Studies with sibutramine and orlistat in a clinical setting have been designed to show what happens in ‘real life’. Results from both are favourable, and indeed broadly comparable. On average, one can expect weight loss of around 9% maintained over 12 months, among those who respond to, and continue treatment. However, while every physician involved in weight management will be able to tell you of the marvelously successful patient who lost 40% body weight, they will equally be able to tell you of their abject failures.

Sibutramine

When used in conjunction with a low-calorie diet, data show that 77% of sibutramine-administered patients achieve a medically beneficial weight loss of at least 5%. Importantly, continuation of therapy can sustain these weight losses for at least 2 years. Further, a recent meta-analysis has shown that, in sibutramine-administered obese patients, subjects who achieved weight losses of over 4 kg in the first 3 months of treatment were more likely to achieve long-term weight loss maintenance if therapy was continued. This in turn, led to marked improvements in metabolic factors such as lipid profile, insulin sensitivity and hypertension.

Orlistat

A placebo-controlled study involving obese patients found that orlistat can promote and maintain weight loss (when administered in conjunction with a hypocaloric and a eucaloric diet, respectively). During the weight-loss phase (year 1), orlistat patients lost 10.2% body weight, compared with 6.1% in the placebo group. Results from the weight-maintenance phase of the trial (year 2) showed that patients who continued on orlistat regained half as much weight as patients switched to placebo. Weight-loss-associated improvements in cardiovascular risk factors, including lipid profile, blood pressure and fasting glucose, have also been demonstrated.

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WEIGHT LOSS/BODY-BUILDING

Recent probes into the theory of retrograde menstruation reveal that a great percentage of women show an increased amount of blood in the pelvic cavity around menstruation and after ovulation. Blood has even been present in the dialysate (liquid drawn from the abdominal cavity) of women undergoing kidney dialysis while they had their periods. What this proves, again and again, is that retrograde menstruation it common.

Earlier experiments, specifically those performed in the 1950s, were more aggressive. One team—doctors R. B. Scott, R. W. TeLinde, and L. R. Wharton, Jr., of Chicago’s Northwestern Medical Centers-created pelvic endometriosis in rhesus monkeys by inducing retrograde menstruation in an extreme manner. Basically, what they did was cot into the monkey’s uterus, opening it so that menstrual blood spilled directly into the pelvic cavity instead of being washed out through the vagina. Six of the ten experimental monkeys developed endometriosis—some within two and a half months, whereas others had no signs of it for nearly three years. In 1958 a number of women voluntarily submitted to an experiment wherein doctors injected endometrial cells into a laparotomy incision. This experiment also produced endometriosis in most women,

Sampson’s theory has found a few detractors, but most doctors agree that the backward spraying of menstrual blood places endometrial tissue on vulnerable organs. Even Sampson postulated that in all probability there is “more than one” avenue available for the development and spread of this disease. One conclusion was that, he wrote, “the invasion and dissemination of endometrial tissue employ the same channels as the invasion of cancer.” This meant that fragments of endometrial tissue reached other parts of the body through channels such as the blood and lymph systems. The actual process of tissue transference from one organ to another by blood or lymph glands is known as metastasis.

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It is thought that women with endometriosis have higher concentrations of prostaglandins in their peritoneal fluid and that these higher concentrations may contribute to infertility by hindering or preventing conception and implantation in a number of ways.

It is possible that prostaglandins interfere with the functioning of the ovaries and prevent the release of the ovum thereby preventing fertilisation.

Prostaglandins may affect the sperm as they move towards the ovum by slowing down their movement and thus reducing the number of healthy sperm that can reach the ovum in time for fertilisation.

Prostaglandins help the ovum move along the fallopian tube.

If the fertilised ovum is propelled too rapidly along the tube the ovum will reach the uterus too quickly. Therefore, when the fertilised ovum reaches the uterus it may not be mature enough to implant itself in the endometrium or the endometrium may not be ready to accept the fertilised ovum. If the fertilised ovum is propelled too slowly down the fallopian tube it may not reach the uterus in time to embed itself in the endometrium.

Prostaglandins may also affect the relaxation and contraction of the uterus. If they produce excessive contractions of the uterus they may prevent implantation of the fertilised ovum or they may cause it to be expelled soon after implantation.

