О язве двенадцатиперстной кишки-About duodenal ulcer

На протяжении многих лет самым основным методом диагностики язвы кишечника остается рентгенологическое исследование, при котором на снимке двенадцатиперстной кишки можно увидеть дефекты слизистой оболочки.

Язву слизистой оболочки можно обнаружить и с помощью гастродуоденоскопии. При проведения этого исследования пациент проглатывает специальный зонд, с помощью которого врач видит слизистую оболочку кишечника и может взять ее частицу для лабораторного исследования.

Важным исследованием также является проверка секрета желчного протока и установление в нем наличия хеликобактер пилори.

В настоящее время основной терапией является фармакологическое лечение, которое ставит своей целью уничтожение болезнетворной бактерии и восстановление слизистой двенадцатиперстной кишки. Такой способ заменил, широко использовавшийся ранее, хирургический метод, который сейчас применяется только для лечения прободных язв и остановки кровотечения в кишечнике.

Боль в эпигастрии, которая проходит после еды или после приема антацидов, дает возможность предполагать язву двенадцатиперстного отдела кишечника, но часто у больных с такой симптоматикой она не обнаруживается при эндоскопическом и тщательном рентгенологическом обследовании. Бариевое исследование верхних пищеварительных путей считается объективным методом определения язвы. Рентгенология, в зависимости от мастерства и настойчивости рентгенолога, позволяет диагностировать около 80% случаев, когда язва не определилась при эндоскопии. Новейшие методы исследования с методами двойного воздушного контраста позволяют достичь 90 % точности. Обычно язва выглядит как кратер диаметром 1 см в проксимальной зоне луковицы.

Фиброволоконная эндоскопия значительно облегчает диагностику язвы двенадцатиперстной кишки. Она хорошо подходит для определения язв, которые лишь подозреваются по данным рентгенологии или при деформированной луковице, а также небольших поверхностных язв.

Основной целью лечения является заживление язвы и купирование боли. Профилактику осложнений и обострений можно отнести к второстепенным задачам. Традиционно используют антацидные препараты, которые нейтрализуют кислоту и при этом не всасываются в путях пищеварения. К ним относятся: карбонат кальция, бикарбонат натрия, окись алюминия. Также широко используются антигистаминовые препараты, которые подавляют гистамин гладкой мускулатуры кишечника. Еще применяются антихолинергические и обволакивающие лекарства, которые действуют в щадящем или местном режиме.

You may have something in common with Charlotte other than the physical symptoms of the disease. You may be striving, working woman in your twenties or thirties who has put off childbearing to pursue a career. A surprising third portrait reveals you as a teenage girl, highly sensitive, but with a strong sense of competition that may or may not be fully expressed.

What do personal issues of fulfillment through work, or work as a matter of sheer economic survival, have to do with endometriosis? Don’t unambitious, nonstriving women—even altruistic, spiritual women—develop the disease? Certainly they do! But they are not the most vulnerable. In these transitional times, working women are most likely to succumb to endometriosis.

In the 1980s it is nearly impossible for a gynecologist and obstetrician to care sensibly for a patient without identifying, describing, and fully examining some crucial details of her personal life. As part of treating the person, not just the symptoms, we must examine the external influences—physiological and psychological—that create changes in her health.

These are exciting times for women with professional aspirations, with greater chances than ever for taking on new responsibilities. In 1985, one-third of American earning power was a result of women’s work on every level. In 1970, 26 percent of women between eighteen and twenty-four years of age were unmarried. In 1986, 56 percent of the same age group were single—most of them in the work force. More relevant to our story, in 1950, 80 percent of women had borne at least one child by the age of thirty, whereas today, the figure has dropped to 60 percent.

Beyond job stress, women are juggling the minute-to-minute priorities of work and intimacy, confronting any ambivalence about achievement along with conflicts over dependency on men, figuring out how to achieve a balance on a day-to-day basis—and they are postponing childbirth.

