Dangerous blood clots (thrombosis), which may lodge in any part of the body, can occur after surgery. Risk factors for thrombosis include being overweight and heavy smoking. If a hysterectomy, myomectomy, or endometrial resection is not urgent, it should be deferred in women who are overweight and who smoke until they have taken off excess kilos and quit smoking.

Surgeons can also help prevent thrombosis during major surgery, such as hysterectomy, by artificially stimulating the calf muscles to contract during the operation. This does no harm. Another technique is to inject an anticoagulant, such as heparin, to reduce the clotting activity of the blood. This has the disadvantage of increasing the amount of bleeding that occurs during surgery, but is generally considered preferable to the formation of a blood clot.

Women having any form of surgery should be able to recognise the early signs of thrombosis in the legs or a blood clot (embolus) in the lungs. The middle of the calf may become tender at rest or sore when moved, or the ankle may swell. An embolus in the lung may cause pain on breathing, a dry cough, shortness of breath, and soreness or pain in the chest If any of these symptoms occur, it is important to tell your doctor or nurse promptly. An early diagnosis nearly always averts further problems.

Paradoxically, there is some evidence to suggest that women who smoke are less likely to have a hysterectomy. The reasons for this are unclear but it may be related to the suppression of oestrogen by some of the toxic components of cigarette smoke. It is presumed that smoking keeps the oestrogen required for fibroid growth under control.

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Progesterone is the hormone which maintains the pregnancy during the first few weeks. After the egg has been released from the ovary, the ruptured follicle then develops into the corpus luteum which produces progesterone. If the egg is not fertilised, after 14 days the corpus luteum withers, progesterone levels fall and a period occurs. If the egg is fertilised and the embryo implants successfully and starts to produce another hormone hCG (human chorionic gonadotrophin) then the corpus luteum gets the message to continue producing progesterone. Without sufficient levels of progesterone, the pregnancy cannot continue, and that is why anti-progesterone drugs are now used to terminate an early pregnancy without the need for an operation.

Because of this obvious link between progesterone and maintaining pregnancy, many doctors give progesterone as injections or pessaries to prevent a miscarriage. But Professor Lesley Regan, in her excellent book Miscarriage, states that ‘Injections of hormone, in the early weeks of a pregnancy at risk, may prolong the miscarriage but they cannot reverse it. Low progesterone levels in early pregnancy are the result rather than the cause of miscarriage.’

After the egg has been fertilised, the womb (endometrium) lining will also stay thick where the embryo will implant and develop. If the womb lining is inadequate, then the embryo will not ‘hold on’ and a miscarriage will occur. It is possible to have good levels of progesterone and yet have a thin womb lining, perhaps because the womb lining is not responding to the levels of progesterone. Other doctors, however, do give progesterone to women with a history of recurrent miscarriages and they have gone on to have a successful pregnancy.

Ultrasound can also be useful for those women with a history of recurrent miscarriages, as it can often pick up an indication of corpus luteum failure before any drop in progesterone level is seen in the blood. This is where the use of progesterone can be beneficial.

There are so many factors that govern the efficient functioning of the cycle that it is not always easy to identify cause and effect. Every part of the cycle is dependent on what went before so we may not be able to ‘fix’ problems in the second half of the cycle without looking at what has gone wrong in the first half. By going back to the basic foundations of health and getting yourself back into balance, you have a much better chance of maintaining a pregnancy without the need for hormones or other drugs.

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Some of the questions that you might like to ask your doctor include:

• Does the doctor have a partner who knows about you and can treat you if your own specialist

is unavailable?

• Can the doctor see you immediately if you have an urgent or serious problem?

• Will the doctor personally answer and return phone calls or will those phone calls be taken

and answered by a secretary?

• Are phone calls answered promptly; does your doctor receive messages to contact you when

Requested?

• Can the doctor be contacted out of hours?

• Will the doctor see you out of hours?

• Will the doctor read out to you the results of pathology reports or referrals, etc., or will the

results be given via the doctor’s secretary.

Getting the best from a doctor

To get the best out of your doctor you need to be well-informed and provide honest and accurate information.