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The diagnosis usually involves several stages which may include some or all of the following:

Reporting your symptoms to a doctor

Giving a history of your symptoms

Having a physical examination

Having an ultrasound

Having a laparoscopy

Taking a biopsy during a laparoscopy.

An early diagnosis is important as endometriosis is generally thought to be a progressive condition in which treatment is more effective in the early stages. If the progression of the condition can be stopped, or at least slowed down, then the likelihood of developing long-term complications such as infertility, adhesions and chronic pain is reduced.

For many women the road to a diagnosis is often long and it is not uncommon for women to see several doctors regarding their symptoms over a number of years before a diagnosis is made. In a survey conducted by the Endometriosis Association (Victoria), the average time between the onset of symptoms and diagnosis was over six years.

The long delay in diagnosis experienced by many women is partly due to the fact that endometriosis is often difficult to diagnose, especially in the early stages. The symptoms are easily confused with several other conditions and some doctors are not fully aware of the range of possible symptoms. In addition, a pelvic examination often appears normal.

Unfortunately, the diagnosis of endometriosis is also sometimes affected by doctors’ attitudes to the symptoms. Many doctors do not take women’s and teenager’s symptoms, such as period pain, seriously. Like many people in our community, they tend to assume that period pain is normal or psychological.

Doctors often do not consider a diagnosis in women and teenagers who do not conform to the traditional stereotype of women with endometriosis. Consequently teenagers and women under the age of 25, women who have had children and women from lower socio-economic backgrounds are often simply not considered for a diagnosis.

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To optimize your health, you should eat plenty of unrefined complex carbohydrates. This means choosing brown whole meal bread, brown rice and brown pasta, instead of the refined white versions which have been stripped of essential vitamins, minerals, trace elements and valuable fibre content. (In order to digest these refined foods your body has to use its own vitamins and minerals, thus depleting your stores.)

Simple carbohydrates, in the form of fruit and dried fruit, certainly have a place in a healthy, balanced diet. But it’s important, for your health and fertility, to maintain a steady blood sugar level. For this reason, you should avoid sugar, honey and undiluted fruit juice, which can all produce a sudden rise in blood sugar, followed by a sudden fall.

Soya

Soya is being studied extensively around the world for its effectiveness in lowering cholesterol and preventing cardiovascular disease. It also appears to have an important role to play in balancing male and female sex hormones. Scientists believe that hormonal imbalance and over-exposure to chemicals that have oestrogen-like qualities may be one reason for the rapid increase in breast and prostate cancers over the last couple of decades. Crucially, this hormonal dysfunction and overload are also implicated in the menstrual and reproductive problems that affect fertility.

Soya is classed as a phyto-oestrogen, which means that it contains substances that act like hormones. These phyto-oestrogens fit into oestrogen receptors in the breast and block them, effectively shielding the body from exposure to oestrogen which is believed to be one of the major causes of breast cancer. Studies of Japanese women, who traditionally eat a great deal of soya, suggest that it may protect them from this disease.

Oestrogen is not only implicated in breast cancer but is also believed to play a part in causing other problems like endometriosis, fibroids, and heavy and/or long periods – all of which can affect female fertility.

Some women have problems conceiving because the second half of their menstrual cycle, just after ovulation, is shorter than it should be. This ‘luteal phase defect’, as it is known, means that there is not enough progesterone at the right time to maintain a pregnancy. Scientists have found that if they add soya to a woman’s diet it can lengthen the cycle by 2.5 days.

For all these reasons, it’s well worth adding soya to your diet – perhaps in the form of soya milk and tofu (soya bean curd, often used in Oriental stir-fried dishes). However, you need to ensure that the soya used to manufacture these products is not genetically modified, so buy organic.

So, for optimum health, you should eat plenty of:

• Essential fats (nuts, seeds and oily fish)

• High-fibre foods (fruit, vegetables, whole grains, beans, nuts and seeds)

• Complex carbohydrates (whole grains, beans, pulses and vegetables)

• Non-GM organic soya

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There are a few extra things to keep in mind if you’re over 60 years of age.

