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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You may be told by your doctor not to drink during the first three months of pregnancy but it is fine after that as long as it’s only one or two glasses now and again. However, unfortunately, we now know that even a little bit can be too much. During the first 12 weeks, the highest rate of cell division takes place and all the major organs are formed, so there is more risk if a toxin like alcohol gets to the baby then. After the third month the baby grows and matures. This period is important because, even though the baby is fully formed, his or her organs cannot function on their own yet. As well as the heart and lungs the brain is also maturing. It is the brain that can be vulnerable to damage after the first 12 weeks.

It has been known for centuries that drinking during pregnancy can cause problems with the health of the baby. In the 1720s ‘gin epidemic’, the Royal College of Physicians stated that parental drinking was a cause of ‘weak, feeble and distempered children’.

Alcohol is classed as a teratogen (an agent or drug that can cause malformation of an embryo or foetus). Professor David Smith from Washington points out that ‘there is no known teratogen yet studied in man which clearly shows a threshold effect where the substance is quite safe to a particular level, beyond which it is teratogenic’. In effect, he is saying that the experts cannot say that one glass a week would be fine but two glasses are not. As the World Health Organization states, ‘no alcohol during pregnancy is the only safe limit’.

By day 36 of pregnancy, the neural tube of the embryo opens and a rudimentary system is formed. If a teratogenic substance like alcohol is drunk at this most crucial time, it can result in various malformations in the newborn (e.g. defective heart and muscular skeletal abnormalities).

Remember that you will be two weeks pregnant before you know you are. You only know that you might be pregnant when your period is late.

However, although the first three months are the most critical, the teratogenic effects of alcohol continue throughout pregnancy, affecting, at the later stages, brain development and function, in particular. Low birth weight and congenital abnormalities have all been linked to the teratogenic effect, with the probability of twice the risk of abnormalities.

The placenta does not act as a barrier. Alcohol is a low molecular substance which is quite capable of crossing the placenta and entering the baby. It does not take a mathematician to work out that, in relative terms, a dose of alcohol must have a much more profound effect on a minute developing embryo than on the much larger mother.

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Having breast cancer will change you. With luck and the safe passage of time, you will find ways to appreciate what this life-changing diagnosis has done for you. You will grieve for the woman you used to be as you come to understand and value the woman you are becoming. The process you will pass through is complex and multifaceted and will demand your energy, your attention, and all of your patience. It is a journey in much the same way that life itself is. The final destination for everyone is, of course, death. But if you continually focus only on the destination, you will miss the journey, and it is the process of living day by day, and night by night, that constitutes the voyage. The final destination will come soon enough.

Living with breast cancer is similar in many ways to grieving other losses. As those of you who have suffered the loss of a dear one or other life tragedies already know, grieving is a complex and demanding task. It takes patience and courage. You will find, as time passes, that you experience a wide range of feelings and reactions. Some common feelings include:

? Shock, disbelief, denial, and anger

? Active suffering in the mourning process, letting the pain penetrate and register, letting yourself feel and express joy and sorrow

? Acceptance (and this happens only slowly)—coming to peace with yourself, your altered image, the loss of your former state of health and your sense of immortality, perhaps the loss of body parts and perhaps the loss of the potential to conceive and bear a child. You have lost who you were and will grow into who you will be.

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Tamoxifen is the most common hormonal therapy used for the systemic treatment of breast cancer. Tamoxifen has been used for many years to treat metastatic breast cancer, and more recently, to treat postmenopausal women with new breast cancer. Even more recently, it has been added to the full treatment of some younger women, usually after the completion of chemotherapy.

Breast cancers are classified as being either estrogen and progestrone receptor positive or negative. This will be one of the things described by the pathologist who reviews your tumor cells. Those cells which are er/pr positive require estrogen to grow and divide. Tamoxifen acts as an estrogen blocker (anti-estrogen), making any remaining cancer cells unable to respond to estrogen. The cells then die.

Many node-negative postmenopausal women whose breast cancers are er/pr positive will be given tamoxifen for five years in lieu of systemic chemotherapy. Older women whose breast cancers are er/pr negative may well receive chemotherapy. Occasionally, the situation demands that postmenopausal breast cancer be treated with both chemotherapy and tamoxifen.

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Your plastic surgeon will likely tell you of his/her successes, and there most certainly are some. We have known women who have comfortably gone to nude beaches after breast reconstruction. However, you need to remember that not everyone is so happy with the result, and once a reconstruction is done, it is hard to undo. Talk with other women about their choices. Try to see several reconstructed breasts. Take a little time to consider your choices.

