DEALING WITH UNPREDICTABLE PERIODS: ANEMIA AND MENSTRUATIONI have heavy periods and cramping and I always have felt incredibly fatigued while I am bleeding each month. My gynecologist took a blood test and I discovered that I am anemic. I have started taking twelve tabs of iron a day from the onset of my flow until it is over, and I find that I feel much better and the cramping recedes. I didn’t even know that I had heavy periods because women have no measurement for comparison, and I think there are probably a lot of women like me who have severe anemia and their doctors don’t realize it.—A.W.Louisville, KentuckyA woman may have heavy bleeding for a number of reasons. There may be a fibroid tumor that has broken through the uterine lining and is causing heavy bleeding. Some women don’t coagulate well, which means that their blood does not clot properly, because they are taking aspirin or other types of anticoagulant medication. An IUD may be causing heavy bleeding, or a woman may be suffering from adenomyosis, a condition in which the uterine wall is exceptionally spongy and bleeding is particularly heavy.When a woman bleeds heavily, she can become susceptible to anemia because the blood she is losing is not just extra blood she can afford to lose. During menstruation the endometrium, the glandular spongy lining of the uterus, the unused nest for a fertilized egg, is expelled. The uterus is cleansed and prepared for the buildup of another endometrium during the following cycle.The menstrual flow will vary from woman to woman and sometimes from cycle to cycle. If an excessive amount of tissue is built up inside the uterus during one month, a woman will usually bleed more heavily because in order to expel the endometrium the uterus must contract more intensely. Since the activity in the womb is great, the uterus itself may lose blood too, and the result will be heavy bleeding which may cause anemia.The uterus is supposed to squeeze like a tourniquet to prevent unnecessary blood loss, but if it doesn’t squeeze properly, bleeding might emanate from the uterine cavity to which the endometrium is attached. A doctor has several alternatives if this happens. One of them is to prescribe a medication called Ergotrate, which makes the uterus squeeze tighter if bleeding becomes a serious problem. Ultimately, the menstrual flow is connected to the entire circulatory system, so a period cannot be allowed to continue unchecked.When a woman notices, because she is using an unusual number of pads or tampons, that her periods are heavy, or if she sees large clots in her flow, then she should visit her doctor. If she is also fatigued, she may be anemic and may need vitamin C and iron to strengthen her blood count. Depending on the cause of her bleeding, her doctor might suggest a D & C, or prescribe the uterine-contracting drug Ergotrate. If the problem is an abundance of prostaglandins, the prostaglandin-blocking drugs Motrin or Anaprox may lessen the flow.*52\333\2*

Indications. Women who have symptoms from prolapse of the vaginal walls or uterus.

Symptoms may include a lump, feelings of pressure or dragging, pain, discharge, sexual difficulties, and urinary or bowel problems.

Method. There are different techniques for fixing a prolapse, depending on what is in the wrong place and why. Basically, the operations can include or combine:

• repair of the front or back vaginal wall tissues (anterior or posterior colporrhaphy)

• repair of the perineal (pelvic floor) muscles (perinorrhaphy)

• surgically hitching and securing the uterus in place, rather than relying on stretched ligaments.

Vaginal repair can be performed with hysterectomy, as this will sometimes give a better result than vaginal repair alone.

Complications. The complications common to most surgery (anaesthetic problems, infection, bleeding) could occur, but precautions would be taken to prevent these.

Specific problems which may be encountered include urinary trouble, as the bladder neck (outlet) and the urethra are close to the action when operating. That is why most surgeons would use a urinary catheter to drain the urine away from the bladder for the first few post-operative days.

Because the vaginal skin and surrounding tissues are usually cut and then sewn up again, the sensation to the area may be altered. This may lead to altered sensation during sexual contact. Cut skin usually regains normal sensation within a few months.

One occasional complication of prolapse repair is not really a complication, but the fact that the condition may recur, despite surgery. Removing the potential aggravators, like obesity, straining, coughing, etc., is a way of increasing the likelihood of the operation being successful.

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There have been many studies, involving hundreds of thousands of women all over the world, looking at whether the pill is linked to breast cancer. The suggestion that it might be probably arose out of what we know about breast tissue being sensitive to oestrogen and progesterone (the hormones in the pill). We know that some forms of breast cancer have what are called oestrogen receptors, which infers that oestrogen may stimulate that particular tumour.

The studies have individually come out saying ‘there is no association between breast cancer and the pill’, and ‘yes, there is’, and ‘maybe’. The studies we tend to hear about in the media are the ones which show a correlation.