Diet

Good nutrition is always important. It’s hard to know just how important particular types of diet are in maintaining health. Around the world, people who have widely varying diets are now living to a ripe old age. Japan and Sweden have the highest life expectancy, with diets that could hardly be more different. Australia is close behind. The French, renowned for the richness of their cuisine and their wine consumption, also have excellent life expectancy.

If you’ve reached the age of 70 and you’re in good health, what you’ve been eating so far hasn’t done you any harm. Most people of this age will have grown up being taught that meat and dairy produce were good for you and bread and potatoes were the ‘baddies’. The new dietary guidelines are different, but they are based on a modern understanding of nutrition so it makes sense to follow them.

One big advantage of the new guidelines is that they advise you to increase the amount of fibre in your diet. This reduces the risk of constipation, which for some people increases as they grow older.

If you have problems with chewing, see your dentist promptly. Inability to chew properly used to be one of the main causes of malnutrition in older people.

The most important thing about food is to enjoy it. Eat enough of a mixture of foods that you like to maintain a healthy weight. Your doctor will advise you about healthy weight range for your height.

Try to choose foods from the Diet Pyramid to ensure that you obtain all the nutrients you need for good health. This will help increase your resistance to infection and keep you feeling healthy and vital.

As already discussed, many women are unhappy about certain features of their breasts. Because of their powerful sexual significance in our society, breasts seem to be a greater source of dissatisfaction than most other body features.

It’s easy to say that we should accept our bodies as they are and that people love us for our whole selves whatever the size of our breasts, the colour of our hair, the shape of our noses and so on. This type of statement doesn’t make much of an impression on the woman who’s been embarrassed since her early teens because of her big bosom, or the young woman with one breast twice the size of the other, or the woman whose breasts droop so much after her first pregnancy that she won’t undress in front of her husband.

I agree with the ideology that people should accept and love us for ourselves, warts and all. But unfortunately many people can’t love themselves if they feel that they have a physical feature that is freakish or ugly: they become depressed and withdrawn. I believe that there are many instances where the benefits of cosmetic surgery, in terms of improved self-esteem and confidence, outweigh any amount of ideological argument.

A skilled, caring surgeon and thorough counselling are the most important factors in ensuring satisfactory results.

Should we wear bras?

This question would never have arisen between about 1910 and the mid-1960s when all women wore bras, either to flatten and conceal breasts in the ‘flapper’ era, or to mould them into the fashionable shape of the 1940s-60s.

Today, the main advantage of a bra is that it supports the weight of the breasts, thus preventing premature stretching of the fibrous ligaments that anchor the breasts to the chest wall. Support is more important for heavy breasts, especially in the following circumstances:

Lack of oestrogen is the most important factor in the development of osteoporosis in women. Oestrogen decreases bone breakdown, prevents loss of calcium via the kidneys and improves absorption of calcium from the bowel. Even with enough exercise and calcium, women who lack oestrogen before or after the menopause will lose more bone more rapidly that those who don’t.

Health authorities now recognize the importance of oestrogen replacement in maintaining older women’s health, especially in the prevention of osteoporosis. However, some women don’t want to use HRT, and it would be overkill to recommend that all women take oestrogen to prevent fractures when two out of three postmenopausal women won’t suffer the symptoms of osteoporosis. It’s generally possible to predict whether a woman is at increased risk.

Techniques have been devised to measure bone density and the degree of bone loss from osteoporosis. These tests may be used to identify early those at higher risk of fractures in later life so that vigorous steps can be taken to prevent further bone loss. Your doctor might suggest such tests if you seem to be at high risk, though many doctors skip the tests and encourage all middle-aged women to begin and maintain a routine that will prevent them from ever suffering disability from osteoporosis. This means having enough exercise and calcium, and hormone replacement if needed.

For women who can’t take oestrogen, other medications may be helpful. Calcitonin (a hormone produced in the thyroid gland) and calcitriol (a type of vitamin D) have been used with some success in the prevention and treatment of osteoporosis, but they are not suitable for everyone and should be used only under supervision of a specialist in osteoporosis. Anabolic steroids seem to relieve the symptoms of established osteoporosis and slow down or halt the process, but also may have unwanted side-effects in some cases.