Endometriosis isn’t fair. It isn’t interested in bow hard a woman works and it doesn’t care why a woman has not had children early in life, when there are fewer chances of organic complications. It thrives on stress-related immune system weakness, which, along with other factors that I will discuss in great detail later on, can control a woman’s body and her life. But it needn’t happen this way. With my plan, you eon learn to control endometriosis and not feel that you must choose between your work and your health.

Describing endometriosis as the «career woman’s» or working woman’s disease may be the switch that turns on a highly charged debate among doctors, scientists, and even victims of the disease. But whatever else may be so, the change in life-style is here to stay, and it is every women’s right to pursue the optimal health she desires in order to live a fully productive life.

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Transcutaneous electrical nerve stimulation, commonly known as TENS, is a treatment developed when it was observed that pain symptoms eased when electricity was applied to the skin at the site of pain.

A TENS unit is a small battery-operated machine (about 10 centimetres by 8 centimetres) that is usually clipped to a belt or placed in a pocket. Two small electrodes that are stuck on to the skin with paste at the site of the pain run from this battery. The small electrical impulses emitted from the battery are transmitted through the electrodes and stimulate the nerves which, in turn, control the pain symptoms. The intensity and rate of the impulses can be regulated by a dial located on the machine.

It is thought that TENS may work in two ways. Firstly, the electrical currents may stimulate the nerves to prevent the pain messages from the area reaching the brain. Secondly, it may increase the production of endorphins — pain-killing chemicals produced by the body.

During the treatment women have said that they experience a tingling or pulsating sensation under the electrodes.

There is no evidence that TENS is addictive and during the day it can be used continuously or intermittently.

It appears that the effect of the TENS may be such that after a time you will be able to decrease the amount of time that you need to use it.

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Once the fragments of endometrium have implanted they begin to respond to the fluctuating levels of the menstrual cycle hormones in the same way as the endometrium lining the uterus. Thus, the implants thicken and swell with blood and then break down and bleed each month. This blood then cannot escape from the body so it bleeds directly onto the surface of the surrounding organs, causing irritation which leads to inflammation, scarring and, sometimes, the development of adhesions.

As the disease progresses the implants gradually enlarge in size and may form small cysts.

As a cyst enlarges, the pressure within the cyst may cause it to rupture during menstruation, spilling the contents onto the adjacent tissues. This may in turn lead to the development of new implants.

What does endometriosis look like

Classical implants-Until recently, endometrial implants were thought to be fairly uniform in appearance. However, in the last few years there has been a growing appreciation that they have a range of characteristic appearances.

It is now understood that what were traditionally recognized as being classical implants are, in fact, probably only one end of the spectrum of appearances and that they are probably only typical of older implants.

Classical implants usually appear as tiny dots, or clusters of dots, on the surface of the organ or ligament on which they have implanted. They are usually only pinhead in size but they may be up to a centimetre or more in diameter. They range in colour from brown to black depending on how much old blood they contain. When magnified they may look like clusters of black grapes.

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Ionising Radiation

This type of radiation – which gives off charged particles called ions – is produced from X-rays. It has the power to change cells and can cause infertility and miscarriages.

The male testis is one of the most radio-sensitive tissues and must be carefully protected during routine X-rays. Studies have shown that even low doses of X-ray delivered directly to the testes can reduce the sperm count temporarily to zero. If the same dose is split up over time, instead of being given in one recovery of the sperm can take up to ten years. Clearly, men exposed to X-rays through their work are likely to have reduced sperm counts.

Non-ionising Radiation

This does not create ions and is produced naturally by the sun. We are exposed to it every day through microwaves, radar, mobile phones, radio waves, televisions, computers, electric blankets, etc.

Mobile Phones

There have been lots of scary stories in the media about the dangers of mobile phones. It has been claimed that they can cause a harmful rise in blood pressure. Other research has found that regular users have more headaches. And there are concerns that mobile phones can cause ‘hot spots’ in the brain, with a possible link to brain tumours. But investigators have stressed that more research needs to be done.

Meanwhile, scientists at the University of Montpellier in France have found that chick embryos can be damaged by electromagnetic signals sent out by VDUs and televisions. When chick embryos were exposed to mobile phone radiation during the 21-day, incubation period there was a five-fold increase in chick deaths, which suggests that there might be an increased risk of miscarriage in humans. The possible increased risk of miscarriage and the effects on human male and female fertility have not yet been investigated.

