Past newsletters have dealt with the basics questions about pap smears, normal and abnormal. This article goes beyond the initial "panic" of the abnormal pap smear. Having recently experienced this "scary" news, myself, I thought I'd share additional information to help you understand should you find yourself in the same situation of your gynecologist saying, "We noticed something unusual in your Pap smear results. Could you come into the office so we can redo the test?" [Twlight Zone theme song playing in background]. Perhaps the drama continues after another Pap smear is done, and some of the terms our gynecologist uses - colposcopy, electrocautery - cause additional stress and concern. Hopefully, this article will allay some of those fears.

The general consensus is ... DO NOT PANIC - an abnormal PAP smear does not necessarily mean that you have cancer. The PAP smear test detects changes in the cells of the cervix. Such changes include precancerous, cancerous and other changes that take place as a result of an infection of the cervix. Early detection of these changes is important as treatment is most effective when instituted early.In the case of precancerous changes, complete cure is achievable with early detection and effective treatment.

• Investigation of abnormal PAP smears

Your clinic or private physician has all the facilities for the investigation and treatment of abnormal PAP smears. One of the most common investigations done is colposcopy.

• Colposcopy

A colposcope is an instrument which magnifies the view of the cervix. Colposcopy allows the doctor to examine the cervix to see where the cell changes are and to assess the extent of the changes. He will then decide if treatmentis necessary, and if so, the most suitable type of treatment.

During the procedure, the colposcope is positioned about 30cm away from the vagina. A speculum is inserted into the vagina (just as it is done in the PAP smear test) to hold the walls of the vagina slightly apart. The doctor may start by repeating the PAP smear test, after which, a very mild acetic acid is applied onto the cervix to expose any abnormal cells. This should not hurt, although a stinging sensation may be felt. During the examination, the doctor may take a tiny sample (biopsy) of the abnormal area for pathological examination. This will determine if there is any abnormality.

The colposcopy will take about 10 minutes. After this examination the doctor will be in a better position to discuss the results of the earlier PAP smear test. If a biopsy has been taken, you will be given another appointment in two to three weeks' time to review the results and discuss the treatment.

• Treatment
• There are several methods of treating precancerous changes in the cervix.
Laser Vaporisation
Loop Diathermy
Cone Biopsy
Electrocautery
Cryosurgery
Cold Coagulation
• The first three methods are most commonly used

Both laser vaporisation and loop diathermy will take only a few minutes. For most women, these procedures will be performed under local anaesthesia in the Women's Oncology Centre on an outpatient basis. However, in some instances, the patient may be admitted. For cone biopsy, patients may or may not be warded. If the patient is warded, the average hospital stay is two to three days.

• Laser Vaporisation

A laser beam is used to destroy the abnormal cells on the cervix. The treatment is very effective and the healing is excellent.

• Loop Diathermy

An electrodiathermy instrument is used to excise the abnormal area on the cervix. The excised portion is then sent to the laboratory for examination.

• Cone Biopsy

The cone biopsy is a minor operation where a piece of the cervix, including the abnormal cells, is removed. It is usually recommended when

The abnormal area extends into the endocervical canal, which is the canal that leads from the vagina through the cervix into the uterus.

The PAP smear test repeatedly shows abnormal cells but the colposcopy result is normal.

This may mean that the abnormal cells are from the endocervical canal.

The doctor is concerned that the abnormal cells have actually formed a very early cancer.

The biopsy specimen will be sent for pathological examination to confirm the diagnosis and to ensure that all the abnormal cells have been removed.

There is usually little discomfort after this procedure. A tampon may be inserted into the vagina to stop the bleeding. You may be asked to remove the tampon 24 hours later.

• Post Operative Care

If you experience abdominal cramps (like period pains), take a mild painkiller, such as Panadol, to relieve it. Expect some pinkish discharge from the vagina as the treated area will take a few weeks to heal. To help healing, vaginal cream or antibiotics may be prescribed. Your subsequent period may be a little heavier than usual. However, if the bleeding is very heavy, please contact your doctor.

• Avoid sexual intercourse for four weeks.
• Regular Follow-Up

After treatment, follow-up appointments are necessary to ensure that all the abnormal areas have been treated and the cervix has healed well. To ensure that you remain well, regular follow-up is needed.

• WHAT IS URINARY INCONTINENCE?

Urinary incontinence is the condition in which there is uncontrolloble leakage of urine causing a social or hygienic problem.

• What are the types of urinary incontinence in women?

There are four types of urinary incontinence in women:

1. Stress incontinence

Stress incontinence is the commonest type of urinary incontinence in women. It can occur in young women, during pregnancy, after childbirth and around the menopause (when the menses end). In these women there is uncontrollable leakage of small amounts of urine when they cough, sneeze, laugh, excersise and sometimes even during sex.

2. Urge incontinence

In this type of incontinence a woman feels a strong urge to pass urine that she cannot control; resulting in a continuous leakage of urine, usually until the bladder is empty. Sometimes coughing, the sound of running water or hand/dish/clothes washing may trigger off urge incontinence. Poor toilet training eg. the habit of passing urine very often may lead to this type of incontinence when the brain cannot control the bladder.

3. Overflow incontinence

In overflow incontinence the bladderis not functioning because its nerve supply is impaired. This results in a distended bladder which leaks urine whenever the bladder becomes overfilled: such women do not feel the urge to pass urine. The bad habit of delaying the need to pass urine in certain occupations (eg. shop assistants, factory assembly line workers), medical conditions like diabetes and spinal injuries can cause this type of incontinence.

4. 'Continuous' incontinence

In this very uncommon type of incontinence there is leakage of urine more or less all the time without any warning. 'Continuous' incontinence is caused by urinary tract abnormalities which may be congenital (since birth) or resulting from childbirth (rare these days), pelvic surgery (eg. complicated hysterectomy, radiation treatment (for cancer of the cervix or uterus) or advanced cancer within the pelvis.

• I have urinary incontinence, how can my doctor help me?

Your doctor will have to find the cause of your incontinence first. This may include:

• A list of questions about factors which may affect your urinating habits.
• A record of the amount of fluid you drink, the amount and timing of urination and leakage of urine.
• Your medical history.
• A physical and pelvic examination to detect any condition that might be linked to incontinence.
• A pad test to determine how much urine you leak.
• Laboratory tests to detect urinary tract infection.
• Special tests to determine the capacity and control of the bladder, the pressure within the bladder and urethra, the way you pass urine, and what the inside of your bladder and urethra look like.

Note: Not all these tests are required in every patient. Your doctor will then select the most appropriate treatment for you.

• What are the treatment options available for my incontinence?

