There is a popular myth that if you have an unplanned pregnancy it is the result of irresponsible or illicit sexual activity, or a lack of planning. It’s estimated that in up to a half of terminations, the pregnancy was the result of misunderstanding of the contraceptive method or that method’s failure to work even when it was used properly. Having said that, there is a group of people who don’t make the practical link between heterosexual intercourse and pregnancy, even though they know their biology. The ‘it can’t happen to me’ syndrome is well at work here. There are other women who don’t take their fertility seriously until they have an unplanned pregnancy — the ‘I have done it without protection before and I didn’t get pregnant’ school of thought. It’s easy to be lulled into a false sense of security.
The trouble with withdrawal is that it doesn’t account for the estimated seventy percent of men who produce some fluid before they orgasm, the so-called ‘pre-ejaculate’, and the fact that this fluid can contain enough sperm to result in a pregnancy. Nor does it account for accidental loss of control in the heat of the moment.
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There are other situations that you think are safe until you have the whole story. Like the fact that diaphragms don’t work in the bathroom drawer. Actually, diaphragms raise an interesting point. There are a lot of women who feel very uncomfortable about touching themselves in the genital area and many who are not familiar with their normal anatomy. Every so often someone asks me to check out a lump they discovered in their vagina, usually when a tampon has been inserted, and the concern” is that it might be something nasty like a cancer. What these women have discovered is their cervix, the bottom end of the uterus, which you can usually feel about a finger-length inside the vagina. Anyone wanting to use a diaphragm needs to know where the cervix is and what it feels like because you have to check that the diaphragm is covering the cervix for it to be effective. It takes a certain degree of familiarity with your body, and even then it can take a bit of practice to get it right.
Family planning experts say that more women need to know about the ‘morning after pill’, more accurately named the ‘panic pill’ because it can be taken up to three days after unprotected intercourse. There are objections in some quarters to this form of contraception, usually from people with a very punitive and judgmental approach to life. Their argument is that if you are not responsible enough to arrange your contraception before you have sex then you should have to suffer the consequences. Although it is not recommended as a routine form of contraception, if intercourse does happen without any contraceptive protection, or if a condom breaks, it is worth knowing about this method because it does reduce the risk of pregnancy. There is nothing exceptional about the ‘pill’ at all. It is simply a regular contraceptive pill which is normally taken once a day as a routine. In the case of a ‘panic’ or ‘morning after’ situation, you take several pills a day for a few days. Your doctor can tell you exactly what to do. It is a high dose, but only over a short time. Some women get nauseated though, so they may need to take something to help. A scare like that is usually enough to make you think about your contraception and adapt it to your needs.
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Before any sort of sexual interaction with another person, it’s a good idea to find out all you can about sexually transmitted diseases so you can avoid them. Before heterosexual intercourse it is imperative that you know how pregnancy starts, so that if you choose not to have a baby you can avoid that too.
Sharing the responsibility for contraception and choosing what’s right for you and your partner is a part of sexual communication. Contraception means facing your sexuality together and talking honestly about what you want.
There is this myth that it is the responsibility of the woman not to get pregnant. Well, she can only ever be responsible for half of the genetic material that goes to make a pregnancy. This means men taking full responsibility for their own genetic material. One of the important things we need to learn is that, just as good sex takes two people giving each other mutual pleasure, reliable contraception takes two people to talk about the alternatives.
Contraceptive needs change according to your life situation and the state of your relationship. Choosing the type of contraception that suits you at any particular time depends on your age, the state of your relationship, and your future plans. Are you planning a baby in twelve months? Do you want children at all? How old is your partner? Do you have more than one partner?
You need to know how reliable the different forms of contraception are, and exactly how to use them. I am continually astounded at the number of women who take the Pill every day, yet could not tell anyone which one they are on. ‘Oh you know, the one in the gold pack with three different colored pills. I don’t know, I just take it.’
Knowing the pitfalls is part of understanding your contraception; being aware, for example, that if you miss just one Pill, especially near the beginning or the end of the pack, you can get pregnant. The same goes for vomiting it up or, in the case of diarrhea, not giving it time to be absorbed into your system. One interesting new method of contraception that overcomes a lot of these difficulties is the vaginal ring, or ‘the Pill you don’t have to take.’ It is a firm, rubbery ring about five centimeters in diameter that contains (I was going to say, ‘ … is impregnated with’) the same hormones that make up the oral contraceptive Pill. This is inserted into the vagina where it stays for three weeks out of every four and is then replaced. It constantly releases the hormones into the system. If it passes all the scientific tests they are doing, it should prove very popular because it is so easy.