Microwave Cooking

The first microwaves went on sale in the UK in 1974 and now almost three-quarters of British households own a microwave oven. A microwave oven heats food by using high-frequency electromagnetic waves, similar to television. The molecules of the food agitate at over 2,000 times per second so that the food heats itself. The idea is that the metal oven is a sealed unit: microwaves cannot penetrate metal so they cannot escape. However, most of the health concerns have centered on the possibility that radiation could be leaking out during cooking and affecting fertility. There are also worries that food cooked in a microwave may be inherently changed in ways we are not yet aware of.

Because microwaving does not use water, vitamins which are water-soluble (like vitamin C) are conserved in the food. For example, potatoes keep 82 per cent of their vitamin Ñ when they are microwaved, as compared to 40 per cent when they are boiled.

But microwaving tends to destroy the fat-soluble vitamins, like vitamins A, D and E. Pumpkin seeds, which have valuable amounts of essential fatty acids, lose 46 per cent of these oils after 10 minutes of irradiation. These essential fatty acids are vital for both male and female fertility.

Microwave cooking also seems to destroy the cell walls of plant foods like vegetables. Studies on microwaved carrots and broccoli show that the molecular structure is deformed, whereas in conventional cooking the cell structure stays intact.

What this means is that the microwave process seems to encourage the production of free radicals (highly reactive chemical fragments which have been linked to cancer, coronary heart disease, rheumatoid arthritis and premature ageing).

At a time when you are aiming to increase your fertility by optimizing your health, anything that may compromise your health should be looked at carefully.

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Genital warts (also called condylomata accuminata) are caused by infection with the human papilloma virus (HPV). More than 60 different types of HPV have been identified so far, but only a dozen or so of these are found in the genital area. Fewer still cause genital warts. Different types cause common skin warts and warts on the soles of the feet.

Our knowledge about HPV has only begun to grow since the mid-1970s: before then it was believed that all warts were caused by the same virus. Today, every month scientific journals report new discoveries about HPV, and the more we learn about it, the more we realize is still unknown. There are many questions about the wart virus that can’t yet be answered.

HPV can invade and multiply in the cells of stratified squamous epithelium anywhere in the body (including the skin, external genitals, vagina, anus, oral cavity and larynx), causing the cells to overgrow and form warty lesions.

Some HPV types cause changes that can’t be seen with the naked eye in moist membranes such as linings of the vagina, ecto-cervix, mouth and larynx.

Genital HPV is the most common sexually transmitted viral infection; more than three times more common than genital herpes. Experts believe that the number of people infected is increasing.

Genital warts are lumps formed by clusters of finger-like projections of overgrown skin with a cauliflower-like surface. Some types of HPV cause flat-surfaced lumps (plane warts); others cause pimple-shaped lumps (papular warts). Genital warts usually feel softer than skin warts.

If you have warts that can be seen or felt it is called a clinical or macroscopic (able to be seen with the naked eye) infection. It’s thought that there are many more people with infections that can’t be seen (these are called subclinical).

You may have a single wart, but usually there are more. They can vary in size from just visible up to 1 cm across (rarely bigger). They may all look the same, or you may have a mixture of cauliflower-like, flat and pimple-shaped warts.

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Urinary problems often cause ill health among women. The anatomy of our lower urinary and genital systems, some consequences of pregnancy and childbirth and a shortage of oestrogen after the menopause make us more vulnerable than men to certain problems. The most common are cystitis, kidney infections and incontinence.

Here are some of the most common symptoms of urinary disorders.

Frequency

This means that you feel the need to empty your bladder more often than is usual for you, or more than about six times during the day. Of course you’ll have extra urine to pass if you drink a large volume of fluid in a short time, especially if the drinks contain caffeine or alcohol (both increase urine production).

Urgency This means that when you get the urge to pass urine, it strikes suddenly with little or no warning, and it really is overwhelmingly urgent.

Dysuria This is pain or difficulty when passing urine.