These would depend on the precise cause of your problem:

• Antibiotics to treat infection.
• Drugs to control abnormal bladder contractions (for urge incontinence).
• Drugs to help your overdistended bladder to contract (for overflow incontinence).
• Hormone replacement therapy for menopause and stress incontinence.
• Pelvic floor exercise to strengthen the muscles that surround the openings of the urethra, vagina and anus in stress incontinence.
• Electrical stimulation of the muscles around the bladder and urethra in stress and urge incontinence.
• Surgery to correct pelvic support defects in stress incontinence, urinary tract abnormalities or to remove abnormal tumours eg. uterine fibroids pressing on the bladder.

Urinary incontinence is a very common problem in women. If you are bothered with symptoms of urinary incontinence, or if they affect your daily living, tell your doctor. A complete and thourough examination is needed to find the cause of the problem. In most cases urinary incontinence can be treated with success.

• An insight into the urinary tract

The urinary tract is made up of kidneys, which produce urine; tubes called ureters that carry urine to the bladder, a sac- like muscular organ, where it is stored; and the urethra, a small, muscular tube about 5cm long that channels urine from the bladder to the outside of the body.

The cause of your incontinence will first have to be established by the physician, and then they can offer you the most appropriate treatment taking into consideration your age, occupation, lifestyle and home environment.

What is a D&C?

This procedure consists of two parts:

1. Dilatation or the gentle stretching of the opening of the cervix (neck of the womb) wiht an instrument, and
2. Curettage or scraping of the inside lining of the uterus (womb)

• Dilatation is performed with smooth instruments known as dilators. This is carefully inserted into the cervix to gently stretch its opening and to make it large enough to allow th ecuretting instrument to reach the inside of the uterus.
• Curettage is performed with an instrument known as the curette. The curette is shaped like a scoop and is used to carefully scrape away the tissue that lines the uterus. The tissue removed by the curette is collected and examined by the pathologist, whose report will help your doctor to determine the diagnosis and thus offer the appropriate treatment.
• Do I need to be hospitalized?

If you have no medical problems and are below 45 years of age, you do not have to behospitalised as the D&C may be doneas a day surgery. This arrangement allows you to return home on the day of surgery. If you are 45 years of age or have some medical problems, you may have to be admitted to the ward for investigation. Alternatively a full investigation may be done at the outpatient clinic to assess your suitability for a day surgery case.

• Will there be any medications to take after the D&C?

You do not need any medicine usually. However your doctor may prescribed some pain relief if you experience after the procedure.

• How long do I need to rest?

You should be able to resume your normal physical activities within the first week after surgery. You may resume mormal sexual relations within 2 to 3 weeks after discharge from the hospital. There are no restrictions on your diet though you may wish to take only light meals e.g.porridge, noodle soup on the first day after the operation.

• Important points to note:

You may expect some vaginal bleeding (spotting) during recovery. Do not be alarmed. Come to the hospital at once, if you develop a fever or have other signs such as excessive bleeding, severe headache or sever abdominal pain.

What is Endometriosis?

The uterus(womb) is lined with a layer of cells called the endometrium. Sometimes these endometrial cells developed outside the uterus e.g. in the ovaries, fallopian tube, cervix (neck of the womb). When this happen, the condition is called ENDOMETRIOSIS.

How do I know I have Endometriosis?

The common symptoms include:

• Excessive or increase in pain during menstruation (menses). Pain can be severe and incapacitating and can radiate down to the knee and referred to the back.
• Sometimes there may be lower abdominal pain before or after menstruation.
• Pain during sexual intercourse.
• Infertility

How does the doctor know I have Endometriosis?

If you have any of the above symptoms, your doctor may find a swelling arising form the areas where the ovaries are situated on gynaecological examination. He may also perform an ultrasound to locate the endometrial tissues or cysts which may appear outside the uterus.

Sometimes during a routine pelvic examination or surgery for some other conditions, your doctor may discover that you have endometriosis.

To confirm the diagnosis, your doctor may have to perform a laparoscopy.

What is LAPAROSCOPY?

Laparoscopy is a procedure performed under general anaesthesia and uses a small viewing instrument known as the laparoscope.

A small puncture is made in the skin just below the umbilicus. The laparoscope is inserted through the abdominal wall and enables the doctor to "peep" into the abdominal cavity and look for endometriotic cysts which may be large or small.

What treatment do I have to undergo if I am found to have Endometriosis?

The methods of treatment available include medical and surgical treatment.

• Medical
• Hormone treatment for 6-9 months, given either orally or by injection
• Surgical
• Small endometriotic cysts are usaully removed during laparoscopy by burning them with an electrical current or laser. This can be done as a day surgery case.Large endometriotic cysts however are removed through a bigger incision in the abdomen. This procedure is referred as a laparotomy. In this case, a stay in the the hospital for 5-6 days is required.

With modern diagnostic techniques and treatment methods, your doctor will choose the method of treatment that is best for you.

• If I had an operation, what foods should I avoid?
• There are no dietary restrictions. However you may wish to take only light meals(eg. porridge, noodle soup) on the first day after the operation.

Nearly 480,000 American women died last year from heart disease. One in 8 women in the United States over age 45 has suffered a heart attack or stroke, and women are more likely than men to die from a heart attack.

`We don't want to wait until menopause to evaluate a woman's heart disease risk, but with menopause, a woman's risk for heart disease increases.

The onset of menopause is an important time for women and their doctors to take a closer look at a woman's overall health.

"Evaluating a woman's risk of heart disease and making appropriate diet and lifestyle changes can help decrease a woman's risk of developing heart disease. Hormone replacement therapy at menopause and after also helps to reduce a woman's risk.

Heart Disease is traditionally considered to be a man's disease. However, once women pass through menopause, the risk of heart disease increases dramatically as circulating estrogen diminishes. Estrogen seems to protect women against heart disase during the childbearing years. One in nine women between the ages of 45 and 64 has some form of cardiovascular disease, a category that includes coronary heart disease, hypertension, angina, and stroke. The incidence rises to one in three for women age 65 and older. Yet recent studies have shown that doctors may be treating women with heart disease less aggressively than they treat men.

Medical researchers theorize that the amount of estrogen is associated with the level of high density lipoproteins (HDL). HDLs help to remove cholesterol from the tissues and reduce death from heart disease. Although many factors come into play, there are indications that postmenopausal estrogen replacement therapy may be helpful in reducing the risk of heart disease. The statistics on heart disease and women are staggering. Heart attack is the number one killer of American women, although men are more likely than women to have heart attacks during the middle-age years. Women who have heart attacks are twice as likely as men to die within the first few weeks; women are two to three times more likely than men to suffer a second heart attack compared with 31 percent of men. Women also may be less likely to benefit from bypass surgery, a riskier procedure for women because they have smaller blood vessels than men and are more likely to have more advanced disease at the time of surgery.