Other risk factors

Other factors can influence the risk of fractures from osteoporosis.

Body build

Thin women are at greater risk than plump women. Body fat can convert hormones from the adrenal gland into oestrogen: not as much as the ovaries produce before menopause, but enough to slow down bone loss. Also, the bones of heavier women are more stimulated by the greater weight they support. Short women are at greater risk than tall women, because they have less bone mass and so lose relatively more bone as they age.

Family history

Our genes determine our body shape and height, and family habits of diet and exercise may also be important factors in the development of osteoporosis.

Drugs and smoking

Certain drugs promote bone loss, mi through their effects on body calcium. These are alcohol, some diuretic anticonvulsants, thyroid hormone, cortisone and tetracycline antibiotics. Women who are prescribed these drugs for a long time will have been warned by their doctors that they may need more calcium.

Cigarette smoking encourages bone to by increasing the rate of oestrogen breakdown in the body and perhaps the rate of calcium loss in urine.

Amenorrhoea

Women who’ve had long episodes amenorrhoea between puberty and menopause are more likely to begin postmenopausal years with reduced bone strength.

Until recently one in three women coil expect to suffer a fracture from osteoporosis if they lived beyond 65 years. Now we can help prevent osteoporosis from casing disability by maintaining healthy bones before menopause, and by continuing adequate exercise, taking enough calcium and using HRT if needed, after menopause. If you’re around the age of 50, discuss these measures with your doctor.

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It’s generally better to set off for the hospital early rather than too late. Check with the delivery suite if in doubt (there is someone on duty 24 hours a day). Your partner or the taxi driver could probably rise to the occasion if necessary, but I’m sure that both you and they would prefer
experienced hands for your delivery! Until about 70 years ago, most babies were born at home, usually with the help of the local midwife or GP. During the 1920s the trend to having a baby in hospital began, and by 1950 a home birth in Australia was a rarity. Childbirth in hospital became (and still is) favoured for its greater safety, leading to the rapid growth of obstetrics as a speciality, and medical technology was applied to childbirth. We’ve now gone the full circle. Since the late 1970s there’s been an increasing demand for the services of midwives for home births and for hospital services that would allow a natural delivery if appropriate, rather than every confinement being subjected to high-technology
interference.

Twenty years ago women rarely questioned what happened to them during hospital confinement. Today the reason and need for many common obstetric procedures has been challenged, and women expect to have a much greater say about how they would like their childbirth to be managed. The aim of all obstetric interventions should be the birth of as healthy a baby as is possible with minimum risk to the mother. Here are some of the controversies.

Recent changes in approach to childbirth

Many women these days have well-formed ideas about how they would like their labour and delivery to proceed. Judith was delighted when I confirmed her first pregnancy. She said: ‘I want to have this baby naturally. Jim and I have decided that we want our baby to be born without anaesthetics or any interference.’ Marie’s reaction was quite different. She said: ‘Refer me to a hospital where they believe in pain relief in labour. I don’t mind how the baby is born, as long as everything is done to ensure a safe delivery.’

Which approach is best? It’s impossible to say. It’s good to gather information about modern childbirth services so that you can decide what you would prefer, and then find a birth attendant – GP, midwife or obstetrician – who will respect your wishes, answer your questions clearly and carefully explain anything that necessitates a change in plans.

Judith may be sadly disappointed if, for safety’s sake, she needs assistance during delivery. On the other hand, Marie may be pleasantly surprised if she doesn’t need pain relief during labour. Because what’s going to happen is so unpredictable, I think it’s better to keep an open mind.

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It wasn’t until the invention of the microscope in the late eighteenth century that sperm were seen in semen and identified as the male contribution to pregnancy. At this time sperm were thought to be miniature men, and one scientist of the time even claimed to have seen microscopic horses cantering through semen! The first human vasectomy was performed in England in 1893, but for treatment of a prostate disorder rather than sterilisation. Over the next few decades die operation became disreputable because it was used involuntarily to treat sex offenders, to prevent masturbation and for eugenic purposes. Voluntary vasectomy as a method of birth control didn’t become established until after the Second World War, and even then there were doubts about its legality in some countries. The first nationally promoted vasectomy programme began in India in 1956, but acceptance of male sterilisation worldwide was slow until the 1970s and it is still forbidden by some nations and religions.