Nocturia This is having to empty your bladder more than once during the night.

Urinary incontinence This scribes the involuntary escape of urine from the bladder. Incontinence can range from loss of one or two drops when уou cough or sneeze through a slight dribble before you reach the toilet to total loss control.

Other urinary symptoms include pain above the pubic bone, pain in the loins (small of the back), burning of the skin of
the genitals on passing urine and blood-stained, cloudy or strong-smelling urine.

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Many cells of our bodies (and especially those that form covering or lining me branes, and glands) divide often to place ‘worn-out’ or shed cells. In health, cell division is well controlled so that just as many new cells are formed as are needed. When cell division becomes uncontrolled, too many new cells are produced. These cells are usually abnormal in appearance and function. This is primary cancer.

At first the cancer is small and remains within normal tissue boundaries, but with time the mass of cells outgrows its site
and breaks through these boundaries to invade nearby tissues and organs. This is invasive cancer.

If the cancer cells invade blood lymph vessels, they may travel and set down to grow in distant parts of the body. This is metastatic cancer, and the growths that spread to distant parts of the body are called metastases or secondary cancers. The time taken for cancers to and spread is very variable, depending on the type of cells affected, the age of the patient, and many other factors not well understood.

Cervical cancer is the sixth most common cancer in Australian women, after breast, bowel, lung and two types of skin cancer. About one in a hundred women will die of cancer of the cervix: eight times as many women die of breast cancer. The highest rate of cervical cancer occurs in women aged 50-54 years.

There are two types of cervical cancer. By far the most common begins in the squamous cells that cover the ectocervix. Less common (though recently seen more frequently, especially in younger women) is cancer that begins in the lining of the cervical canal.

What causes cancer of the cervix?

We don’t know. Some factors are suspected because they are often found in women who develop cervical cancer.

Sexual behaviour

Women who don’t have sex rarely develop squamous cervical cancer. The greatest number of cancers and abnormal Pap smears (possibly pre-cancerous) are found in women who began sex early and/or have many partners. However, the majority of women with similar sexual behaviour don’t develop abnormal Pap smears or cancer.

The wart virus

Evidence of wart virus can be found in some women with cervical cancer. However, in older women with cervical cancer associated wart virus is rare. It is suspected that certain types of HPV are more likely to cause abnormal cell divisions in younger women. The majority of women with HPV don’t get cervical cancer.

Immunodeficiency

Smoking and dietary deficiencies are known to alter immune resistance. Cancerous cells are more likely to survive and grow in some types of reduced immunity. Development of cancer of the cervix is now counted as a sign that women with HIV infection have progressed to AIDS.

Symptoms

It is believed that it can take up to 30 years to progress from the earliest precancerous cell changes to cancer of the cervix. Before it becomes invasive, squamous cervical cancer rarely causes symptoms and is seldom detected by looking at or feeling the cervix; after invasion, the most common symptoms are bleeding between periods and after sex, and pelvic pain. Any woman with these symptoms should always be checked to exclude cervical cancer, even if the Pap smear is normal. Sometimes the first symptoms come from organs that have been invaded, such as bleeding or other symptoms from the bladder or bowel.

Treatment

Hysterectomy is always advised, plus removal of as much as possible of any cancerous spread beyond the uterus. Radiotherapy may be given after surgery to destroy spread to parts that can’t be removed by surgery.

Treatment of cervical cancer after it becomes invasive is difficult and not always successful. However, it can’t be repeated too often that pre-invasive cancer and the cell abnormalities that precede it can, in almost every case, be completely removed by simple means, and the progress of the invasive cancer stopped. Established cancer is much more likely to be cured by treatment if it is picked up early by Pap smear. Hence if all women were screened by regular Pap smears, most deaths from cervical cancer could be prevented.