In addition, an older woman's risk of high blood pressure is greater than a man's. High blood pressure, or hypertension, becomes more common with advancing age, and after the age of 65, a higher proportion of women than men have hypertension. A healthy blood pressure is 120 (systolic pressure) over 80 (diastolic pressure), written 120/80. A reading over 140/90 is considered high. One form of hypertension - isolated systolic hypertension (ISH) - is particularly common in older people. ISH occurs when the systolic pressure is evaluated and the diastolic pressure remains within the normal range. Older African American women have twice the rate of ISH as White women and African American or White men. Research has recently demonstrated a low-cost drug treatment that can prevent strokes, heart attacks, and other cardiac problems resulting from ISH.

Hypertension has been called the "silent killer" because it damages the kidneys, eyes, blood vessels, and heart without necessarily causing any symptoms. Eventually, this damage may lead to kidney failure, blindness, stroke, and heart attack. A person with high blood pressure is three times more likely than someone with normal blood pressure to develop congestive heart failure and eight times more likely to have a stroke. Although most cases of hypertension cannot be cured, they can be controlled with weight loss, exercise, changes in diet, and medicaton.

Women also are more likely than men to have high levels of cholesterol in their blood. High cholesterol levels are associated with cardiovascular disease. An inherited tendency to accumulate blood fats and a diet high in saturated fats and cholesterol can cause high cholesterol levels. About half the women over 55 have high blood cholesterol (over 240 mg) compared to one-third of men the same age. And women have a much higher rate of strokes, which occur when a blood clot clogs an artery that supplies blood to the brain.

How can women lower their risk of heart disease? they can stop smoking, control high blood pressure, start an exercise program with the approval of their physician, avoid obesity, and limit their intake of fat and cholesterol from eggs, organ meats, high-fat dairy products, deep fried foods, red meats, and most snack foods.

Women who are to undergo radical hysterectomy have many questions about the procedure and its effects. Knowing what is normal and expected can be reassuring.

This briefly describes the surgery, hospital stay, and recommended follow-up care. Your doctor will explain your individual situation and answer any questions you may have.

A radical hysterectomy is surgery performed to treat cancer of the uterine cervix.

The cervix is the lower one-third of the uterus or womb. When cells in the cervix grow abnormally, a tissue mass called a tumor forms. Tumors can be benign or malignant. Benign tumors are localized to one place and are not capable of spreading into surrounding tissues. Malignant tumors can spread or metastasize and interfere with normal tissue function.

Malignant tumor cells can spread directly into nearby tissues, through lymphatic (drainage) channels, or through the bloodstream. When cancer of the cervix spreads, it is usually by direct extension into nearby tissues, such as the uterus, or through the lymphatic system.

More tissue is removed in radical hysterectomy than in a standard hysterectomy because this surgery is designed to treat not only the malignant tumor in the cervix, but also the adjacent areas into which the tumor may have spread.

The uterus and cervix, nearby supporting tissues, the innermost part of the vagina, and pelvic lymph nodes are removed in radical hysterectomy. All tissues are examined carefully under a microscope to determine precisely the extent of the disease.

Initial Evaluation

Your attending physician will review your medical history and do a physical examination. He or she will review pathology slides, as well as pertinent past medical records.

You may be asked to have X-ray studies of the kidneys and bladder (an intravenous pyelogram or IVP) and of the bowel (barium enema) to determine if there are any abnormalities that may be related to pressure caused by the tumor.

Your attending physician will discuss the findings and alternative methods of treatment with you. When all your questions are answered, admission to the hospital should be planned.

Planning for Hospital Admission

There should be a patient care coordinator to handle the scheduling of your surgery - the day of surgery, the time of admission, and any further tests requested by your physician. The coordinator can answer many of your questions about hospital routines, financial coverage, or other services you might want.

You will need to inform your insurance company of your planned hospitalization. The patient care coordinator should also call to pre-certify your admission. The insurance company usually sends you a letter confirming your admission.

Your insurance company initially may pre-certify hospitalization for a limited time--for example, three or four days. Most patients who have a radical hysterectomy stay in the hospital from seven to ten days.

Preparing for Surgery

The day before surgery, your gynecologist should meet with you to review the plans initiated by your attending physician, answer any questions, and ask you to sign the standard operative consent form for the surgery.

You may have routine urine and blood studies, as well as a chest X-ray and EKG (electrocardiogram), at this time.

The anesthesiologist will examine you and discuss the surgical anesthetic. He or she will order medications for sedation before surgery, including sleeping medicines for the night before, if you wish.

A nurse will go over instructions with you, such as what time to go to the hospital on the day of your surgery. In most cases, you will be at home the night before surgery. You may have a regular dinner (unless special instructions are given), but nothing to eat or drink after midnight, not even water.

If you usually take important medicines (for example, heart, blood pressure, or diabetic medications) in the morning, ask your doctor whether or not you are to take them (with a sip of water) on the morning of your surgery.

You will be encouraged to walk soon after surgery because activity stimulates the body's return to normal function.

Your family or significant others are welcome and encouraged to join you for any of these discussions or orientations. They also may be with you before you go to the operating room. During your surgery, they will be directed to the second floor waiting area adjacent to the operating room.

Surgical Risk

With any surgery there are risks of bleeding, infection and unusual anesthetic reactions. You may require blood transfusions during or after radical hysterectomy.

In radical hysterectomy, there may be additional risks related to the area of the surgery. There may be damage to the organs next to the surgical site--bowel, bladder, ureters (tubes that drain urine from the kidneys to the bladder)--or to the large blood vessels and nerves. Blood clot formation, nerve damage, prolonged leg swelling, and damage to the urinary tract, with resultant urine drainage through the vagina, may occur, but are rare. Your physician will discuss these risks with you.

Surgery and the Post-Operative Period

A radical hysterectomy usually takes five to six hours, followed by two or three hours for recovery from the anesthetic. An operating room nurse or special volunteer in the surgical waiting area will keep your family or significant others informed during surgery, and your doctor will talk with them afterwards to let them know how you are doing.

As you awaken, you will become aware of the nurse checking your condition frequently. Your blood pressure, pulse, and temperature will be monitored, and you will have an intravenous (IV) line until you are able to drink and eat normally.

Two tubes--hemovacs or Jackson-Pratt (JP) tubes--are placed in or below the incision to drain excess fluid from the surgical site. These will be attached to a suction device. You will also have a catheter in your bladder to drain urine. Do not be alarmed if you are receiving oxygen or a blood transfusion upon awakening. These therapies are common following surgery. Antibiotics are generally given before and following surgery to prevent postoperative infection.

Back in Your Hospital Room

You will be encouraged to take deep breaths and to cough deeply every two or three hours to prevent lung congestion. Nurses will help you to turn periodically in bed and to exercise your feet and legs gently to maintain good circulation.

Special compression leg covers or periodic injections of a blood-thinning medicine (heparin) are used to prevent the formation of blood clots. These are discontinued when you are able to walk. You will be urged to sit on the edge of the bed within 24 hours after your surgery and to begin walking as soon as possible.