The technique of reconstruction may involve a saline implant, an expandable saline implant, a flap of tissue (muscle, fat, skin) moved from the abdomen (TRAM flap) or from the back (latissimus dorsi flap), and not infrequently both a flap and an implant. To determine which choice you prefer, you should do two things: first, schedule an appointment with one or more plastic surgeons to discuss your options; second, find women who have had the different procedures you are considering and talk to them. Although your plastic surgeon will be very knowledgeable about the various procedures, unless she has undergone the surgery herself, she will not know what it feels like to live with the results of the surgery on and inside the body ever after.

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Latency age children may have lots of questions. Some children will be more curious than others; try to answer all questions as briefly and honestly as possible. Answer only what you are asked. Remember to think of this the way you would health or sex education, if you do not know the answer, say so.

Children this age also need reassurance that they will be cared for while you are in the hospital or having treatments. They need to know that their daily lives and routines will be disrupted as little as possible. If you will be spending time in the hospital, they may like to have a calendar to mark off the days you will be away. Some might like a special blank book to write or draw in. Others might want to write you notes while you are in the hospital; give them paper, cards, envelopes, and stamps. Frequent short phone calls are a boon.

Invite your children to accompany you to the hospital when you are going for a short appointment. Particularly if you ask your doctor or nurse to suggest a good time for a visit, your children will be welcomed; they will be interested in meeting your caregivers and seeing where you are spending so much time. Children are rarely frightened by the treatment areas; indeed, they are generally quite reassured by seeing them. Their fantasies are much more frightening than the realities.

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Several of us have found it helpful while living through this crisis to encourage different family members to attend age-appropriate support or focus groups. Even when children don’t want to go to such meetings initially, they almost always feel surprisingly positive afterwards. With children, it is important to find groups divided by age; the issues most important to elementary school children are quite different from those most pressing to high school students. Even though your kids may be reluctant or resistant to going the first time, most of them will find solace in being with peers (even though they will be strangers) who are dealing with a parent’s cancer. They find it a relief to be able to talk about a range of deep-seated fears and feelings that they are reluctant to discuss with friends whose parents are healthy. If you choose to involve your children in a support program or group, you must inquire about the family situations of other children in the group! Just as it would be frightening for you to attend a group with women who are dying from breast cancer, it would be completely overwhelming and destructive to your children’s well-being to be in a group with others who have a terminally ill parent. Be sure of this before you send your children anywhere!

Having made a careful decision, trust yourself and trust your new doctors.

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Play activities

Childhood play activities have been regarded as indicative of the type of sexual orientation a girl is likely to develop. If homosexuality grows out of a female’s rejection of her femininity, as psychoanalytic theory suggests, then this rejection may be expected to become manifest not only in a girl’s gender identity and personal traits but also in the play activities she chooses or avoids. Thus, it has been thought that extended tomboyishness or lack of interest in typical girls’ activities may reflect a deeper rejection of feminine roles and a tendency to adopt masculine roles instead. Moreover, it has also been suggested that typical girls’ play activities provide a sort of “training ground” for feminine roles in later life. Activities such as playing house, playing with dolls, or dressing up in their mothers’ clothing, for example, have been seen as providing girls with an opportunity to “rehearse” adult feminine roles and to develop the types of interpersonal skills that go along with such roles. Again, psychoanalytic theory would suggest that girls with little experience in typical girls’ play activities might be less able to accept their own femininity or feminine roles later on.

Research in this area has consistently found homosexual women to have been less attracted to typical girls’ activities and more attracted to boys’ activities during childhood than were their heterosexual counterparts. It has been reported, for example, that homosexual women were more likely to have been tomboys in childhood and to have continued their tomboyishness into adolescence. Other investigators, comparing homosexual with heterosexual psychiatric patients, reported that while they were growing up the lesbians were more likely than the heterosexual women to have disliked dolls and girls’ games and to have been tomboys who preferred boys’ games. According to another investigation, homosexual women were less likely than heterosexual women to report that as children they had played “grown-up lady” games, pretended to have a baby, “mothered” a doll, or played house with themselves as mother.

Gender traits

Many theorists believe that the development of sexual orientation in women is related to the degree to which they define themselves as “feminine” and embrace popular expectations of the way women should behave. Thus, heterosexuality would be expected to develop most frequently among girls who have strong feminine identities and feminine interests. They include a tendency to be accommodating toward males, to seek personal fulfillment through the roles of wife and mother, and to anticipate “completion” through a physical and emotional union with a man.

The development of a homosexual life-style in females, it has been suggested, is related to a more “masculine” orientation. According to psychodynamic theory, for example, homosexuality may represent a woman’s rebellion against her place in the world and a desire, conscious or unconscious, to attain the privileges and status that men enjoy. Whereas for men marriage is seldom an overriding concern, for women marriage—and thus heterosexuality—is supposedly definitive of their lives, e.g., their principal investment is in homemaking and motherhood. Homosexual women, it has been proposed, reject this life-style and seek instead a relationship with another woman in which neither partner rigidly adheres to a conventional sex role.

