Health News

Combined treatment for endometriosis involves the use of a course of hormonal treatment before or after surgery.

Who is suitable for combined treatment Combined treatment is sometimes used for women with the more severe forms of endometriosis in association with a conservative laparotomy though it may also be used in combination with a hysterectomy. Laparoscopic surgery is often followed by a course of hormonal treatment regardless of the severity of the condition.

What does combined treatment involve

Gynaecologists vary in the way that they use combined treatment. Some believe that the hormonal treatment is best used before surgery and some believe that it is best used after surgery, while others believe that it can be used both before and after surgery.

Those who recommend that the hormonal treatment be taken before surgery believe that it makes the surgery easier to perform by reducing the size and number of the implants that need to be removed and makes them easier to remove. They also believe that it reduces the development of adhesions following surgery.

The practice of using the hormonal therapy after surgery is based on the thinking that surgery can only remove those implants which are visible and accessible. The hormonal therapy is used to eradicate any implants remaining after surgery, including any microscopic implants.

If the hormonal therapy is used before surgery, two to six months of treatment is usually prescribed, whereas if it is used after surgery up to nine months of treatment is generally used.

Effectiveness of combined treatment

There are few statistics on the benefits of combined treatment. Many gynaecologists believe that combined treatment is probably more effective than hormonal or surgical treatment alone.

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Endometriosis is A condition in which endometrium (the lining of the uterus) is found in locations outside the uterus. It can occur in menstruating women at anytime from puberty to menopause. This misplaced endometrium is most commonly found on the ovaries, the ligaments supporting the uterus and the Pouch of Douglas. It can cause a wide range of symptoms including period pain, pelvic pain, painful intercourse, bowel problems and infertility.

How long has endometriosis existed-Endometriosis has probably been around for as long as the human race. The first mention of the characteristic symptoms of endometriosis has been found in ancient Egyptian scrolls which date back to the year 1600 B.C. The first reference to endometriosis in medical literature appeared in 1860. But it was not until 1921 that an American doctor, John Sampson, first gave an accurate description of the disease and named it endometriosis.

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Many people don’t realize there are a number of infections that can damage fertility. Some can cause infertility in both men and women, some can stop the embryo implanting once fertilisation has taken place, and some can cause miscarriages.

In men, infections in the seminal vesicles or the prostate gland can affect the sperm in several ways. Pus cells will reduce the sperm’s swimming ability and certain infections may kill off the sperm. Some infections can cause blockages in the male reproductive system, stopping the effective transport of the sperm. Cytomegalovirus (CMV), which is caused by a herpes virus, has been linked with low sperm count and inflammation of the testes.

Chlamydia

Chlamydia may sound like an exotic flower but it is actually a sexually transmitted bacteria which can lead to infertility in women without causing any symptoms. It is effectively an infertility time-bomb, which is claiming growing numbers of victims (particularly teenage girls). The Royal College of Physicians’ Committee on Genito-urinary Medicine estimates that it is the most common sexually transmitted disease in our society.

A number of countries, such as Sweden, routinely screen for chlamydia trachomatis and the fall in the number of clilamydia cases there has been dramatic. But there is no routine screening in the UK. It is known as the ’silent illness’ because only a small number of women experience actual symptoms such as a discharge. Men can also get chlamydia. They feel a burning sensation on passing urine. If men do not get the symptoms investigated then they will infect their partners, and possibly damage their own fertility.

In a woman the chlamydia bacteria can lie dormant for many months before passing through the cervix, and from there unnoticed into the womb and up the fallopian tubes where it causes the majority of pelvic inflammatory diseases (PID). If untreated, it can damage the fallopian tubes, resulting in blocked or scarred tubes which can mean infertility or increased risk of an ectopic pregnancy (where the fertilised egg implants into the fallopian tube instead of in the womb). In men it can cause inflammation of the testes and the tubes surrounding the testes.

Women can be screened for chlamydia with a cervical swab and/or a urine test and men can have a urine test. If caught early it can be treated successfully with antibiotics.

Mycoplasma and Ureaplasma

Mycoplasma hominis and Ureaplasma urealyticum are very common organisms that can infect the genito-urinary tracts of men and women. These organisms don’t always cause infertility, but:

• According to a study in the 1970s, there seems to be a higher frequency of these organisms in the ejaculates and cervical secretions of couples with unexplained infertility problems. And when the couples were treated, pregnancy rates increased.

• In men, this type of infection can decrease the sperm count, reduce motility and increase the number of abnormal sperm.

• These organisms have also been linked with an increased risk of miscarriage.