Your physician will order pain relief medications for you, as these activities may be uncomfortable after surgery. Your nurse will work with you to schedule medications for adequate pain control, balanced with rest and increasing activity.

Bowel function. After abdominal surgery bowel function normally is sluggish, due to the anesthetic and surgical exploration. As bowel function returns, you can begin to drink and eat. When your diet advances to regular meals, intravenous fluids will be discontinued.

Persistent slowed bowel function following radical hysterectomy may be caused by the unavoidable cutting of tiny nerves at the surgical site. Dietary management (daily prune juice, high fiber or high bulk diets) or other bowel programs (stool softener medications or mild laxatives) may help prevent difficulties. Increased fluid intake also helps improve bowel function. Once your normal diet and activity are resumed, bowel function usually returns to normal.

Bladder function. A bladder catheter may be left in place for approximately three to six weeks after surgery. This relieves pressure on the surgical site and also allows for greater healing of the tiny nerves to the bladder. These nerves help you sense when your bladder is full and help you empty your bladder as well. The catheter is necessary to prevent your bladder from becoming too full until you can urinate on your own.

It may be possible to remove the catheter before leaving the hospital; more typically, however, bladder healing requires keeping the catheter in place for a longer period. While in the hospital, you will learn how to care for the catheter and how to remove it prior to your first post-operative clinic visit. (See Post-Operative Clinic Visit section on page 10.)

Drinking plenty of fluids--six to eight glasses a day--is important to prevent bladder infection while the catheter is in place. Once the surgical incision has healed, you may take tub baths or showers.

Drainage tubes. The two drainage catheters left in or near the surgical site will be there for several days. When only a small amount of fluid drains from them, they will be removed.

Incision. Staples (or occasionally stitches) closing the surgical incision will usually be removed five to ten days after the operation. There may be a reddish to brown discharge from the vagina for several days. This is part of the normal healing process.

Emotions. Any major surgical procedure consumes a great deal of physical and emotional energy. Increased fatigue, hospital confinement, and temporary physical limitations may lead to feelings of nervousness or frustration and even anger. Although these reactions are normal and temporary, they may distress you. It often helps to share your concerns with a close family member, friend, or one of our staff.

Recovering at Home

Before leaving the hospital, you will be told what to expect in the coming days. Although it is unusual to encounter complications after hospital discharge, do inform your doctor if you experience any of the following:

• Excessive Bleeding
• Fever above 100 deg. F
• Shaking chills
• Unusual pain or swelling
• Disturbing vaginal or wound discharge
• Any other related problems that concern you

It is recommended that you get adequate rest and nutrition, as well as mild physical and diversional activities, during your recovery from surgery. A balanced diet with an emphasis on high protein foods will help to build your strength and aid healing.

Light activity is encouraged in the first two weeks after surgery or until you are seen in the UWMC Women's Care Center for the first time following your surgery.

Delay driving or prolonged sitting for three or four weeks. You may begin isometric (tightening) exercises of the abdomen after three or four weeks. Avoid heavy lifting and strenuous exercise for two to three months after surgery.

Emotional Adjustment

Each woman reacts to radical hysterectomy in her own way. You may temporarily feel anxious or insecure about the surgery's effect on you, your partner, or on the way you live.

The idea of having cancer is stressful, and radical hysterectomy is a complicated treatment. Do not expect your emotional stress to resolve instantly. Talking with someone close to you or with one of our staff may help you to adjust physically and emotionally. Most women, however, do feel comfortable resuming their normal activities over time, often within a few weeks to several months.

Hysterectomy, or surgical removal of the uterus, is one of the most common major operations for women. For certain noncancerous conditions, however, there may be alternatives to hysterectomy, some of them developed only recently.

A third of all hysterectomies are performed because of fibroids, or noncancerous tumors, growing in or on the uterine wall. If they are causing no symptoms, then a ``wait and see'' approach may be recommended, especially if you are nearing menopause. Once your body stops producing estrogen, fibroids typically stop growing and shrink.

If you have problems, however - such as bladder pressure, pain or infertility caused by the size or location of fibroids - treatment may be necessary. A procedure known as myomectomy can sometimes be performed to remove the fibroids but spare the uterus.

The three surgical methods for performing myomectomy are hysteroscopy, an outpatient procedure that uses a thin instrument to remove fibroids inside the uterus; laparoscopy, a similar technique that removes tumors outside the uterus; or abdominal surgery, a more extensive, in-hospital procedure.

Sometimes, fibroids are treated temporarily with drugs that cause them to shrink.

Painful scarring from endometriosis (a disease where tissue from the uterine lining grows outside of the uterus) and uterine prolapse (sagging of the muscles and ligaments that hold the uterus in place) together account for another one-third of all hysterectomies.

Scarring from endometriosis may respond to drug treatment. Patches of scar tissue can be removed through endoscopic surgery (in which a small surgical instrument is inserted into the pelvic area).

Pelvic prolapse is sometimes prevented with simple muscle contractions known as Kegel exercises, which help restore muscle tone to surrounding tissue. A pessary device can sometimes be inserted into the vagina to help support the uterus.

Treatment for abnormal uterine bleeding will depend on what is causing the problem. Sometimes hormone or drug therapy can help. In some cases, bleeding may be controlled after a dilatation and curettage (D&C) procedure, in which uterine tissue is scraped to diagnose problems.

Endometrial ablation - the destruction of the uterine lining with laser or electrocautery - may help a woman who no longer wishes to bear children but wants to keep her uterus.

Precancerous cervical tissue often can be removed through minor surgery, using techniques like lasers, that allow a new layer of normal cells to grow.

If hysterectomy has been recommended, talk with your doctor about alternatives. If questions remain, consider a second opinion. Know your options.

Dr. Frigoletto is president of the American College of Obstetricians and Gynecologists.

Many women believe that a hysterectomy will cause menopausal (change of life) symptoms such as hot flashes, night sweating, or mood changes. However, it is removal of the ovaries, not the uterus, which produces these symptoms in younger women, and removal of the ovaries can be avoided at the time of radical hysterectomy. Removing the uterus does cause cessation of menstrual periods and loss of childbearing function.

Sexual feeling need not be altered as a result of this surgery. However, sexual intercourse, as well as vaginal douching or use of tampons, should be delayed for three to six weeks after surgery, depending on wound healing. Feel free to discuss concerns you or your partner may have about sexual activity with your physicians and nurses at any time.

Post-Operative Office Visit

At your first clinic visit after surgery, your bladder function will be tested. If bladder sensation and function have returned so that you are able to empty your bladder completely, the catheter can be permanently removed.

Two to three hours before your scheduled appointment, remove the catheter as you were instructed in the hospital.

If this second catheterization shows that your bladder contains only minimal amounts of urine, the catheter will be permanently removed.

