INTERSTITIAL CYSTITIS (IC) OR PAINFUL BLADDER SYNDROME

This is a poorly understood condition, which millions of people suffer from around the world. Two thirds of these are women.  Here we will focus mainly on women. They suffer from pain in the bladder area (that is why it is also called bladder pain syndrome or BPS). There is pain in the inner thighs, back ache, chronic pelvic pain, pain on passing urine, need to pass urine frequently without much urine in the bladder. There is no bladder infection. The problem must be going on from 6 weeks to 6 months. The Bladder is the bag where the urine collects from the kidneys, when it is full the brain sends a message to pass urine. Normally it is not painful; except when there is a bladder infection. However IC or BPS the frequency of going to the toilet 50 – 60 times during a 24hr period, middle of meetings or odd times makes sex life distorted, due to exaggeration of symptoms for several days following sex.  Even more pain during menstruation and any kind of stress, acidic type of food, strawberries, lemons, oranges, coffee, and chocolate.  It is commonly believed that cranberry juice helps urinary symptoms but in fact it makes IC worse all this makes life very difficult for women. There are many conditions, which cause symptoms similar to IC that women suffer with and some of these are Irritable bowel syndrome, Endometriosis, Sexually transmitted infections, kidney disease, bladder cancer or stone, chronic fatigue, fibromyalgia, multiple sclerosis, emotional behavioural and sexual dysfunction consequences.  Many of these are quite serious. What causes IC is not understood. There is some genetic predisposition, female sex, fair skin, red hair, chronic pain disorders, some kind of autoimmune problem (that is when the body attacks itself). Can it be Hormonal, as it is more common in females?  Is this a viral or unknown infection?  There are defects  seen in the bladder mucosa, it is not  clear, if it is the cause or the result of the disease, a leak  from these  areas  irritates the bladder by the substances in the urine.

Many researchers believe that a substance called, antiproliferative factor (Substance that can interfere with healing, APF) found in the urine of people, with IC hinders the healing of the damaged mucosa of the bladder. In fact these researchers are seeking to use APF as a biomarker for IC. Many other conditions need to be excluded before we start thinking of IC. Some of these are, as already mentioned others can be radiation treatment, drugs that may have caused allergy to the bladder, pelvic floor disorders, damage or entrapment of pelvic nerves, vulvodynia, (pain in the vulval area without any obvious infection or skin disease) prolapse of pelvic organs, vulval or vaginal or cervical pathology, pelvic masses such as ovarian disease, and trigger points causing pain tenderness and muscle spasm.  

For making a diagnosis history is very important. It must be going on for 6 weeks to 6 months, take a family history, any radiation any drugs or any other problems. It is most important to exclude any bladder infection at present and during this time. Do a urine culture and urine cytology, this will exclude any infection or cancer cells. A clinical pelvic examination can exclude any prolapse, vaginal, vulval, uterine and often ovarian pathology.  In IC the bladder base is tender on an internal examination. Another test that is that can be performed is called Urodynamics. This can measure the bladder pressure and its capacity, women with IC start feeling the pain very soon after it starts to fill and get a desire to pass urine. The other test that is done by a few   doctors but not recommended by everyone is a Potassium solution test. In this test, water is used to fill the bladder followed by a potassium solution and in women with IC; filling with potassium solution is very painful. The other test called a Cystoscopy needs to be done by a specialist gynaecologist, urologist or urogynaecologist. In this test the bladder is instilled with fluid and then examined by a Fibroptic light with a Telescope. 

This shows petechial haemorrhages in the bladder wall (small pinpoint bleeding, also called Glomerulations) in different quadrants of the bladder, reddened mucosa, submucosal bleeding, and mucosal disruption, oedema with or without bleeding. This is diagnostic of some forms of IC. Depending on these finding IC is classified into four grades. Then, there are striking reddened patches on the bladder wall called Hunners ulcers. 

This finding also suggests another type of IC. Hunners areas, decreases the bladder capacity due to fibrosis and is more distressing than the one with minute haemorrhages.  A bladder biopsy is taken from these ulcers; this shows inflammation, mast cells that can cause severe allergic reaction, fibrosis and granulation. There is a questionnaire about pelvic pain frequency (PPF) and urgency of micturition which is filled by the client and if the score is 10 or more it is in favour of IC. It has been shown that the Clinicians under diagnose IC by a large percentage because they do not always think of IC in women suffering from chronic pelvic pain.
This  is  difficult  to  understand  what  causes  all  these  problems? The main question is; what is the solution? This depends on the age, severity, and how much stress is it causing and interfering with the quality of life.  

For a start, self help is required, stop the trigger factors, stress, foods that upset IC, smoking, meditation, yoga, planned breaks for toilet, gentle stretching exercises and restrict drinks before bed time. Physiotherapy for pelvic floor muscles, psychotherapy, proper bladder retraining.  Some drugs such as simple paracetamol, non steroidal anti inflammatory drugs (NSAIDS), antihistamines (anti allergy drugs) and antidepressants have all   been tried. Some tablets that help to relax the bladder are tried in more serious cases

There is one special tablet called, Pentosan Polysulphate Sodium which is an oral medication which is tried in many clinics. It takes 2-6 months to help.  Pain relief takes the longest time .First it is tried for 3 months and then for further 3 months. Its side effects are minimal nausea, headaches, dyspepsia and liver dysfunction, these are all reversible. They probably act by mast cell deregulation, immunological and neurological effects. These down regulate the activity of the sensory fibres that take the pain sensation to the brain. There are also drugs that are instilled into the bladder weekly for 6-8 weeks and then 2-5 weeks to relieve the pain and relax the bladder for three months. These are called Dimetylsulfoxide (DMSO). Some clinicians mix Heparin and Lidocaine( a local anaesthetic) for better relief of symptoms. Nerve stimulation technique is also tried by a Tens Machine, or Sacral Nerve Stimulation by a device similar to a Pacemaker called InterStim.

