Any woman on the Pill should come off it a month before surgery, substituting a non-hormonal method of contraception, such as a condom or diaphragm in the meantime. Women who smoke should stop at least a week before a hysterectomy. They should also consider a permanent break from smoking as their risk of heart disease and osteoporosis is likely to increase as a result of the surgery, and smoking will increase this risk still further.

A GnRH agonist may be prescribed prior to surgery in a bid to reduce the size of any fibroids a woman may have. When this approach was systematically studied in 142 women, only half of whom received a GnRH agonist, the results were encouraging. The surgery was less likely to be difficult in the treated women who also experienced significantly less blood loss on average. It has been suggested that the beneficial effect of GnRH agonists is due partly to their ability to shrink fibroids and partly to their reduction of uterine blood flow.

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Our homes are full of devices which emit electromagnetic radiation, including televisions, radios, mobile phones and microwave ovens.

Here are some simple tips to reduce your exposure to radiation at home:

• Don’t use an electric blanket which can stay on all night. Apart from the electromagnetic radiation, it can also be too hot for the man’s sperm. It is better to heat the bed up first and then switch it off. Better still, use an old-fashioned hot water bottle.

• Position electrical alarm clocks and radios so that they are not right next to your head while you are sleeping.

• Keep a good distance away from televisions and VDUs.

Mobile Phones

To reduce the risk from mobile phones:

• Keep use of your mobile phone down to a minimum and use a landline whenever possible.

• Buy a separate mike so that the handset is not next to your head.

• When the phone is being carried, or if you are using a mike, keep the handset as far away from your body as possible. I regularly see men carrying a mobile phone in their breast pocket right over their heart.

Microwave Ovens

What you can do:

• Think whether you really need to use a microwave oven at all.

• If you continue to cook with a microwave then do not stand directly in front of the oven, especially if you are pregnant.

• Have the oven checked periodically for leaks.

• Never open the door when the oven is on.

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The decision whether or not to have your ovaries removed is an extremely complex and difficult one because at the present time there are no clear answers regarding the pros and cons of removing or retaining the ovaries.

Some gynecologists routinely remove the ovaries in women with endometriosis; others base their decision on the extent and severity of the woman’s disease and her age, while still others routinely retain them except under special circumstances.

It is extremely important that you find out what your gynecologist intends to do and that you make your decision perfectly clear as to whether you want your ovaries removed or retained.

If you retain your ovaries you will not undergo a premature menopause but there will be a greater likelihood that your endometriosis will persist or recur. Unfortunately, it is not known how often endometriosis persists or recurs following a total hysterectomy: the few statistics in the medical journals range from around 10% to 85%.

Many gynecologists believe that the ovaries should be retained in the majority of cases as they believe that the risk of recurrence is low and the risks of a premature menopause are considerable.

If your ovaries are removed you will undergo a premature menopause and have less likelihood of having a recurrence of endometriosis because it does not recur if you do not produce oestrogen. It is estimated that as few as 3% to 5% of women will have a recurrence if their ovaries are removed. The unusual cases where endometriosis recurs following a radical hysterectomy are usually due to the fact that a piece of an ovary was left behind because the gynecologist either could not see it or could not remove it safely.

Surgical menopause – menopause due to the surgical removal of the ovaries – is usually more severe than the natural menopause because it occurs instantaneously in a younger woman whose hormone levels are higher. The drop in the hormone levels is both dramatic and sudden and many women will experience significant symptoms as a result.

Most women will experience the early symptoms of the menopause soon after their surgery – often within 24 to 48 hours. The most common early symptoms are hot flushes and night sweats. Some women will also experience tiredness and lethargy and sometimes depression, particularly if their hot flushes and night sweats stop them sleeping.

After a couple of months most women will start to experience some of the other effects of menopause. These include a dry vagina, which may cause painful intercourse, a change in sexual response, decreased libido and decreased breast size.

The main long-term effects associated with surgical menopause are a substantially increased likelihood of developing heart disease and osteoporosis later in life.

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Palpitations and heart thumps

Palpitations (bursts of rapid heartbeats) are another common symptom at this time and are not a sign that you are about to have a heart attack. Alcohol and smoking aggravate them. They settle with relaxation and removal of the hot flushes. Some may persist and cause more discomfort, and these may be treated further. Heart thumps (extra systoles) may appear first at this time, particularly when lying down after a heavy meal, after alcohol or aerated soft drinks, or smoking.

Emotional problems

There are many women who suffer from emotional change

There is a variety of explanations for why this occurs, but I do

not entirely agree with some psychiatrists’ views of the causes of the depression which is occurring as a flrst-up symptom in this age group of patients, that is those who have not been depressed either repeatedly or deeply before in their lives. I think this is because I see a different group of women. Psychiatrists see the more deeply depressed women.

I see women who come through the door and who have had no past history of depression and say ‘I’ve never felt like this before in my life. I am irritable and nasty with my family and husband and furthermore I know I’m doing it. I am over anxious. If I have to do something unexpected I am unable to cope with it.’ The psychiatrists state there is a mid-life crisis in both sexes. In addition the women get an extra hormonal thump, which produces added symptoms.