However, if large amounts of urine remain in the bladder at the time of the second catheterization, the second catheter will need to stay in for one or two weeks longer. Do not be discouraged if this happens to you--it is a function of how fast nerve function returns, which varies from person to person. Please tell your physician about any unusual bleeding from the catheter or unusual pain or irritation associated with it.

Even after the catheter is removed, there may be a continued loss of the sensation of bladder fullness. You may have to empty your bladder "by the clock" every two to three hours, rather than waiting for the sensation of fullness. Your physician will discuss this with you.

Follow-Up Care

Follow-up examinations are recommended every three months for the first year and then at six-month intervals during subsequent years. It is often possible to arrange some of these follow-up examinations with your local or referring physician.

Despite treatment, there is a risk that cancer may recur and further treatment may be required. If you have any questions, don't hesitate to call your doctor, who should always be available as a resource to you.

Resources

University of Washington Medical Center

Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Washington School of Medicine.

Katy Jusenius, RN, OCN, in collaboration with Benjamin E. Greer, MD; David C. Figge, MD; Hisham K. Tamimi, MD; Joanna M. Cain, MD; Wendy Brown, RN; Laurie Towe, MSW; Joanne Iritani, RN; and Laura Peterson, patient care coordinator. Medical illustrations by Jan Hamanishi.

Information

Cancer Response System 1-800-227-2345 (American Cancer Society)
Cancer Information Service 1-800-422-6237 (Fred Hutchinson Cancer Research Center)
Cancer Lifeline (24-hour emotional phone support and assistance) Washington State
1-800-255-5505 King County (206) 461-4542

See Power Surge Resource List

The American Cancer Society estimates that more than 150,000 women will be diagnosed with breast cancer in the United States this year, and that nearly 40,000 will die from this disease.

The breast is a glandular tissue, and its main evolutionary role is to prepare and store milk. It has 15 to 20 lobes, each containing thousands of cells which produce milk. When a woman breastfeeds her baby, the milk stored in the lobes travel down the ducts to the nipple.

Surrounding the breast are several collections of lymph nodes, which are part of the lymphatic system. Lymphatic vessels are tiny, milky-white vessels running from the limbs towards the heart, usually beside veins. They carry a fluid known as lymph, which is a collection of dead cells, waste material and leakage from ordinary blood vessels.

At various points along a lymphatic vessel lie lymph node. These are usually small - 5mm or less in most places. Lymph nodes are scattered at various points around the body, but the most important ones for breast cancer lie in the armpit.

Lymph nodes swell in times of infection because of all the dead cells and waste material they are gathering. Cancer cells also travel along lymphatic vessels and collect in lymph nodes. In breast cancer, the lymph nodes of the armpit are usually the first site of spread.

As well as its role in feeding, the breast plays a role to varying extents in a woman's self-image and sexuality. Check out the Power Surge comprehensive list of breast cancer support groups.

There are a number of different types of breast cancer. The great majority of breast cancers are adenocarcinomas, which arise from the ducts. The term "breast cancer" usually refers to adenocarcinoma.

Other types, much less common, include ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS). DCIS is not an invasive form of cancer and usually can be treated with breast conservation, unless it involves a large area of the breast. LCIS is not really cancer - it requires careful watching rather than active treatment. It is not known how long breast cancers take to develop, but they are usually slow-growing cancers.

If they spread, the first place of spread is usually the lymph nodes. The nodes of the armpit are the most prominent ones and are the easiest to feel, but the cancer also spreads to nodes within the breast.

If the cancer spreads outside the breast and lymph nodes, it tends to go to the bones and the lungs. This is known as metastatic disease, and is not covered by this book.

More Facts About Breast Cancer

• Every woman is at risk for breast cancer.
• Breast cancer is the most common form of cancer in women in the United States. It occurs rarely in men.
• A breast cancer is newly diagnosed every three minutes, and a woman will die from breast cancer every twelve minutes.
• Breast cancer is the second leading cause of cancer death for women between the ages of 35 and 54.
• One out of nine women in the United States will develop breast cancer in her lifetime--a risk that was one out of fourteen in 1960.
• Eighty percent of women who are diagnosed with breast cancer are over the age of 50.
• Breast cancer is the leading cause of cancer death for African American women.
• Women of low socioeconomic status are more likely to be diagnosed with late-stage disease and die of the disease.
• Over 70 percent of breast cancer cases occur in women who have no identifiable risk factors.
• The cause of breast cancer is unknown.
• Over 80 percent of breast lumps are proven benign, but any breast lump must be evaluated by a physician.
• More than 1.6 million breast cancer survivors are alive in America today. The five year survival rate after early-stage diagnosis and treatment is over 90 percent.

Source: National Alliance of Breast Cancer Organizations (NABCO)

Breast cancer claims 44,000 women every year. But 95 percent of breast cancers are curable if detected early!

The current health outlook for American women over 40 is excellent and getting better all the time. Breast cancer falls far behind other leading causes of death in women over 40. While your risk of getting breast cancer increases with age, 95 percent of breast cancers are curable. With annual pap smears, virtually no woman would have to die from cervical cancer.

You must have heard about someone you know who had fibroids in the womb. In fact approximately 1 in 5 women develop fibroids in their lifetime. What are fibroids? They are benign tumours of the muscular and fibrous tissues of the uterus. They are most common during the childbearing age and usually atrophies after the menopause. The type of symptoms that patients have is diverse and it depends on the size and location of the fibroids. There may be a lump in the abdomen, heavy menstrual bleeding, infertility, abdominal pain, urinary problems, vaginal discharge and problems associated with pregnancy.

The commonest condition associated with fibroids is heavy menstrual flow and painful menstruation. In severe cases, the excessive blood loss causes anemia. The fibroids may distort the shape of the uterus and cause infertility, miscarriages and problems during pregnancy. Fibroids tend to enlarge during pregnancy. The sudden enlargement may cause severe abdominal pain. There may be difficulties in differentiating them from problems like appendicitis and other acute conditions. Fibroids in pregnancy may distort the uterus and cause the baby to be in an abnormal position. Breech presentation may result. Obstruction to the urinary bladder may occur causing problems in urination. During labour, the birth passage may be obstructed by the fibroids. Fortunately, not all uterine fibroids causes problems. In fact a large number of women do not have any symptoms associated with fibroids, and the fibroids are diagnosed by a doctor during a medical examination.

Fibroids: Is a hysterectomy necessary?

Question: I am 39 years old. I have fibroids, and my uterus is enlarged(13-14 weeks pregnant). My hemoglobin has been as low as 6.6 and is now at 9.7 thanks to iron supplements. My doctor wants to do a hysterectomy. Should I have the operation?