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Feminization of male genitals

‘Testicular feminization’ sounds like a contradiction, and in a way it is. It is a rare inherited enzyme deficiency in males that prevents body tissues from responding to male hormones. Those affected have normal male chromosomes (XY) and -because the Y determines testicular development – normal testes (though often within the abdomen or in other abnormal sites) producing normal amounts of androgens and MIH. But because tissues can’t be influenced by androgens, the external genitals develop in the female pattern. However, because Müllerian tissue can respond to MIH, there are no tubes, uterus or upper vagina. When the genitals are inspected at birth, female sex is generally wrongly assigned. What’s more, because the testis produces oestrogen as well as androgens, bale secondary sexual characteristics (breast enlargement, widening of hips, female body hair pattern and female voice) develop at puberty. People with testicular feminization are usually raised as females and the problem may not be suspected until there is failure to menstruate during puberty. The diagnosis is confirmed by the buccal smear test and finding the testes (which are usually removed because they can become malignant if left within the abdomen). Because no treatment is possible, they usually continue their adult lives as females. After the testes are removed, oestrogen replacement therapy must be continued until at least 50 years of age. A vagina can be created to allow sexual intercourse.

I’ve described these unusual congenital conditions as examples of how sex may be wrongly assigned at birth. Errors in sex identification in infancy can have devastating consequences in later life. Unfortunately, most errors aren’t discovered until puberty or later, when gender identification and attitudes to sex are usually established beyond correction. It is always extremely disturbing for a young person to learn that they have been brought up as the wrong sex. Expert initial and follow-up counselling are always needed.

‘Ectopic’ means ‘out of place’. Ectopic gestation is a pregnancy that implants outside the uterus, usually in the fall tube; rarely, on the ovary or in the abdominal cavity. It is common in women whose tubes been damaged by previous surgery or infection, but often no cause can be found.

Though there are a few bizarre reports of ectopic pregnancy being maintained for long enough for a live baby to be delivered by abdominal surgery, the usual come is rapture of the pregnancy sac or death of the pregnancy within the first three months.

When the ectopic sac ruptures suddenly, it often causes severe abdominal and profuse internal bleeding that can lead to shock. This emergency needs immediate surgery to remove the pregnancy and the damaged part of the tube in order stop bleeding. Blood transfusion may necessary to save the mother’s life.

Sometimes the symptoms may be less
dramatic because blood leaks more slowly from the ectopic or because it just dies slowly without bleeding at all. This can lead to an assortment of puzzling symptoms that may include erratic bleeding from the vagina, dizziness or fainting, recurrent abdominal pain, pain in the shoulder tip and pain on intercourse. Diagnosis can then be particularly difficult in women who don’t suspect that they’re pregnant (the faulty gestation results in lower-than-usual pregnancy hormones in the blood and often no pregnancy symptoms). Today, the use of ultrasound and highly sensitive pregnancy tests make diagnosis easier. If the pregnancy test is positive and ultrasound doesn’t show a pregnancy in the uterus, an ectopic pregnancy must be ruled out (the other possible cause is complete or incomplete miscarriage within the last few days before the test).

An abortion pill for Australia?

For several years we have been heart’ about the abortifacient drug RU486 (mifepristone) that was developed in Fran’ and is now available in some countries.

RU486 is a synthetic substance that opposes the action of progesterone, ovarian hormone that is essential for implantation of the developing embryo in uterus. When RU486 is given within the first seven weeks of pregnancy (that within three weeks after the first missed period) its anti-progesterone action causes the implanted embryo to separate from the lining of the uterus. Vaginal bleeding and expulsion of the separated pregnancy starts within three days and in the majority of cases has finished one week later. Giving a dose of prostaglandin (a hormone that causes the uterus to contra’ on the third day after RU486 shortens bleeding time.

Three visits to a doctor or clinic are necessary for an RU486 abortion. Тhe first confirms that the pregnancy is no more than seven weeks from the last period; if so the drug is given (usually three pills by mouth). Two days later the woman returns for the dose of prostaglandin. A third visit is necessary to make sure that the abortion is complete. Before treatment is given, all women are asked to consent to surgical abortion if RU486 fails.

The efficacy or safety of RU486 are not under question. Studies on 60 000 French women who have used it report 96 per cent successful termination of pregnancy, very few complications and no major side-effects. There has been one death in France from heart attack, but the woman who died had a serious heart condition before treatment.