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I worked part-time in an AIDS clinic for four years, so when I started to write this section on AIDS I thought, ‘That will be easy’. I was wrong. When I sat down, surrounded by references and with my head full of information and experiences, I didn’t know where to start, or what to include and what to leave out. So I asked one of my (adult) daughters what she would want to read about women and AIDS in the 1990s. Without hesitation she answered ‘What I and all my friends want to know is what’s happening. How bad is the epidemic? How many women are infected, how did they get infected and how can we prevent ourselves from ever getting infected?’. I’ll try to answer these questions, hoping that it’s also what you want to know.
The public has been provided with more information and education about HIV/AIDS and its prevention than about any other infection, so I won’t go into a lot of detail about it. Information leaflets about all aspects of HIV infection and AIDS are available free of charge at every hospital, doctor’s surgery and health clinic.
I’m sure that you all know that the human immunodeficiency virus (HIV) is transferred from one person to another through body fluids. Once inside the body, HIV invades and multiplies within lymphocytes and eventually destroys them. Lymphocytes are cells that are an essential part of our immune systems. When many lymphocytes are destroyed by HIV, we can no longer fight off infections and some other diseases, resulting in the illness known as AIDS (short for acquired immunodeficiency syndrome).
The HIV/AIDS epidemic
We have known about HIV/AIDS since 1981.
HIV is responsible for a worldwide epidemic that already has claimed many thousands of lives, and that is growing. So far there is no cure for the disease and no vaccine to prevent infection. The AIDS epidemic is very bad news.
AIDS is the most baffling infectious disease of our times. Though present-day research into this disease is more intense than for any other human illness, experts are still grappling with its mysteries and there is still some uncertainty and disagreement about how the epidemic started and why the infection behaves differently in certain groups of people.
One of the many extraordinary features of the HIV virus is that there can be a very long incubation period between infection and development of illness. A person may become infected and remain well for years – possibly up to 20 years. Whether all those infected will eventually develop AIDS is at present unknown.
It is believed that millions of people have been infected with HIV. If this is right, most don’t know that they’ve been infected and are the greatest worry in the spread of the infection and growth of the epidemic. Even when there are no symptoms the virus can be passed on.
Though the biggest ever public-health education campaign has been aimed at stopping the epidemic, there are still many misunderstandings about the infection and how it spreads. One of the barriers to acceptance of the realities of AIDS is that because so far it has been most often transmitted by gay sex or intravenous drug use, many people think ‘it can’t happen to us: it only affects other people who do things we don’t do (and don’t approve of)’.
The education campaign is beginning to break down this barrier. We now know that it is a myth that AIDS is a disease of homosexual and bisexual men who practice anal intercourse, even though in some countries, including Australia, it first appeared in this group. In some parts of Central Africa almost half of the young women and men are infected with HIV. In parts of Southeast Asia the same situation is rapidly developing. The World Health Organisation stresses that transmission through heterosexual intercourse is now the major risk worldwide.
How many Australian women are HIV-infected?
The total number of women carrying HIV is unknown. Of all Australians known to be infected with HIV, less than 1 in 25 are female. Of the cases of AIDS (not just HIV infection) reported so far in Australia, less than 1 in 33 have been female. Of those women infected for whom heterosexual transmission is likely, about nine out of ten had sexual partners known to be infected or at high risk of infection.
In Australia there is now virtually no risk of transmission from blood transfusion. The infection seems set to spread more rapidly now among intravenous drug users. At present, because it is uncommon among heterosexuals, the risk of heterosexual infection seems to be low in Australia, but authorities warn that this is no reason for complacency and that safe sexual hygiene should be practiced by all.
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Why are women prone to cystitis?
The anatomy of our lower urinary and genital systems makes us more liable to infections and other inflammations of the bladder and urethra.
The urethra is the tube through which urine passes from the bladder to the outside. Women’s urethras open onto an area where there are always plenty of bacteria, including those from the bowel and vagina. Some germs live in the lower end of the urethra all the time. These bacteria generally do no harm, but can cause inflammation if they get into the bladder in circumstances that make it easy for them to grow. And because women’s urethras are only about 4-6 cm long, germs don’t have far to travel to the bladder.