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There’s a myth going about that women who’ve ever had genital herpes must have their babies delivered by caesarean section. This isn’t true. However, if you’re pregnant and you or your partner have been infected with HSV, tell your doctor or midwife. You’ll be checked when you come into labour: if a recurrence is suspected, caesarean delivery will be considered. However, even if a baby is delivered to a woman with an undiscovered recurrence, the chance that the baby will be infected is low because it gets some immunity from the mother.

If you get a first attack of herpes during the early months of pregnancy, you will be advised to take antiviral drugs. If you get a first attack towards the end of pregnancy, antiviral treatment will reduce the risk of the baby becoming infected during birth. Severe infections in newborns are extremely rare, and are likely only if the mother has an undiagnosed first attack near delivery.

Some women who’ve had herpes ask whether they should take antiviral drugs during pregnancy to prevent recurrences. This is something you should discuss with your doctor. So far we don’t know whether these drugs are safe if taken during pregnancy. Records have been collected since 1985 from all pregnant women who have used them. To date there have been no problems.

Radiation therapy

Radioactivity can damage all living cells, but it is more destructive to cells that are multiplying rapidly (as cancer cells do) than to normal, slow-growing cells. Radiotherapy, which focuses a measured amount of radioactivity on an area affected by cancer, may be used to shrink a tumour before surgery, as a follow-up to surgery, and in some forms of spread. Your radiotherapist will discuss possible side-effects with you before treatment.

Radiation following lumpectomy doesn’t often cause troublesome side-effects: many women manage to drop in for their treatment before or after work. There may be mild nausea and tiredness that disappear when the treatment is finished. Changes such as skin discolouration, altered skin texture and tightening of the breast may persist in the area treated, though the focusing of the rays has become so accurate that these side-effects are now much less common.

Systemic therapy

This is treatment given by mouth or injection so that it circulates to all parts of the body. It is used to prevent further growth of any cancer cells that may have spread beyond the breast. There is increasing evidence that systemic therapy can reduce the risk of relapse of breast cancer.

There are two types of systemic therapy.

Tamoxifen, an anti-oestrogen drug, prevents the growth of cancer cells that are stimulated by oestrogen. It has few serious side-effects. Some patients experience nausea, hot flushes, headaches and vaginal dryness.

Anticancer drugs (chemotherapy) are toxic to all cells but, like radiotherapy, are much more destructive to the rapidly growing cancer cells. Chemotherapy usually causes some side-effects, mostly on the day of treatment and for a day or so after. Some patients have persistent problems that need treatment, including nausea and vomiting, mouth ulcers, tiredness and anaemia. Temporary hair loss is common, but complete regrowth is usual within six months.

Your doctor will tell you the reason for advising any systemic therapy, what side-effects to expect, how long they may last, and what can be done to relieve them.

Whatever surgery and other treatment you have, you will probably be more shocked than you expected by the reality. Many patients become depressed after treatment for breast cancer. The more you know about your condition and the reactions you may have to its treatment, the better you will be able to cope with your feelings afterwards. Don’t be afraid to admit that you need some help. Speak to your doctor about how you feel. Be honest with your family and friends – don’t tell them you’re ‘fine’ when you’re miserable. You’ll need their support, but they can only give it if they know how you really feel. During recovery from surgery, Breast Cancer Support Service volunteers will visit you in hospital or at home if requested, so do make use of this service.

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Treatment isn’t always necessary. If it is, it consists of removing the abnormal area. Five types of treatment are used.

Laser destroys the abnormal cells with the heat produced by high-frequency light beams. This can be done as an outpatient procedure with local anaesthetic in a clinic or gynaecologist’s rooms, or with general anaesthetic in a day surgery or hospital, whichever you prefer.

Diathermy destroys abnormal cells with the heat produced by an electric current. This is usually done under general anaesthetic in a day surgery or hospital.

Cryosurgery is a method of destroying abnormal cells by freezing. Usually no anaesthetic is needed, so it can be done in your doctor’s rooms or an outpatient clinic.

Loop biopsy a loop of wire that carries a diathermy current is used to remove the abnormal epithelium and some underlying tissue from the cervix. Local or general anaesthetic may be used. This treatment is usually done in a day surgery or hospital.

Cone biopsy is the surgical removal of a cone-shaped section of the cervix. This needs general anaesthetic and usually a few days in hospital after the procedure.

All forms of treatment are effective. Your doctor will advise which treatment is most
suitable for the type and extent of your abnormality. In a small number of women the abnormal cells reappear after treatment. When this happens, treatment is repeated.

After treatment

There is usually some bloodstained discharge, often increasing three or four days after treatment when the destroyed tissue separates and is shed. Spotting may continue for several weeks after the procedure. Sex can be resumed when bleeding stops.

You will be advised to have a smear test and colposcopy six months after treatment, followed by another smear at 12 months and then annual smears for die next five years. If all remains normal, you can then go back to routine Paps every two years.

What about pregnancy?

