If the reproductive organs are accessed through the vagina, the operation is called a vaginal hysterectomy. This approach may be considered when:

• a woman has a prolapse and her uterus, bowel or bladder has already started to intrude into her vagina

• there are fibroids that are small enough to enable the uterus to be pulled down and out through the vagina

• the ovaries are to be left intact.

Vaginal hysterectomy is unsuitable when the uterus is very large or contains one or more sizeable fibroids. It is more difficult to perform than abdominal hysterectomy and should always begin and end with a laparoscopic inspection of the pelvis. This helps ensure that any abnormalities, such as ovarian cysts, are identified prior to surgery and alerts the surgeon to any bleeding that has occurred during the operation. Bleeding must be contained or the patient will form large blood clots in the pelvis which may lead to adhesion formation and infection. Removal of any clots will involve another trip to the operating theatre and an extra two to three days in hospital.

The debate among doctors about the relative merits of abdominal and vaginal hysterectomies is ongoing. Proponents of the vaginal approach argue that it involves less post-operative pain, is less costly and requires a shorter hospital stay. Some research has suggested it may be safer than the abdominal approach, resulting in fewer deaths and a lower complication rate but analysis of Australian hospital data indicates that this is not necessarily so. Nevertheless it is argued that the vaginal approach could be used for most hysterectomies if appropriate training programs for doctors were available.

In contrast, doctors who favour the abdominal approach claim that the types of complications more likely to affect women having a vaginal hysterectomy are a cause for concern. They claim post-operative infection and large blood losses necessitating transfusions are more common with the vaginal approach; and they suggest that there is an increased risk of damage to other pelvic organs due to the confined space in which the surgery is performed. Repairing this damage entails further surgery. They also say that vaginal hysterectomy is more likely than abdominal hysterectomy to result in a vaginal prolapse, where the upper part of the vagina collapses inwards. The upshot is that at present in the US, UK and Australia, about 25% of hysterectomies are performed vaginally.

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•     Avoid, as far as possible, food and drinks in plastic containers or wrapped in plastic, especially fatty foods in plastic. This is because xenoestrogens are lipophilic (fat-loving) and will therefore migrate into foods like cheese and crisps. Remove food from plastic packaging as soon as possible. And reduce your own intake of saturated fats.

•     Do not heat food in plastic especially in a microwave oven. (Scientists have discovered that Clingfilm used in the microwave leaches damaging chemicals into the food.)

•     If your vegetables and fruit are not organic, wash them thoroughly. You can buy a wash (like Veggi Wash) from your health food shop which claims to be able to remove farm chemicals, waxes and surface grime. Washing cannot alter the amount of pesticides inherently absorbed into the vegetables. But peeling fruit can lower the pesticide residues by about three-quarters.

•     Increase your intake of fibre – it helps prevent the absorption of oestrogenic chemicals into the bloodstream. Fibre is found in wholegrain, vegetables and fruits (organic ones of course!).

•     Eat more cruciferous vegetables, like broccoli, Brussels sprouts, cabbage and cauliflower, because they are high in a substance called indole-3-carbinol which reduces the metabolism of oestrogen into a toxic form while speeding up its elimination.

•     Eat phytoestrogens, like soya, which can reduce the toxic forms of oestrogen in the body.

You may be saying to yourself: ‘Why can’t they leave our food alone?’ Unfortunately, the producers’ agenda is never health or safety. It is always financial. But it is important to emphasize that you do have a good deal of control over the food you eat. The British public has been much quicker than the Americans to reject GM foods, forcing the issue out into the open and proving that public pressure does make a difference. For example, in 1989 a chemical called alar that was routinely sprayed on apples was withdrawn after mothers organized a nationwide protest against the suspected cancer-causing chemical. Once you realize what is in the food we eat, you will probably want your family to be protected from the dangers all the time – not just when you are trying to conceive. Get a water filter that can remove a high percentage of oestrogens from the water supply. Some filters can also remove pesticide residues, fluoride and heavy metals like lead.

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Apart from the general measures outlined, such as keeping your interests going or taking up new ones and planning to do things together after the family has gone, simple measures should be tried first.

Some people take up yoga, others benefit from relaxation or exercise programmes. Group therapy helps others. Simply knowing that other women are going through this stage and have similar problems seems to help. Of course a good night’s sleep is essential, and if this is disturbed by flushes and sweats these must be treated. Hormones settle many, and these women describe a general feeling of well-being and ability to cope. This has been confirmed by scientific studies.Only after all these measures have been tried should tranquillisers and antidepressants be used.

