WOMAN'S HEALTH:
| SEXUAL DISEASES | CONTRACEPTION |
Our Practice provides full contraceptive services to all age groups and emergency contraception 7 days a week.
All the Partners have the Family Planning Certificate and are capable of undertaking insertion of IUCDs (coils).
The choice of contraception is very much a personal matter, although your doctor will offer you specific guidance as to your circumstances.
Barrier methods, notably the condom, are strongly advised in addition to taking the Pill where there is any doubt about the sexual history of the partner. Barrier methods, as well as providing a reasonably effective contraception, also prevent the transmission of infections between partners. In the younger age group there is a considerable risk of contracting infections if barrier methods are not used. These include chlamydia, which often remains undetected and is later associated with pelvic infection and subsequent infertility. The wart virus, which is not necessarily related to external warts, is significantly associated with development of cervical cancer and is to a large degree prevented with condoms. Other diseases include gonorrhea, syphilis, hepatitis B and the HIV virus.
PRESCRIBING TO UNDER 16s
Doctors will provide information and contraception to those under 16, which has been established by the 1985 House of Lords ruling in the Gillick case. The prescribing of such contraception is applicable providing the doctor feels that the patient is capable of understanding the nature and possible consequences of the procedure and includes the potential risks and benefits of contraception. The doctors normally encourage minors to discuss contraception with their parents, however, in practise this does not often occur and the rights of confidentiality remain just as strict respecting the patients confidence as if the patient were over 16.
METHODS OF CONTRACEPTION:-
EMERGENCY CONTRACEPTION
Emergency contraception is available in two forms. Most commonly this is using the 'morning after pill ' which is a high dose progesterone pill ( Levonelle2 ) effective up to 72 hrs following uprotected intercourse ( It is however most effective in the first 24 hours). It is available from your GP, Family planning clinic and recently from the Casualty department. It is strongly advised that you attend the Health centre at a later time to receive on going contraception.
The other emergency contraception involves inserting a coil , and offers the only real advantage of effectiveness up to 5 days following unprotected intercourse.
THE COMBINED PILL
The combined pill contains an oestrogen and a progesterone in varying amounts, which suppress the menstrual cycle. As it is designed in 21 day packs it results in a regular withdrawal bleed on a monthly basis. It is the most effective and safe form of reversible contraception available, although it must often still be used in conjunction with a barrier method. Although there are minimal risks to taking the Pill it is still considerably safer for a sexual active woman to be on the Pill than take the risks of less effective contraception, which may result in risk and complications of pregnancy or termination.
When stating the Pill for the first time it should be started on the first day of the menstrual cycle and. continued until the end of the packet, restarting again after the 7 day break. The exception being the "Every Day Pill" normally ending in the word ED. It is essential that no more than 7 days elapse before restarting the Pill.
REASONS FOR PILL FAILURE
1. Extending the Pill free week.
2. Missing Pills.
3. Failure to extra precautions during episodes of either diarrhoea or vomiting.
4. Failure to take precautions for up to 7 days following a course of antibiotics.
If you forget your Pill and it is less than 12 hours, providing you take the Pill immediately there is no need to worry.
If, however, it is over 12 hours it is essential that you still take the Pill, but then use extra contraceptive methods, such as condoms for the next 7 days. You should then look at your packet of Pills to see how many more pills are left in the packet, if there are 7 or more pills, then finish the packet as usual . However, if there are less than 7 pills in the pack you must finish the pack and start the next pack immediately, without a break.
If you develop any of the following you should see your doctor immediately :-
1. Sharp chest pains, particularly on breathing.
2. Painful or swollen legs.
3. Breathlessness or coughing up blood.
4. Increasingly severe migraine episodes.
5. Slurring of speech, weakness or pins and needles or your arms and jaundice (going yellow).
Side effects are more common if you are overweight, you smoke or your have a family history of a thrombosis.
If you are going into hospital for an operation it is important that you stop the Pill at least 6 weeks beforehand and take adequate contraception.
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THE MINI PILL
The Mini Pill is a progesterone only Pill, it does not contain oestrogen and, therefore, does not have any of the risks of clotting in the veins or thrombosis and it is, therefore, safer for older women and women who smoke. It is, however, not as effective as a contraceptive. Between 1 and 4% of women taking this in a year will become pregnant. It is, therefore, more effective
over the age of 40 as the fertility declines.