Having an abnormal Pap smear test result doesn’t affect your ability to have children, but there are two points you should consider.

1 If you’ve had an abnormal smear, it is wise to have the abnormality assessed by colposcopy and treated if necessary before becoming pregnant.

2 If an abnormal Pap smear is found when you are already pregnant, your doctor ill probably recommend colposcopy, which won’t affect the pregnancy. Almost always any treatment that might be needed can wait until after your baby is born.

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The reproductive organs don’t always develop properly. Many defects are minor and may never cause problems or can be easily corrected. Others may have a profound effect on sexual development and the ability to have children. To understand the congenital abnormalities that are possible, we must know something of reproductive development before birth.

Beginning around the sixth week of pregnancy, the female foetus’s XX sex genes stimulate the development of its ovaries. Two pairs of foetal structures – the Wolffian ducts and the genital ridges on each side – contribute tissue to the ovaries. The ova and ovarian stroma come from the genital ridge. The Wolffian duct makes only a small contribution to each ovary. Its lower part regresses.

It is the Y chromosome in the male foetus that leads to the development of the testis. The tissues that produce sperm and hormones come from the genital ridge, and the Wolffian duct contributes the collecting tubules of the testis, the epididymis, the vas deferens and the seminal vesicles.

In both sexes, the Wolffian ducts make a large contribution to the development of the kidneys.

The tubes, uterus and upper vagina develop from another pair of structures in the foetus – the Müllerian ducts – which run the length of the developing abdominal cavity near the Wolffian ducts. This development begins around the eighth week of pregnancy. The upper ends of the Müllerian ducts remain separate, forming the fallopian tubes. The remainder fuses in the middle to form the uterus, cervix and upper vagina. The development of the Müllerian ducts in female foetuses is independent of ovarian hormones. In male foetuses, this development is suppressed by the Mullerian inhibitory hormone (MIH) produced by the foetal testis.

The external genitals and lower vagina develop from the foetal structure that also forms the lower urinary system. The difference between female and male genital development is determined mainly by the effect of male hormones from the foetal testis.

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Can miscarriage be dangerous?

Sometimes miscarriage can be dangerous. The main risks are haemorrhage and infection as complications of incomplete abortion. When the uterus can’t contract properly because all or part of the placenta is still attached to its wall, haemorrhage can be severe. The uterus must be emptied (by suction or curettage) as quickly as possible. Rarely, transfusion may be needed if blood loss has been great.

When dead or dying products of conception remain in the uterus and the cervical canal is open, conditions are ideal for infection. Incomplete miscarriage complicated by infection is septic abortion. The infection can spread rapidly beyond the uterus to the tubes and other pelvic organs. Infection can also enter the mother’s bloodstream, resulting in septicaemia. Before the advent of antibiotics, septicaemia from septic abortion was one of the most common causes of maternal death. Happily for us, prompt treatment with curettage and today’s antibiotics can prevent or rapidly resolve the risks of infection from incomplete miscarriage.

What to do if you bleed

If you have any bleeding at any time during pregnancy, don’t wait to see what happens. Contact your doctor and remain within easy reach of medical care, as heavy bleeding sometimes develops very quickly. Camping trips to remote places are definitely unwise. Try not to worry too much: remember that half of those who have bleeding won’t miscarry. An important reason for reporting all bleeding in early pregnancy is that it may be the first sign of ectopic pregnancy.

What are the consequences of miscarriage?

There are usually no physical consequences from complete spontaneous miscarriage. The uterus returns to normal and the next menstrual cycle starts a few days after the pregnancy has been expelled.

Blood transfusion, though rarely needed, now prevents the prolonged illness and anaemia previously common after haemorrhage from incomplete miscarriage. Prompt use of antibiotics to prevent or treat septic abortion has reduced the chances of the tubes being damaged -with subsequent risk of subfertility – by spread of infection.

Environmental health entails everything around us – our food and water, our work, our habits, where we live and travel, climate, things happening in other parts of
the world – and these things are all connected.

The effect of the world we live in on and our health has received much well deserved attention during the past decade. This doesn’t mean that environmental health hazards are new: they’ve always been around, but they’ve changed over the centuries. A thousand years ago the greatest health risks would have come from unsanitary water supplies and living conditions, spoiling of stored food and the possibility that a wolf or tiger might attack you outdoors. The greatest worries in the twentieth century are about radioactivity; toxic substances used in farming, food storage and industry; predicted climatic changes (though there’s still much dispute about whether these predictions will our come true); transport hazards; problems caused by the increasing number of people in the world. Many of today’s worries have resulted from attempts to correct some of the problems of the past. For example, many people fear that water purification processes may be harmful to health; some people are allergic to chemicals used to sterilise and preserve food; there are fears that agricultural pesticides enabling us to grow food for our increasing population may be toxic or have unknown long-term effects; some synthesised substances that have become important to humans such as chemicals (including medicines), fibres and plastics may turn out to be dangerous to health.