In order to be well informed you should read about the menstrual cycle so that you understand how the cycle works, know about hormonal changes and their effect, and understand what endometriosis is. This can be achieved either by yourself or by your doctor suggesting reading material and other sources of information. You can also contact your local women’s health information centre.

It is important to recognize that your doctor is not a mind reader, and that it is up to you to tell her or him what your problems are so that your doctor can get an overall picture of your illness. Identify the major areas of concern for you – infertility, pain control, improvement of lifestyle.

It may be a good idea to keep a diary in which you can record your visits to your doctor and make notes of any side effects of drugs or surgery or other treatments suggested by your doctor and list questions for future visits.

Be honest about symptoms and make sure the information you give is complete, accurate and relevant. It is of no benefit to you to withhold information.

It is important to be able to talk openly to your doctor and to feel that you can discuss your needs and fears.

If you have concerns about the side effects of drug therapy, you should feel comfortable discussing these with your doctor. If you have printed information about drugs or treatment you want to discuss, take this with you to the appointment so that your doctor can comment.

Always report the positive as well as the negative feelings you may be experiencing.

Vital decisions and concerns such as marriage, sexual relationships, careers and children should also be discussed with your doctor since these make up the total picture.

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Some women have jobs that they find too difficult to manage during chemotherapy. If this is true for you, inquire about short-term disability, extended sick leave, or sick day banks. There is likely to be something that will help you financially if you decide to take a leave from work.

If you can possibly arrange to have a family member or close friend accompany you to your chemotherapy sessions, do so. Ask someone who has a calming, soothing effect on you; you need support and encouragement at this time, not additional anxiety or escalating fear. Depending on the time of day you schedule your treatments and whether you will be returning home or going on to work, you may want to have someone come with you who will also be able to drive you to the hospital and back home again. After your first treatment, you may decide that you want company for all your treatments, or you may decide you are more comfortable going alone. If possible, try to arrange to have someone go with you the first time. It will be helpful to have a companion who can support and distract you; you may also be very glad to have someone else contend with driving and parking.

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Adolescent daughters are likely to be worried about their own risk of breast cancer. Whether or not they themselves bring this up, you should do so. It is honest to be optimistic about their future health, and you should say so.

Reassure your children that they can continue to have friends come over once you feel up to the company. Tell them you will not embarrass them on purpose, but make sure that they tell their friends what to expect—for example, Mom may be wearing a hat/turban/wig while she is waiting for her hair to grow in. Mothers of adolescent boys in particular have told us many stories of endearing behavior centered around their parent’s baldness. If you are comfortable at home without anything on your head, it is likely that your children will be, too. You may find that your son’s friends make a point of rubbing your bald head as they say hello. We have even known a few sons who shaved their own heads in solidarity with their mother, and we heard of one son’s entire basketball team doing the same thing as a way of showing support.

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Many women find that during the first weeks or months of breast cancer, they are very interested in any treatment that might help them. Newly diagnosed women may embark upon an ambitious program of careful diet and other modalities of care. These same women oftentimes lose interest in these activities, decide that they do not wish to spend so much time, energy, and money focusing on cancer, and resume their usual life patterns and habits. Once again, you will find your own way and make choices that fit you and your life. Do not feel that, on the one hand, you must partake of multiple complementary therapies or that, on the other, you must avoid them all.

At the very least, it is worth knowing that these other therapies exist. If you like, you might consider how to use them as adjuncts to your medical care, once you have discussed these possible choices thoroughly with your physicians. Reserve the right to change your mind as time passes.

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So there may be an indication in the history, and more information can be obtained from physical examination. A doctor can perform a pelvic examination, which can help to identify any abnormalities or tenderness. Ultrasound is sometimes used to examine the organs in the pelvis. Sometimes cysts suggestive of endometriosis may be seen on ultrasound, but a normal ultrasound does not exclude it.

The real test for endometriosis is actually having a look. This is done via a laparoscope, and the technique.

Spots of endometriotic tissue may be seen inside the pelvis, where they should not be. There may be any amount—just a few patches, or the pelvis may be literally covered with the stuff. There might be cysts of it on the ovaries, or scarring and adhesions.

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