Medical Weblog

On a warm day in April, two women working together at a television station decide to have a light lunch at a nearby sidewalk cafe. It’s a friendly, crowded place, with small round tables set close to each other. Barbara, usually the more easygoing of the two women, seems worried as she leans forward and remarks to Jane: “Laura could lose her shot for a job in the newsroom. She’s missed so much work lately. Maybe she doesn’t want the job at all.”

Jane: Between us, it’s not the job. Laura’s always in pain . . . she’s got some real problems.

Barbara: What do you mean by problems? Jane: She has endometriosis. Barbara: What’s that?

Jane: For years, Laura had terrible cramps and pain, but no doctor could tell her what was wrong. Now it seems that the disease has done so much internal damage that she can’t get pregnant. Endometriosis spreads!

Barbara: How? Is it some new type of V.D.?

Jane: No, its not a disease you can catch. That’s all I know for sure.

A conversation like this one was exchanged over lunch somewhere in Manhattan, but one could easily find “Barbara” and “Jane” meeting at any coffee shop, discussing the plight of “Laura.” Such conversations are no longer isolated cases, because the subject—endometriosis—has tragically become a widespread topic. Compassionate friends like Barbara and Jane can only begin to describe the extent of the disease’s symptoms and effects. Every day in every city, millions of concerned women who know someone with endometriosis or who are themselves plagued by it are also searching for solutions to this new and growing health problem. Who are these women?

One might be a friend, a boss, a relative—or she might be yon. The facts now tell the story: a conservative estimate counts 20 million women with endometriosis, but realistically, there are more than twice that number of victims at varying stages of the disease. Millions of Lauras face the possibility of infertility and needless Buffering. Millions more are crippled by relentless pelvic pain and its complications, such as debilitating cramps and bladder disorders. Some have lost faith in professional medical care, as one doctor after the other (ailed to diagnose their disease before it grew out of control. More important, vast numbers of women may have endometriosis and not know that they do.

*4\43\4*

Acupressure originated in China as a first aid technique. It is based on the same principles as acupuncture but the acupuncture points are stimulated by finger pressure instead of needles.

Acupressure is easy to learn and can be performed by yourself or by a friend. It can be used for the relief of symptoms such as menstrual cramps and can also be a means of strengthening and balancing your body’s deep energies for the well-being of your body and mind.

Shiatsu.

Shiatsu is a form of acupressure. It is an ancient Japanese art of applying pressure to acupuncture points and is combined with oriental massage. With regular use it is believed to improve your health by increasing the flow of energy through the body.

Shiatsu should be pleasurable, not painful. Once the correct technique has been learnt from a qualified person it is possible to have a friend give you a massage or even to do it yourself.

*75\83\2*

The actual location of the endometrial implants in the body depends on the way in which they were transported to their new site. Because the majority of implants are transported to their new location by retrograde menstruation, almost all endometrial implants are found in the pelvic cavity. As blood and lymph transportation of endometrial fragments is rare, it is unusual to find implants in other parts of the body.

The ovaries are one of the most common sites for endometriosis and at least 50% of women with endometriosis have some implants on one or both of their ovaries. The other most common sites are the utero-sacral ligaments, the Pouch of Douglas and the peritoneum.

Less common sites for endometriosis include the appendix, the surface of the bladder, the recto-vaginal septum, the surface of the uterus, the fallopian tubes, and the surface of the small and large bowel.

On rare occasions, endometriosis has been found in almost every part of the body including surgical and episiotomy scars, the cervix, vagina, diaphragm, navel, lungs, breasts, arms and legs, the groin and the nose.

*15\83\2*

Mercury

Mercury is a heavy toxic metal which now contaminates the air, soil and water in many parts of the world. Mercury pollution has been caused by the burning of fossil fuels and the increased use of mercury in industry and agriculture. Traces of mercury can be found in pesticides, dental fillings, and in fish (especially tuna). The saying ‘mad as a hatter’ came about because hatters used to polish top hats with mercury and many of them were poisoned by it. It is extremely toxic and can affect fertility.

Female dental assistants, for instance, who are exposed to mercury through the amalgam fillings they handle, have been found to be less fertile than female dental assistants who do not come into contact with the metal. And women dentists, it is claimed, have a higher rate of miscarriage.

There are real concerns about the impact of mercury on male fertility, following research in Hong Kong where people eat a lot offish and shellfish containing minute and supposedly safe quantities of the metal. Here, scientists found a significant link between the level of mercury in hair and male sub-fertility. Eating mercury-contaminated fish over a number of years stopped sperm development in many Hong Kong men.

Mercury seemed to be one factor in the case of Teresa and her partner.

Case History

Teresa and her partner conceived easily but she was diagnosed with a blighted ovum when she was 10 weeks pregnant and had to have a D&C. Teresa had deficiencies of both zinc and selenium and her partner was low in magnesium with above average levels of mercury. He told me that as a child he had played with mercury. Mercury is an unusual metal, in that it is liquid at room temperature and forms small balls as it flows. Over the four months of the Preconception Plan they both took specific nutritional supplements to correct their deficiencies and Teresa’s partner had extra antioxidants and support for his liver in order to eliminate the mercury. They now have a baby boy.

Lead

Lead is a heavy toxic metal which is naturally present in the earth but we get a high exposure to this metal from lead pipes.

Lead was used in the past to induce an abortion, and severe lead intoxication has been shown to result in infertility and miscarriage. It could be argued that these problems are due to lead poisoning and that most of us are not exposed to such high levels. However, women who just live in lead-polluted areas have also shown a greater risk of miscarriages.

According to a 1991 study, of all the toxic metals, lead seems to pose the greatest threat to male fertility. Research shows that it can reduce the sperm count, increase malformed sperm and make the sperm more sluggish.

Cadmium

This is an inorganic poison present in tobacco smoke which accumulates in the body. It blocks nutrients like zinc – which is absolutely crucial for both male and female fertility.

Copper

Copper can be both toxic and essential, depending on how much you are exposed to it. Your body absorbs copper from water pipes, contraceptive coils, swimming pools and jewellery. Copper tends to increase its concentration in the body after any hormonal treatment, such as the Pill or fertility drugs. Copper and zinc are antagonistic which means that if you have too much copper, your zinc levels can be reduced. As zinc is so vital for fertility for both of you, it is important that your copper levels are kept in check.

Zinc deficiency and high lead levels were certainly factors for Janet and her partner.

Case History

Janet, 38, had a miscarriage at 12 weeks before she came to see me. Her nutritional analysis showed that she was low in calcium, selenium and zinc, and had higher than normal levels of lead. Her partner, 34, had low levels of selenium and zinc and very high levels of lead. I felt it was important that they both got themselves back into optimum health by following the Four-Month Preconception Plan, before they tried again, in order to try and prevent another miscarriage. I recommended appropriate supplements for their deficiencies, as well as antioxidants like vitamin Ñ to help eliminate the lead from their bodies.

Janet and her partner waited until their mineral and lead levels were back to normal and then conceived and gave birth to a healthy baby boy.

*14/73/5*

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.

*306/31/5*

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.

*277/31/5*

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.

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.

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.

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’.