In some cases surgery is tried by electro  cautery or laser for  the bladder ulcers, resection of  the  abnormal area, Sub mucosal   injection. In rare situations enlarging the bladder size by using the gut is performed, but this does not help with pain. Extremely rare situations bladder is replaced by a bowel loop. There are many such techniques; this requires very special surgeons and special care of the urinary diverted loops or opening stoma. On a simpler front acupuncture and herbal remedies are tried.

Interstitial cystitis is a very stressful condition which mainly affects women causing pain, urgency and frequency of micturition in absence of any infection of the blabber or any other discernible pathology. There is no definitive treatment for IC. It cannot be cured. A combination of treatments goes a long way to relieve symptoms. Treatment is generally started in simple ways.  Progressively more and more complicated procedures are performed to help a very distressed woman.

PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse simply means that the pelvic organs descend into the vagina. This includes bladder (cystocele ) rectum (rectocele), uterus and bowel (enterocele ). All of these are not seen all the time in the same person, different combinations of POP is present in different women. It is also classified in degrees depending how far down it has come , when it is a bit in the vagina it is first degree , when it is at the opening of the vagina it is second degree, when it is outside it is called third degree, when it hangs totally outside it is called procendentia .

Globally one in five female suffers from it. However women do not complain about it, perhaps they are embarrassed about it and do not know that it can be treated. In developing countries almost 50% of women suffer due to difficult child birth at home. The main cause of POP is child birth, chronic cough, smoking, constipation, obesity, and hormone deficiency at during and after menopause. It can be occupational due to standing too long and heavy lifting all the time. POP in women who have never had a child is very rare; it is usually due to developmental defects either in the pelvis or the spine. Women who have POP also suffer from urinary problems such as leakage of urine (incontinence) and even faeces.

The symptoms women experience is a feeling of pressure in the vagina and with a finger they can feel a lump. Other symptoms are, pain on standing, backache, belly ache, difficult sex, urinary and bowel problems. Often in very severe cases the pelvic organs constantly hang out. Treatment can be started very soon after child birth with pelvic floor muscle exercises. In fact in many places when maternal health is taken seriously they are taught to the mother at the time of discharge. The most common is called Kegal exercise which has been going on for generations.  Perhaps some women may remember being told about it, when they had their baby. Changes in life style factors is also important,  such as avoiding constipation, smoking,  being overweight, proper eating habits, use of oestrogens if women are in the menopausal age group.  The other non surgical treatment is pessaries.

These help to keep the pelvic organs pushed inside.  They need to be changed every three to six months. Sometimes the women can do it themselves but it is best if a clinician can do it, so that they can look for any infection, ulceration and can do cervical smear when required. This treatment is ok when the women do not wish for operative treatment or are unfit for it or often too old.

Operative Treatment

This depends on several factors; how old is the women, what is the actual problem, for example a cystocele and what else, most importantly is the preservation of the uterus required or is it a nulliparous POP? (This means a woman has never had a child). The operations are cystocele and, rectocele repair or both and repair for descending cervix.  If it is a nulliparae’s prolapse the cervix is lifted up by different types of sling operation, hitching it to sacral promontory of the spine. These were invented by Indian gynaecologists as this is common in India.

Some other sling operations are also performed if there are urinary and bowel problems. I will discuss these in my next blog. Side effects of these operations are they can recur in 20-30% of women, especially after a child birth and soon after repair, or a POP can come up in another place. If the rectocele repair becomes tight it causes painful sex and bowel problems. In older women when preservation of uterus is not desired a vaginal hysterectomy with the repair for other defects is performed. Following these operations a catheter is left in the urinary bladder while the tissues heal.  Women are usually in hospital for 2-5 days.

One very last operation is the total vaginal fusion. This is done when intercourse is never desired and the uterus is absent. A slightly modified operation called La forts operation was once performed in 1877 and then it sort of died out.  Now it is coming back as women are living longer. This is a very simple operation with a success rate of 90%.  It can be performed under local anaesthesia. Hospital stay of 2 -3days, hardly any complication rate and satisfaction rate of women is very high. With changing demographic this is more often required.

POP is a big subject now so much so that it has become a separate speciality within the field of gynaecology. There should   be more public awareness so that the women are not hesitant to ask for help in early stages of POP problems.

ADENOMYOSIS: ENDOMETRIOSIS OF THE UTERUS

Eva is 37 years of age has 2 children; 6 and 4. For many months she had been having very heavy and painful periods. She was unable to cope with her day to day life; her quality of life was getting progressively worse. She went to see her GP, and complained to him about all her problems. He asked her if she had any difficulty with her bowel and urination, she immediately answered yes. I have pain both on urinating and bowel action and also frequency of passing urination. When the GP examined her he noticed that she was looking pale, he could feel her enlarged uterus on abdominal examination and confirmed this on pelvic examination, that it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The uterine size is expressed with reference to the size of pregnancy; however during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally it is about 11-12). He was an experienced GP, and gave her a diagnosis of a uterine Fibroid or a condition called Adenomyosis.