In contrast, men’s urethras are around 20 cm long and the skin of the tip of the penis is unlikely to harbour as many bacteria as the skin around women’s genitals. This is one reason why women are more prone than men to bladder infections. Also, after the menopause the linings of the urethra and bladder are more fragile and prone to infection.
Sex and cystitis
A woman’s urethra and bladder base are very close to the front wall of the vagina where they are liable to trauma from friction during intercourse, especially if the vulva and vagina aren’t sufficiently lubricated by sexual arousal before penetration.
Frictional trauma alone is enough to cause inflammation of the urethra. Some germs probably always get into the urethra and bladder during sex, but normal defences usually overcome these. However, if the tissues are also inflamed from frictional trauma, their defences will be down and infection is more likely to get a hold.
Some women are more prone than others to develop urinary symptoms associated with sex. Sometimes problems only happen when sex is repeated frequently over a short time (for example ‘honeymoon cystitis’).
Some unfortunate women develop bladder symptoms just about every time they have intercourse. They come to fear sex, knowing that it’s likely to bring on another attack. The fear inhibits their sexual arousal so that they’re less well lubricated and more likely to suffer mechanical trauma – the beginning of a vicious cycle of sex and bladder problems. This can play havoc with a relationship.
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Fibroids, also called fibromyomata, are benign (non-cancerous) tumours composed of fibrous and muscle tissue that grow in the wall of the uterus. At least one in five women are known to have them and probably many more have small fibroids that cause no problems and are never found.
You can have just one fibroid, but multiple tumours are much more common. They start when some of the fibrous and muscle cells start to grow and divide more quickly than the surrounding tissue, to form small pea-sized nodules within the wall of the uterus. Fibroids grow very slowly: they often stop growing before they reach the size of a golf ball but after growing for years may become as big as a baseball and very rarely, a football: there are some on record that weighed 10 kg! As fibroids grow they enlarge the uterus and distort its shape by bulging from its outer wall or into its cavity. If the uterus has become larger than a baseball you can usually feel a firm lump pushing up behind the pubic bone.
What causes fibroids?
We don’t know exactly, but their growth seems to depend on hormones, mainly oestrogen. Fibroids are rarely found in women under the age of 25 and they stop growing and shrink after the menopause.
What problems do fibroids cause?
Often none, but, depending on their size and position, they can cause any of the following.
• Large fibroids may press on the bladder, reducing its capacity and causing frequent need to pass small amounts of urine. Pressure on the rectum may make it hard to empty the bowel.
• Fibroids that bulge into the cavity of the uterus can cause heavier and prolonged menstrual bleeding. Occasionally a fibroid that hangs in the cavity by a stalk may push through the cervical canal to be felt as a lump in the vagina and to cause bleeding after sex and between periods.
• Pain is an uncommon symptom, but can happen if the tumour presses on a nerve or if a fibroid on a stalk twists so that its blood supply is disturbed.
• Fibroids don’t usually cause problems in pregnancy. Large tumours bulging into the uterine cavity may cause miscarriage or premature delivery. A tumour in or near the cervix could obstruct labour. Fibroids seldom interfere with fertility.
Is treatment necessary?
Only if the fibroids cause problems. For women who still want to have children the tumours can usually be removed, leaving the uterus. For those whose families are complete, hysterectomy is usually recommended.
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The Müllerian ducts can completely fail to join up, resulting in a double uterus, cervix and vagina. More common are partial abnormalities of joining, resulting in varying degrees of septate uterus. However, often the evidence of incomplete joining is no more than an indentation in the fundus and a heart-shaped uterine cavity. Uterine malformations often cause no symptoms and may be discovered by chance. However, they sometimes cause problems with menstruation or pregnancy.
Rarely one or both compartments of the uterus don’t open into the vagina. In this case the uterus will begin to fill with menstrual blood at puberty, and will eventually need removal or a surgical procedure to connect it with the vagina so that the menstrual flow can drain.
The increased endometrial surface area in uteruses with a well-developed septum can be a reason for heavier periods.
Infertility isn’t a problem as long as there is a functioning ovary, a tube that connects with the uterine cavity and a cervix opening into the part of the vaginal where ejaculation takes place.
Some women with these abnormalities of the uterine cavity have no problem will pregnancy or delivery, but in general there is a higher risk of problems than in women with a normal uterus. Some abnormalities can lead to increased risk of miscarriage, often between the fourth and sixth month of pregnancy. The reason may be that the placenta can’t develop properly in the distorted uterine cavity, or because there isn’t enough room for the foetus to grow.
