HORMONAL REPLACEMENT THERAPY: GETTING THE DOSAGE RIGHT

There is such a wide range of dosages available that your doctor should be able to adjust your prescribed dose to your symptoms. If your symptoms are mild, you will start on a low dose; if they are severe you will start on a higher dose. (The further you are from the menopause, the more likely you are to get side-effects in the early days of taking oestrogen, so a low dose would probably be prescribed for you initially.) If the low dose is not getting rid of the symptoms, ask your doctor if he can give you a higher dose; if the higher dose is producing unpleasant side-effects, ask for a lower dose. Women who have had a hysterectomy or oophorectomy will usually be started on a higher dose, as their symptoms will probably be more severe than women passing through a natural menopause.

If you have severe symptoms of breast tenderness, nipple sensitivity, leg cramps, continuing weight gain and feelings of nausea, you might feel better on a lower dose of oestrogen. If you develop acne, bloatedness, disturbances of your digestive system, a drop in libido, breast discomfort, and feelings of pre-menstrual irritability, then you might feel better on a lower dose of progestogen. However, before you rush off to the doctor, be prepared to stick with your initial treatment for two or three months, unless the HRT is giving you really awful side-effects; in most cases they diminish considerably, and often go completely after a few months.

Women who start HRT before their periods stop completely may find it takes longer to get the dosage exactly right This is because if you are still having natural periods, then you are still producing some oestrogen, even though its falling levels may be causing hot flushes, night sweats and all the rest If you take extra oestrogen in the form of HRT, don’t be surprised if you suffer some of the effects of this extra dose. Also, as your own level of oestrogen falls steadily, your HRT dose may need gradually to be increased in order to compensate.

The other group of women who may initially suffer side-effects from higher doses of oestrogen (tender breasts, for example) are those who are many years past the menopause and haven’t produced much oestrogen of their own for a very long time. If this happens to you, your doctor may suggest that you start on a lower dose, and then progress to a higher dose when your body has adjusted to the oestrogen. Alternatively, it may help if you take the HRT on alternate days to start with. You may also find that evening primrose capsules bring relief for breast tenderness.

As well as adjusting the dosage to menopausal symptoms, your doctor will want to consider whether you are at risk of osteoporosis or arterial disease. If you are, he will probably suggest starring at a medium or high dose, as the low dose may not give enough protection for some women.

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LAPAROSCOPICALLY ASSISTED HYSTERECTOMY

Surgeons gain access to, and remove, one or more of the reproductive organs in a number of ways. This is the basis for another method of classifying hysterectomy.

In recent years, another technique has been developed that combines elements of both the abdominal and vaginal approaches. It entails using the laparoscope, described in chapter 3, to gain access to the abdomen through several small (about 1 cm) pelvic incisions. The laparoscopic view of the inside of the abdomen is transmitted to a video screen and the surgeon manipulates cutting, burning or laser instruments within the pelvis according to what is seen on the screen. Direct vision laparoscopy tends to be used only when perception of depth is unclear, otherwise all surgery is performed while watching the screen.

After detaching the uterus and any other organs to be removed with diathermy, and closing blood vessels and realigning tissues using staples or sutures, the surgeon makes an incision near the top of the vagina where it meets the cervix. The unwanted tissue is then extracted through the opening in the vagina. This technique is called laparoscopically assisted hysterectomy or laparova-ginal hysterectomy. It has now been carried out on hundreds of women who would otherwise have had an abdominal hysterectomy. Laparoscopically assisted hysterectomy requires special equipment and a team of doctors and nurses skilled in gynaecological laparoscopy. It is considered to be suitable when:

• fibroids are of intermediate size

• endometriosis is a major reason for the surgery

• a reduced recovery period is important

• there is an early stage endometrial cancer and the ovaries are to be removed.

Margaret had a laparoscopically assisted hysterectomy instead of an abdominal or vaginal hysterectomy largely because of business pressures. A senior staff member of a company involved in a takeover bid, she was appreciative of the shorter hospital stay (one to four days instead of seven to ten days) and the reduced period of convalescence (one to four weeks instead of up to two or more months). After her convalescence it took her another few months to regain total well-being, but nevertheless she was able to contribute meaningfully at a critical time in her company’s business operations.

There is some evidence that laparoscopically assisted hysterectomy has a lower complication rate than either vaginal or abdominal hysterectomy, although this claim has been disputed and the results of clinical trials are awaited with interest. The operation takes somewhat longer to carry out than the other types of hysterectomy (one to two hours on average, although the French have reduced their operating time to less than an hour, compared with thirty minutes to an hour for an abdominal hysterectomy) and requires more costly instruments.

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BIOLOGICAL CLOCK: ORCADIAN RHYTHM

Have you noticed that, even without looking at a watch, we usually wake up at about the same time every morning and feel sleepy and go to bed nearly the same time each night? We do not need to know the time to do all these things. Somehow our body knows the time, as if we have a clock inside. This internal clock is called the biological clock.

It is well known that all living things have a biological clock within them. This is because we live on a planet that rotates once every 24 hours, such that a period of light is followed by a period of darkness within every 24 hour cycle. Our sleep patterns, body temperature, hormonal excretion, body metabolism, and other biological functions fluctuate within this cycle as day becomes night and night becomes day. The biological clock governs our body rhythm repeatedly every day, and this rhythm is known as the arcadian rhythm. Orcadian is a Latin word meaning ‘about a day’.

This circadian rhythm is endogenous and is as if governed by an internal clock which is situated inside our brain. The body functions such as sleep patterns, body temperature, etc. appear to follow this internal clock. This body clock is quite robust and possesses a certain amount of durable inertia, and resetting of this clock may take from a few days to a week to complete. This is illustrated by the interesting case of the fiddler crab.

Scientists have noticed that the fiddler crab of North America changes colour according to whether it is night or day. These crabs are flown by air from New York on the east coast to California on the west coast. Because our earth rotates towards the east, New York on the east coast sees the sunrise many hours earlier than California. When the crabs first arrive in California they continue to change colour as if they were still back in New York; they have

not yet adjusted to the new timing of day and night in California. But after about ft week the crabs adjust to the local time in California and change colour according to this new local time. Obviously the crabs do not wear watches. Their biological clock is gradually reset to the new timing of daylight in California.

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