and neck as you breathe out slowly. Then let your breathing become quieter and peaceful.

• Relax your facial muscles: your brow; around your eyes; your mouth and youth jaw. Once your face becomes tranquil the mind and body tend to follow.

Mind-body exercises such as yoga, T’aichi and meditation can help you to become more serene.

Reasoning with yourself in a positive way When things go wrong, most of us blame ourselves and become swamped with regrets (‘I should have known better’ and ‘If only . . .’). We also tend to put ourselves down and wallow in pessimism. Reminding yourself of the good things that have happened in your life can help you regain self-esteem and feel more optimistic. It may be a cliché, but if you can convince yourself that your problem isn’t the end of the world, you’ve reached a good starting point for solving it.

Diversion When we become enmeshed in worries it can be hard to think of anything else. If you can get your mind off your problem for a while you can often see things in a different light. Exercise such as a brisk walk or a swim can do wonders to clear your mind and restore positive energy, or an entertaining film might do the trick.

Assertiveness This is one of the most important tools in preventing and overcoming stress. It means saying and doing what is right for you in situations where you’re under pressure to do otherwise. It doesn’t mean being aggressive, just acting in your own best interests, including saying no’ when that’s what you want to say.

The more you experience in life, the more you know yourself, and the better you’re able to take the initiative for making sure that your needs are met. Many I people are brought up to believe that f thinking about one’s self is selfish. However, no one can know your needs better than you. You can’t expect people around you to know by instinct what you want and feel, so be fair to yourself and others by saying clearly what you need. Even if people can’t always do what you want, you’ll feel better if your needs have been taken into account in others’ plans – just as you feel better in the long run if you count others’ needs in your plans.

Life can be tough and we’re all under stress at times, but some people rarely suffer from it.

• People with strong support systems (family and friends) suffer less stress-related illness than those who feel lonely and isolated.

• Some lifestyles help strengthen us against the effects of stress: a good diet; regular exercise; adequate rest and recreation; wide interests; being able to concentrate on one thing at a time; knowing when to slow down and relax.

• A sense of humour helps. If you can find something to smile at (though this can be hard when the future looks bleak) your face will relax. This makes you more likeable, and people will reach out and make contact.

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People who go to fitness classes may find that some exercises in the routine may do them more harm than good. Most fitness instructors don’t have an opportunity to individualize a routine for each of their class members. The following list of exercises that may be harmful in certain cases will allow you to ‘sit out’ those that may not be good for you. If in doubt, ask a physiotherapist.

The deep squat This puts a lot of strain on the knee joints and knee caps, especially of women, because the angle between their knees and hips is wider than that in men. It should not be done by women unless prescribed by a physiotherapist, and should be avoided by anyone with knee problems.

Abdominal exercises Physiotherapists have reported seeing pelvic-floor problems among women who do a lot of abdominal muscle-strengthening exercises such as ‘sit-ups’ and leg raising. Strong abdominal exercises put excessive strain on the pelvic floor, especially if it is weakened by child-bearing. Any weakness of the pelvic floor can lead to problems such as difficulty in controlling the bladder and prolapse of the pelvic organs. You can protect your pelvic floor by bracing its muscles before each abdominal exercise. Simply contract the pelvic muscles as if trying to close tightly the outlets of the bladder, vagina and bowel.

Sit-ups The straight-legged sit-up puts too much strain on the lower back and has been eliminated from most exercise routines. Even the sit-up with flexed knees and hips is thought to place too much pressure on the lower spine. People with back problems should not perform the full sit-up (45 degrees is enough) and for older or pregnant women, raising the shoulders off the floor is all that is recommended.

Isometric exercises (such as pushing or pulling an immovable object, which increases the tension in muscles without changing their length) raise blood pressure and therefore should not be done by people with hypertension or other heart disease.

Exercises on a carpeted floor, those done lying down especially, can cause problems for those with respiratory allergies such as asthma or hay fever.

Of course if you have any chronic health problems, particularly heart or lung disorders, always ask your doctor’s advice before taking up any new exercise.

*25/31/5*

In discussing the reproductive system and its problems, the word ‘epithelium’ is often used. So, before going further, I will explain what it means. This and related terms given below are used in Pap-smear reports and to describe other gynaecological conditions; knowing what they mean can remove much of the mystery and anxiety of hearing or seeing them used about your health.

Cells that form layers covering the outside of the body and lining internal cavities that open onto skin are called epithelial cells, and the layer itself is called an epithelium. Epithelial cells can have protective, filtering or secretory (glandular) functions.

Epithelial cells are packed tightly together to form sheets. No blood vessels pass between the cells, so they must obtain their oxygen and nutrients from blood vessels in the connective tissue on which the epithelial cells lie. This connective tissue is an important part of all covering and lining membranes.

Epithelial sheets may be one cell thick, described as ‘simple’, or many cells thick, described as ‘stratified’. Stratified epithelium is found where a tough, protective covering is needed, such as skin and in the mouth and vagina. Simple epithelium performs secretory or filtering functions. Cells from epithelial layers often grow down into the connective tissue beneath to form glands, for instance the glands in the lining of the uterus and the cervix. The epithelial cells of glands that lie beneath the surface become modified so that they can secrete; this happens, for example, in the sebaceous and sweat glands of the skin and the milk-producing glands of the breast.

Epithelial membranes are also described according to the shape of their surface cells: flat cells are ‘squamous’ (from the Latin squama, meaning ‘a flat scale’); taller cells are ‘cuboidal’; tallest cells are ‘columnar’. Thus ‘stratified squamous epithelium’ is many cells thick with flat cells on its surface; ‘simple columnar epithelium’ describes a single layer of tall cells.

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The concept of ‘cellulite’ is one of the great confidence tricks of our times, intended to rope women into spending big bickies attempting to change their body shapes. The word ‘cellulite’ is a recent addition to our language. It was invented earlier this century by the French slimming industry to describe the dimpled appearance of the skin over type II fat deposits.

I’ve already told you about fat storage in some detail so that you’ll know that everybody has the capacity to develop dimpled fat, but some people have it more, and in different places, than others. And the ‘dimplies’ are being ripped off by the slimming industry. ‘Cellulite’ has been promoted as being ugly and ‘bad’ fat by the people who want to sell you something to get rid of it. Some quacks even tell people that it’s ‘an accumulation of toxic wastes under the skin’ or ’caused by a faulty elimination system’ and treat it as a disease that needs (expensive) treatment. This is nonsense! It’s normal fat storage. Look at any healthy baby’s bottom and you’ll find dimpled fat.

Because our society has become so obsessed with leanness and we’ve been taught to believe that ‘cellulite’ is unattractive, we women are sitting ducks f those who aim to make their fortunes by selling ‘cures’ for it. But dimpled fat car be removed by massage, pummelling; herbal cures and other diet supplement special creams and injections, or sweating it off by exercising in rubber or plastic girdles. Going to ‘cellulite’ salons will make your wallet thinner, but not your thighs. The only way to reduce the amount of dimpled fat is the same as for any other fat – by using up more energy than you take in as food. This means diet and exercise.

Fat storage is essential to life and health. It insures against lean times, and fat beneath the skin is important for insulation and as a cushion between some bones and muscles and the hard knocks and surfaces of the world. Women have the capacity to store twice as much body fat as men to see them through pregnancy and breastfeeding. However, you can have too much of a good thing, and excessive fat storage (called obesity) is bad for health and self-image.

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