Adenomyosis is a condition in which the endometrial cells grow within the uterine muscle layers. It can be scattered in the muscle or form a mass like effect, unlike fibroids it does not have a capsule or an outer cover. It is believed that it affects up to 65% of females in their life time. A few decades ago it was thought that it does not affect young women who have had no children. Recently with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI it is believed that 35% of women suffering from ADENO are nulliparae’s (women who have never had a pregnancy), in fact in English medical literature some cases had been reported in adolescent girls. One third of the females suffering from ADENO have no symptoms. Others suffer from heavy painful menstrual periods, lower abdominal pain, and pain on intercourse, passing urine and on bowel actions. It also causes infertility, miscarriages and even premature birth. If associated with polycystic ovarian syndrome it is even worse due to high oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine peristalsis, and makes embryo implantation difficult; a toxic and altered hormonal environment makes it further worse.

One problem is that it is a long disease, which lasts for years almost up to menopause. It often becomes mild after menopause or goes away. I have removed some very enlarged painful uteri, in post menopausal women.   A patient’s medical history and a clinical pelvic examination give a good clue to its diagnosis. Blood tests can be done to assess a woman’s condition. New high resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test and not always available ultrasound is nearly as good. In recent times it has been advised to always keep AENO in mind if you have a young adolescent girl with intractable pain and painful period, please do an ultrasound.

Why does ADENO happen? It can be due to trauma to the myometrial and endometrial zone during child birth, an operation such as curettage, caesarean, this is a process of tissue injury repair. The endometrium invades into the myometrium.  The other theory is that, stem or embryonic cells change into endometrial cells and make these endometrial nests or even masses.

The treatment of ADENO initially conservative especially if the woman is young and fertility is an issue.  Antinflamatory tablets are given during periods so that they help pain and excessive bleeding, its effect are minimal to moderate. Next in the line of treatment are hormones, they are either given to make the periods milder or stop them completely.  They all have their side effects and most of them stop fertility, however the good thing is that all of them are temporary.  Let’s start from oral contraceptive pills, then progesterone tablets or injections and vaginal rings. These also give Adenomyosis time to heal, but how much it does; we do not know.  When they are stopped the problem starts again. Another treatment is a progesterone implant a small rod implanted in your upper arm under the skin it lives there for 3 years. It can cause some irregular spotting, prevents pregnancy.  One of the good hormone is Danazol tablets, or danazol loaded intrauterine device which fitted in your uterus for 6 months.  This has a great advantage that a woman can still achieve a pregnancy while she is using this.  A strong hormone treatment is Gonnadotrophin releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly intervals. This suppresses our pituitary gland, thus our ovaries, hence no more periods. This cannot be a very long term treatment; it causes side effects like menopause. Add on treatments are given for these.  One serious side effect is the loss of bone density. In contrast to this, a group of drugs called Aromatase inhibitors which stop the formation of oestrogens in the body from other hormones that exist in the body fat. They are also found to be useful particularly in obese women where extra oestrogen is formed in the body fat. GnRH is unable to do this.

An present an intrauterine device containing Levonorgestal is found to be the best reversible treatment of Adeno. It prevents fertility and can be used repeatedly, after every 3-5 years.  The failure rate of treating symptoms is only 20 percent. There is a smaller IUD now available and can be tried in adolescents. Local excision of adenomyosis has been tried, but it is not easy and long term results are a bit questionable and unsatisfactory. The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy is the best treatment, although uterine artery embolization and endometrial ablation is also tried with some success.  As long as a patient agrees to surgery, a hysterectomy can be performed abdominally, vaginally or laparascopically and now even robotically.

Generally ovaries do not need to be removed.  In some very difficult cases it is found to spread into the bladder and bowel.

Adenomyosis is a difficult and painful condition from which women used to suffer a lot in the past, but the new techniques of diagnosis and treatment have helped the gynaecologist in its management.  

CAUSES OF HOT FLUSHES AND NIGHT SWEATS

Most women in their life time experience hot flushes and sweating at night or even during the day. When peri menopausal, menopausal and post menopausal; it is estimated that this happens in about 15% of women throughout their lives. This can be very uncomfortable and very embarrassing depending on where you are and what you are doing at the time. The simple answer is to wear light clothing, give up smoking if you are a smoker, try HRT if it is ok for you, or natural remedies.

There are many other endocrine conditions which cause hot flushes and sweating, overactive Thyroid (this controls our body function and is located in the neck). If the hot flushes are not controlled by menopausal treatment, have your thyroid tested. It is common to have thyroid disorders during menopausal years, and the treatments are simple.

There are few other endocrine causes which can cause these symptoms, these are 1) Pheochromocytoma, this is a tumour of the Adrenal gland, 2) Carcinoid syndrome, is a complex syndrome arising from the appendix. This can occur at any age and will have many other symptoms associated with it. Often if someone is diabetic and is on insulin or diabetic drugs, sweating can happen due to low blood sugar, this is a serious problem and can be life threatening. Treatment is simple, sugar drinks or a glass of fruit juice with some food.

Various infections also cause sweating; some of these are very serious, such as Tuberculosis, Osteomylitis (bone infection), Endocarditis (infection of heart valves), HIV, Abscesses formation, Malaria and other infections.

Cancer also causes sweating and fever. Lymphomas are more common to do so.

Certain drugs particularly antidepressants are known to cause sweating.

Stroke and Heart Attacks can cause severe sweating.

Many disorders of the nervous system also cause sweating

My idea of giving women this list is to make them aware of the many causes of sweating. Most of these can happen suddenly and at different age groups, along with many other symptoms, so take notice and do not ignore them.

URINARY TRACT INFECTIONS IN FEMALES

Urinary tract infections (UTI’s) are a very common problem in women and young female children. What is a urinary tract in humans? It consists of two kidneys on either side of our spine in our abdomen. Two tubes called the ureters run one from each kidney into a bag called the urinary bladder. In the female a small tube called the urethra opens to the outside from where females pass urine. In men it is different, it is long and on the way it is connected to other tubes. 