There can also be problems with delivery because of breech or transverse lit of the foetus, poor uterine contraction or maternal haemorrhage from abnormal placental attachment.
Surgical correction of any degree of septate uterus is only attempted if the abnormality causes problems.
Absent uterus
toy rarely all the organs derived from Müllerian tissue are absent (tubes, uterus and upper vagina). The cause of this depot is unknown. The lower vagina may be just a small dimple at the site of the introitus. Girls with this condition are generally otherwise healthy and have normal ovaries producing hormones that lead to normal pubertal development of breasts, external genitals, height, and body shape and hair; often nothing is suspected until menstruation fails to occur by the age of 16 years. In such cases a vagina can be created by plastic surgery or by using dims to stretch the vaginal ‘dimple’ to a space large enough for sexual intercourse. A normal sex life can follow, but of course pregnancy is impossible. Women with an absent uterus may also have kidney abnormalities; often one kidney is missing and the other is in an abnormal place, commonly in the pelvis. The kidneys should always be checked (usually by intravenous pyelogram): there are a few disastrous records of a single pelvic kidney being removed in the belief that it was a uterus or tumour!
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A number of things are essential for a pregnancy to begin:
• there must be sufficient normal sperm in the semen
• sperm must be deposited in the vagina and move upwards through the cervix and uterus to the tube
• the woman must produce a healthy egg (ovum)
• the ovum must enter the fallopian tube and be moved along it
• one sperm must unite with the egg in the outer part of the tube
• the fertilised ovum must travel to the uterus and implant properly in its wall.
Anything interfering with any of these processes interferes with conception. Many things can break the conception chain.
Inadequate sperm production Often no cause for this can be found. Known causes include the testes not having descended into the scrotum; testicular disease that destroys the sperm-forming tissue; a mass of varicose veins, called a varicocele, in the scrotum, which keeps the temperature of the testis too high for sperm production; occupational factors such as working in a very hot environment or with certain other chemical or physical influences (a rare cause); some general health disorders, including a past history of mumps that has affected the testes; some treatments, particularly radiotherapy and chemotherapy for cancer. Excessive smoking and alcohol have been associated with reduced sperm count, and decreasing or stopping smoking and drinking may improve sperm production.
Disorders or disease of the spermatic ducts These ducts are the series of tubes that carry sperm from the testis to the ejaculate. Blockage of the duct system may result from scarring after previous infection, injury or surgery.
Irregular, infrequent ovum production This, or no ovulation, usually goes with a history of irregular, infrequent periods or no periods, though occasionally a woman may have regular menstruation without ovulating. This is basically a problem with the hormones that control ovulation.
Blockage of the passageway from ovary to uterus This may be due to adhesions resulting from peritonitis in the past, other pelvic infections such as those occurring after previous childbirth or surgery, or sexually transmissible infections such as gonorrhea or chlamydia; or endometriosis.
Cervical mucus that prevents sperm from getting through This may be due to an antibody in the mucus that kills the sperm or stops their movement, inflammation of the cervix. If a woman is ovulating, the hormonal influence produces cervical mucus that is optimal sperm penetration.
Less common reasons include problems with sexual intercourse (such impotence) so that the semen is not deposited in the vagina; congenital abnormalities of the reproductive organs; disorders of the lining or the wall of uterus; immunological problems.
The reason for subfertility is generally found to be around 40 per cent in the man, 40 per cent in the woman and 20 per cent in both. No reason can be found in about one in ten couples who conceive.
There are some old myths about conception that have proved wrong but many people still believe. You should know that:
• a woman doesn’t have to have of at intercourse to conceive
• a woman with a retroverted (backward-leaning) uterus is just as capable of conceiving as a woman whose uterus is in the forward-leaning position
• no position for intercourse is more likely than any other to result in pregnancy, as long as the semen is ejaculated
into the vagina
• adopting a child or taking out adoption papers will make no difference at all your chances of conceiving.
