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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SOLUTIONS TO INFERTILITY: PROTECTION AGAINST POULLUTANTS AND CHEMICALS AT HOME

Household pesticides

A number of children have been diagnosed with Charge Syndrome which is characterized by major abnormalities including heart disease. It’s believed that the condition is caused by exposure to pesticides and insecticides during pregnancy. One baby was born with severe handicaps after her mother had been exposed to a cockroach pesticide when she was six weeks pregnant. Another woman gave birth to a handicapped child after exposure to flea insecticide during pregnancy.

Dr Jeff Howell, of South Bank University, has strong concerns about the use of permethrin to treat woodworm. This chemical has been linked to skin and eye irritations but also to birth defects. Home-owners have always been told that the treatment chemicals fall to safe levels eight hours after application. But research carried out by the Faunhofer Institute of Toxicology and Aerosol Research in Germany shows that house dust picks up permethrin and deposits it on food and kitchen surfaces. So you can end up breathing and eating it.

Parents in the UK and USA are suing the manufacturers of a garden pesticide they claim caused eye deformities in babies following use in the early months of pregnancy.

What You Can Do

• Try not to use pesticides in your garden. If this is not possible then make sure you don’t handle any of this stuff in the four months leading up to conception.

• Do not have your home treated for woodworm in those four months either. Do any house treatments before you actually move in so that you are not living, breathing, eating and sleeping in a potentially toxic environment.

• Treat your pets for fleas with natural herbal sprays. They do not kill the fleas but repel them, making them less likely to stay on the animal. There are also other ways of dealing with fleas which can be obtained from the vet. You can feed your cat a substance or put drops on their necks which change the blood so the fleas don’t like the taste. Garlic works the same way. If you crush up garlic tablets into your pet’s feed, this may keep the fleas off.

• Garlic can also be used to deter other insects. A few years ago we had some ants in the kitchen. We opened up some garlic capsules and spread the garlic around the opening the ants seemed to be coming from. Interestingly, the ants would not cross over the ‘garlic’ line and went back down the crack.

Household Chemicals

Decorating your home can be a problem. Solvent-based paints and white spirits release gases into the air and these can stay around for weeks after painting has finished. Apart from causing irritation, these gases can be inhaled and cause dizziness, nausea and headaches. Years ago, paint and furnishings were made from natural products but nowadays they are usually made from chemicals. Unfortunately, there is also a tendency to paint the baby’s room just before it is born so the baby ends up sleeping in a sea of chemicals. In addition, new carpets often contain chemical preservative called formaldehyde which can irritate the mucus linings of the eyes, nose and throat.

What You Can Do

• Decorate at least four months before conception.

• When you redecorate, buy solvent-free paints.

• Minimize the amount of chemicals you use in your home (such as polish, bleach, detergents, air fresheners, etc). Buy more natural and more biodegradable household cleaners, available from health food shops.

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HYSTERECTOMY AS SURGICAL TREATMENT OF ENDOMETRIOSIS: YES OR NOT

When a woman is faced with the decision of whether or not to have a hysterectomy she has almost invariably had a harrowing and traumatic fight with unrelenting endometriosis for many years. Her symptoms are usually so severe and persistent that they have taken over her life completely and there is no other way out. The decision to have a hysterectomy simply becomes a quality of life issue.

Nevertheless, most women have to hit rock bottom and cross that ‘invisible barrier’ of knowing emotionally that they have reached the end of their tether before they can make the decision to have a hysterectomy.

The decision to have a hysterectomy should be yours and yours alone. Do not allow anyone else – your gynecologist, your partner, your mother or your best friend – to make the decision for you. You have to live with the decision, not them.

The decision must also be made at your pace. Do not let yourself be pressured into making a hasty decision just because your gynecologist or someone else wants an answer by a certain date. Only you will know when you have finally reached the end of your tether so take as much time as you need. If you have to ask yourself whether or not you are ready for a hysterectomy then you aren’t.

Even though you must make the final decision it will usually be beneficial if you discuss your options with your gynecologist, partner, family and friends, as well as other women who have been through the same operation. It is often worthwhile talking to a counsellor to help explore and resolve the issues.

Before you make a final decision get as much information as you need about the operation and its likely consequences. Do not hesitate to ask your gynecologist any questions that you may have. If you have any doubts about the need for the operation get a second, or even a third, opinion.

Women who make the decision themselves and at their own pace usually recover more quickly and have less physical and emotional problems following their surgery.

