Reassuringly for those who do not have the urge to run or swim marathons, most of the benefits for heart health occur with moderate exercise programs. You can walk for a total of six hours a week, play golf for five hours or swim for four hours to achieve the level of activity necessary to provide significant benefits for health. Unfortunately, nearly 40% of women around the age of

menopause do not get this amount of exercise, if the Melbourne Women’s Midlife Health Project is any guide. A further 15% have borderline energy expenditure levels, while just under half have good or very good weekly activity levels.

A program of regular moderate physical activity is one of the first things to consider when feeling out of sorts. In general, it is best to set a manageable target, beginning slowly and increasing the level of activity progressively. Setting too high a target can be counter-productive and may send you backwards. Sticking to an exercise plan for a couple of weeks does wonders for morale and, instead of seeking excuses to avoid exercise, you may find you can’t start your activity program soon enough. In working out an exercise plan, there are some important factors to consider.

• The aim is to make regular physical activity part of your life, so choose something you enjoy — something that is convenient, interesting, can be done independently and is realistically achievable.

• If you are over forty years of age or have high blood pressure, diabetes or a known heart problem, check with your doctor before you start your plan. A preliminary health check is sometimes advisable anyway, especially if you intend working up to strenuous forms of activity.

• Always warm up for at least five minutes before exercising, and cool down afterwards. Include some stretching exercises in the warm-up to reduce the risk of muscle strain.

• Never exercise if you are not feeling well. If illness interrupts your plan, resume at a lower level and build up again slowly.

• Tell your doctor about any symptoms you experience during exercise, particularly chest discomfort or undue dizziness.

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Not only have you and your partner suffered a loss but you will obviously be worried about why it happened. You may be concerned that it was somehow your fault or feel that the doctors have made light of a very personal and traumatic event. Above all, you will want to know how you can prevent a miscarriage happening again.

The reason why the medical profession often seems lacking in sympathy is that miscarriages are actually very common. In many cases a woman does not realize that she has had one because it happened before she knew she was pregnant and she might have just thought she had a rather heavy period.

It is estimated that at least a quarter of all pregnancies end in miscarriage, usually before the twelfth week of pregnancy, and often (unknown to the woman) much earlier. Scientists believe that in many cases these early miscarriages are nature’s way of dealing with an abnormal foetus that could not succeed in becoming a healthy baby.

That does not make it any easier to get over a miscarriage. But it does mean that you must not automatically assume that there is something wrong with you or your capacity to sustain a pregnancy. This kind of anxiety causes the kind of stress that can upset your system so much it stops you conceiving again.

What you must do is be positive. Look at all aspects of your health and lifestyle and follow the Four-Month Preconception Plan to give you and your partner the best chance of a successful pregnancy. If you have suffered a miscarriage the doctor will have given you advice on how long you should wait before you try to conceive again.

Use that time to get yourself and your partner really healthy in the way I have outlined. If you do this you will dramatically improve your chances of avoiding another miscarriage when you conceive.

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Help yourself become well-informed by talking to your doctor, attending sessions run by self-help groups and using the resources offered by women’s health services.

Read as much as possible about endometriosis and talk to other sufferers. This will not only keep you well-informed but remind you that you are not alone.

Take control

It is your body and you have to live with your decisions. Carefully consider your doctor’s advice and take into account the information you have read. But remember the final decision should be yours.

Communiñate

Talk to women who have been through similar experiences. Talk with your family and your partner, if you have one. Talk to your doctor. Get the best possible care. Do not be frightened to seek a second, third or fourth opinion before you make any final decision.

Be assertive

Remind yourself that you have the right to the best possible care and that you have the right to voice your concerns and opinions. Do not be pushed into any decisions that you feel uncomfortable with.

Set realistic goals. Take it step-by-step, day-by-day. Do not rush yourself or allow others to rush you into decisions.

Do not be afraid to ask for help. Seek help if you are finding it difficult to make decisions on your own.

“You may come across many conflicting ideas about the best way to approach decision making. Remember to investigate all avenues, ideas and suggestions before you make choices.

