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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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Your egg is mixed together (not fertilised) with your partner’s sperm and put back into the fallopian tubes so that fertilisation takes place where it would happen naturally anyway.

Who Should Have It?

GIFT can only be used when a woman has open and healthy fallopian tubes.

What Happens?

The use of the drugs is identical to IVF but the difference is that the egg retrieval is done by a laparoscope (telescope) through the abdomen and so a general anesthetic is needed. A maximum of three eggs are put back in the fallopian tube.

The other difference between GIFT and IVF is that fertilisation, if successful, takes place inside the body. GIFT is more invasive and expensive than IVF.

Success Rate

There are no official success rates for GIFT treatment because it does not come under the HFEA which only monitors techniques involving an embryo outside the body.

One clinic estimates that GIFT is approximately one and a half times more successful than IVF because fertilisation takes place inside your fallopian tubes and the embryo does not reach the womb until approximately seven days later, as nature intended. (As we have seen, IVF fails most commonly at this crucial implantation stage.)

Frozen Eggs

Any excess eggs from a GIFT procedure can be fertilised with the sperm outside the body, as in IVF. This makes it possible to see whether fertilisation actually takes place, and the embryos can be frozen.

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Isolation

‘I feel so alone. I have never heard of this disease and most of my family and friends don’t even know how to pronounce it let alone understand what it means. How can I explain it to them in simple terms when I don’t understand it myself?’

This is a common cry for help. Many women find it difficult to discuss their gynecological problems with family or friends because they are embarrassed or simply do not want to burden people with their problems.

Some may find that they feel isolated because partners or family and friends have heard about the symptoms for so long that they no longer want to discuss it now that a diagnosis has been made.

Others believe that once the woman has had surgery such as a laparoscopy or laparotomy she is cured and should have no more problems. Little do they realize that this may be just the beginning.

Anger

Most women with endometriosis have felt anger at some stage. It may happen after you overcome the initial confusion and feelings of isolation because then you start asking yourself: ‘Why me?’, ‘Why am I infertile?’, ‘Why didn’t doctors pick this up sooner?’, ‘Why isn’t there a cure?’, ‘What research is being undertaken?’, ‘Why isn’t more information available about this disease?’

With all these questions racing through your mind it is difficult to realize that you have not been singled out to suffer. You will feel angry that at some stage this disease may interrupt your life or that it may prevent you from having children, or attaining other goals in your life or pursuing some sporting interest or hobby.

You may also feel angry because endometriosis is a chronic disease for which there is no ‘cure’. You may be angry because a diagnosis has taken so long, because doctors do not have all the answers and it seems that no-one understands your turmoil.

Your partner too may be confused and frustrated by the disruption the disease has caused to your lives. He may feel angry that there is no cure, or may find it difficult because you may need his constant support.

How do you cope with this anger and frustration that you both may feel?

Try to include your partner in talks about the disease. Encourage him to accompany you on visits to the doctor or to meetings of support groups.

Let your partner talk about his fears and concerns and include him in any decision making.

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What does it do?

The reason we should be jumping up and down about PID is that infection in the pelvis can permanently damage the tissues which are inflamed. For example, fallopian tubes may be kinked and blocked by infection and subsequent scarring in the pelvis. Abscesses may form in the tubes or elsewhere.

The chances of having permanent damage to the pelvic organs varies. More severe infections may damage the tubes more man milder infections. Not every woman who has PID ends up with blocked tubes. However, the incidence of damage increases with subsequent infections. This means that with the first episode, your risk of tubal damage is about 10 per cent. For the second episode it is about 30 per cent, and if you have three episodes of PID your chance of having tubal damage is about 75 per cent. The fact that you have damaged tubes is likely only to be found if you are being investigated for chronic pelvic pain or infertility. Tubal damage from PID is a major cause of infertility in our society.

The other risk you face with damaged tubes is that you have a greater chance of having an ectopic pregnance. This can be a life-threatening event, and the routine treatment usually involves further damage to the affected fallopian tube.

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You have a range of options for your antenatal care and delivery, including public or private hospital, birth centre, home birth, midwife, GP or specialist care. Availability and health insurance may limit your options. Despite the apparent differences, the fundamentals of antenatal care are similar, wherever they are offered.

The first antenatal appointment will usually be arranged for when you are seven to twelve weeks pregnant and this visit is usually the longest. You will be asked details of your past history and your family history, as there are some conditions which may affect, or be affected by pregnancy. It is important to know about diseases and genetically inherited conditions which run in your family or your partner’s family. You will be examined by a doctor, who will listen to your heart and lungs, and will usually take a pap smear and perform a pelvic examination. You will also be weighed, give a urine sample, and have some blood tests performed. These include a blood count (checking specifically for anaemia and iron deficiency), and screening tests for hepatitis, syphilis, rubella (German measles) immunity, and your blood group. These tests ate usually done on everyone because certain conditions can cause harm to the baby, and if they are identified, the appropriate management can be started. It is preferable to check for rubella immunity before getting pregnant, and if necessary be vaccinated at least three months before getting pregnant. If you are found not to be immune when you are actually pregnant you can be vaccinated when this pregnancy is over, so you will be immune in the future.

