Precisely what will happen when you have your laparotomy will depend to some degree on what sort of surgery you are having, the practices of your gynecologist and the practices of the hospital. What follows should only be used as a guide.
You will probably be in hospital for about five to seven days if you are having a conservative laparotomy, or seven to ten days if you are having a hysterectomy.
You will usually be admitted to the hospital the day before the operation. After you have gone through the formalities of being admitted to the ward someone will probably take your medical history. A nurse will take and record your temperature, pulse, breathing rate and blood pressure. An electrocardiogram and blood and urine tests may be taken, particularly if you are having a hysterectomy. Your pubic hair and the lower part of your abdomen will usually be shaved and you may be given a suppository if you have not opened your bowels that day.
A physiotherapist may visit you and teach you some breathing and foot and leg exercises to do after the operation, especially if you are a smoker, an asthmatic or prone to chest infections.
The anesthetist will visit you to discuss the operation and ask you about any allergies and previous problems that you may have had with a general anesthetic, such as nausea.
Some time before your operation you will be given a consent form to sign so that you can give your permission to undergoing the operation. You may have previously signed the consent form when you discussed the operation with your gynecologist during an earlier visit.
At bedtime you may be offered a sleeping tablet to help you sleep in the unfamiliar hospital ward. It is important to have a good night’s sleep before your operation so it is advisable to take the sleeping tablet if it is offered.
You will not be allowed to have any food or drink for at least six hours before the operation. Shortly before the operation you will be asked to shower and put on a gown and you will be asked to empty your bladder. About an hour before you are due to go to the operating theatre you will probably be given an injection, known as a pre-med or a pre-medication, which will probably make you feel relaxed and sleepy and make your mouth dry.
If you are apprehensive about your surgery you may like to ask if you can have your partner or a friend or a close relative come to stay with you for the hour or two before you go into theatre.
Immediately before the operation you will be taken to the operating theatre. In the operating theatre an intravenous drip will be inserted into your arm and you will be given the general anesthetic. After you have lost consciousness a tube will be placed in your throat and connected to a machine that breathes for you.
A tube known as a catheter may be inserted into your bladder to drain the urine.
A horizontal cut about ten centimeters in length will usually be made across the abdomen along the pubic hairline. Sometimes the cut will be made vertically between the middle of the pubic hairline and the navel, particularly if you have previously had a vertical cut or if bowel surgery is likely.
The gynecologist will then thoroughly inspect the pelvic cavity for any signs of endometriosis, adhesions and other damage so that she or he can plan the operation and decide which procedures need to be carried out.
When the surgery has been completed the gynecologist will stitch up the wound and the tube in your throat will be removed. You will then be taken to the recovery room for about half an hour before being taken back to your bed in the ward.
*49/41/5*
In anorexia, the first goals are to stop the patient from starving and to reverse her weight loss. Only then can we work on the emotional problems that led to the disorder in the first place.
Another goal is to show her how to reduce anxiety, not just about weight gain, but about food and eating as well. For an anorexic, who also binges and purges, an additional goal is to stop her bulimic behavior. Although some of the methods described below are for inpatient treatment, they can also be adapted for use with outpatients.
As in bulimia, there are three phases of behavioral treatment. First is the evaluation. During this time we conduct medical tests and get to know the patient. We draw up the treatment contract, which spells out the goals for weight gain and which both the patient and her parents sign. In this early phase, we tell the patient she must maintain at least the same weight she had when she was admitted. Otherwise she will be confined to her bed to save precious calories.
Once things have settled down we move into the next phase, during which we work toward the goal of bringing her weight back up to a healthier level. The contract specifies this target range, which is not subject to further negotiation because it is based on what we believe will be physically healthy for the patient.
We monitor the patient’s progress by weighing her daily. To get the most accurate reading, we weigh her in the morning, before breakfast and after she has gone to the bathroom. She wears only a robe. If knowing her weight will make her anxious, she faces away from the scale. We reward her for actual weight gain, rather than for her eating behavior during meals. The reason for focusing on weight rather than eating behavior is that the patient may give the appearance of eating all she is being served but may be getting rid of the food when no one is looking.