Answer: Ask your doctor about alternatives to hysterectomy. There are drugs, but they are highly unlikely to be enough in the situation you describe. Removing the fibroids alone and leaving the uterus is an option. However, the large size and your hemoglobin (which I will assume is due to the fibroidal bleeding) may be factors that are causing your doctor to favor total hysterectomy and disregard the others as impractical. Whether or not you want (more) children is also a factor in determining the best treatment option.

• When is treatment necessary?

It is obvious the if the fibroids are causing the patient problems, then treatment is necessary. However, if there are no symptoms at all, the decision to treat depends on the size of the fibroids. If the asymptomatic patient's uterus is enlarged by fibroids to a size that is felt in the abdomen, then treatment is necessary.

Types of treatment: The surgical removal of fibroids is the main modality of treatment. Treatment using drugs to suppress the growth of the fibroids tend to have a temporary effect. The fibroids enlarge again after the injections (which is very expensive) are stopped. Hysterectomy, where the uterus and the fibroids are surgically removed, is the treatment of choice in women who had completed childbearing. Fears that hysterectomy may affect the women s femineity and sexual function is totally unfounded. The ovaries are usually conserved in the younger women and they continue to secrete hormones. In fact many women who had hysterectomy with ovarian conservation do have monthly sensation of breast fullness similar to the time before the hysterectomy. The other method of surgical treatment for fibroids is myomectomy. The fibroids are removed and the uterus is conserved and future childbearing is possible. Small fibroids can be removed though the laparoscope (through small incisions in the abdomen) and fibroids in the cavity of the uterus can be removed via a hysteroscope (through the cervix and into the cavity of the uterus). Myomectomy as a treatment for fibroids is usually offered when the patient desires future childbearing, or if the are a only a small number of fibroids present. Myomectomy may not completely cure the patients symptoms and the fibroids may recur over time as very small fibroids not apparent at the time of surgery grows larger subsequently.

• What about the risk of cancer?

The risk of cancer in fibroids is very low. Cancerous changes known a leiomyosarcoma are usually found in large fibroids. The symptoms and clinical presentation of leiomyosarcomas are similar to benign fibroids. The diagnosis can only be made after surgery or a curettage of the uterus.

• Heavy menstruation:What next?

Heavy menstruation is a common problem among women and many a time it is attributed to fibroids . In fact other problems such a endometrial, cervical cancers and hormonal disordrs often present with symptoms of heavy menstrual bleding. A complete evaluation by a doctor familiar with these conditions is important before attributing these symptoms to benign fibroids.

Source: Dr CF Koh

Cancer of the cervix is a global problem. Like in other developed countries it is the fourth commonest cancer among females in Singapore. However, unlike most other cancers, it is potentially preventable. Cervical cancer has significant morbidity and mortality if it is not detected before it reaches an advanced stage (when symptoms appear). If the disease is detected in its precancerous stage, complete cure is achievable.

Cancer of the cervix develops in the neck of the womb. Over time, if left untreated, it can spread to other parts of the body including distant areas such as the lungs, liver and the brain. It is also locally invasive involving the rectum and bladder. In the late stages, the cancer may obstruct the urinary tract, giving rise to kidney failure and death.

• What causes cancer of the cervix?

Nobody knows the exact cause of cervical cancer. However, there are factors that are frequently associated with it. Some of these include early age of first intercourse, multiple sexual partners, heavy smoking and genital warts.

• Signs and symptoms

Irregular vaginal bleeding · Frequent foul smelling vaginal discharge · Bleeding after intercourse

• Is there a precancerous stage?

Fortunately there is a precancerous stage, which is termed dysplasia or more correctly called cervical intraepithelial neoplasia (CIN), which precedes the development of invasive cancer. It is this precancerous stage which is detected by a very simple and reliable test called the PAP smear test. Treatment of this precancerous stage prevents cervical cancer from developing.

• What is the PAP smear (cervicalsmear) test?

PAP (Papanicolaou) smear screening for cervical cancer has become an established practice in most countries since the 1940s.

The PAP smear test helps to detect cancer of the cervix at a very early stage, when simple treatment can result in total cure. The test is special in that it spots cancer even before it starts.

A PAP smear is a collection of vaginal fluid and cell from the surface of the cervix. These cells are shed from the cervix.

Taking a smear involves nothing more than having an internal (vaginal) examination. This procedure is very simple and not painful.

You are asked to lie on the couch and an instrument called a speculum is gently inserted into the vagina. The speculum allows the doctor to see your cervix. A spatula is then gently wiped across the cervix. The specimen is then smeared onto a glass slide and fixed in alcohol before it is despatched to the laboratory. The whole procedure should be over in a minute or two.

• How to reduce your risk?

All women should have their first PAP smear test within 2 years of becoming sexually active. PAP smear tests should be done once every one to three years. More frequent tests may be needed if you have any of the above mentioned risk factors.

Cervical cancer is preventable. Cancer of the cervix used to be one of the leading causes of death from cancer in women. Today, if every woman were to have an annual pap smear, virtually no woman would have to die of cervical cancer.

• What happens when I have an abnormal PAP smear?

An abnormal smear does not necessarily mean you have cancer! It means that there are abnormal cells which require further evaluation by a doctor. This usually involves referring to a doctor for a colposcopy examination.

Again this is a painless procedure and it should take no more than 10 to 15 minutes. The procedure includes the introduction of a speculum as in doing the PAP smear test. The cervix is then viewed through the colposcope which is positioned at a distance from the vagina.

A colposcope is simply an instrument with a magnifying glass through which a better view of the cervix can be obtained with better lighting.

Depending on what is found, a small biopsy may or may not be taken from the cervix for further evaluation. Many patients do not feel anything at all. Depending on the results of the biopsy, you will be advised on the best treatment.

If the result reveals that you have a precancerous condition, then a simple procedure to destroy the abnormal area of the cervix would suffice. You will need a regular follow up after your treatment.

• Who can do a PAP smear test for me?

Your family doctor · Your gynecologist · A Women's Clinic

Invasive Cancer of the Cervix

• What if your doctor informs you that you have cancer of the cervix?

This is NOT the end of you! There are 4 stages in cancer of the cervix, the first stage being the earliest. The prognosis is good with earlier cancer.

Late cancers confer a less favourable outcome but treatment, if given as soon as possible, reduces and delays the complications from advanced cancer.

• Treatment of Cancer of the Cervix

There are 2 main methods of treatment for cancer of the cervix.

Surgery, which involves the removal of the uterus(womb), the fallopian tubes, the ovaries (in older women), the surrounding supporting tissues and the Iymph nodes, is suitable for early invasive cancer of the cervix.

An alternative treatment is radiotherapy. Radiotherapy involves the use of internal and external radiation. The complete treatment takes about 5 weeks. Other than a 2 to 3-day stay for internal radiation, the rest of the treatment is done on an outpatient basis. Each outpatient radiation treatment lasts for about 20 minutes. Radiation treatment is painless and the complications are generally easily managed.

