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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:

• Endometriosis can lead to a difficult decision having to be made. If you had an oophorectomy, then you will probably have particularly troublesome hot flushes, and if you had the operation before about the age of 45 you will be at a much greater risk of developing osteoporosis, so HRT would seem an important treatment for you. However, the excess tissue that built up in endometriosis may get worse on HRT, even many years after the menopause, suggesting that you should not use this form of treatment. This is obviously something you should talk over with your doctor.

• If you have a family history of cancer of the breast or uterus, your doctor will want to consider what your chances are of developing either of these diseases if you take HRT. Once again, only you can decide by weighing the relative risks against the relative benefits. Benign breast disease needs careful monitoring, but HRT needn’t always be ruled out.

• Fibroids tend to get worse in the presence of oestrogen, and may enlarge if you take HRT. But this doesn’t usually cause extra problems and most women with fibroids who are on HRT find they just have heavier periods.

• The presence of gallstones means HRT has to be prescribed with caution, as it can lead to an increased risk of this condition becoming worse. A non-oral route, such as the patch or implant, avoids the digestive system, so may be acceptable. Oestrogen can make gallbladder disease worse.

• High blood pressure should be investigated before starting on HRT, but once it has been brought under control, your doctor will probably feel it is alright for you to be on HRT. High blood pressure is not in itself a contraindication.

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The preceding discussion has assumed heterosexual sexual behaviour. However, not everyone is primarily attracted to members of the opposite sex; some people, both males and females, are aroused by and form homosexual relationships with members of their own sex. Research on the effects of hysterectomy on the sexual relationships of lesbian women is extremely limited and deserves more attention.

Another area in which knowledge is limited is the previously mentioned role of the uterus in sexual response. Direct stimulation of the cervix during sexual intercourse also seems to have a role in the sexual response of some women and men.

More information exists about the effects of changes in hormone production after hysterectomy. Even when the ovaries are retained, oestrogen levels seem to be affected by hysterectomy in some women. About a quarter of women whose ovaries remain after hysterectomy experience early loss of ovarian function (on average four to five years earlier than in comparable women who have not had a hysterectomy) which can lead to vaginal dryness and hot flushes. In a bid to prevent or overcome these problems, many women with indications of low oestrogen levels are prescribed oestrogen therapy after a hysterectomy whether or not their ovaries have been removed.

A woman’s attitudes — and those of her partner — can be an extremely important influence on sexual relations after hysterectomy. In the aftermath of her hysterectomy, Kay was already questioning her femininity and attractiveness. She had regarded her main role in life as childbearing and suddenly, without the ability to do this, her life lost meaning. But her agitation grew when Kevin failed to respond to her attempts to arouse him sexually. She worried that she was now less attractive to him and new tensions entered their relationship. This unfortunate chain of events continued until the couple sat down and communicated their feelings and fears; Kevin explaining that he was worried about causing Kay pain when they made love, Kay coming to grips with the reasons why Kevin and others valued her.

In the case of Vin, talking did not help a great deal. He thought his wife Mary was less of a woman after undergoing hysterectomy but found it difficult to say exactly why. He understood that Mary had tried many other approaches to resolving her medical problems without success, and that something had to be done to relieve her pain and bleeding. In cases such as this, it can be helpful if a spouse or partner is involved in the decision-making

process, thus providing opportunities to discuss any concerns with the doctor. It may also alert women to the need for a concerted effort on all sides to overcome unforeseen barriers to reestablishing a satisfactory sexual relationship.

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One of the commonest causes of insomnia is stress.

The Oxford Dictionary defines ’stress’ as a force, an effort, a demand upon physical or mental energy. We use the word ’stress’ very often, but what is stress, what is it doing to us, and how do we react to stress and cope with it? Stress can be compared to a mechanical force or pressure exerted on an object To understand the relationship between stress and the object under stress, let us look at a simple example, such as what happens when pressure is exerted on a piece of fruit.

If you put a lot of apples in a bag, the apples exert pressure on each other, and each apple is subject to pressure from surrounding apples. This is a normal level of pressure and stress. However, if you take an apple out of the bag and drop it to the floor, the apple is bruised. If you accidentally step on this apple, you leave a big scar on it Dropping the apple and stepping on it are both extraordinary stresses not normally exerted on apples.

Hence, to put it in plain language, there are two kinds of stresses in our lives: ordinary stress, which most of us experience every day, as in the example of the apples in the bag, and extraordinary stress, comparable to dropping the apple or stepping on it, which we only experience once or twice in our lives, and which some of us may never have to face at all.

However, we are not all apples. Some of us may be stronger, like a coconut, which when dropped on the floor will not be harmed as it takes a few strokes of a hammer to crack it. Or some of us may be weak, like a ripe tomato, that even ordinary pressure can bruise. People come in all shapes and sizes and possess different inner strengths and energies. Some of us may be like coconuts, some like apples, and some like ripe tomatoes. We have no choice as to what we are, as part of this is our inheritance from our parents and part is based on our life experience, just as an apple cannot change into a coconut, and a tomato cannot change into an apple. However, with some help we can strengthen ourselves a lot more and can deal with stress a lot better. Einstein reminded us that we use only 10 per cent of our potential, and there is a lot of strength inside us that we have not recognized.

Hence there are two factors in stress. The first factor is the kind of stress, whether it is ordinary stress or extraordinary stress. The other factor is how tough the person is. Some of us may not be able to face up to ordinary stress, just as the ripe tomato. But some of us may be extremely tough and need a hammer to crack us, like the coconut.

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