Once you are well informed you should make a decision that you are happy with.

Decisions should not be put entirely on your shoulders. Encourage and involve others, including doctors, family, partners, friends and other women with endometriosis, self-help groups and women’s health centers, to help you make the right choice. Remember – you are not alone.

Infertility

This can cause heartache, disappointment and loneliness – but couples do cope. If you have been on the infertility merry-go-round at some stage you will need to ask yourself, ‘Have I had enough?’. When are you prepared to stop infertility treatment? Ask yourself how much is too much. How long can you continue to be disappointed when yet another treatment has failed? How long can you put up with the disruption to your life? If you agree to continue with infertility treatments, will these be at the expense of other plans you have for your life?

Realize that you may never have a child; try and accept this – getting help if you need it – and then re-evaluate your goals.

Accepting that you will be childless may actually signal success and show that you have come to terms with your limitations. You have recognized the need to go on with other aspects of your life.

But do not be pushed into making a decision one way or another. It is your choice so make your own decision, in your own time, for the right reasons for you.

Calling it quits

You have the right to decide when you have had enough so that you can come to terms with the impact of your endometriosis. It may mean that you will never have children if you decide to have no further treatment or investigations. If you have had enough of the pain, the treatments and the disruption that endometriosis can cause, then the final decision may be to have a hysterectomy.

It is important to remember that if you are not coping at any stage, do not feel ashamed or embarrassed to seek professional help.

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Knowing that it exists helps. If you decrease your chances of getting sexually transmitted diseases by practicing ’safe sex’, you decrease your chances of having PID.

You should have any suspicious symptom, such as spotting between periods or pain with intercourse, investigated promptly.

Consider having a test for chlamydia and other STDs if you may have been at risk but have no symptoms. You may choose to do this on a regular basis, perhaps at the same time as your routine pap smear, or more frequently.

If you have a surgical procedure, like any of those listed above, make sure that you are aware of post-operative instructions. If antibiotics are prescribed, take them. Find out if there are specific things you should do or avoid after surgery. If you have any problems at all following a surgical procedure, notify your doctor.

If I have had PID, how can I find out if there is tube damage?

Having a laparoscopy (see appendix 1) is the most reliable test available for tube function. Under anaesthetic, a dye can be inserted and the flow through the tubes can be watched using the laparoscope. However, having a laparoscopy is not a procedure to be performed without a significant season, because it, like other operations, is not without risks. Laparoscopy is usually warranted as an investigation for infertility, or if a woman is suffering from chronic pelvic pain. This means that many women who have had PID (but don’t have chronic pain, or are not currently experiencing difficulty getting pregnant), will not know if they have damaged tubes or not. So unfortunately it is an area of frustration for many women.

This disease can cause a great deal of individual suffering. Some women who have PID may have the double trauma of the initial infection followed by the long-term problems of infertility and chronic pelvic pain. This disease also costs our community money. The arrival of reproductive technology (for example IVF) has helped infertile couples, but it is, and probably will always be, an expensive technology. Some infertility is preventable. If we can work on preventing infertility, we may suffer less as individuals, and as a community.

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The costs of private hospital and private doctor care are shared between the government (a proportion of the cost is recoverable from Medicare) and private health insurance funds, and usually includes some out-of-pocket expenses for the patient as well. People who opt for private obstetric care will need to have private health insurance cover. Without it, the costs of private hospital care put it out of the reach of most people.

Home birth. Women may choose to deliver their babies at home, as women have done for many generations, and still do in some countries. In Australia it is usually with the assistance of a midwife, and there are some doctors who practice home birth.

Like the birth centre option, women may be choosing home birth because they feel it allows them more control over their labour, in a less clinical, and more familiar environment.

As the majority of women who have babies have no problems, it is an option some women prefer. The trouble with home birth, from the point of view of many in the medical profession (including the Royal Australian College of Obstetricians and Gynaecologists), is that not all women, even those with low-risk pregnancies, will have straight-forward deliveries. Unexpected complications may develop quickly. Obstetric or paediatric emergencies can be dealt with better in an equipped environment with experienced staff.