The progesterone works by thickening the cervical mucus and, therefore, preventing sperm entering the uterus. It does not prevent ovulation.
Its main disadvantages are that it does not regulate the cycle in the same way as a Combined Pill and it is common to have irregular bleeding or spotting, which may need to be assessed if this continues for more than 3 months. It is also essential to be vigilant on taking it. It must be taken at the same time of day and no more than 3 hours late from the time it is normally taken. However, if the Mini Pill is missed extra precautions are only required for the next 48 hours after it has been recommenced.
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INJECTABLE CONTRACEPTIONS
These injections, normally using Depo-Provera, are given every 3 months and act in the same way as the Mini Pill, although they are far more effective in that they stop ovulation. The failure rate is approximately 1 per 100, or 1% failure per year. The Depo-Provera must be given every 3 months and it is essential that the injection date is not missed. It is ideal for those women who find it hard to remember to take the Pill regularly and need a reliable form of contraception.
Its main disadvantage relates to a potentially delayed fertility for up to a year following the injection, so it is not ideal for those couples wishing to start a family imminently. Occasionally there are reports of weight gain, headaches and in the initial stages bleeding irregularities. These usually settle or the periods cease completely after several injections.
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INTERUTERINE DEVICES
These are small devices approximately one inch in size that are inserted into the uterus by your GP, which prevent the implantation of the pregnancy into the uterus. They are a reasonably reliable form of contraception having a failure rate of between 1 to 3 per 100, or 3%. Although they do not prevent pregnancies in the fallopian tubes [ ectopic pregnancies ] .
There are two form of IUCD , the traditional copper containing IUCD , and more recently the hormonal IUCD called the MIRENA . The copper containing IUCD are used for general contraceptive purposes , whereas the Mirena , is used specifically to reduce menstrual loss often creating an absence of periods ( amenorrhoea ) . It is probably more effective as contraceptive with a lower risk of ectopic pregnancy. IUCDs, or coils, are ideal in women who have had pregnancies, as they are tolerated better, and there is less risk of sexually transmitted diseases. There is a small risk of pelvic infections and it is noted that the periods are frequently heavier and more painful with the traditional IUCD although these do improve with time.
The IUCD has the advantage that once inserted and tolerated it lasts for up to 5 years before it needs replacing.
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DIAPHRAGMS OR CAPS
A diaphragm is a rubber barrier device that is inserted in the vagina over the cervix (the neck of the womb) to prevent sperm reaching the uterus. It must be inserted before intercourse and then removed 6 to 12 hours later. If it is used correctly with spermicide there is a failure rate of 2% per year. However, it does require some practise to use it appropriately.
It does, however, have the benefit of preventing sexually transmitted diseases and reduces the risk of developing cervical cancer, since it prevents sperm coming into contact with the cervix.
Caps can be fitted by either your GP or our specially trained practice nurses.
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More extensive contraceptive advise is available from this excellent
site
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(Thinning of bones)
What is it? Bone is made up of two types of tissue. First there is a protein network which forms the structure for the bone. Secondly, there are calcium salts which are deposited and reinforce the protein network and give the bone its strength. Osteoporosis is a condition where both the protein network and the Calcium salts are deficient. This makes the bone softer. There may be very few symptoms until about one-third of the bone strength is lost. Then pain occurs due to distortion and fracture of the bone. It is usually in the spine, which carries the major weight load. One or more vertebrae of the spine may collapse completely, giving acute pain and later shortening of the spine. The deformity is responsible for some cases of so-called dowager's hump. Wrist and hip fractures are more likely to occur, especially in patients beyond the age of 65. They are mostly brought about by a minor fall or injury, which alone would not cause fractures in otherwise healthy people.