How vasectomy is done

This simple operation is usually done with local anaesthetic in a doctor’s rooms or outpatient clinic. Counselling, preferably of the couple, is best done at a separate visit beforehand.

A small incision is made in the centre font of the scrotum after injecting a small amount of anaesthetic (some surgeons use an incision on each side). The vas from each side is brought through the opening, cut, folded back on itself and tied. Many surgeons also cauterise the cut end. Each bid is then buried in the tissue beneath the skin. The incision rarely needs a stitch; a small dressing is usually enough. The procedure takes 30 minutes or less and most men say it causes little or no discomfort. Afterwards there may be discomfort, swelling and bruising of the scrotum that usually settle in a week or so. A scrotal support or firm-fitting underpants should be worn until the scrotum returns to normal. Usual activities can be resumed the next day (including sex if the man feels like it), though heavy exertion should be avoided for about a week.

Vasectomy doesn’t immediately result in sterility.
The long spermatic ducts between the site of vasectomy and the prostate are full of sperm-containing semen at the time of the procedure. It takes about 15-20 ejaculations to clear out all these sperm. Couples are advised to continue their usual method of contraception until semen examination has shown that all sperm have disappeared. The first test is usually done two months after vasectomy (or after 15 ejaculations, whichever is sooner), when more than 95 per cent will have zero sperm counts. If any sperm are seen, the check is repeated four weeks later. Checking picks up failure in the operation before there’s any risk of pregnancy.

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The main reasons for the continuing controversy are moral and political. It is feared that injections may be given to women against their will or without telling them that they are for contraception and/or without telling them of the possible side-effects or problems. This is an abuse of human rights that should be condemned in every circumstance.

The opponents of DPMA certainly have a strong case against its abuse, but their arguments against its proper use to treat disorders or for contraception tend to ignore the evidence that it is safe and exaggerate the risk of side-effects.

To eliminate the possibility of abuse, any woman who is offered DPMA must be given full details about all its possible effects plus an unbiased account of the controversy, so that she can make a fully informed decision about using it.

DPMA has been used for many years in high dosage to treat breast and endometrial cancer, and has been used in low dosage for contraception by more than 10 million women. As a contraceptive, it has less health risks than the Pill, and no deaths have resulted from using a contraceptive injection. DPMA is used for contraception in more than 80 countries, and has been endorsed by such prestigious groups as WHO, the International Planned Parenthood Federation and the American and British Colleges of Obstetrics and Gynaecology.

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How long do periods last?

They usually continue for three to six days. The most common pattern is for the discharge to be slow and darkish for the first few hours; then a steady, brighter red flow; for the next day or so; becoming slower: and darker over the next couple of days.

How much blood is lost at menstruation?

First of all, the menstrual flow is not all blood, though there is blood in the endometrium when it is shed, plus some more that leaks from the raw surface it leaves behind. The flow also contains the liquefied endometrium and some secretions from the cervix and vagina.

The average blood loss per period is around 40 ml, though it seems like more when it’s spread out on pads and tampons (but pour just 10 ml – 2 tsp – of coloured liquid onto a pad and see what a wide area it covers). A loss of more than 80 ml is abnormally heavy bleeding.

How can menstrual flow he measured?

The usual way has been to get women to save all the tampons and pads used during a period, and to extract the blood pigment (haemoglobin) they contain. By measuring the amount of haemoglobin per ml in each woman’s blood, her blood loss during the period can be calculated. Measuring the total amount of fluid in the Sow is more difficult. One way would be to weigh all pads and tampons before and after use and attempt to calculate the weight of the fluid, but this doesn’t give an accurate measurement.

Why doesn’t menstrual blood clot?

This is because the liquefied endometrium contains substances that dissolve blood clots. If there are clots in the menstrual flow it means that blood is flowing so quickly that it dilutes these substances I too much for them to be effective.

How long is the menstrual cycle?

It’s conventional to describe a menstrual cycle as covering 28 days, and in the majority of women menstruation does occur around every four weeks. However, anything from 22 to 35 days is within the normal range, and for most of us the cycle can vary by a few days from one month to the next.