Deciding to have a hysterectomy is a major and irreversible decision that will affect all aspects of your life. In making the decision you need to consider both the physical and emotional aspects.

You need to think about the degree to which your quality of life is compromised by your endometriosis and weigh that up against the likely advantages and disadvantages that the surgery will bring.

A hysterectomy will probably mean much less pain and disability. It will also mean that you cannot have children in the future so you will have to decide whether retaining your possible ability to have children is more important to you than relief from your symptoms and getting on with life. Your sexual response will probably change too – for better or worse – but you will not know how until after you have had the surgery

You need to think about what effect not having all of your reproductive organs will have on your self-image. You may also need to consider the reactions of others after you have had a hysterectomy and what effect that will have on your relationships with them.

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MENOPAUSE: THEORIES

The hormonal theory

Changes in hormones do affect the emotions; in some women this is pronounced, and in others it is hardly noticeable. This depends to some extent on how rapidly the hormone levels change and also of course on the general make up of the woman and how she reacts to it, but the menopause may be a time of instability. The actual level of circulating hormones also has an effect. The depression associated with hormonal changes at the menopause is similar to the emotional instability at puberty and postpartum depression which often occurs after delivery of a child. During pregnancy there are high levels of circulating oestrogens followed by a sudden drop at delivery; at puberty also there are changes in hormone levels.

The involutional theory

If her periods have gone it is thought that a woman feels that death is around the corner. I think that women who are well don’t feel like this. Death is something that ‘happens to someone else’ if you are on top of things. But, admittedly, in this youth-oriented society, depending on what you have valued in the past, changes at this time do perhaps suggest a loss of youth. Fortunately, more and more women realise that there is more in life than youth, and I feel that with the increase in the interests of women this will be less of a problem in the future.

The empty nest syndrome

I also feel that the ‘empty nest syndrome’ has been overplayed, although it is, of course, also a factor. But numerous women sit in front of me telling me that the last thing they want is another baby. Others tell me that they are fed up with waiting on a bunch of young adults who can well look after themselves. They want time to pursue their own interests. Those who don’t have these feelings and feel a loss at this time should view this period of their lives just as people view retirement, and prepare for new interests in their lives.

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MENOPAUSE PROBLEMS: VAGINITIS PROBLEMS

Vaginal infections are more common after menopause, probably due to the alteration in acidity of the vagina. Before the menopause the vagina is more acid than alkaline although this varies during menstrual cycle to some degree. When oestrogen levels are high the vagina is more acid, and after the menopause the alkalinity therefore increases. With high oestrogen levels the lining of the vagina is also thick and moist, and this, plus the acidity, protects the vagina from harmful bacteria. Bacteria may migrate from surrounding areas, such as the rectum or bladder, or may be introduced during intercourse. Most women at some time in their lives before menopause have had a vaginal infection. Particularly, these occur during or after a course of antibiotics, because the antibiotics alter the normal bacterial inhabitants of the vagina, and make foreign bacteria happier there, and they multiply. After the menopause some women get one infection after another due to the low oestrogen levels, and also the thinning of the vaginal mucosa.

Prevention The genital region should be kept as dry and well-aired as possible, therefore cotton pants should be worn. Synthetics keep the area moist and warm and should not be worn. Tight jeans should be avoided particularly in hot weather, as also should pantyhose. Wiping yourself from front to back after urinating and bowel movements, or simply dabbing to dry oneself and avoiding courses of antibiotics – these are preven-’ tive measures to keep in mind. Do not douche as this destroys the normal bacteria and makes the vagina more prone to infection.

Oestrogens are useful as the vaginal wall becomes thicker, moister and more acid when they are present. They may be given orally or locally as a cream or pessary.

Medication If you have an infection and medication is prescribed by your doctor, it is important to complete the whole course as prescribed, or the infection may recur and become chronic.

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ROUTINE TREATMENT FOR MENOPAUSAL PROBLEMS

There is a mistaken impression in the community that women are psychologically unstable at menopause, facing sociological changes that they cannot cope with. But this applies equally to both sexes. The difference for women is that they suffer a hormonal imbalance as well. Adjust this and the rest usually falls into the place.

We see no point in our clinics in running group therapy sessions. This is not done for any other hormone deficiency condition such as diabetes or thyroid deficiency. We stabilise the women’s hormones, and if following relief of their oestrogen dependent symptoms, they still need help, we refer them to psychiatrists or other expert professionals. Those who still need help after their hormones are stabilised are shown to be unable to cope with the stresses of mid-life which are common to both men and women.