Occasionally chemotherapy involving the use of cytotoxic drugs are used, but the response is less predictable.

Index



SCIENTISTS FIND LEAD TO POSSIBLE CERVICAL CANCER VACCINE By Peter Modica
Medical Tribune News Service

One day, it may be possible to vaccinate women against cervical cancer, a small preliminary study suggests.

Cervical cancer is one of the most common cancers worldwide, with 465,000 new cases each year. It accounts for 15 percent of all cancer deaths worldwide, according to the study, published in Thursday's issue of The Lancet.

This year, more than 15,000 women will be diagnosed with cervical cancer in the United States, according to the American Cancer Society.

Hoping to fight the human papillomaviruses, (HPVs), that are implicated in cervical cancer, a team of scientists from Cardiff, Manchester and Cambridge, led by professor L.K. Borysiewicz, developed a vaccine against two strains of the virus, HPV16 and HPV18, most often linked to cervical cancer.

Eight women with late-stage cervical cancer were given the experimental vaccine. One woman produced a type of immune response that could help scientists develop a vaccine for wider use.

The patient who developed an immune response was also free of cancer 15 months after vaccination, the researchers found.

Existing evidence closely links the disease with sexually transmitted infections, often associated with HPVs. Women who have had many sexual partners, or whose partners are not monogamous, face a higher risk of cervical cancer, according to the ACS.

The findings look promising even for women with impaired immune systems, said Dr. Denise Galloway of the Fred Hutchinson Research Center in Seattle, Wash.

The vaccination did not produce any notable side effects in the women, according to the researchers.

Along with the woman who produced an immune response, the researchers detected antibodies against HPV in three of the patients. This may suggest that the responses were induced by immunization with TA-HPV, according to the study.

With a sample size of eight it is hard to reach any strong conclusions, Galloway wrote in a commentary in The Lancet and the success of the one immune-impaired patient may also have been due to chance, Galloway added.

Despite the success of screening, cervical cancer remains a problem, Galloway writes.

A Pap test is commonly used to detect the early signs of cervical cancer and can be performed during a pelvic exam. This test should be performed annually on women who are, or have been, sexually active or who have reached the age of 18, according to the American Cancer Society.

Index



SEXUALITY AND THE GYNECOLOGIC ONCOLOGY PATIENT

Sexuality is a warm and wonderful part of who we are as individuals. It is central to our sense of self and the way we express our femininity, and is closely tied to our sense of health and well-being.

Each of us expresses our sexuality in different ways at various times in our lives--for example, by flirting or working hard to become attractive to someone, or just enjoying being attractive. Intimate physical closeness is part of our sexuality, as well as a way we establish emotional closeness with another person. Sexuality is an important aspect of personal growth--of living our lives to the fullest, being and becoming all that we possibly can.

Cancer and cancer treatment may affect your sexuality. While coping with the stress of the cancer diagnosis and treatment, it is common to put sexuality issues aside. You may eventually find yourself considering such questions as Will I change? How will I change? How will others feel about me? Will I be able to do what I want? Will I be able to function sexually? It may be difficult to talk about these very personal feelings.

This information is a beginning step to assist you in understanding cancer's effect on your sexuality. You should be aware of the common experiences and temporary or permanent changes that may result from cancer and its treatment, and changes that can occur with advanced illness.

Ask questions - - your doctor, nurse, or social worker can help you find answers. By increasing your awareness and ability to handle possible changes in sexuality caused by cancer, you will feel more comfortable and secure about your sexuality during this time.

• Sexuality and Cancer

One of the first things many women feel after hearing that they have cancer is concern about how others will react to them. They fear family members or friends may reject them, as if they had somehow changed.

Normal interactions may be strained by the cancer diagnosis. The patient, as well as friends or family members, may not know what to say or how to talk about the cancer.

Fear of losing friends or just experiencing changes in your life, now or in the future, can be upsetting. These are normal concerns, and we can help you deal with them.

The location of your cancer could have an impact on sexuality. Cancer of the breast or reproductive organs might affect sexual activity and closeness more than lung cancer, for example, because those organs are closely linked to sexual response and to our perception of what it means to be feminine.

Remember, there are no right or wrong feelings to have. It is possible that your sexuality will not be affected in any way.

It may help you organize your thoughts first to find out what specific physical changes will occur. Ask your doctor or nurse if there will be changes in sexual organ function. You then can consider what effects these changes might have on important relationships and if and how your role as provider, homemaker, spouse, or parent might be affected.

Your partner's sexuality, as well as your own, can be considered when discussing these issues. Either of you may have a variety of concerns at any one time, and these might change over time.

It is important to remember that cancer is not contagious. If you or your partner feel the other can "catch" cancer, sexual closeness may be unnecessarily curtailed.

Understanding and accepting changes in body appearance require significant adjustment. Keep in mind that various treatments may make you feel sick, weak, or physically uncomfortable and may temporarily diminish your interest in sexual activity.

Your partner may be concerned about visible signs of cancer (skin changes, rashes, tubes and dressings necessary for treatment), or his ability to support you emotionally, or he could have personal concerns about his own self-image and worth. You might be more worried about changes in your body's appearance or function, or about feelings that you alone are experiencing, such as fear, fatigue, pain, discomfort, or loss of sexual drive.

Your usual ways of sexual expression may have to be postponed or modified. You might find that the need to be touched and held is more important to you at this time than actual sexual activity.

Perhaps your sexual desires are unchanged, but you assume your partner does not feel the same interest in you. Your partner could feel guilty about sexual feelings he has toward you, while you might welcome them and even rejoice in the knowledge that you are still important to him and desirable as a sexual partner.

Check with your doctor or nurse to see if there are physical reasons to restrict sexual activity or physical closeness, and share this information with your partner. If talking together about these things is awkward, you may feel very much alone. In some cases it might be helpful to individually, or jointly as a couple, seek the advice of a counselor in this area either.

• Medications

There are several types of medications that can affect sexual desire or ability. For example, pain medicines can decrease sexual interest or affect energy. However, they can also contribute to comfort if used prior to sexual activity.

Decongestants and high blood pressure medicines can have drying effects on sexual lubrication glands. Antidepressants, sedatives, and tranquilizers can increase relaxation and sedation and may affect sexual interest. Hormone preparations may affect sexual desire. Alcohol is a central nervous system depressant; although it may temporarily decrease inhibitions and promote relaxation, a decrease in sexual function may occur later.

Medications often cause only subtle effects, which can be tolerated if the reason is understood. In other cases, your doctor may be able to substitute a similar medication which will have less effect on your sexuality.

• Surgery

Surgery is performed to diagnose, determine the extent, and remove and treat cancer. It may vary from an office procedure to an extensive operation. Your doctor will explain your surgery to you, but undergoing surgery remains physically and emotionally stressful and can affect your sense of self and your sexuality.