Minor side-effects have been few. A small number of women report a feeling of weakness and vomiting after taking RU486, but it’s hard to know if these symptoms are related to the drug or the pregnancy. Many women experienced uterine cramps, like period pain, after being given the prostaglandin.

Women who have used RU486 prefer it to surgical abortion because it is less painful and it avoids the risks of surgery, anaesthetic and infection. The total cost is about half that of surgical abortion. The real controversy that surrounds RU486 is that it introduces another method of abortion. Anti-abortion protests have prevented RU486 from becoming freely available in many countries. The Australian protesters have kept up their vigilance. Every time RU486 is mentioned in the media the campaign of lobbying against it intensifies.

Politicians don’t hear nearly so much from those who want RU486 made available, even though they’re in the majority. A recent opinion survey in Queensland, reputed to be our most conservative State, found that two-thirds of those surveyed were in favour of introducing RU486 and of repealing the State’s anti-abortion laws. It seems wrong to me that women who need it are denied a safe, effective, cheaper and less intrusive means of abortion because of the harassment of a minority group.

In an ideal world there would be no abortion debate: contraception would be perfect and all pregnancies would be planned or wanted. So far we haven’t achieved this ideal. Safe, lawful abortion services will be needed until we do.

General community services for women

The following services may be useful. You’ll find them listed in your local telephone book. Many have toll-free numbers.

How effective are condoms?

The effectiveness of modem condoms as a contraceptive is theoretically excellent, though studies still give widely varying results depending on who is studied. Most failures are thought to be the result of incorrect or irregular use. There is no longer any truth in the old Russian roulette belief about one dud in every six. Condoms are now subject to strict quality-control testing. Those who use condoms bearing the seal of approval of the International Standards Association need have no fear!

Types available

Today’s competitive market provides a wide range of condoms: plain; coloured; contoured, ridged or with other surface projections claimed to enhance sexual sensation; there’s even a flavoured range (old favourites like mint, chocolate and strawberry -I don’t think there’s yet anything as sophisticated as cognac, avocado or macadamia). Many condoms are pre-lubricated, some with spermicide, to reduce the risk of breakage from friction if the surfaces in contact are too dry. Many have a reservoir (teat) at the tip to hold the ejaculate. The choice is yours.

Should spermicides be used with condoms?

This is a vexed question. For many years, family planning authorities advised that spermicides should always be used with condoms. Nobody knows the origin of this advice. Perhaps it started during the depression and war when an unplanned pregnancy could have been a disaster, and legal abortion wasn’t available. It was assumed that the spermicide would provide additional protection against pregnancy if the condom broke or came off (today, ‘morning-after’ contraception is advised if this happens).

Many couples found using spermicides irksome, messy and expensive, and the insistence that they were necessary to prevent pregnancy put people off the method. This was in the days before much other contraception was available, and the result was many more unplanned pregnancies (and illegal abortions) than if condoms had been promoted as effective without spermicide.

There is no proven reason to insist that condoms need additional spermicide to prevent pregnancy. We know that they provide effective contraception by themselves, and no one has ever studied whether condoms are more effective with spermicide than without. Until we know more, it’s your choice. However, the use of spermicide can provide additional protection against some sexually transmissible diseases.

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How important is foreplay?

Foreplay is any caressing or other stimulation that increases sexual arousal before intercourse. Enough foreplay is needed to make the penis erect and the vagina sufficiently lubricated. We need and like different amounts and activities. Some people are ready for penetration in less than a minute: others need or prefer half an hour or more.

What’s the best position for sex?

Any position you enjoy. It seems that position isn’t an important factor for either woman or man to complete the full response cycle and reach orgasm. Most of I us have our preferences, but it’s fun to try something different. You’ll find a dazzling array of positions illustrated in most of the many books about sex in any library j or bookshop.

What proportion of women reach orgasm during intercourse?

It depends on whose study is quoted. Surveys give widely varying results, ranging from 20 to 75 per cent usually experiencing orgasm during intercourse; 30 to 45 per cent who experience it sometimes; and 5 to 80 per cent who have rarely or never reached orgasm during intercourse.