Researchers have now had a look at all the studies which have been done, and have analyzed them. It seems that the vast majority of the studies showed no correlation between the pill and breast cancer. A couple of studies said there could be (they are the ones we heard about).

An interesting observation of one large analytical study suggested that if there was any increased risk of breast cancer, it would be in the younger age group (under 45). There seemed possibly to be a protective effect against breast cancer in the older age groups in women who had used the pill. As the majority of breast cancers occur in older women (77 per cent occur in women over 45 years of age), the overall effect of the pill may be at least neutral for breast cancer, and possibly even protective against it.

There may be cases for avoiding the pill for fear of breast cancer. For instance if a woman has already had a breast cancer diagnosed and treated, most doctors would not suggest she have extra oestrogen in the form of the pill, or hormone replacement therapy if she is menopausal. It is also suggested that women with a very strong family history of breast cancer should also avoid the pill. These women are already at an increased risk of developing the disease, but the effect of added oestrogen is not known, so it is usually not prescribed just in case. However, the particular circumstances of women differ, and these decisions can be examined on an individual basis.

We are constantly making choices about what risks we are prepared to take, for what benefits we may gain. Each person should have the opportunity to make a decision based on accurate information. Unfortunately it is difficult sometimes to work out what is accurate, when we hear so many conflicting views.

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• You have had surgery on your scrotum or it has been injured in the past The issue here is that there may be a lot of scar tissue, which would make the vas hard to move. If the vas can’t be moved easily, the procedure would be painful even with a local anaesthetic. It really would be better to have the vasectomy under general anaesthetic in hospital. The doctor will recommend the best procedure for you.

• You are very overweight This can make it hard to feel the vas easily within the scrotum.

• You feel very nervous about having the vasectomy and you really want to have it done under a general anaesthetic.

• Your scrotum has skin that is unusually thick or very tight.

• When you are examined by the doctor it is found that you need to have surgery under general anaesthetic for something else, like repairing a hernia It is usually better to have the vasectomy done at the same time.

• You have a varicose vein in the scrotum. The doctor may be concerned that it might bleed a lot during the procedure.

• You have had a lot of infections in your genital tract in the past. This can also lead to scarring which can make the operation more difficult and painful.

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How do you use the Billings (Mucus) method?

The Mucus method relies on you noticing changes in the mucus at the opening of your vagina every morning when you wake up. You feel just outside the vaginal opening with your finger and notice if you feel wet or dry. If there is any mucus on your finger you can see what it looks like. Depending on what the mucus looks and feels like, you can tell whether you are fertile or not Then you know whether it is safe to have sex that day.

There are three different types of mucus to check for. As soon as your period finishes, your vaginal opening will feel dry, and any mucus will be thick, flaky and sticky. Around the time that you are ovulating, your vagina will feel wet, and the mucus will be clear, watery and stretchy, like egg white. After you ovulate, the mucus will be cloudy, thicker, and sticky again, and your vagina will feel dry around the opening. With this method you can presume you are safe three days after you last feel the slippery wet mucus.

There are several things you must do to use this method as safely as possible. Firstly, in the early part of your cycle before ovulation, you can only have intercourse every second day because if there is any semen from the man in your vagina you would not be able to tell if there is any mucus there. Secondly, you can only have intercourse on a day when you have felt dry in the morning. Thirdly, if you have any bleeding or spotting during the cycle you must treat that as the same as fertile mucus.

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The minipill works best to prevent pregnancy between three and 21 hours after you have taken each pill. It’s a good idea to work out the best time to take it so that you will be fully covered if you have sex. If you usually have sex at night, or first thing in the morning, then the best time to take the minipill would be at lunchtime or early in the evening, just swallow the pill with water.

The minipill comes in a pack of 28 pills, so when you’ve finished one pack, start straight away on the next pack. You don’t have any break from taking the pills.

If you are not having periods, for example if you are breastfeeding, and your periods haven’t returned since the baby was born, you can start taking the minipill whenever you like.

It is important to use other contraception, like condoms, if you have sex during the first seven days after starting the minipill, to make sure you are covered against pregnancy.

Keep on taking the minipill until you decide that you want to use another type of contraception, or you want to get pregnant

What do I do if I miss a minipill? If you miss taking a minipill, take the next pill as soon as you remember it, and take the following pill at the usual time. If you are more than three hours late taking your pill, and you have sex during the next two days you should use condoms, or another form of contraception.

If you miss pills around the time that you have unprotected sex you may want to think about using emergency contraception.

You can ring a Family Planning Centre or your doctor if you feel worried. It’s better to be absolutely sure what to do, than to wait and see what happens.

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