The worst fear is that chemicals, radioactivity and other environmental influences could change our cells’ genes to cause cancer in those exposed or defects and illness in future generations.

• Carcinogens cause cancer. The sun and cigarette smoking are our greatest carcinogenic risks.

•Mutagens cause changes (mutations) in the genes of living cells. When mutations occur in gametes (ovum and sperm cells) they can be passed on to future generations. Large doses of

radiation are mutagenic.

•Teratogens can cause errors of development of the foetus, leading to spontaneous abortion or birth defects. The rubella virus and some drugs can be teratogenic.

Toxins can enter our bodies through our skin, through our intestines, and through our lungs from things inhaled. A large dose of any toxic agent usually has a severe, immediate effect such as second-degree burns from the sun or intense illness due to swallowing chemical poisons or inhaling toxic gas. Prolonged low-dose exposure more often causes chronic illness, and there may be a latent period between exposure and the development of disease. Skin cancer from the sun, emphysema or lung cancer from cigarette smoking, and chronic bronchitis from living or working where the air is full of smoke are examples of latent effects.

There are plenty of naturally occurring environmental hazards. Radioactivity occurs naturally (though in most places in very small amounts); ultraviolet rays in sunlight can cause skin cancer; many plants and some animals can poison humans; many people suffer respiratory disorders from inhaling plant pollens.

Other hazards are the result of human activity, such as synthetic pesticides, pollution of rivers and oceans with sewage or industrial effluent, tobacco and industrial smoke, increased pollen counts in air from farming, altered content of minerals in the air, soil and water due to mining and agriculture.

The media tend to exaggerate and sensationalise health risks. Some reports give unbalanced emphasis to worries about possible hazards that are unfounded without giving the full story or mentioning known benefits. I feel that a lot of our concerns come from not enough knowledge and understanding (at least in my case) of the accelerating technology of today. The unknown is always frightening.

Now, whenever I hear about a new environmental health risk, I try to find out more about it before getting worried. I remind myself that when steam was first used to turn engines and when electricity was introduced for lighting and power, many people predicted that harnessing these great powers surely would soon bring about the end of the world.

If you’re worried that something in your environment may be causing illness, ask someone with knowledge in environmental health (maybe your doctor or council health inspector) for advice. Beware, you may get several conflicting answers to your questions. When there is dispute over environmental hazards, I prefer to take advice from committees of experts nominated by differing interest groups, such as the committees of the National Health and Medical Research Council (NHMRC), which investigate and issue statements on all concerns about environmental health, including standards for safe maximum residue levels (MRLs) of pesticides, agricultural chemicals, feed additives, veterinary medicines and noxious substances in food; guidelines for clearance of water treatment chemicals and processes; and guidelines for controlling emission of pollutants. If you can’t find information about your concern, write to your federal and State ministers for health, or your mayor or shire chairperson. Our government is more vigilant than most and quick to respond to concerns that Australians may be exposed to unnecessary health risks.

There are heavy penalties for industrial pollution, and all new technology must be proven to have a great deal more benefits than any known risks. Otherwise it is outlawed. If there are any possible risks however unlikely, manufacturers are required to provide warning and information about safety precautions. Still, not al processes (and especially older ones) have come under scrutiny and there is always the possibility of undetected risks. We must all maintain our vigilance about environmental health risks.

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Tinea, a fungal infection of the skin, is a very common problem in Australia. We all carry a few fungi on our skin, generally without problems. However, when their growth is encouraged by excessive dampness of the skin, they can cause
inflammation.

Tinea of the feet causes redness, itching and sometimes painful cracks on the sole and between the toes. It’s often called athlete’s foot because it’s so common on hot, sweaty feet that spend a lot of time
in gym shoes. It’s also very common in
people who use communal showers at swimming pools, gyms, residential colleges and so on.

You can help to prevent tinea of the
feet by wearing thongs in communal showers, drying thoroughly between your toes, always wearing cotton or wool socks
(to absorb sweat) with closed shoes and by wearing open shoes as often as possible in hot weather (but watch out for cracked skin). If tinea strikes, ask your pharmacist to recommend an antifungal preparation, which you should continue
to apply for a week after all signs have disappeared.

Tinea can also affect skin crevices (such
as the groin, between the buttocks and under heavy breasts) in hot, humid weather, causing a red, itchy rash with an irregular edge. This rash can spread quickly, so if it occurs see your doctor about treatment (and to make sure that it is tinea). You can reduce the chance of this type of tinea by drying carefully in skin folds, always wearing cotton next to your skin, helping sweat to evaporate by wearing loose cotton clothes and using fans when it’s hot and humid.

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