· How does it occur? Osteoporosis is a gradual process which probably starts at least
20 years before the first symptom appears. It may result from generally poor diet, especially
one which is low in Calcium. It may also come from long periods of bed-rest, such as might
occur with severe or prolonged illness. The pull of muscles, in ordinary body movements and
particularly regular exercise, is now known to be an important way of keeping bones strong. Most cases result simply from ageing. From the age of 35, most people have a gradual reduction in their bone strength. It is the strength of bone at this age which partly decides whether the bone loss which occurs with ageing will lead to serious bone thinning or not. Some people lose bone strength (Calcium) faster as they age; others lose much less. The sex hormones protect the bones to some extent from this ageing effect. For this reason, after menopause, women lose bone rather more rapidly than they did before the menopause. They also lose bone faster than men. It is therefore post-menopausal women who are at greatest risk from osteoporosis.
A menopause which occurs earlier than usual (as, for example, after removal of the ovaries and womb) is particularly likely to result in osteoporosis. Some disorders, like multiple myeloma, overactive thyroid and overactive parathyroid glands, can also produce general thinning of the bones. These are comparatively uncommon, but important to identify. These causes are treated by correcting the underlying condition.
· Why does it occur? There appears to be no regular hereditary factor. The two things which lead to "common" osteoporosis are a reduced bone strength at the peak of maturity (approximately age 35), and the rate at which Calcium is lost from the bones during the next 20-50 years. Negroid are less likely to get osteoporosis than either Caucasians or Asians.
· What does treatment/management involve?
DIAGNOSIS Once pain or a fracture occurs, doctors set about working out why the thin bones occurred. Tests are done to try to find a cause. Sometimes it is obvious (for example removal of the ovaries at the age of 35). Other blood and urine tests may be needed. The density of bone can be measured using either special x-ray systems or radioactive isotopes. Occasionally, a piece of bone (biopsy) is taken from the hip. Analysis may help to assess the severity and the cause of the problem. Doctors are always careful to exclude osteomalacia. This is another cause of "thin bones" which can be treated by giving vitamin D tablets.
TREATMENT Once osteoporosis occurs, it is hard to restore the strength of the bone. It may however be possible to stop further worsening. Newer forms of x-ray and isotope screening make it possible to pick up 'thin bones" before they cause symptoms, so that treatment can reduce the likelihood of further bone loss (and fracture). Once symptoms have occurred, a high-calcium diet is advised. Sometimes, additional calcium tablets are given on a regular basis. You will be urged to keep up or develop regular exercise like walking and swimming. These are known to help push calcium back into the bones.
Giving sex hormones (hormone replacement therapy: HRT) to women is now known to slow down (but not totally prevent) the bone loss of ageing. The closer it is begun to the time of menopause, the more protection it gives. It is not known how long this treatment should continue. Other types of hormone (called anabolic steroids) are used in some patients. They are given either by tablet or by injection. Other forms of treatment are being developed. A new group, called biphosphonates, are already showing promising effects on strengthening bone. .\t the moment it appears that prevention and early detection are the best approaches.
What to watch out for during treatment Changes in symptoms are never dramatic whatever the cause or treatment. Some patients incorrectly stop their treatment, just because they cannot feel the benefits of it. HRT is usually safe, but in excessive dosage can lead occasionally to blood clots or to high blood pressure. Calcium-containing medicines are usually without side-effects. Anabolic steroids may produce abnormal hair growth in women.
· What to watch out for after treatment Further fractures and pain may occur. If these involved the spine, it may be helpful to have some form of spinal support or corset.
What would happen if the condition was not treated? There is no definite proof that patients who already' have symptoms are necessarily worse off as a result of not being treated. Only some patients seem to benefit. Osteoporosis without symptoms at the time of diagnosis is likely to produce symptoms later in life if HRT is not given. It is likely that picking up the condition early is the only way to deal with the problem.
What is involved for family and friends? Chronic pain is always a heavy burden on people close to the patient. They will need to be understanding and provide regular support and help.
Self-help group
National Osteoporosis Society, P0 Box 10, Barton Meade House, Radstock, Bath BA3 3YB. ~ 0761 32472
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A cervical smear is a simple procedure which involves painlessly taking a few cells from the end of the cervix in order to analyse early signs of the development of cervical cancer. The cervix is the neck of the womb, or uterus and can be affected by the development of cervical cancer. This is an extremely preventable condition if detected early with cervical smears but if left undetected, is the cause of approximately 2000 deaths in England and Wales many of which are in the younger age group.