Of all the urinary tract infections that happen 80% happen in women. According to one study almost 50% of women have had at least one UTI in their lives by the time they are 50. UTI’s when simple are confined to the urinary bladder  this is called cystitis.  In some women and children it happens repeatedly than it becomes more significant. It can even travel to the kidney, and it is called pyelonephritis, it can become more serious. In even more neglected cases it can cause serious infection in parts of the body, so do not ignore UTI’s or simple bladder infections. What causes UTI’s so commonly in women. It is because our urethra is small, it is close to the rectum, and bacteria easily travel to the urethra and causes infection. It is also possible that local hygiene is not so good. Women often need a catheter after an operation, during labour, or other times if they are unable to pass urine. Other causes can be obesity, unprotected sex with an infected person. Some diseases such as Diabetes, Multiple Sclerosis, Parkinson’s Disease and some local abdominal diseases such as  Fibroids (a benign uterine tumour ), Endometriosis, Ovarian Cysts, Vaginal Infections, Kidney or Bladder Stones and using local contraceptives such as Vaginal Foam and a Diaphragm. Menopausal and post menopausal women are also very prone to UTI’s due to lack of protection from Oestrogens. Chemotherapy and commercial personal hygiene products. Malformations of the UT may be a cause of UTI’s. This will show in childhood and often recurrent.

What are the symptoms of UTI’S?

Rarely there are any symptoms, mostly women have frequent moments of passing urine and it is painful to do so. There is back ache (where kidneys are located), pain in the stomach and on the side of the abdomen. There can be nausea, vomiting, fever and even diarrhoea. The urine can be smelly and may contain blood. A young child will have all these problems. She may refuse to eat. The best thing is to go to the doctor. They can do a dip test with a strip in urine to confirm  infection and send a urine sample collected after wiping the vagina called the mid stream urine, for culture and appropriate antibiotics are started immediately. The symptoms improve within two days. If this does not happen the ABS are changed as the urine culture report will tell the doctor about the infecting bacteria and the suitable Antibiotic. A urine culture is also done after treatment to ensure that the infection has cleared. If a woman or children have recurrent infections, many other tests are done. These are an ultrasound, tests for STD’s,  a Cystoscopy meaning there by looking with a telescopic light inside the urinary bladder. Also make sure that the child is not being molested by anyone. Children sometimes have a problem that when they pass urine some urine goes back into their ureter. (The tube connecting kidney to the bladder) This requires surgical treatment. If this is not done the kidneys maybe damaged.

Women and girls who get repeated UTI’s should address their life style factors. Drink plenty of water, do not wear tight clothing, and do not wear anybody else’s clothes. Avoid grapefruit and cranberry juice that is recommended on social media for UTI’s. Use correct and safe contraceptives. Always have safe sex. Keep good hygiene for external parts of the body, when wiping bottom, wipe from top to the bottom.

         For women who get recurrent UTI’s meaning they have 2 episodes in 6 months or 3 in a year, Prophylactic treatments are required; with Postcoital Antibiotics, Continuous Low Dose Antibiotics and treatment for any voiding problems such as prolapse management of serious infections such as Aids, Antibiotics with UT instrumentation such as catheters.   

        

         Pregnancy and UTI’S

         In pregnancy UTI’s are important. In fact in all pregnant mothers a urine test is done and if there is bacteria even in absence of infection this is treated. UTI’s in pregnancy an cause premature  labour and due to  abdominal pressure, the infection can quickly go into the kidney causing pylonephritis. The women become very sick, symptoms become more severe, they are given intravenous antibiotics. They need to be hospitalized. If UTI’s happen again during pregnancy a woman is given prophylactic ABS for the rest of her pregnancy.

In UTI’s in addition to ABS we use urinary antiseptics they help and prevent bacteria, if the infection is simple and in the bladder alone for prophylaxis. In these situations we need to watch the sensitivity of bacteria so that the resistance bacteria do not develop,which will be impossible to treat. This is one big disadvantage of using prophylaxis.

Besides UTI’s there are a few other common problems with URINARY TRACT which are not strictly infection. One of them is called Interstitial Cystitis (IC) or Bladder Pressure Pain. This is a painful condition without infection. It is poorly understood, difficult to diagnose and treat. It is believed that there is some defect in the bladder lining which is irritated by food, sex and some vulval hygiene products. Diagnosis is made by using a cystoscopy in which they use a potassium solution for bladder wash this causes pain in women with IC. Treat is not very effective, women need a lot of psychological help, nonsteroidal anti inflammatory tablets, antihistamines and tricyclic anti depressants. In USA, FDI has allowed one oral drug Pontosan polysulfate to a maximum of six months. Change of life style factor is also recommended. Other urinary problem often in the elderly is over sensitive bladder when you need to go to the toilet frequently but there is no UTI. For this, one has to do pelvic floor exercises, bladder training, scheduled toilet trips, absorbent pads or underwear. Local oestrogen cream may help and intermittent catheterisation which in itself can be risky.  Usually the bacteria in UTI’s is ECOLI, which comes from our bowel but in unusual circumstances and in nursing homes they can be more serious and  difficult to treat, these are Proteus , Pseudomonas , Klebsella and bacteria from STD’s

Urinary tract system in our body is very important, as it gets rid of all the waste products from our body. If kidneys fail humans are on death bed. Special attention should be paid to all our Urinary tract problems particularly in children, women, pregnancy and the elderly. Never ignore blood in the urine, rarely can it be due to UTI’s but it can be a sign of cancer. Women do die from UT cancers.