Other questions about the menstrual cycle

Do other animals menstruate?

Only mammals (animals that breast-feed their young) have reproductive functions similar to those of humans. In cycles where there is no conception most other mammals absorb the dead lining of the uterus back into their bodies. Apes and some species of monkeys menstruate.

Can you tell when you’re ovulating?

Some women can. They notice brief lower abdominal pain at mid-cycle (also called mittelschmerz - German for ‘middle pain’) when the ovarian follicle ruptures. The pain may be followed by 12 hours or so of a tight feeling and tenderness in the lower abdomen due to irritation of the pelvic lining by the fluid released with the ovum. A few women regularly have a spot or two of bleeding from the vagina with ovulation.

If you’re watching your cervical mucus and basal body temperature, ovulation is near the time of peak fertile mucus, and you’ll know that ovulation happened 12-24 hours before the mucus becomes thick and sticky and the temperature rises.

Do women ovulate every month?

Regular periods don’t necessarily mean that you ovulate every month. The ebb and flow of hormones can lead to bleeding even if the ovarian follicles don’t ripen completely and release an ovum. This is called an anovulatory cycle. Without ovulation, bleeding may be somewhat heavier and longer and is usually painless.

Anovulatory cycles are very common for a year or so after the menarche and in older women approaching the menopause.

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The process of growing up includes! some experimenting and risk-taking to I find out what life has to offer and what is safe, good and right for you. If you didn’t take some chances you’d never grow up. Many of your new experiences will be wonderful and enrich your adult life. Unfortunately a few new adolescent activities bring risks to health and life.

Accidents

It’s a great day when you get your driving licence. What an exhilarating feeling of freedom and power to be in charge of a; car or motorbike. But whoa! It’s also a great responsibility. Are you ready for it? It takes time and practice to develop prudence and caution needed for safe driving.

I think the P-plate system helps young people learn to drive carefully. Most so keen to retain their licence that the] take all precautions during the provisions period. Still, road accidents seriously injure and kill more young people than any other cause. In more than half of the accidents, the driver is under the influence of alcohol or drugs. Even a blood alcohol level of 0.05 doubles the accident risk; at 0.15 a crash is 25 times more likely.

Never, never take a chance with drugs or alcohol on the road. Don’t drive yourself, and don’t be a passenger if the driver’s alertness and co-ordination could be affected by drinking (or anything else) This may sometimes mean that you must take public transport or a taxi home and collect the car next day. A nuisance? Yes, but it’s never worth risking serious injury or death.

Teenagers and alcohol

A survey of New South Wales school students that’s been going on since 1971 shows that they now drink twice as much as they did 15 years ago. Many are drinking regularly at the age of 14, with the heaviest drinking occurring among the 16-17-year-olds. Girls now drink as much as boys, so it seems that the old attitude that it was manly but unladylike to drink has disappeared in Australia. Boys tend to stick with beer, while girls prefer more sophisticated mixed drinks like rum and Coke (which don’t taste like booze but make you drank very quickly). Meanwhile health authorities continue to hammer away about the dangers of alcohol: its association with road accidents, domestic violence and increased risk of heart disease, liver disease, brain damage and all the social evils of alcoholism. You wonder why anyone drinks! Why do teenagers start drinking? And why so young? Teenagers see drinking as a thing adults do and seem to enjoy, so they want to try it. Often they see no harm come from it. They may doubt the message of the health authorities when they see no ill effects from Mum and Dad having a drink after work and a glass or two of wine with dinner, though the teenager whose home life is wrecked by a drunken parent may have a different opinion.

The fact is that alcoholic drinks are part of our way of life. Drinking is part of most of our social rituals. Australians swallow more alcohol per head than any other country in the Western world. It would be hypocritical to advise young people not to drink at all when they see their parents and other adults drinking all around them; alcohol is advertised everywhere and many big sporting contests are sponsored by breweries.

The credible message for young people is moderation, know your limits, don’t get drunk and, of course, never drink any alcohol if you’re going to drive. Still, a lot will get drunk once, just to see what it’s like. Let’s hope that most of them will decide in the misery of the next morning that they’ll never do it again.

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