Our usual inpatient contract asks that the patient gain one half-pound a day. Such a goal is both reasonable and safe. Gaining weight too fast can cause edema or cardiac failure. If the patient reaches this goal, and is in no medical danger, she earns full privileges, such as complete recreation and visiting privileges. A gain of between a quarter and half a pound means only partial privileges. No gain-back to bed. This isn’t a punishment-bed is simply the safest place for a starving person to be. We also negotiate other incentives for weight gain at various points along the way: new clothes or records, special trips outside the hospital, and so on.
Gaining weight requires more calories than simply maintaining weight. Patients gradually work up to eating perhaps four thousand calories a day. Since the goal is not to teach someone to eat huge quantities of food or become bulimic, I usually add high-calorie liquid supplements such as Sustecal or Ensure to her normal amount of solid food.
Instead of requiring a specific daily weight gain, some doctors use a graph. A curve on the graph represents what the patient should weigh as time progresses. As long as her weight stays above that line, she earns full privileges. This method has one advantage over a daily weight-gain requirement. Especially during the early phases, a patient’s weight may fluctuate quite a lot, even if she is eating well, due to changes in water balance. A graph can take such fluctuations into account, which may keep the patient from being unfairly penalized.
Critics of the behavioral contract point out that an anorexic needs to develop a sense of self. She must find an identity that doesn’t depend on starvation. The contract, they claim, robs her of the opportunity to grow by imposing on her a mechanistic, prefabricated set of rules.
I disagree. My experience convinces me that many people with eating disorders welcome intervention by others, so long as it is done in a way that genuinely respects their individuality. A contract sets up boundaries and limits. It gives shape and focus to a world that is spinning out of control. The patient knows what to expect and what the consequences of her actions will be. I’m not saying that she necessarily likes those limits. Sometimes one benefit of the contract is to give her something to react to-or against. She finally has a focus for her anger. This in turn might help her to express anger rather than turn it inward. For people with an eating disorder, recognizing and dealing with anger is a good step in the right direction.
*74/35/5*
In 1987, Fay Hodge stepped onto a scale at a Weight Watchers meeting. It was the first step of a journey in which she would lose 111 pounds and find a tremendous power within herself: the power to choose.
Fay had struggled with her weight since childhood. Like most of us, she was taught to eat everything on her plate. “My grandmother used to say that what I didn’t finish at dinner, she’d scramble into my eggs the next morning,” recalls the Fairfax, Virginia, resident. “She was teasing, but I got the message. My family worked hard to put food on the table. My job was to eat it.”
Unfortunately, the combination of eating too much and exercising too litde quickly took its toll. At age 7, Fay was put on her first diet by her doctor. It didn’t work. Neither did the diets that followed. She just kept gaining. At age 33, she weighed 266 pounds— “I was uncomfortable in my own skin and getting ready to develop another set of stretch marks,” she says.
At the time, a friend of Fay’s was going to Weight Watchers, and she urged Fay to join, too. It was through the organization’s weekly meetings that Fay came to a profound realization: Her weight and her health are the culmination of countless choices that she makes every day.
“I can choose to eat the right foods in the right portions and be successful, or I can choose to eat foods and portions that will cause weight gain,” she explains. “The decision is mine. I’m in control.”
With a newfound sense of empowerment, Fay embraced the Weight Watchers principles, eating a wider variety of nutritious foods, monitoring her portion control, and drinking lots of water. She also increased her level of physical activity by walking briskly three or four times a week. And sure enough, the weight came off.
“There is nothing more exciting than discovering a hip bone. I felt like Columbus!” she says. “I was absolutely intrigued that there was a body underneath all of those layers.”
In just 1 year, Fay took off 111 pounds. And she has kept off the weight for 11 years. Today, at age 45, she’s a statuesque 5′ 11″ and a size 12. She was so inspired by her own success that she became a Weight Watchers leader, helping others take the first steps of their own weight-loss journeys.