SMOKING IN PREGNANCY

Smoking as such, is a serious social activity in the modern world.  Luckily a lot of attention is being paid all over the world against smoking. Smoking during pregnancy, child birth and post partum is a serious preventable habit. Sadly it happens more often in single young women. They are often unemployed. This leads to increased neonatal and maternal morbidity and mortality. Luckily the percentage of women smoking has decreased. In UK 15% of women smoked in 2006-7 now in 2018 it is about 10% , they are aiming to bring it down to about 6% . 1 billion men smoke, so you can calculate the risk of passive smoking. Smoking can interfere with conception itself. Then there is increased risk of an ectopic pregnancy; meaning pregnancy in the fallopian tube that never grows.  This is life threatening, risk of miscarriage, premature labour, abnormally located placenta, premature separation of placenta, all these can lead to severe morbidity and mortality. This is not just it; a lot of these babies are born with many abnormalities, such as deformed limbs, cleft lip and palate, clubfoot, deformed heart valves, and poor brain development. Later in life they die of sudden infant death syndrome (SIDS). They can develop diabetes, become obese, and suffer heart disease. Not only do they suffer as a child they become very difficult to look after due to autistic disorders (ADHD) poor at school and at college if they ever get to that point in life. I hope after reading all this you are already longing to give up cigarettes.

There are three compounds in cigarettes, which are very harmful. These are carbon monoxide (CO) tar, and nicotine. Of these CO is most dangerous. The CO that a woman exhales combines with an iron atom at the cost of oxygen producing carboxyhaemoglobin. 400 -500unit of (PPm unit to measure CO) are exhaled after smoking one cigarette gives a reading of 3-8% of carboxyhaemoglobin. In non-smokers it is 1%, this impairs the oxygen delivery to the uterine muscle and fetoplacental area causing all the problems. At present time in many countries every woman’s PPm is measured at the time of booking by the midwife, irrespective of the story, this can pick up even all those who are passive smokers and wanted to hide their smoking story. The test is explained to women in detail, the machine is also checked that it is in perfect working order in most places. The women are explained the problems and referred to clinics for smoking cessation. The test should be done within a few hours of a cigarette; otherwise it can give a negative result. Some hospitals refer them with a PPm of 3- others accept a value of 6-8 to be fool proof. They should keep asking these women on every visit if they have decided to quit. Maybe repeat the CO test.

Tar is the other harmful part. Some of the tar disintegrating material stains woman’s skin, mucous membranes. These are fetotoxic and teratogenic (causing foetal abnormalities). Cadmium is a heavy metal in the tar which collects in the placenta and causes foetal growth restriction, resulting in small feeble babies.  There are many other toxins in the tar about which we do not know or understand. It is believed that tar is very dangerous.

Nicotine is the third constituent of a cigarette. It affects the foetus and the placenta. This binds to the foetal brain resulting in abnormal brain development resulting in hyperactivity disorders, learning disabilities, cognitive, emotional and behaviour problems and addiction in later life, including smoking. These babies and children have poor health, infections, diabetes, obesity health problems even in adulthood. Nicotine is a very dangerous drug. It is produced by tobacco plants. It can also be synthetically produced. It is a very dangerous drug initially and it was classified as a poison.  Once a person gets addicted to it, is very difficult to give it up. In our brain it combines with acetylcholine receptors and this results in the production of dopamine which is a happy compound.   Normally dopamine is only produced in the brain when a user feels happy, smoker feels alert, euphoric, increased concentration, and a person is happy, increased levels of endorphins which reduce anxiety. When the effect of cigarette finishes the person wants to light up again and that is how it goes on. Nicotine also stimulates Adrenal gland and it has its own effects. In the 21st century there is a great effort to get people to stop smoking, particularly pregnant women. In fact this effort is paying off. Currently in many countries in the world have pre pregnancy consultations and the care givers must talk about active or passive smoking and talk to the women about how good it is to stop smoking even before becoming pregnant and how smoking can complicate your pregnancy.

The other very important action that is being taken in many parts of the world is to do a CO test at the time of booking. The booking midwives are well trained about this and if CO level is high they are advised to attend a quit clinic .The woman has to be agreeable to this. Do not force her, but ask her on every visit about smoking cessation. Do not force her.  Also arrange for a psychosocial and behaviour support. One of the big problems for quitting is nicotine dependence. This is not too bad, as the toxic effect of smoking is CO and TAR. Nicotine replacement therapy (NRT) is not too bad. They can use Nicobate patches for 16 hours a day remove it at bedtime. Then there are chewing gums, nasal sprays, mouth sprays, lozenges and micro tabs. Do not use more than one product without the knowledge of your caregiver.

The other very popular smoking device is an E-Cigarette or Vaping.

This does contain some harmful products but in much less concentration. It is like a hot water that one can smoke. Its safety and usefulness in pregnancy is not yet proven. It is suggested that in future pregnant women should be included in research on non smoking research.

Smoking is a serious preventable habit and it will save babies and mothers.