The investigations that have addressed the question whether homosexual and heterosexual women differ with regard to their gender traits give mixed results. One study found that homosexual women, compared with their heterosexual counterparts, described themselves as having been more masculine during childhood. Another study, however, compared homosexual and heterosexual females on projective tests and found no evidence that the homosexual women were more rejecting of the female role.

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Marital relationships

The relationship between a girl’s parents has been thought to influence her sexual orientation, primarily because of its effect on her attitudes toward heterosexual relationships in general and, specifically, toward the traditional female roles of wife and mother. It has been hypothesized that a home situation in which parents are openly affectionate with each other and the mother, in particular, seems fulfilled by her role in the family leads girls to anticipate similar satisfactions in their own relationships with males. Family disharmony, on the other hand, has been thought to hinder the development of heterosexuality in females. The girl whose parents are obviously unhappy with each other and whose mother appears to derive little satisfaction from her marriage might well conclude that marriage is an uncertain road to happiness and that any kind of relationship with a man will prove to be unrewarding.

Several studies appear to support such contentions. Among those who grew up in intact families, for example, several studies have found heterosexual females to be more likely than homosexual females to describe their parents’ marriages as happy or harmonious. In another investigation (which did not involve a heterosexual comparison group), all the homosexual females reported that their parents showed little affection toward each other. In addition, it has been thought that homosexual females are more likely than heterosexual females to have divorced or separated parents or to come from unstable homes marked by significant discord between the parents. A number of empirical investigations have supported such a notion. Several studies, for example, reported more broken homes among homosexual than heterosexual women. In another study it was reported that half the lesbian subjects had come from broken homes. (It should be noted, however, that the homosexual female subjects were not compared with a heterosexual control group.) Finally, additional evidence of familial instability on the part of homosexual females has been provided by one investigator who found that more homosexual than heterosexual women’s mothers had died, while another researcher found that homosexual women were more likely than heterosexual controls to report having a stepfather. In another study most of the homosexual women were reported to have grown up without a firmly established nuclear family or with one or both parents absent (again, however, no heterosexual control group was involved).

Marital dominance

In keeping with the general view that the parents of homosexual females are likely to have experienced considerable strain within their marital relationships, some theorists have supposed that this distress is the result of a mother’s insistence that she “wear the pants” in the family and of the father’s resentment over her usurpation of his special prerogatives. Indeed, one empirical study did find that the homosexual women in the sample were more likely than heterosexual women to describe their mothers as the dominant parent.

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Over-the-counter methods for women are reversible barrier methods of birth control. They include:

• contraceptive foams

• contraceptive creams

• contraceptive jellies

• contraceptive films

• contraceptive suppository capsules

• vaginal pouches (female condoms)

If you choose one of the over-the-counter methods for women, you will insert it deep into the vagina before intercourse. Foams, creams, jellies, films, and suppositories are liquids or solids that melt after they are inserted. They contain chemicals that immobilize sperm (spermicide).

Vaginal pouches are polyurethane sheaths with flexible rings at each end. The pouch is inserted deep into the vagina like a diaphragm. The ring at the closed end holds the pouch in the vagina. The ring at the open end stays outside the vaginal opening.

How Over-the-Counter Methods for Women Work

Contraceptive foams block the entrance to the uterus with bubbles and contain a spermicide that immobilizes sperm, preventing it from joining with the egg.

Contraceptive creams, jellies, films, and suppositories melt into a thick liquid throughout the vagina. They block the entrance to the uterus and contain spermicide that immobilizes sperm.

Vaginal pouches collect semen before, during, and after ejaculation and keep sperm from entering the vagina.

Effectiveness of Over-the-Counter Methods for Women

Of 100 women who use contraceptive foams, creams, jellies, films, or suppositories, 21 will become pregnant during the first year of typical use. Five will become pregnant with perfect use. Using a condom increases effectiveness.

These over-the-counter methods may provide some protection against certain sexually transmitted infections, including chlamydia and gonorrhea.

Of 100 women who use vaginal pouches, 24 will become pregnant during the first year of typical use. Ten will become pregnant with perfect use.

The pouch provides some protection against many sexually transmitted infections, including HIV.

Advantages of Over-the-Counter Methods for Women

• All are easy to buy in drugstores and some supermarkets.

• Prescriptions or fittings are unnecessary.

• Once learned, insertion is easy and may be done by your partner as part of sex play.

Vaginal pouches allow women to take responsibility for protection against sexually transmitted infections.

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