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Most couples decide to have a baby because it’s the right time and they have a strong desire for children. Some have clear plans about the number and spacing of the children they want. Others just take their chance, accepting each pregnancy as it happens. Some pregnancies result from forgetting to use or failure of contraception. Not all unplanned pregnancies are unwanted: on the contrary, many are greeted with as much joy as if they’d been carefully planned, though it may take longer to adjust to what’s ahead. In the past men have felt left out of child-bearing and child-care when these things were mostly considered ‘women’s business’. But it takes two to make a baby. One good outcome of the new balance in relationships between sexes has been that men now generally take more part than previously in family planning, pregnancy, childbirth and bringing up children. Many fathers now go along to antenatal checks, preparation-for-birth and parenthood classes, and are present during labour and can even participate (such as by cutting the cord) in delivery of the baby. This was unheard of 30 years ago, and would have been unacceptable to parents-to-be and their attendants. But some men still seem unsure about what’s expected of them. If you and your partner can share all your feelings – plans, joys, woes, hopes and fears – about child-bearing and parenting, it must strengthen and deepen your relationship. There are many facets to having children. Most of them are wonderful, both physically and emotionally. Some are not so good. No matter how carefully it was planned, it may be only when pregnancy is confirmed that you face up to the reality of the next nine months and the rest of your life as a parent. This can bring on mixed feelings, doubts and ‘cold feet’.
Can you cope – physically, emotionally, financially – with the changes and responsibilities ahead? How will a baby affect your relationship, your career, your other plans for the future. Will you be a good parent? Have you realistic expectations of what it means to have a family?
Everyone you know will tell you about their experiences with pregnancy, labour and new babies – all of them are different. Your own experience will be different again. You need to balance all the information and advice you’re given. Books, magazine articles, films and TV programmes produced by experienced professionals provide a reliable background for assessing ‘hearsay’.
Your first pregnancy can make you feel as if you’re embarking on a perilous but very important journey of discovery. It’s important to have confidence that together you’ll be able to find the right paths. However, all parents make mistakes and take wrong turnings, and learn a lot about themselves and their children on the way. Children learn better from your mistakes if they’re acknowledged.
In child rearing you may want to change some of the ways of your parents, but don’t try to do the opposite. It’s more effective to make small changes. After all, your parents must have done something right for you to get where you are now. Nobody can be the ‘perfect parent’. It is very important that you and your partner be able to look after yourselves as well as your children’s needs.
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Condoms for women
These have been developed during the past decade in response to a perceived need for better protection for women against sexually transmissible diseases, especially AIDS. By partly or completely covering the external genitals, female condoms could offer protection against transfer of genital skin infections such as herpes and warts. When these devices become available, women can take total responsibility for their protection if their partners are reluctant to use penile condoms. And, of course, any barrier that prevents genital transfer of bacteria and viruses will also pork as a contraceptive by preventing sperm from entering the cervix. A device called the Femidom is a transparent plastic pouch with a flexible ring inside the upper, closed end and a larger 5 at the open bottom end. You insert nth your fingers, pushing the upper ring behind the pubic bone. During intercourse, the device is kept in place by the outer ring, which tucks around (and covers) the vulva. The manufacturers report that in four years of testing on 1700 en in the USA, Femidom has proved resistant to slipping, tearing or penetration by bacteria, and its pregnancy-prevention rate is comparable to that of the diaphragm. Some unexpected comments during the North American trials include complaints about noise from the crackling of the plastic during use, and praise for increased sexual pleasure from stimulation of the clitoris by the outer ring. The Femidom isn’t yet available in Australia.
Also being tested is the ‘woman’s choice female condomme’ (a blatant tautology!) – a latex vaginal pouch inserted with an applicator – and what may possibly be the ultimate in contraception and disease prevention, the unisex condom garment’ – latex pants with attached crotch sheath that becomes a vaginal pouch or penis cover, depending on who wears it!
How to use condoms
Most condom packs include a sheet of instructions on ‘How to use’. However, because the instructions are in the outer box and not with the individual condom, and because the time of immediate need may not be ideal for going through a list of instructions, it may be useful to repeat the main points here.
• Remove the wrapping carefully, avoiding contact with sharp fingernails.
• Don’t unroll or test the condom before putting it on.
• Press the air out of the teat (or 1 cm at the tip if there is no teat) to make room for the semen.
• Roll the condom onto the erect penis before any genital contact.
• After intercourse withdraw the penis before it becomes too soft, holding the condom around its base so that it doesn’t slip off and so that the semen doesn’t spill.
• If you need additional lubricant, don’t use petroleum jelly (Vaseline), baby oil or any oil-based substance (which might affect the latex and increase risk of breaking): use a water-based lubricant or spermicidal jelly.
• If the condom breaks or comes off during use, consult a doctor or family planning clinic within 48 hours to see if ‘morning-after’ contraception would be advisable.
• Use condoms once only.
• Keep stored condoms in a cool place and check the expiry date before using.
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