GONORRHOEA INFECTION - ANOTHER STI

Our current lifestyle is a permissive one and as a result, almost 50% of high school students are sexually active. It is estimated this results in almost 1 million people around the world, get 4 major STI’s Chlamydia, Gonorrhoea, Trichomoniasis, and Syphilis every day. This is a huge burden on society. Most of these are young adults between the ages of 15 – 24. How very sad. Gonorrhoea is a sexually transmitted infection caused by bacteria called Neisseria Gonorrhoeae.  In women it comes after sexual intercourse from the penis of an infected partner. The time it takes for the infection to take hold is 1-14 days. It can cause infection in the vagina, throat, and anus to start with, depending on your sexual preferences.  Some men and women do not have any symptoms to start with. However the main symptoms are vaginal or urethral discharge, pain on passing urine, having sex or during periods. Women may also get bleeding during sex or even at odd times. It can cause a sore throat, pain on bowel motion, itching around the anus. If left untreated for a while it can affect the cervix, uterus and fallopian tubes, resulting in full blown pelvic inflammatory disease. This can make women really sick with fever, vomiting, and lower abdominal pain. It can even spread into the blood causing arthritis, tenosynovitis, dermatitis and conjunctivitis; this is called Disseminated Gonoccocal Infection and can be a serious problem. If a woman has an STI, it is easier to catch HIV and other infections.

Diagnosis is made by a nucleic acid amplification test, which tests the DNA or the swab cultures from the urine, urethra, and the cervix.

The partner should always be tested. The treatment is by two antibiotics, ceftriaxone and azithromycin. This takes care of Chlamydia as well as it often occurs with gonnococcal infections. If a woman is found to have one STI, she should be tested for all others. If a woman is pregnant the baby can acquire the infection and can sometimes cause blindness.

The only way to prevent these infections is to always have safe sex with condoms or dental dams.

Nutrition, Exercise and Personal Relationships

Nutrition is a basic consideration in any discussion on menopause. It is particu1arly important at this stage in your life as the body’s metabolism starts to slow down. Middle-age is usually associated with some weight gain and with a redistribution of the body’s fat.  These changes are contributed to by aging as well. More seriously, the risks of heart disease, diabetes and osteoporosis increase.

To overcome these risks, a diet low in cholesterol and high in calcium is recommended. You may also have other specific dietary needs because of diseases such as diabetes, hypertension which commonly occur in this age group.

Maintaining a good weight

            It is important to have realistic expectations about shedding kilograms:

believing in yourself and having a positive self-image is important. The criteria for maintaining your correct weight are based on eliminating bad eating habits such as snacking between meals with food high in calories and controlling your intake of fat, salt and sugar and partaking in some form of healthy exercise on a daily basis. To assess your weight you take your height in centimeters minus 100, gives you your best weight in kilograms. Example: If you are 170cms in height you subtract 100 from this and your best weight is 70 kilograms. Abdominal circumference is important from the point of review of subsequent medical problems, along with the BMI.   

Eat sensibly and moderately from these five food groups:

1.     Fruit and vegetables  

2.     Meat, eggs, fish and soya beans  

3.     Bread and cereals.

4.     Fat, however be mindful of cholesterol rich food.

5.     Milk and milk products (600 ml daily) — women after menopause, should use fat-reduced and calcium-enriched milk products.

To stay healthy, eat less fat, less salt and less sugar and reduce your alcohol consumption. Drink plenty of water. Never allow yourself to be hungry as this is a temptation to eat indiscriminately. It is a good idea to keep a food and drink diary and to understand the following simple principles of behavior modification which are the basis of many weight loss programs.

            If you want to lose weight, there are some simple changes you can make to your eating habits. Healthy food eaten in smaller quantities, by using a smaller plate can make a big difference, have one sandwich instead of two; cut down on refined carbohydrates (such as starch and sugar),  limit your intake of eggs, fatty meals and deep fried foods; switch to skim milk and drink black tea or coffee in moderation. Caffeine taken in any form has a negative effect on bone density

            Reduce your alcohol intake as it adds calories, lowers bone density and weakens your dietary self-control. Some drinks have more calories than others. For example, beer has many more calories than whisky and soda; tonic water can be surprisingly high in calories. Be careful when you choose low calorie drinks as they are often loaded with salt which promotes fluid retention.

            For lasting results, you should maintain a weight-loss program over several months. The average recommended weight loss should be half to one kilogram a week. Using fad diets to achieve weight loss usually only gives short-term results.

Diet, in your menopausal years, should be well balanced. If weight loss is not required, then your daily intake should be about 2000 calories.

Smoking

            More women die from lung cancer than from any other cancer yet more and more women are smoking today. Smoking also increases the risk of heart disease and osteoporosis as it adversely affects deposition of cholesterol on the blood vessel walls and the changes in body metabolism concerned with maintenance of bone thickness. Smoking always causes early onset of menopause and more symptoms.

Calcium

       An adequate calcium intake helps to prevent osteoporosis; it helps to improve the muscle tone.  It is very useful to transmit messages between our body parts and brain by transmitting enzymes and hormones. Milk and milk products are the richest source of calcium along with broccoli, artichokes, brussel sprouts, cabbage, celery, cauliflower and mangoes. Nuts and sesame seeds are also rich in calcium. Include some of these in your diet to meet your recommended daily calcium intake of about 1000 mgm and if your daily calcium intake is less than 400 mgm; you can take inexpensive calcium supplements from your chemist or supermarket.

In the menopausal years, calcium absorption can be impaired because of smoking, and inadequate vitamin D and oestrogen, both of which are necessary for the absorption and deposition of calcium in the bones. It is suggested that too much calcium interferes with the body’s ability to absorb zinc and iron. It can also cause constipation. Excess of supplemental calcium has been linked to the increased risk of kidney stones. Some researchers have indicated that an excess of calcium in the blood increases the risk of cardio vascular disease and stroke.

Magnesium

    Lack of magnesium causes tiredness and fatigue, it can also cause muscle cramps. Adequate magnesium helps to prevent high blood pressure, vascular disease, muscle spasms, osteoporosis and migraine headaches. The daily magnesium requirement is about 400mg. Dark green leafy vegetables, some fish like tuna and mackerel, lentils and beans and many grains for example like quinoa, burghal contain magnesium.