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Here are some of the likely causes of the problem. Some are infections, some are not.

Warts. Genital waits are a common reason for attending the doctor’s surgery saying ‘I’ve found a lump’. These are painless, skin-coloured growths, usually in clusters, and varying in size from tiny (pin-head size) to bigger (pea-sized). They may cause the area to feel itchy or irritated. They are the result of a viral infection, which can be spread by sexual contact. The warts themselves are not dangerous, and can be treated with various methods. The virus cannot be eradicated with medication, which is why these things have a tendency to recur.

The only problem with having genital warts (apart from the fact they are a bit yucky, like warts anywhere else), is that there is thought to be an association between wart virus and the development of abnormal pap smears. Women who have had genital warts should make certain they have regular yearly pap smears.

Sebaceous cysts and boils. Sebaceous cysts are usually small painless lumps just under the skin. They often have a tiny little ‘punctum’, which it like a little hole. Inside these cysts is a collection of white cheesy stuff, called sebum, which is an oil made by the skin cells. The sebum drainage system gets blocked, and it builds up into a cyst, or lump beneath the skin. They can be anywhere on the body, and can sometimes grow quite large.

Sebaceous cysts may sometimes become infected, which will lead them to become painful, red, bigger, and sometimes discharge pus (that is, they become boils or abscesses). If this happens they may be treated with antibiotics and drained, by a doctor making a little cut, under local anaesthetic, and letting the pus out. Occasionally they disappear on their own. Sometimes they are cut out if they are annoying, becoming infected, or growing bigger. Sebaceous cysts do not develop into anything else (apart from boils, and sometimes scars), and they do not become cancerous.

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Yeast infections may be more likely to occur at certain times, and under particular conditions. The conditions thrush seems to like best are where it is warm and moist, and it likes extra sugar and oestrogen (female sex hormone), not many white (infection-fighting) cells around, and not much competition. This might explain why thrush is more prevalent in:

• pregnant women

• women taking the combined oral contraceptive pill

• certain times in the menstrual cycle (related to the variation in natural hormone levels)

• diabetics

• people with altered immunity (difficulty fighting infections, for example leukaemia, AIDS, etc.)

• people taking medication which affects their immune system (for example steroids)

• people taking medication which affects the natural balance of microorganisms in the gut (for example antibiotics).

Many women will notice that if they wear tight, occlusive pants or underwear, especially in synthetic fabrics like lycra and nylon, they suffer more often from thrush.

Of course many of us will have thrush without identifying any of these extra reasons. We just seem to get it.

Symptoms. Although thrush can affect other parts of the body (under the breasts, in akin folds, nappy areas in babies). Women who have vaginal thrush may have no symptoms at all. More commonly they will be aware of an itch in the vaginal area, and some discomfort. It may progress to give a burning feeling and pain on passing urine or having sex. There is often a white/yellow discharge, and the skin of the vagina and vulvae (‘lips’ area outside the vagina) can become quite red and swollen. It is very important that a woman who has soreness, itch or discharge goes to a doctor and is properly examined. Although it may be a simple case of thrush, there are other conditions which can give similar symptoms.

Men who have thrush (yes, they get it too) in the genital region may have a reddened area of skin, which also may be itchy and sore. If the foreskin it involved, there may be some swelling. The rash can be anywhere, but it is often on the tip of the penis.

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There are varying degrees of severity of this condition. It has been suggested that about 30 to 40 percent of women suffer from some manifestation of premenstrual syndrome. Only a few (probably 5 per cent) suffer from debilitating symptoms. However, it is still a significant cause of distress in our population. There are other conditions which do not tend to follow a cyclical pattern, and it is important to distinguish PMS from these. You may have many of the symptoms listed above if you are suffering from anxiety, depression, thyroid disease or anaemia. Sometimes blood tests are used to exclude certain conditions. A useful exercise is to document the symptoms on a menstrual calendar, to see if there is a cyclical pattern to the symptoms and any relation to the luteal phase.

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