Many women say that they can enjoy sex without necessarily having an orgasm every time, which seems difficult for men to understand.

What happens if you don’t reach orgasm during intercourse?

If you become sexually aroused and the build-up of blood in the pelvis isn’t released by orgasm and resolution, it can leave you feeling uncomfortable, wakeful and dissatisfied. If this happens time and again it can cause a feeling of fullness in the pelvis, abdominal discomfort and, sometimes, chronic pelvic pain and backache. Pelvic congestion can be relieved by masturbation, but this solution isn’t acceptable to all women.

What’s the difference between clitoral and vaginal orgasm?

We have Freud to thank for the idea that vaginal orgasms were ‘right’ and clitoral orgasms ‘wrong’. The studies of Masters and Johnson showed that there is no difference.

Are orgasms from masturbation different from orgasms with a partner?

Physiologically there’s no difference, but many people notice a difference in quality between the two, both in intensity and in the emotional satisfaction experienced.

Can vaginal size affect sexual enjoyment?

Not often. If the vagina is very small or absent because of congenital malformation, intercourse may be difficult or impossible, but sex can still be enjoyed with other genital stimulation. Most congenital problems can be corrected to allow intercourse.

In women whose pelvic floor has been badly torn during childbirth and not repaired, constriction of the lower third of the vagina during the plateau phase may not be sufficient to grasp the penis, so that there is less stimulation of the clitoris during thrusting. This problem is rare now that perineal tears are repaired immediately after delivery.

How important is the size of the penis?

There’s no truth in the belief that the bigger the penis, the better lover a man will be. In fact, though there’s a lot of variation in the size of flaccid penises, they all reach about the same size when erect. The smaller the flaccid penis, the more it enlarges during arousal and vice versa.

What effect does hysterectomy have on women’s sexual enjoyment?
There are plenty of studies that show that sexual response is no different after hysterectomy, though of course the contractions of the uterus during orgasm will be missing. The majority of women say that this makes no difference to their sexual enjoyment. However, libido may be reduced in women who are emotionally upset by hysterectomy.

What’s the G-spot?

This is an area on the front wall of the lower third of the vagina, behind the urethra. Its name comes from Dr Ernst Grafënberg, who first described it as an intensely erotic zone. It’s not known whether all women have a G-spot or how important it is in sexual enjoyment. Some women who’ve found this spot say that is their most powerful erotic zone: others say that different erotic zones are equally or more stimulating. Many women who can’t find a G-spot still find sex wonderful, so it doesn’t seem to be essential.

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Most of you will wonder if this could ever he a problem, but there are some people who, probably because of their inherited pure, just can’t gain those few extra kilograms they want to give them a bit pre shape. Unfortunately, most young women who are too thin suffer from eating disorders.

Eating disorders are common among adolescent girls. About one in twenty has some sort of problem. There are two main types of eating disorders.

Anorexia nervosa This is an intense fear of gaining weight or becoming fat. This leads to undereating and a dangerously unhealthy weight loss, and often exercising to exhaustion. Anorexics have a distorted self-image and see themselves as overweight, even when everyone assures them that they’re not. They also have strange beliefs about food. One girl told me that she’d eaten nothing but raw or steamed green vegetables for six weeks because she believed that this was the best way to lose weight and be healthy. She was seriously ill. Another said that if she ate four small squares of chocolate or half a muesli bar it made her gain 5 kilograms!

Bulimia This is also an obsession with body shape and weight. Bulimics go on binges of eating high-energy foods after which, because they fear weight gain, they deliberately vomit or use diuretics, laxatives and strenuous exercise. These measures purge the body of vital nutrients and put a great strain on body organs, especially the heart.

Anorexia and bulimia often go together, with alternate bouts of bingeing and starving. People with these problems have little or no control over their eating behaviour. They long to be ‘ordinary’ about eating, but can’t. This lack of control adds further to their already low self-esteem.

Many are severely depressed. Anorexia and bulimia can both lead to severe illness, even death from prolonged fasting or purging or from suicide related to depression.