Zinc    

      The excretion of zinc is increased during times of body stress such as surgery, burns, alcoholic liver disease or starvation. It is also found to be high in women suffering from osteoporosis. Recommended daily allowance for zinc is 15 mg. While there are no current recommendations for zinc supplements to be taken by women with osteoporosis, it may be a matter for further investigation. It seems that a deficiency of zinc can cause retinal degeneration, night blindness and cataracts. It can also cause repeated infections, and too much zinc can cause abdominal pains, cramps and diarrhoea. The highest source of zinc is in oysters however it is present in most of the vegetables, nuts and grains we generally eat. It is not often necessary to take zinc supplements   

Iron

     During menopausal transition years women often suffer from abnormal and often heavy periods, this can cause anemia and make them very tired. So when you have your tests done at menopause make sure you are not anemic. There are different types of anemia but bleeding causes iron deficiency. Make sure that you are not deficient in iron, making you tired; you can easily make this up by consuming green leafy vegetables and red meat.

Vitamin D

      Vitamin D is essential along with calcium. The main source of vitamin D is cutaneious synthesis from exposure to ultra violet light from the sun. Food such as fish, salmon, mushrooms and fortified nibbles contain vitamin D. Vitamin D deficiency is caused by poor exposure to sunshine, poor diet, some medical problems and finally at menopause. Besides bone health, vitamin D is also supposed to prevent heart disease, certain cancers, and maybe diabetes, however there is no consistent proof for this. It is recommended that vitamin d levels should be 50nmol/L or higher. It is important to take vitamin d until a satisfactory level is reached. Take it under medical supervision, as high levels of Vitamin D can be harmful.

Diuretics

      Hormone replacement therapy can cause fluid retention and your doctor may advise you to take an occasional diuretic. A salt restricted diet also helps to decrease your fluid retention. Many natural foods such as celery, parsley, cucumber and asparagus have a diuretic effect. Try to include these foods in your daily diet.

Low salt and salt-restricted diets

      A small amount of salt intake is necessary for your body to function correctly.  Normal, healthy individuals require 200 mg of sodium daily. People with high blood pressure or heart disease should follow a salt- restricted diet. Try to avoid foods with a high salt content such as bacon, ham, salami, and all tinned food.

Sugar

There is no harm in consuming a small amount of sugar daily. There are several natural alternatives for sugar available such as apple juice and honey concentrates, both of which can be used for food preparation.

Fiber

      A high fiber diet prevents constipation and is believed to prevent bowel cancer which is prevalent in Western society. It is also valuable in reducing abdominal pain, appendicitis, hiatus hernia, colitis, hemorrhoids and varicose veins. An excellent intake of daily fiber is a breakfast of two heaped dessert spoons of unprocessed bran and one heaped dessert spoon of wheat germ mixed with stewed fruit, with or without sugar depending on your weight problem. Almonds are another effective way of avoiding constipation. The daily requirement of fiber is 25 mgm.

Cholesterol

       Low cholesterol diets are recommended for the menopausal years recent research has shown that adverse changes in blood cholesterol take place within six months of menopause.

      Cholesterol rich food is not the only cause of high cholesterol in the blood. The human body can also make its own cholesterol; the amount often depends upon your genetic make-up. It is not necessary to starve yourself to lower your cholesterol level. You should seek the advice of your doctor before making a major dietary change. Beware of the overly simplistic view of cholesterol often reported in the media. These days there are often comments about unsaturated fats, saturated fats and Trans fats. There type depends on the chemical structure of the fat. It is best to know that the fats that remain liquid at room temperature are the best fats to use: ie:- Olive Oil, Flaxseed Oil, Peanut Oil and Rice Bran Oil. Please avoid trans oils which are generally used for take away deep fried foods. They are made by hydrogenating ordinary oils and can be used several times for frying and hence are cheap for commercial cooking. They are harmful as they increase our LDL (Bad cholesterol ) and decrease our HDL (Good cholesterol).

Vegetarian diets

Vegetarian diets are high in fiber content and dairy products and are low in fats.  High fiber content protects against bowel cancer, a low fat diet protects the heart and blood vessels.

Besides all the important foods we eat, carbohydrates, fats, proteins, don’t forget the herbs and spices which are equally good for our health. Some of the Indian herbs, like Turmeric, Fenugreek and Cinnamon are very important to help us with our dementia, cholesterol levels and blood sugar levels. Vegetarian and vegan have to take special care that they some food fortified with vitamin B12 or take supplements. Its lack can cause nervous system disorders, similarly Vitamin  D is important but that you can get from sunlight and supplements are easily available. Some mushrooms are rich in both B12 and Vitamin D.

Exercise

Exercise plays a key role in our lifestyle particularly in the menopausal years. Lack of daily exercise causes the body’s metabolic rate to decrease. It is important to maintain an adequate exercise program as this can help reduce fat and stress as well as improve posture, appearance, positive self-image,  mood and concentration.

Useful exercises

•      Walking

•      Cycling

•      Jogging

•      Swimming

•      Skipping

 The three main types of exercise

The first group is aimed at keeping fit and minimizing the risk of heart disease and osteoporosis. These exercises are generally aerobic. They include walking, jogging, swimming, bicycling, dancing and canoeing. Make sure that you are fit before starting any form of exercise. A simple test to establish your fitness is the talking test: if you are 50 or over, and run on the spot for two minutes and still carry on a conversation; if you are fewer than 50, the recommended time is three minutes. Another test is to watch your pulse rate before, during and after exercising. Pulse rate indicates fitness.