Real physical reasons

The patients I see have real physical reasons for being depressed — they are concerned about their state, their inability to control their flushes and, in addition, their change in sexuality. There are definite changes in the cells of the vagina and this may well affect comfort with intercourse. There may be a drop in libido at this time. In addition, some women are simply short of sleep due to the insomnia that occurs at this period. However, I feel we should look at the theories put forward for the reasons for depression at this time.

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Many women feel a sense of loss and guilt when they experience a loss of libido and this can contribute toward depression at the time of the menopause. This is particularly so when they have had a good sexual relationship with their partners.

While sexual intercourse improves relationships it is not the only factor. Many couples in their later years find that mutual respect, and the shared experiences of surviving the various ups and downs of life produce bonds that perhaps substitute for the loss of sexual experience. This is obviously a personal state of affairs which every couple must work out for themselves. It is important that those women who do not feel the same sexual desires that they felt in their youth do not feel they have nothing left to offer their partners. There is pressure within the community to have women believe that unless they are having intercourse into their seventies they are just not ‘with it’.

Change in attitudes

With the alteration of women’s self-image, and the change of attitude of society about their place, following reproductive failure, they and their partners are altering their expectation of this time of their life. Early surveys in our clinic obtained false information in this area until it was realised that women were uneasy about discussing personal sexual problems unless directly asked.

Standard menopause assessment and indexes, derived twenty-five or more years ago and still used to score symptoms, did not include libido or comfort with intercourse. This has changed. In many cases today, these features are the presenting symptoms, or the main reasons why many women have attended our clinics.

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After the clinicians meeting it was felt that the benefits of replacement therapy for women still outweighed the possible side effects; furthermore such problems had been rare in our clinics. In eleven years in a busy clinic at Prince Henry’s Hospital, we have had only one case of hyperplasia and no cases of cancer of the endometrium. We investigate all women with irregular or excessive bleeding and refer them to gynaecologists, so it is unlikely that we would miss one.

If oestrogen is given in excessive doses, taken continuously or if progestogen is not given with it, conditions may be set up which may lead to cancer in certain women. But progestogen produces a period, thereby clearing out the lining of the uterus so it does not get abnormally built up by the constant stimulation of the oestrogen.

Oestrogen is like any other therapy; all patients must be assessed individually. It should not be withheld from those who need it, nor should it be used indiscriminately. We have definite rules and routines of therapy in our clinics, worked out in the interests of women’s safety and based on work done in much larger population studies than we can do in Australia. These will almost certainly be the views of any conservative, well-informed doctor you consult.

Hormones are only given to relieve symptoms, that is we do not follow the practice used some time ago, of giving oestrogens to all women after the menopause.

Not all women will take oestrogen. The endocrinologists who helped me set up the clinics in the first place had told me that if I wanted to give women oestrogens I would have to sell them back their periods or I would run into problems. How right they were. To those women who say, ‘But I don’t want my periods back’, I can only reply, ‘You can’t have your cake and eat it. You can’t have the hormones of your youth without the disadvantages if you want to take it safely.’

The benefits must be weighed up against the risks. We have regular guidelines:

• we use the lowest dose which relieves symptoms.

• the oestrogen is never given without regular administration of the other hormone, progestogen (present in the monthly cycle when young), following which a small bleed often occurs.

• every year we wean patients off therapy over a month or so, and then remove therapy altogether to see if symptoms return and whether or not they need further treatment.

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Probably many factors are involved. One is the loss of hormones after the menopause. Exercise and diet are also important. Oestrogens are known to help in calcium retention and bone

formation, just as the male hormone, testosterone, does in the man. Women lose their hormones more suddenly, while male hormones taper off gradually into old age Osteoporosis in men, therefore, only seems to have become important in a much older age group. Some studies have suggested that oestrogen reduction in the body is in some way responsible for osteoporosis, and the fact that osteoporosis starts at the menopause certainly seems to confirm this. Galiagher and co-workers found that postmenopausal women lose calcium in their urine while they sleep, and they found that this could be totally reversed by the administration of daily oestrogens, an effect that was detectable within two weeks.

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There is no doubt that women tend to put on weight at this stage of their lives. It is due to many factors.

A change in metabolism Some women say ‘I hardly eat a thing’ or ‘I have not changed my intake.’ I believe every word of it, but if your weight is increasing, your intake is too much for your metabolism at this stage. Some women need to cut their intake to less than half to maintain their previous weight.

Less exercise Less exercise and a more sedentary existence sometimes creep up particularly for women who are not working outside the home. Children have left home, there is less housework and shopping to do, and you may also have given up your weekly game of tennis.

More leisure More leisure and increased alcohol consumption are likely, particularly when there is less call on your purse; you may be out playing bridge and eating afternoon teas, having a drink before dinner, etc – it all adds up. Whatever the cause, straighten yourself up.

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