Are eating disorders a modern problem? It’s hard to know, but today’s attitude to leanness must be an influence. Being thin is in vogue. The emaciated, hollow-cheeked models used by the fashion industry, advertising and women’s magazines show us the ideal we’re expected to aim for. Even a little bit to spare is considered ugly, unhealthy and ‘bad’. But the cause of the problem is believed to be much more complex than just wanting to conform to fashionable slenderness.

How can you tell if you or someone you know has an eating disorder? Look for the following signs:

• sudden, unexplained weight loss

• hoarding or hiding food

• preoccupation with food, dieting and exercise

• skipping a lot of meals, or eating alone

• frequent weighing

• spending a lot of time in the toilet, especially after meals

• frequent use of laxatives, diuretics, diet pills (these are often hidden)

• unexplained vomiting

• eating huge amounts without weight gain

• being defensive when asked about eating habits

• withdrawal from family and friends

• menstruation stopping for no other reason

• loss of scalp hair and the development (at an advanced stage) of fine, downy hair all over the body. Bingeing on a favourite food occasionally or skipping the odd meal doesn’t mean that you have an eating disorder. It’s the constant obsessive behaviour you have to watch for. If you suspect that you (or any of your friends) have an eating disorder, you must speak to an adult you can trust. If your parents want to talk to you about your eating behaviour, listen to them. They’re not just nagging. They know the dangers of these problems and are genuinely worried about your health even though you’ll probably insist there’s nothing wrong. You must, for your health’s sake, take your parents’ advice and see your doctor.

There are clinics that specialise in the treatment of eating disorders, where team of experts helps the patient. The team includes a psychiatrist, psychologist, nutritionist, exercise counsellor, social worker, family therapist and nurses, with special training in the management of eating disorders. It may take months or years to get over the problem. Severe easel (seriously ill and at risk of death) may need admission to hospital.

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Women have been doctors’ strongest critics, and perhaps I know why. Between puberty and the mid-fifties, women consult doctors far more than do men. The majority of women’s consultations are about pregnancy, fertility control, and problems of the reproductive and urinary systems. These concern behaviours and parts of the body that most of us (including the doctors) were brought up to regard as very private.

Until recently the majority of doctors were men (this is not the case for the future: today half the medical students are women), most of whom would have been just as embarrassed and awkward as their patients in consultations about the reproductive and urinary systems. Remember all those things that we learned not to mention in mixed company? The men would also have learned ‘not in front of the ladies’. No wonder they were awkward in discussions of ‘intimate’ matters. Many would have had little experience or confidence in dealing with women, except in the family or as carers or teachers. And a patriarchal society and their training would have taught doctors that it was their responsibility to make all decisions! It’s hard to be authoritative when you’re sweating with embarrassment: the awkwardness often came across as being cold, uninterested or dismissive.

There was also a lack of training in some aspects of women’s health. When I was a I student in the 1950s there were university by-laws that forbade teaching us anything about contraception, and sex wasn’t I mentioned except that we were warned I always to have a nurse present to chaper-1 one women undressing and gynaecologi-1 cal examinations (on the assumption that I all doctors were men: it wasn’t suggested I that we women needed chaperones when I we examined male patients). To ask about] sexual function when taking a health history would have been viewed as impertinent and prurient. Now it’s routine.

If you’re aged under 35 you may find it hard to understand these attitudes. You will have grown up during the ‘sexual revolution’ with a new frankness about reproduction and sex. You’ll have had more access to information and discussion about these matters than your parents would have imagined possible. Today’s openness has made it easier for all of us to deal with sex, but it’s still hard to change attitudes and behaviour influenced by taboos learned in childhood. We must remember this and respect people’s feelings.

Am I being too defensive of my profession? Perhaps. We all know that the criticisms have been justified in some cases. They have had the effect of making the medical profession take a good look at itself and lift its game to provide what the consumer wants.

Communication skills and social medicine have been added to undergraduate and postgraduate training. Practicing doctors flock to out-of-hours courses on counselling, effective listening, stress management, relaxation therapy, sexuality, and many other subjects that might expand and improve their practice skills. Some doctors also study hypnotherapy, acupuncture, massage, yoga and other alternative therapies not based on conventional science.

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