Recommended training pulse rate chart

                   Age (years)                   Beats per minute

                           40                                 120—150

                           45                                 115—145

                           50                                 110—140

                           55                                 105—135

                           60                                 110—130

            Walking for at least 20 minutes a day, four times a week, keeps the body metabolism in good condition. Move your hands and arms at the time to get maximum benefit. An exercise bike is also very useful with pressure adjustments to simulate a steep hill. This exercise stimulates your metabolism, leg muscles and cardiovascular system. Golf, tennis or gardening is also beneficial.

            No one is ever too old to start exercising. Well-conditioned muscles till help to prevent stiffening of joints and will give you a sense of wellbeing. Swimming does not help prevent osteoporosis, despite being excellent exercise for general fitness and strengthening your cardiovascular system.

            The second group of exercises is useful for toning up your body face muscles. An excellent technique to tone up your abdominal muscle is to lie on your back and raise your legs one or two inches from the bed while counting to six. Do these exercises six times. Then, lie on your back and raise your alternate leg at 90 degrees to the rest of your body, and count up to six; slowly lower your leg. Again do this exercise six times. Next, keep your body on the floor and lift both legs and stay in the position for a count of six. Another exercise is to lie on your side, keeping your leg straight and lift it up. Now raise and lower six times; change sides and repeat.

Pelvic floor exercises

            The third group of exercises tones up the muscles of the pelvic floor and helps prevent problems such as stress incontinence. Stand against a wall and lift your pelvic floor and contract your buttocks. Do this six times and then cross your legs and do the same exercise a few times again. The other way of supporting your pelvic floor is to contract all your pelvic flood muscles as if you suddenly have to stop passing urine. Do this exercise 200 times a day to tone up your bladder. However you can now get multiple devices to assist in pelvic floor exercises. I used a system called Neotonus, which I found to be very successful in strengthening the pelvic floor function.

Personal relationships

            Personal relationships are important in middle years. Sex can be even better with age. As the life expectancy for women increases, almost third of a woman’s life is now spent after the menopause. It would be a pity not to appreciate our sexuality at this time. Many women enjoy sex after menopause more than ever before as the risk of an unwanted pregnancy no longer exists, there are no more premenstrual tension, no period pains, and life experiences allow them to enjoy a new freedom and open communication with their partners.

            There are two types of sexual problems which commonly arise after menopause. Firstly, painful intercourse and loss of sexual interest due to oestrogen deficiency and, secondly, problems that are often due to partner’s declining sex drive or impotence inability to sustain erection. At this age, a man’s sexual performance is often influenced by stress and anxiety, diseases such as diabetes and arterial narrowing and the effects of medication used for treating high blood pressure. Excessive consumption of alcohol and cigarettes also effects sexual performance.

            The best way to improve your sexual enjoyment is to work at improving communication with your partner to find out the real causes of any problems in your relationship whether they are physical, psychological or both.

            The treatment of any medical problems for either partner is recommended, particularly with a caring doctor who can do a careful assessment, including a physical examination with appropriate treatment.

Hormonal changes, sexual interest and intercourse

            Loss of sex drive can occur at any age so lack of oestrogen cannot be completely blamed for a waning interest in love making. After menopause, a woman may lose her self-confidence if she feels unwanted or physically unattractive. General feelings of emotional instability and domestic stress seem to magnify frequent night sweats.

            Where loss of sexual interest is a problem, either from natural or surgical menopause, testosterone blood levels are often found to be low. Benefit can be obtained from a testosterone implant or injection. Although oestrogen replacement improves vaginal lubrication and elasticity, its role in sexual desire is not yet fully understood.

It is, however, generally believed that oestrogen does influence sexuality.

            Age generally means a gradual slowing of sexual response and arousal can take longer. However, sexual satisfaction can often be achieved in other ways, and a mutual understanding of each other’s needs and communication between two people are often the basis for a healthy sex life, regardless of your age.

            Embarrassment should never stand in the way of good medical advice. If you want help, seek professional counseling from your general practitioner or a clinical psychologist specializing in psycho—sexual health for couples.

            Commonsense, thoughtful communication with your partner, counseling and HRT where appropriate can make your sex life a happy one or perhaps better than you have experienced before. Currently laser therapy for improving the vaginal health is greatly helpful. Urinary problems are also improved by many new operative treatments. SERMS are a group of oestrogens which act differently on different tissues. These  will be discussed in a  new additional chapter on Genitourinary syndrome of menopause

How your family can help

            A supportive family is important. Families who can show understanding and consideration and make allowances for irritability, forgetfulness and mood swings will make your menopause much easier. You could encourage your partner to come to a menopause discussion group, as understanding of why you are behaving differently from usual, can make a tremendous difference to the smooth running of the family.

Key points

1.     Your diet should be sensible with adequate calcium, reduced fat, and sugar content, and high in fiber. Have realistic expectations about the weight you want to lose. Do it by sensible eating and exercise and not by fad diets.

2.     The exercises recommended for women in this chapter will keep you fit, minimize the risk of osteoporosis, improve your urinary problems and help you to maintain your weight.

3.     Sexual difficulties at menopause are often a combination of biological, psychological and social factors.

4.     Sexual problems can result from your partner’s physical performance as much as from yours. A caring, considerate attitude by your partner helps.

5.     Discuss your problems and seek support from your family, friends and most of all your family doctor.

6.     Modify your lifestyle. Quit smoking and decrease your alcohol, coffee and tea intake.

7.     Discuss with your care givers the latest management of genitourinary syndrome of menopause .