The surgery itself can cause temporary fatigue and some postoperative pain. Discussing temporary, alternative methods of sexual expression with your partner prior to surgery can relieve tension during the recovery period.

The results of surgery may be long-lasting. Your body may look or function differently after surgery, depending on the site of the cancer (for example, breast removal in mastectomy or the formation of a colostomy). Even a surgical scar can be distressing, since it is a reminder of illness.

Removal of specific organs can have an impact on sexuality. Removal of the uterus causes cessation of menstrual periods and loss of childbearing function. In premenopausal women, removal of the ovaries may bring on menopausal (change of life) symptoms such as night sweating, hot flashes, or mood changes. Sometimes these symptoms can be alleviated by taking a hormonal medication, which may be prescribed by your physician.

Some surgical procedures directly affect sexuality. Removal of the clitoris to treat vulvar cancer will change a woman's sexual responsiveness, but satisfactory responsiveness is still quite possible after this surgery. Removal of the vagina may be needed in some types of cancer treatment, but reconstructive surgery can create a new vagina. Such reconstructive surgery can be very successful in helping women return to satisfying sexual expression and relationships. Ask about surgical alternatives and options that may be available to you.

The reproductive organs are sometimes perceived as symbols of life or self or youth. If they must be removed, it can feel like you are losing a significant part of yourself. Grieving, therefore, is a very normal response.

• Chemotherapy

Chemotherapy--taking anti-cancer drugs--is often used to control or cure cancer. Side effects associated with chemotherapy vary, but some can temporarily alter your body image.

Hair loss while receiving chemotherapy, and for a short time after the therapy ends, may cause embarrassment and make you feel unattractive. We can give you information on wigs and recommend that you consider this option before you start experiencing hair loss, allowing yourself some time for adjustment.

Increasing your knowledge of how to use color in your wardrobe and make-up, as well acquiring new skills such as turban selection and scarf-tying, can give you some control in looking your best during this time. Certain chemotherapy drugs leave your mouth and throat very sore, hampering your ability to eat and drink fluids. You may feel nauseated during and between treatments. Medications can help relieve these symptoms, but you may still feel tired and have less energy for your usual activities.

Some of these symptoms may decrease your usual sex drive. This may be difficult for you and your partner to understand and accept. Continued chemotherapy may lead to repeated frustrations. You may want to explore alternative ways of expressing affection during this time.

Ask your doctor if there are restrictions concerning sexual intercourse during chemotherapy. He or she will give you guidelines, depending on the cancer and the effects of the specific drugs you are receiving.

Some chemotherapy drugs can decrease fertility if they are given over long periods of time. Ask your doctor if those you are receiving may affect you in this way. You may also have questions about continuing birth control measures and when or whether pregnancy may be considered. In either case, do not automatically assume you will be sterile due to chemotherapy. We have information on fertility and family planning which we would be glad to share with you.

• Radiation

Radiation therapy is used on very specific areas to kill cancer cells. Treatments are given daily over several weeks by a machine that looks much like a regular X-ray machine. It is not unusual to have some fears about radiation therapy. The techniques used today in radiation therapy are very precise and greatly minimize any side effects of treatment. Your physician will carefully explain your individualized treatment and any possible side effects.

Radiation treatment affects normal cells in the treated site, as well as the cancerous cells. This may temporarily cause the treated skin to become reddened or irritated. If you experience this reaction, it is important to be gentle in touching the affected area and to follow the skin care instructions you receive. Please check with your physician before applying any creams or lotions, because some--particularly perfumed lotions--may make the skin reaction unnecessarily worse.

Vaginal lubrication may be diminished during and for sometime after radiation to the pelvic or low abdominal area. You may wish to use water-soluble lubricants during sexual intercourse to keep vaginal tissue moist and pliable.

External radiation does not make you radioactive. Being close to or touching the treated area will not affect you or your partner. However, sometimes internally implanted radiation devices are used to treat cancer. If you have this kind of treatment, you will be in the hospital while the implant is in place. During this time, prolonged exposure of your partner or the hospital staff to the radioactive implant must be avoided. Once the implant is removed, there is no radiation exposure to you or your partner.

Radiation may also make you feel fatigued. You may need to rest more often during your treatment. This fatigue may also affect your sexuality and your sexual desire, but this is only temporary.

• Advanced Illness

Sexuality tends to represent health and a sense of well-being. In advanced illness, many people assume that sexual activity is no longer possible. Your partner may still wish to interact sexually with you but may be unable to cope with the conflicting emotions aroused by sexuality and terminal illness. Out of frustration, lack of understanding, or fear, your partner may refrain from any sexual contact with you. Your reaction may vary from increased sexual awareness and responsiveness to withdrawal into a state of wanting little or no sexual contact.

Advanced illness may often include weight loss, drug effects, or body changes as a result of treatments. You may perceive yourself differently as your body image changes. However, this does not necessarily diminish your need for an intimate relationship, to be very close to another person.

You and your partner together determine how to express that intimacy. This may include a desire to be with and enjoy each other, to share and confide, and perhaps to hold and be held. An intimate relationship may or may not include sexual intercourse. Just sharing a glass of wine in a candlelit room, listening to your favorite music together, or lying close together may be enough. You and your partner can discuss at any time what intimacy means to each of you, what your current needs are, and how they can be satisfied.

• Summary

Your sexuality is individual and unique. The process of cancer diagnosis and treatment may alter your sexual feelings, expressions, and function from what you are accustomed to or would wish them to be. We hope that the ideas covered briefly here help you and your loved ones in dealing with this very personal issue.

Preserving and maximizing your ability to function sexually despite cancer can enhance your self-esteem, improve your overall comfort, and make it easier for you to cope with this disease. You should feel free to discuss these issues with your doctor at any time.

General

• How will the proposed treatment affect my sexuality?
• Are there ways we can prevent or minimize unpleasant side effects from the cancer or its treatment?
• Intercourse
• How will sexual intercourse be affected by surgery or other treatment?
• What can I do if intercourse is uncomfortable?
• Are these effects temporary or permanent?
• Fertility
• Will this treatment affect my childbearing ability?
• If yes, are there other treatment options that can preserve my childbearing ability or hormonal function?
• Should my partner and I use birth control measures during and after treatment?
• If yes, what method is recommended?
• If I am able to have children after treatment, how long after the treatment is completed must we wait before trying to conceive?
• Alternatives
• What possible alternatives for sexual expression may I safely use?
• If I feel that sexual counseling would be helpful, what resources are available?

Resources

University of Washington Medical Center

Written by Katy Jusenius, RN, OCN, in collaboration with Benjamin E. Greer, MD; David C. Figge, MD; Hisham K. Tamimi, MD; Joanna M. Cain, MD; Wendy Brown, RN; Laurie Towe, MSW; Joanne Iritani, RN; and Laura Peterson, patient care coordinator.

Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Washington School of Medicine.