Health and medical information

Conservative laparotomy procedures vary and are changing all the time. The nature of your surgery will depend on a number of factors including the extent and location of your disease, your symptoms, your desire for future childbearing and your gynecologist’s training, experience and preferences.

The procedures, which will be performed as part of a laparotomy, may include any of the following:

• removal or destruction of implants and small cysts

• removal or destruction of large cysts and endometriomas

• removal of adhesions

• removal of an ovary or an ovary and fallopian tube

• removal of the appendix

• surgery on any other affected organs such as the bowel or bladder

• suspension of the uterus

• pre-sacral neurectomy or utero-sacral neurectomy

• any surgery necessary to correct other abnormalities found.

Implants and small cysts

Where possible any superficial implants and small cysts on the ovary and peritoneum will be removed or destroyed by cutting, cauterization or vaporization, provided that there is no danger to any underlying organs such as the bowel or bladder.

Large cysts and endometriomas

Any endometriomas will usually be removed by cutting them out. This often involves removing a small amount of the surrounding ovary as well to ensure that all the endometrial tissue is removed. Sometimes, endometriomas will be destroyed by puncturing them and then cauterizing or vaporizing their lining. Large cysts on the peritoneum will be removed by cutting them out.

Adhesions

Any adhesions will be cut, cauterized or vaporized and separated so that the normal positioning of the reproductive organs can be restored.

Ovaries

Sometimes an ovary will have to be removed because an endometrioma lying within it cannot be removed safely. Similarly, if one ovary and fallopian tube are severely diseased they may be removed, provided that the other ovary and tube are normal. The removal of an ovary and tube on one side does not seem to decrease the likelihood of pregnancy following surgery but does seem to reduce the risk of the disease recurring.

Appendix

Some surgeons routinely remove the appendix during a conservative laparotomy, especially if the endometriosis is extensive, but most will remove it only if endometrial implants are present.

Bowel and bladder

Most small implants on the bowel and bladder are superficial and can be removed or destroyed without any danger of damaging the underlying organs. If the implants have penetrated the wall of the bowel or bladder they must be carefully cut out and the affected area repaired. Occasionally a section of the bowel will have to be removed if the implants have surrounded and constricted it; if there is any possibility of this being done it is highly advisable that a bowel surgeon be on hand to assist.

Suspension of the uterus

Suspension of the uterus involves tightening or shortening the utero-sacral and/or the round ligaments in an attempt to hold the uterus in its normal position. This procedure is not commonly performed by gynecologists in Australia though it is quite common in America.

Presacral and utero-sacral neurectomy

A pre-sacral neurectomy and an utero-sacral neurectomy are two similar procedures which are only occasionally performed by gynecologists in this country, although they are performed much more commonly overseas. Both procedures involve cutting the nerves that transmit pain from the uterus to the brain. The same nerves are cut in both procedures but in the case of an utero-sacral neurectomy the nerves are cut closer to the uterus than is the case with a pre-sacral neurectomy. The two procedures are performed to relieve chronic pelvic pain but they are usually only effective for a maximum of about twelve months as by then the nerves have re-grown.

If you are contemplating a pre-sacral neurectomy or an utero-sacral neurectomy it is worth remembering that pain is one of the body’s warning mechanisms. If you cannot feel pain in the pelvic area you may not be aware that your endometriosis could be worsening or recurring. If you go into labour you may not be able to feel the contractions which signal the onset of labour. In addition, both procedures can occasionally interfere with normal bowel and bladder function.

Other

If your fallopian tubes are damaged or if you have any other disease or abnormality of the reproductive organs these will usually also be repaired.

*53 /41/5*

In a sense, automatic thoughts are just the tip of the iceberg. Lurking beneath the surface are some implicit rules by which the patient operates. These rules spring from deeply held assumptions, beliefs, and values.

Dr. Christopher Fairburn has come up with a list of the most common of these attitudes:

-”I must be thin, because to be thin is to be successful, attractive, and happy.”

-”I must avoid being fat because to be fat is to be a failure, unattractive, and unhappy.”

-”Self-indulgence is bad because it is a sign of weakness.”

-”Self-control is good because it is a sign of strength and discipline.”

-”Anything less than total success is utter failure.”

In therapy we bring these attitudes to the surface, analyze them, and challenge them. We try to discover both the advantages and the disadvantages of holding on to such beliefs. For example, there are reasons why people may base their feelings of self-esteem on their weight. After all, measuring weight and judging oneself accordingly, is a simple task. Weight is one thing about themselves that people can have some control over. Besides, gaining weight gives a good excuse for failure in other areas of life: “Of course no one asks me out; I’m a fat pig aren’t I?”