The great advantage with cervical smearing is that it detects cells which gradually change from normal to abnormal over a period of 5-10 years so the detection and treatment involves treating a premalignant condition thereby entirely preventing the cancer developing. This is unlike many other screening tests like breast screening.
Screening is undertaken routinely every five years ideally from the age of 20-65 in women who are sexually active. It is important to commence screening one year after being sexually active and therefore the first smear may be applicable in some women at the age of 17 or younger.
Cervical cancer normally occurs in women who are sexually active and is probably due to the transmission of certain wart viruses that go undetected until these are found on a cervical smear. It is therefore important to use barrier methods as much as possible to additionally reduce the risk of cervical cancer.
Smear results are either returned as normal or showing changes which cause a great deal of concern but merely represent a cellular change in the appearance of cells which may or may not revert back to normal cells. For this reason mildly abnormal changes merely require a repeat smear at shorter intervals and do not in themselves pose any great risk. If there are serious cellular changes then your doctor will refer you for an examination by a consultant in Exeter who will perform colposcopic treatment under local anaesthetic to remove the abnormal cells there by preventing cervical cancer.
It is very important therefore that you do not delay in having a smear performed as it only takes a few minutes of your time and could have considerable benefits.
Smears are undertaken by all our practice nurses or by your own doctor which can be done in between your menstrual period when you are not bleeding.
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HORMONE REPLACEMENT THERAPY ( HRT )
HRT is supplementary oestrogen in the form of oestradiol. The preparations provide a maintenance of the natural oestrogen levels when the ovaries fail around the menopause, in doses of only l0-20% of that of the contraceptive pill but with few of the pill's risks. HRT can be initiated before the periods cease and continue for up to 5years.
Benefits
I. Prevention of hot flushes, mood swings, dry vagina and altered libido.
2. Prevention of osteoporosis. HRT is an effective method of preventing osteoporosis, however advice from December 2003, is that is should not be used soley for this purpose. HRT leads to an increase in bone mineral density for the duration of use which on stopping declines at the previously rate. At 5 yrs of use a 70 yrs old lady would therefore have the bones of a 65yrs old and be less likely to sustain a fracture of the spine, hip or wrist.
3 There is a slight reduction in the risks of Bowl Cancer.
Disadvantages
1. Breast Cancer.
It is well known there is a link between oestrogens and breast cancer, there is a slight increased risk in women who start their periods early, and continue for longer. Additionally there is a slight risk of uterine and ovarian cancer.
The recent UK Million Women Study has again shown a link with breast cancer. The Lancet 2003 ;362:419
The background expected Breast cancer risk in women aged 50-65 is 32 /1000 women.
On oestrogen only this rises to 33.5/1000 at 5yrs and 38/1000 at 10yrs.
On Combined HRT 36/1000 at 5 yrs and 51/1000 at 10yrs.
2. Thrombosis It has now been clearly shown that there is a doubling of the risks of thrombosis or blood clot; but this is only really relevant with patients either having had a previous clotting episode or those with a very strong family history of such. More concerningly is that there is also an increase in Heart Attacks which was previously thought to be reduced.
HRT is therefore appropriate for the management of menopausal symptoms, but it should be used for the shortest duration ideally not longer than 5years. It is appropriate in women who experience a premature menopause up to the age of 50. HRT should now not be used solely for osteoporosis prevention. Further information is available from http://www.mhra.gov.uk & http:// heads.medagencies.org
This information is based from the circular from the chief medical officer 3/12/03 as a result of the Million women study and the womens Health Initiative and is based on the European and UK experts.
References Risk and Benefits of Estrogen plus progestin in healthy post menopausal women JAMA 2002; 288:321-333. http://www.jama.com Breast cancer and hormone replacement therapy in the Million Women Study. Lancet 2002; 362:419 http://www.thelancet.com
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DEPARTMENT OF G.U. MEDICINE Heavitree Hospital . Exeter. 01392 405220
Free , confidential advice on all sexual matters, and sexually transmitted diseases.
HIV Testing , and Hepatitis B Vaccinations
Safe Sex Information and Free Condoms.
PLEASE RING FOR AN APPOINTMENT::CLINICS MONDAYS, WEDNESDAYS AND FRIDAYS
( This is a really excellent site for details of Sexually transmitted diseases )