CONTRACEPTION AND THE MENOPAUSE: STERILISATION
The principle of sterilisation, of which hysterectomy is an extreme form, is to disintegrate the Fallopian tubes so that the egg cannot be fertilised by sperm. As the ovaries are not touched, menstrual periods continue until the natural menopause. When ovulation occurs, the egg travels down the tube as far as is possible, then dies and gradually dissolves.
Sterilisation is a highly reliable form of contraception, and in both the UK and the USA it is the first choice of women over 35.
Whatever method of sterilisation is used, none will affect the menstrual cycle or the sex life. However, it is not recommended for women who have had a recent abnormal cervical smear or for those with any uterine or ovarian disorder.
Sterilisation must always be regarded as irreversible, because although, depending on which technique was used, a reversal operation might be possible, this is both complicated and prone to fail; moreover, there is no guarantee of conception subsequently.
The various types of sterilisation procedure are laparotomy, minilaparotomy, laparoscopy and vaginal sterilisation.
Laparotomy
Also known as tubal ligation (having the tubes tied), this is not a serious operation but it does require a general anaesthetic and a short stay in hospital. A small cut (5-8 cm) is made across the abdomen, usually just below the pubic hairline, the tubes are brought to the surface, each is tied in two places, and the short length of tube between the ties is removed.
Minilaparotomy
This is similar to a laparotomy, but the incision made is shorter. The uterus and tubes are pushed, by a special instrument inserted into the uterus from the vagina, towards the opening in the abdomen so that the tubes can be tied. This procedure can be carried out under local anaesthetic and is likely to cause less discomfort than a laparotomy.
Laparoscopy
A laparoscope (like a very narrow telescope) is inserted through a 1-cm cut just below the navel and a second cut made lower down to facilitate the tying of the tubes. This is the quickest and simplest method, usually performed under a local anaesthetic and likely to cause the least discomfort.
Vaginal sterilisation
Entry is via the vagina under general anaesthetic and the procedure is irreversible. This procedure is little used now.
All these types of sterilisation carry a small degree of risk, either from the general anaesthetic, if applicable, or from accidental damage to an organ or blood vessel during the operation. Subsequent complications are rare but could include bleeding, raised temperature, severe pain in the abdomen or uterus, and difficulty in urinating. Occasionally the ends of a tube may grow together again, bringing risk of pregnancy; about 10-20 per cent of such pregnancies turn out to be ectopic.
There is some evidence that the sterilisation procedure gives rise to heavier periods, and an increase in PMS symptoms of up to 30 per cent. These are thought to be due to an upset in the balance of ovarian oestrogen/progesterone hormones caused by nerve and prostaglandin alteration after tubal surgery, and alteration of blood supply. Research into this matter continues.
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TYPES OF HRT AVAILABLE: WHAT IS THE RELATIONSHIP BETWEEN THE OESTROGEN DOSE AND THE LIKELIHOOD OF WITHDRAWAL BLEEDING BEING ESTABLISHED?
Little information is available to address this question. It is stressed that withdrawal bleeding will only occur if the oestrogenic stimulus is sufficient to cause endometrial stimulation, and if the progestogen is administered at adequate daily dose and for sufficient duration . Assuming that the latter criteria are fulfilled, it is to be expected that the percentage of women experiencing withdrawal bleeding will rise as the oestrogen dose is increased. In our experience, almost all patients receiving oestradiol implants experience withdrawal bleeding, and this most probably reflects the more than adequate plasma oestradiol levels achieved with this form of therapy. With conjugated equine oestrogens 0.625 mg/day (or an equivalent such as transdermal oestradiol, 50 mg/day), approximately 85% of women experience withdrawal bleeding: the remainder do not. The absence of bleeding is not a cause for concern and endometrial biopsy is not indicated because of amenorrhoea. The lack of bleeding in this minority most probably reflects the wide inter-patient variation in plasma oestradiol values achieved with all therapies .
Few data are available with lower doses administered systemically, such as transdermal oestradiol 25 mg/day. In our experience, approximately 50% of patients experience withdrawal bleeding with this dose when a progestogen is added.
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NUTRITION BEFORE PREGNANCY
The young woman who is in good health prior to conception and who maintains good nutrition has the best chance of a pregnancy without complications, a healthy baby, and the ability to nurse. During early pregnancy, often before the woman is even aware that she is pregnant, critical development of the fetus takes place.
Two of every five first babies are born to young women under 20 years of age. These young women must still meet the growth needs of their own maturing bodies as well as the nutritional demands of the fetus. Yet, girls in their teens have, far too often, had diets that were inadequate in calcium, iron, and protein. Pregnant girls under 17 years are in an especially high risk category. They have more frequent complications of toxemia, anemia, and long difficult labor. Babies born to them are more often of low birth weight and have a higher rate of neonatal mortality. Repeated pregnancies before age 20 place both the young woman and the unborn child in an extremely high-risk category. Black women are more vulnerable than white women, probably because of their reduced income and consequently poor diets.
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