The downside of this attitude is that the patient will never be satisfied with her weight-and thus herself-for long. Focusing on weight distracts one from working on real problems in forming and keeping relationships. By concentrating on dieting, a person can avoid having to deal with issues of low self-esteem or other bad feelings.

In therapy we look for insight into how these attitudes arose. What influence did the patient’s family, friends, and social forces have on her thinking? When did these beliefs begin? How did they take root and grow? What else was going on in her life at the time the attitude started? One way to shed light on such questions is for the patient to talk to friends of long standing, or look at old family photos or diaries.

The desire to be in control often overwhelms the patient’s ability to think clearly. She believes that if she can’t control her body functions, such as hunger, menstruation, or sexual drive, then catastrophe will result. Such an attitude is one of the hardest to shake.

*78/35/5*

They say that a picture is worth a thousand words. For Julia Ferraro and her mother, Adelaide, a photo is worth 90 pounds.

This particular photo, taken in June 1997, shows a father, mother, son, and daughter, all smiling at their annual family picnic.

It s a moment frozen in time, a vivid reminder of when Julia and Adelaide each weighed 205 pounds. Both women are 5-feet, 2- ST inches tall.

“Each of us got a copy of the picture for Christmas that year. My mom and I cried when we saw it. That was the fattest we had ever been,” says Julia, 37, of Brooklyn, New York. “You know you’re getting bigger, but it doesn’t really hit you until you look at a picture of yourself.”

Instead of stashing the photo out of sight, Julia and Adelaide agreed to display it prominently in the front row of a table full of family photos. It gave them incentive to get serious about losing weight. Their first step was to join Weight Watchers the following February. Now, they attend classes every week.

Every day, Julia and Adelaide take a long look at that picnic photo. Since it was taken, the two women have lost a combined 90 pounds and five dress sizes. Julia, who’s 50 pounds lighter, went from a size 18 to a 12. Her mother dropped 40 pounds, shrinking from a size 18 to a 14.

Both women want to lose more weight, and they’re pleased to report that they’re well on their way. They’ve added a new photo to their tabletop gallery. This one shows a mother and daughter— slimmer and smiling.

WINNING ACTION

Showcase your “before” photo. Find a photo of yourself and keep it where you can see it every day—on your nightstand or refrigerator, for example. As you lose weight, take new photos and display them with your old photo. They’ll serve as visual reminders of where you started and where you’re headed in terms of your weight-loss goals.

*132\89\8*

The notion that menopause and depression are linked was a ‘fact’ commonly stated in medical textbooks well into this century. ‘They [menopausal women] are peevish, irritable, morose and depressed’, Emil Novak wrote in the classic 1923 text Menstruation and its Disorders. ‘The various psychoses of the menopause constitute an important group . . . Many [women] have full blown insanity with melancholia, paranoia and maniacal conditions.’

We can laugh now, but such views had a devastating effect on women’s lives. Many were placed in psychiatric hospitals for problems that could easily have had more to do with society’s weaknesses than theirs. Numerous recent studies have failed to confirm that depressive syndromes increase in middle-aged women. One of the largest studies, conducted by the US National Institute of Mental Health in the 1980s, found that women aged forty-five to sixty-four actually had significantly less depression than men in the same age group.

While fully developed depression is unusual at menopause, ‘feeling blue’ — or thunderously black — is quite common. It’s really hard to separate family stresses and things like financial problems from biological and psychological factors. For some women there seems to be a link between hot flushes, night sweats, insomnia, lethargy, and feeling decidedly depressed. If you are one of these, your cycle of sleeplessness may be broken if you get rid of the flushes with HRT. Even if you are sleeping well, you may find that HRT helps you to dispel uncharacteristically gloomy spells.

*111\38\8*

WOMEN WITH BENIGN BREAST LUMPS Most breast lumps are benign, and once they have been checked there is no special reason to avoid HRT. If examination of a lump shows any unusual cells or indicates that the growth of cells is abnormal, you are already at increased risk of breast cancer and the lump should be monitored carefully to pick up any change at an early stage. Regular monitoring of breast health by mammography, medical examination and self-examination of the breasts are vitally important.

WOMEN WITH ENDOMETRIOSIS This condition may be reactivated by oestrogen when treatment is started soon after menopause, especially if the menopause was surgical and the hormones are given in implant form. If a woman with endometriosis receives HRT, the patch or oral form of therapy is advisable. In theory the use of progestogen should help to keep the endometriosis under control in the first year after surgery, but this has yet to be confirmed.