Knowing your blood group is important in pregnancy (but rarely at other times) because there is a condition called Rh immunisation which can affect some pregnancies (see further this chapter).

Appointments for a further visit and any specific tests required will usually be organised. The tests generally include an ultrasound at about eighteen to twenty weeks gestation. The reason behind the timing of this scan, which is usually the only one most women will have during a pregnancy, is that it is the best time to see the development and anatomy of the foetus. If there is a physical abnormality it is highly likely to be visible on this scan. Earlier scans do not give anatomical detail so well. If there is a major abnormality or problem it is better to know about it at eighteen to twenty weeks, rather than later, in case some action is needed. Assessing the gestation of the pregnancy at this stage is accurate to within seven days or so, and will show twins, triplets, etc.

Some practitioners also do a routine test for a bug called group B strep (streptococcus). A cotton-bud swab test is used to find out if this bug is present in the woman’s vagina at twenty-eight weeks gestation. It is a bug which often lives there and does no harm. In pregnancy, however, there is a small chance that during delivery the baby will come in contact with it, and a small number of babies may develop an infection. To prevent this happening, women found to have this bug at twenty-eight weeks can be offered an antibiotic during labour, and the baby can be given a dose of antibiotic when born. This substantially decreases the risk of infection to the baby.

When all of these things have been arranged, you will be given another appointment for about four to six weeks time. Visits for antenatal care are typically spaced about a month apart until twenty-eight weeks, then every two weeks until thirty-six weeks. After that, weekly visits would be recommended.

Your blood pressure will be checked at each visit Raised blood pressure developing in pregnancy may be associated with pre-eclampsia, or it could simply be pregnancy-induced hypertension (high blood pressure), both of which need watching, and sometimes treatment.

You will also be weighed and have your abdomen examined to measure the growth of the foetus. When the foetus is over twenty-eight or so weeks, the doctor or midwife will listen to it’s heartbeat, using a special little trumpet-like stethoscope or mini ultrasound machine.

Any abnormalities found in the course of the visits can be investigated, and any incidental problems dealt with. These visits are also when you can ask any questions you might have during your pregnancy, and when you can find out what to expect.

If problems arise during the pregnancy and you need extra medical care, you can contact your own doctor or, if you are attending a public hospital, you will have the facilities of the hospital’s emergency department available twenty-four hours a day. If you need admission to hospital before the baby is due, this can be arranged.

When the time comes to go to hospital to have your baby, you will be cared for by midwives (specially trained obstetric nurses) and your own doctor or a hospital doctor, depending on what type of obstetric care you have chosen. If your baby needs specialist care, a paediatrician can be involved.

A postnatal visit at six weeks after delivery is usually arranged, to check on the health of the mother and baby.

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People can have sexual contact and not exchange these fluids. Not all sexual contact necessarily involves intercourse. However, genital contact being what it is, and the tendency for sexual stimulation to lead to a situation likely to transmit fluid (like intercourse or ejaculation), a safer way of having sexual contact is while using a condom. When used properly, the condom can reduce (but not totally eliminate) the risk of transmission of diseases which are spread sexually (to say nothing of the added bonus of stopping sperm!).

Condoms need to be used properly in order to be maximally effective. That means putting the condom on at the beginning of foreplay, because the secretions which come out of the penis before ejaculation (orgasm or ‘coming’) can still be infective. Putting on the condom does not need to be an interruption to foreplay; in the right hands, so to speak, it can be quite fun.

The condom is a neat little thing, a thin, strong latex sheath all rolled up ready to be put onto an erect (hard) penis. In the tip of the condom is a little nipple-like pouch, which is there to catch the semen when a man ejaculates. It is important to squeeze the air our of this pouch before the condom is rolled onto the penis, or the air trapped inside can heat up, expand, and the condom can burst, and that is no fun at all.

The condom is put on the tip of the penis, and carefully rolled all the way down to the base, so the entire penis is covered. It is important to avoid tearing the condom with your fingernails as it is rolled onto the penis.

Although condoms are usually already lubricated, additional lubricant (water-based, like K-Y Jelly, not oil-based like Vaseline or baby oil) is a very good idea. It helps to prevent friction, which can weaken the condom (particularly during anal intercourse). It makes it more comfortable for both participants, as well as safer. Some people use a spermicidal jelly as a lubricant, and as extra protection against becoming pregnant. (Oil-based lubricants weaken the latex, and are more likely to make the condom ineffective.)

When a man has an orgasm and ejaculates, the penis, which has been hard and erect, becomes floppy again fairly quickly. If the condom is not removed promptly and carefully, there is a chance there will be some spillage of semen, and that is not desirable. So the penis should be removed from wherever it has been, while the condom is held on so that nothing spills, and the condom does not slip off. The condom should be removed from the penis, any fluid wiped off the penis, and the condom disposed of in the bin (not down the toilet—it is not very good for the plumbing or the environment). A new condom must be used each time you have sexual contact, as they are definitely single-use items.

If you find condoms break, even with lubricants, buying a thicker condom may be a good idea. There are several different types on the market.