In any medical interview the doctor looks into the workload and stresses of the patient. It is not uncommon to find women in this age group working full time, running a home, coping with a partner facing increased stress at work or retirement, coping with teenagers with their problems, as well as often being a major source of support for old people who may live in the home. It is impossible to assess the problems of menopausal women without taking all this into account.

To assess this, a full general and gynaecological history is taken. The woman is examined including a smear test for cancer of the cervix and a breast examination. She is also instructed on breast self-examination (figure 4.1). The doctor then explains what treatment is available and in what way it can be expected to help, together with a full explanation of the therapy and why it is necessary.

Oestrogen replacement therapy is offered orally, locally or by implant and if this is contraindicated, or if the woman does not want to take this therapy then alternative therapy is made available to her. Those who are not suitable for treatment must be recognised.

• women with a history of cancer of oestrogen-sensitive tissues, for example cancer of the breast or lining of the uterus. This does not apply to the neck of the uterus or cervix

• women with recent liver disease or defective liver function

tests

• women with a history of thrombosis or clotting. In some instances, if symptoms are incapacitating, small doses of oestrogen may be given, particularly certain oestrogens which are said not to affect the clotting mechanism of the blood.

Other treatment is available if oestrogen is unsuitable.

General treatment

Of course any other medical or gynaecological conditions are treated as well. Advice is given on regular exercise; diet and correction of obesity, if necessary, are discussed. Counselling on general problems is given.

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PREVENTION OSTEOPOROSIS: EXERCISE IS IMPORTANT

Oestrogens can help to prevent osteoporosis, and certainly may provide pain relief once osteoporosis has occurred. It is thought that oestrogen does not actually reverse the changes once they occur, although more recent studies indicate it may to some extent do this.

At this stage, oestrogen cannot be recommended for all women postmenopausally, as benefits must be weighed against side effects, but it would certainly be indicated if there were a strong family history or osteoporosis.

Exercise is important

Every woman should h.ave daily exercise other than, for example housework, driving car and shopping Have a programme of exercises and do them daily. Jog or play tennis. It will certainly benefit your bones as well as any symptoms, and also your general well-being. Bones become denser with the stress of exercise. Astronauts have been found to have softer bones when examined after landing and patients confined to bed for any length of time exhibit the same effect.

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WEIGHT LOSS: WHAT CAN YOU DO?

Simple measures Eat half what you do at the moment. Cut down what you know fattens you – refined carbohydrates such as sugar and starch. Fats too should be reduced.

Simple painless measures first Use non-saccharine artificial sweeteners for stewed fruit and beverages, and avoid sugar

wherever possible.

Skim milk to replace milk, however little milk you use, is beneficial. Skim milk is now available in containers from dairies and food stores in the cities (and in most country areas), and tastes very pleasant for those who dislike the powdered form.

Alcohol This not only supplies masses of calories, but weakens the will in many things, including whether you will stick to your planned diet or not. A good idea, if you can’t cut it out altogether, is to make a compromise: drink alcohol only when you are out, for instance at parties; or take half your usual intake. Better if, for a period, you can remove it altogether. Beware the additions to alcoholics drinks, for example tonic water is full of calories. Whisky and soda, or pink gins, are less calorie filled. Beer is out; it is loaded with calories.

Crash diets These are useful in the short term but only after consulting your doctor. Those which completely remove one element in your diet should be avoided; a balance is much safer. Go out and buy a calorie counter at your chemist so that you can see what you are consuming.

Diuretics ‘I accumulate fluid, doctor.’ Some women have this problem – though it is not as common as some believe – but draining yourself of fluids is not the way to reduce weight. There are certain things known to aggravate fluid retention:

• a high salt intake. Salt should be cut down and should not be added after cooking. Like your appetite for sugar, you develop a taste for it but you can gradually cut it back. You need it less and less, even on eggs. This salt reduction also helps your blood pressure.

• a highly refined carbohydrate diet is known to retain fluid so cut this down as far as possible

• smoking.

Diuretics should only be taken under the close supervision of your doctor. In my opinion diuretics will be needed less frequently if the simple measures above are adhered to.

Natural fibre Plenty of natural fibre in your diet is important, as indicated in the section below on constipation, and becomes more important if food intake is reduced. Those who have not been constipated before in their lives sometimes find constipation a problem if they are on restricted diets.

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