*77\38\8*

There is some evidence to suggest that when progestogen is given for ten to fourteen days per cycle to women prior to menopause, it should be taken in phase with the existing menstrual cycle if it is still apparent. This helps to reduce the occurrence of breakthrough bleeding. The experience of Josie, who developed severe hot flushes at the age of forty-five while stiD menstruating regularly, illustrates the point. Her cycle length had always fluctuated around twenty-one days, and when she took progestogen for the first twelve days of each month she experienced repeated breakthrough bleeding that required investigation.

At first her doctor tried manipulating the dose and type of oestrogen and progestogen, but this did not help. Finally, her doctor twigged to the possibility that the bleeding problems could be due to the fact that the hormones her ovaries were still producing intermittently were not synchronising with the hormones she was taking on HRT. Josie was advised to take the last progestogen tablet on the day before the start of the next menstrual bleed she was expecting. Thus, with a twenty-one-day menstrual cycle, she took the progestogen from day nine to day twenty. This simple alteration resulted in much less breakthrough bleeding.

*42\38\8*

For most women menopause occurs between forty-eight and fifty-three, and it is usually preceded by a few years of changing ovarian function, including an end to the release of eggs (ova). Women may view it as ‘one of nature’s design faults’ or ‘a blessed relief from periods and pregnancies’. Each ovary of a newborn baby girl contains about a million immature eggs. Up to five hundred eggs develop to full maturity between puberty and menopause and are released from the ovary in the process of ovulation. No one is sure why the remainder degenerate, nor is it clear what triggers the sex hormone shifts and the stop-starts in ovarian function signalled in the years before menopause by altered bleeding patterns.

About the only certainty is that menopause occurs when the number of eggs in the ovary falls to a critical level.

*8\38\8*

Another potential cause of diarrhoea is the natural laxative effect of some fruits. Prunes, rhubarb and figs are well known for such properties, but other fruits can have similar, if milder, effects, and so can avocado pears. Eating too much of foods such as these may produce diarrhoea in the susceptible person. Eating beans, lentils, chickpeas or other legumes can also cause problems, especially if they have not been properly cooked. Shellfish are another common cause of diarrhoea – they quite often contain toxins that are not destroyed by cooking.

These are common reactions to food, or to food contaminants, which anyone might have. In food intolerance, there is a more specific reaction to one or more foods, which do not produce diarrhoea in most people. The sort of diarrhoea caused by food intolerance is likely to be fairly mild, although with occasional more acute attacks, perhaps in reponse to a change in diet, or to stress. There might also be periods when the bowel reverts to normal function for a while, or brief episodes of constipation. Opinions vary, but some doctors would classify this sort of chronic diarrhoea, without any pain, as a form of irritable bowel syndrome. It is therefore dealt with below, under that heading.

*138\180\8*

As I have said before, sleeping far into the day does not compensate for those hours lost before midnight. An old rule of country folk says: ‘One hour of sleep before midnight equals two hours after.’ This is no delusion but a fact confirmed scientifically, and one that anyone can prove to himself over a two-week period, by going to bed when the sun goes down and getting up when it rises. He will find his nerves have become regenerated and his general health and vitality greatly improved. A clinical experiment carried out for one week produced interesting results. One person went to bed every night at midnight and slept for twelve hours until midday, while another slept from seven or eight o’clock in the evening until four or five o’clock in the morning. Even though the second person slept three or four hours less than the first one, it was found that he was more refreshed, more rested and in better physical shape. This was obvious proof that hours spent in rest before midnight are far more beneficial than the hours after midnight, since they recharge the system with energy more effectively.

Natural sleep is a simple and easy way to help the body stay strong and healthy. All that is needed is a little willingness, a little determination and perseverance.

*1214/28/1*

People who live in the desert keep themselves fit in spite of the continuous heat and we would do well to learn from them and imitate their habits and customs. Since not only hot beverages are important but also the way they dress, we might try comparing their ideas to ours; in so doing we will be surprised to find that the desert people do not at all agree with our custom of wearing light clothing when it is very hot. On the contrary, in the desert they wrap themselves in loose woollen robes that are more like cloaks and keep their heads covered. Watching these people you can see that they feel comfortable and seem to suffer much less in the intense sunlight than we do when wearing tight clothes or swimwear. The loose robes protect the Bedouins wonderfully and we obtain the impression that they do not perspire. We give much too little thought to the fact that the sun’s intense rays are extremely damaging to anyone who has not sufficiently adapted to them. There is the danger of sunstroke, and sunburn can set off permanent or prolonged damage to the peripheral nerve and vascular systems.

The Bedouins do not feel the need to lie around motionless in the hot sun for hours on end; they do their work and moving around early in the morning or in the evening. We can also take a look at animals and their habits to see whether such exposure is beneficial. In fact, no animal, domestic or wild stays in the direct sunlight when it is hot, preferring instead to seek a shady spot or half-shade.

*1145/28/1*