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Vasectomy. The permanent sterilisation of a man is a technically easier procedure. The vas deferens are the tubes that carry sperm from the testes (balls) to the seminal vesicles, where sperm are stored. These tubes are relatively accessible, as they are in the scrotum (the skin sac that the testes are in). Cutting and tying the vas deferens can be done under a local anaesthetic, and is pretty hazard free. Sometimes bruising may be apparent, and, rarely, infection. Questions regarding the possibility of prostate cancer being linked in some way to vasectomy have been raised by some researchers. Further work is being done to establish whether or not there is a relationship, but it seems there is not. Future studies will hopefully sort this out.

Vasectomy has no effects on sexual performance. The man is still able to have sexual intercourse, to orgasm and ejaculate. The only difference is that there are no sperm in the ejaculate. It is important to make sure the ejaculate is free of sperm before relying on the operation for contraception. It is usual for a man to undergo one or two semen analysis tests to make sure the sperm are all out of the system, and until this has been done another form of contraception should be used. The semen analysis may be performed at two or three months, or after a certain number of ejaculations. Doctors may differ in their recommendations regarding when, and how many times, to test the ejaculate, but the process is the same.

Doctors tend to be more cautious about performing this operation on younger men for the same reasons outlined above in relation to younger women and sterilisation. The success rate of reversal of vasectomy is also variable, and it is not recommended that it be considered a reversible method.

In general it is a very safe, relatively cheap, and effective form of permanent contraception. Like tubal ligation, it is becoming more popular as people are looking for effective contraception with a very low side-effect profile. If permanency is desired, it is a pretty appealing option for many couples.

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Dysmenorrhoea is the word doctors use to say ‘painful periods’. It can be ‘primary’ (painful from within a year or so of the first ever period), or ’secondary’ (initially not painful, then periods become painful years after the first period), and ends in ‘orrhoea’, which is an ending on many medical words, meaning ‘lots of’.

A significant number of women have period pain during their reproductive lives. About 10 per cent of women are incapacitated for one to three days each month. Days are lost from school, work, and other usual activities because of period pain. It is no wonder that so many people seek treatment.

Primary dysmenorrhoea is fairly common, although it may not become apparent until the ovaries are working properly, a year or so after the first period. It is usually not associated with any underlying problem, and in many cases gradually lessens with time. Very rarely there may be a physical cause, like a problem with the shape of the uterus, or the cervix not letting the blood out well enough.

If periods have been pain free for years and become painful much later it may indicate an underlying cause, like endometriosis or infection, so it is worth having this investigated. Often there will be associated pain at other tames too like mid-cycle and with intercourse. The pain is more likely to occur before the period, rather than starting with it, although this is not always the case.

Period pain may not feel the same to every person, even though the processes causing the pain may be the same. It will usually start dose to the rime bleeding starts, and may be felt in the lower abdomen, the back, the legs, and accompanied by nausea, dizziness, vomiting, headache and tiredness, all of which may be mild, moderate or severe.

Treating the problem begins with working out if it is primary or secondary. If it fits into the pattern of secondary dysmenorrhoea it should be investigated, and any underlying cause found should be treated. If there is no underlying cause, there are treatments available, with varying success achieved.

The most tried and true method is still the hot water bottle. Local heat does seem to help, but it can be a bit inconvenient if you need to be out and about.

It is, however, a cheap, simple, often helpful remedy, with no chemicals and no side effects (if you are careful not to bum yourself). Relaxation, yoga, and exercise have also been said to help, and arc worth trying.

The most simple medicinal treatments are either aspirin (trade names: Aspirin, Aspro, Buffet Disprin, Ecotrin, Solprin, Spreo, SRA, Winsprin), or paracetamol (trade names: Panado), Tylenol, Panamax, Paralgin) taken to the manufacturers’ recommendations. There are specific anti-uterus-pain medications on the market, such as mefanamk acid (Ponstan, Mcfic) and naproxen (Naprosyn, NaprogesicK and these are available over the counter (no prescription required) at pharmacies. These are related to the antinflammatory drugs used for arthritis, and like all anti-inflammatory drugs should be taken with food to avoid irritation to the lining of the stomach. They should be avoided by people with a history of stomach ulceration, and you should not take aspirin while taking these medicines; paracetamol would be preferable. These anti-uterus-pain tablets work by preventing the increase of a chemical, called prostaglandin. Prostaglandins have been found to be associated with painful periods. As anti-prostaglandins are a sort of ‘preventative’ medication, they work best if you use them just before, or at the very beginning of the period and continue using them for as long as needed.

Some people find that anti-spasm medicines, often used for spasm in other parts, like the bowel, are useful. One available on prescription is hyoscine-N-butylbromide (trade name: Buscopan).

The vast majority of women who have painful periods are able to cope with the methods outlined. Unfortunately some can’t, and in some cases the oral contraceptive pill is prescribed as a treatment for painful periods (and heavy periods), as one of the beneficial side-effects of the pill is that it tends to give lighter and less-painful periods. This is because it suppresses ovulation. Whether or not the pill is a suitable treatment for a particular person is a decision based on individual circumstances; it may not be ideal for everyone.

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