Pregnancy. Pregnancy and body weight increases are intertwined in a complicated pattern. Female fat stores have a primary function to provide energy for pregnancy and lactation. A pregnant woman requires approximately 130 000 kcal extra as the metabolic cost of pregnancy. Women who tend to put on too much fat in the early stages of pregnancy have been shown to keep this longer than those who do not put on excessive fat, or put on most fat later in the pregnancy. The recommended weight gain during pregnancy by the US medical specialists has risen from 7-Skg in the 1920s to 10-12kg in the 1970s. In 1989, the National Task Force on Prevention and Treatment of Obesity raised the recommendations to 14-16kg in 1995. However, there are now suggestions by some experts that this is too much and that the most recent recommendations are based simply on the modern average weight gain of pregnant women in the US. The previously recommended gain of 10-12kg has been suggested as a more appropriate health ideal for which to aim.

Breast-feeding is also known to be an effective form of fat burning, using up to 400kcal of energy per day. In one study carried out in the US, women who breast-fed for at least six months stayed leaner for up to two years than women who did not breast-feed at all or did so for less than six months. It has also been claimed that the risk of obesity increases with parity or the number of childbirths. This may be due to the repetitive exposure to the fat storing hormones of pregnancy, restrictions on physical activity or increased opportunity to eat more. In any case, for some women, pregnancy does appear to be a particularly high risk period for increases in obesity.

Research from the Stockholm Pregnancy and Weight Development Study in Sweden suggests that the greater the weight gain during pregnancy, the more likely the increase in post-partum body fat levels. Cessation of smoking with the onset of pregnancy may increase weight gain in the mother (although it certainly reduces the risk of birth complications in the baby). Those women who gained most weight during and after pregnancy were found to be those who had significantly changed their lifestyle from prepregnancy levels such as increased eating/snack eating and decreased levels of physical activity. Maintenance of physical activity through pregnancy and attention to nutrition, therefore, are most important to ensure a return to normal fat levels, but there are also special considerations for exercise which need to be considered. These are now available from most Health Departments.

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What happens to the space occupied by my uterus?

Women often wonder if an empty space remains after a hysterectomy, but you can be sure this does not occur. Organs such as the bladder, bowel and intestine reposition themselves and take up the space.

I have heard that some women get depressed after a hysterectomy. How likely is this to happen?

Recent studies suggest that, overall, rates of depression in women who have a hysterectomy are less than they were in the same women before they had the operation. In individual cases, however, depression may be increased due to complications of the operation or regrets about having it. Hysterectomy can actually reduce levels of depression in women for whom the operation relieves painful and heavy periods.

How can I improve my health before having a hysterectomy?

Avoid smoking, have regular physical activity, and keep your weight under control. Doing these things reduces the risks associated with surgery and post-operative complications. If you are having heavy bleeds, you should take iron supplements to increase your haemoglobin level.

Will I have an early menopause if I have a hysterectomy hut keep my ovaries?

In theory, removal of the uterus and cervix, but not the ovaries, should not produce menopause. The only change should be an end to your periods and removal of the problems that made the surgery necessary.

In practice, however, a significant number of women whose ovaries remain after this sort of hysterectomy do experience symptoms of menopause up to four years earlier than might be expected. Possible explanations are that the surgery inadvertently altered the blood supply to your ovaries, or the condition that caused you to have a hysterectomy in the first place, such as endometriosis or cysts, had already reduced the natural life of your ovaries.

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It is interesting to observe that some people fall asleep very easily, but some find it very difficult and need sleeping pills. Even the same person may fall asleep very easily at some times in his life but find it very difficult at other times. Why is this?

There are two sets of forces acting against each other which affect sleep onset One group of forces includes good sleep hygiene, falling asleep at the right time of the biological clock, and, of course, being sleepy. The other group of forces includes poor sleep hygiene, trying to fall asleep at the wrong time of the biological clock, being unable to handle stress effectively, and, of course, having a genetic makeup that is of poor quality for sleeping. It is important to increase those forces that facilitate sleep onset and to decrease those that oppose it.

Genetic make-up. Studies of identical twins show that much of our ability to sleep is coded in our genes. Identical twins, who have the same genes, have similar sleep patterns even if they live apart in different environments for years. Some people are born good sleepers and they can sleep at any time of the day and, in fact, anywhere. My wife is a good sleeper, and she could sleep easily at any time no matter what shift duty she was on when she was working as a nurse in the general hospital. My two daughters have different abilities to fall asleep. Melissa is more like me, whereas Melinda sleeps easily, very much like her mother. But for those of us who are not so lucky and have poor quality genes for sleep, we have to improve those factors that facilitate sleep onset so as to tip the balance in favour of the forces that bring about sleep.

Sleep hygiene. This is the most important force in facilitating sleep onset As discussed in chapter 15, Sleep Hygiene, caffeine is the number one enemy; absolutely no coffee or tea. The bedroom is reserved for sleep and sex and no other activities. Leave the clock under the bed, but set the alarm to the same time every morning, even on Sundays and public holidays. A regular waking up time in the morning is an important Zeitgeber for entraining our circadian rhythm to the 24 hour clock. Daytime exercises are good, as they increase the amounts of NREM sleep.

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