Insomnia

Apart from hot flushes and sweats, some women have an altered sleep pattern due to the action of the hypothalamus. Of course if you are depressed this can also affect sleep patterns. Some women find it hard to get to sleep, others wake in the middle of the night. Too many women worry if they do not sleep through the night as they did in their youth, when they are not active enough during the day to warrant it. It is also important not to rush to the drug cupboard, as a few nights’ sleep disturbance will not hurt you. It is important to realise that this is usually only a temporary thing with the hormonal changes that are occurring, and it will settle. Simple measures as usual are the best. Hot milk, a brandy (one), relaxation, reading, etc. Oestrogen replacement almost always relieves insomnia when it first appears at the menopause by calming down the higher centres in the brain. This can be used if the insomnia persists after simple measures have been tried.

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Oestrogens As with oestrogenisation of the vaginal tissues, infections are avoided, so too are urinary symptoms with this treatment. The tissues become stronger and healthier at the bladder outlet. Many patients describe an improvement in this problem with oestrogen treatment and sleep through the night when previously they had been frequently woken to empty their bladder. I treated one woman who, because of X-ray treatment for another complaint, had had her ovaries destroyed. Bladder problems had not been a presenting symptom. Her presenting symptoms had been of hot flushes, depression and loss of libido. We gave her implants of an oestrogen plus testosterone mixture and these fully relieved her symptoms. After several implants she reported to us that one of the ways she recognised her implant was running out was that she was woken three to four times a night to empty her bladder. One of the greatest boons she felt from the treatment she was receiving was that she had an uninterrupted nights sleep.

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• by mouth (orally)

• as a cream or pessary applied locally

• by implants or pellets placed under the skin.

If the uterus is still present, progestogens at regular intervals are essential to stop the build-up in the lining of the uterus, with resultant bleeding or changes which might give rise to cancer of the uterus. Some believe that progestogens should be given in all cases.

The common oestrogens on the market at present are ethinyl-oestradiol (the synthetic oestrogen), conjugated equine oestrogen (Premarin), oestradiol valerate (Progynova), Piperazine oe-strone sulphate (Ogen) and Oestriol. Only ethinyloestradiol is available on the NHS. There are also several progestogens on the market, none of which are on the NHS list.

The government has not altered the NHS list for oestrogens since it was originally decided upon even though this therapy has gone ahead considerably. Complaints have been forwarded to the appropriate bodies from many authorities without results. It is something that women could lobby for through their local members.

Ethinyloestradiol in some instances causes nausea and headaches and is unsuitable for smokers or for women with high blood pressure as it increases thrombosis. It is the oestrogen in the oral contraceptive pill. All other oestrogens are very costly.

Progestogens are also costly and are not on the NHS listing for this purpose although it is recognised that they are necessary if oestrogen is to be taken safely. This is particularly hard on women from outer suburbs and the country areas who cannot attend public hospitals where these tablets are free.

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Calcium and other minerals and vitamins must be taken by mouth to be absorbed and laid down in the bones Diet is therefore of importance. We should all eat foods rich in calcium. The body requirement is covered by 900 mL of milk per day (full or skim milk) or 600 ml of milk and 30 g of cheese. Foods rich in calcium are cheese, yoghurt, egg yolks, green vegetables and nuts – the ingredients of any good diet. If your diet is adequate, you will be obtaining some calcium from other foods, and 600 mL of milk is then sufficient.

It is a difficult task keeping in shape at this time, so milk, eggs, nuts and cheese may not be eaten in sufficient quantities, if at all.

To prevent bone loss, particularly in those women with a family history of osteoporosis, calcium supplements of about 1 g each day should be taken if the diet is deficient in milk, even before the menopause. Calcium should be taken only after consultation with your doctor as overdosage can produce problems elsewhere, for example the formation of kidney stones. Studies at both the Royal Women’s Hospital and Prince Henry’s Hospital in Melbourne showed that 75 per cent of women had insufficient calcium in their diet.

Alcohol and smoking

Bone loss is also accelerated by excessive alcohol consumption, and it is known that heavy smokers lose bone twice as rapidly as non-smoking menopausal women. This is said to apply also to men who smoke.

Prevention and treatment

It is up to you to cut down on alcohol and cigarettes, exercise well, and have a diet rich in calcium foods. This may need supplements if your diet is restricted for weight reduction or maintenance. Oestrogens are not universally prescribed for all women, as the benefits must be weighed against the side-effects.

It is important for women who have had an early menopause, either naturally occurring or artificially induced, to take oestrogens at least into their fifties (when they would normally have reached the menopause), in order to prevent bone loss.

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There appears to be an increased risk in those women who have:

• an early onset of menstruation

• a late first pregnancy

• a late menopause

• a family history of cancer of the breast.

It is important to stress that all women should practise breast self-examination.

Mammography Mammography is a special X-ray of the breasts, having a good pick-up rate for lumps in the breasts.

It is recommended for the high-risk group, that is those women with a family history of mother and sisters with breast cancer. These people should:

• practise breast self-examination monthly

• have regular checks by a specialist

• be examined by mammography if the specialist feels it is indicated.

Mammography is also useful in examining large, diffuse, lumpy breasts where it is difficult to detect lumps by means of breast self-examination. Some authorities are now advising all women over forty-five to have a mammography.

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