WINNING ACTION
It’s never too late to lose. When weight gain starts so early in life, it’s all that much harder to realize that there is a thin person in there, just begging to come out. Overweight needn’t be anyone’s destiny. Determination and the realization that you will succeed is the first step. When you start to doubt, just think of Fay.
*128\89\8*
? How do I know if I’m getting near my menopause?
The most common sign is irregular bleeding – a light period followed by a couple of heavy ones that go on for much longer than usual. You might also notice that you break out in embarrassing hot flushes for no apparent reason. Uncharacteristic moodiness is also quite common, and so are sleeplessness and difficulties with memory or concentration.
? I had an early puberty at the age of eleven. Will this affect the age at which I go through menopause?
No. The average age of menopause – forty-eight to fifty-three for most Australian women – has changed little over the centuries, while girls now begin their periods at an earlier age than they once did.
? My periods have stopped after several months of irregularity. How long should I wait before having sex without contraception?
You should use a barrier method of contraception such as condoms or a diaphragm until you have not had a period for a year. You can then throw away your contraceptives.
*107\38\8*
The effects of oestrogen on the following disorders have been studied in some detail during the past fifty years. The impact of added progestogen is not so well understood.
HRT AND OVARIAN CANCER No consistent link has been demonstrated between HRT and ovarian cancer, but such a link has not been adequately ruled out. There is some evidence of ovarian cancer a substantial time after long-term HRT use. On the other hand, Pill-users (taking similar hormones to those of HRT but at higher doses) seem to be protected somewhat from ovarian cancer. Research in this area is continuing, but as yet no definitive conclusions can be drawn.
WOMEN WITH EXISTING LIVER DISEASE This condition becomes evident from abnormal liver function test results indicating that the liver is having difficulty doing its job of breaking down a wide range of substances. Recommendations regarding HRT for women with liver disease usually hinge on the nature and severity of the problem. In cases of severe active liver disease with abnormal liver function, HRT should be withheld. If the liver disease is mild or has resolved, HRT may be appropriate; in these cases the patch is the preferred way of administering it. This is because it is less demanding on the liver for absorption of hormones to be through the skin than via the stomach. While patches may be suitable for women with mild abnormalities of liver function, remember the reservation expressed at the beginning of this chapter about the lack of long-term research data on patches.
WOMEN WITH UNDIAGNOSED VAGINAL BLEEDING
Until the reason for unexplained vaginal bleeding is diagnosed it is unwise for women to have HRT. The safest course of action is to have the bleeding investigated. This may entail a hysteroscopy and biopsy or curettage.
*73\38\8*
HIGH-DOSE PROGESTOGEN ALONE
For reasons that are unclear, high doses of progestogen alone may prove helpful in relieving the problem of hot flushes if you are one of those women for whom oestrogen has not been recommended (such as those with a personal experience of breast cancer).
TESTOSTERONE ALONE OR COMBINED WITH OESTROGEN AND PROGESTOGEN
Testosterone alone or combined with other hormones may be given to women concerned about their loss of libido when this does not seem to be caused by psychosocial factors or discord with a partner. Testosterone is usually given by implant six-monthly or by injection into muscle tissue every three to six weeks. The dosage by implant is about one-quarter that prescribed for men with libido problems.
*38\38\8*
It happens to every woman, sooner or later. Parenthood you can choose or not. With menopause there is no choice. It happens to women who are nurses, secretaries, politicians, news readers, nuns, teachers, doctors, sales assistants and senior executives, to women who are unemployed and to retirees. It happens to women with young children – the menopause mums who are still breast-feeding when their periods stop – to women who have no children, to women working in the home and from home, to those accustomed to a low-stress existence and to those who have consistently demanded the highest mental and physical performance of themselves. Some wish it would happen quickly so that they can throw away their contraceptives and menstruation paraphernalia. Others regret the sometimes sudden, and perhaps also premature, end to their fertile years.
We’ve talked about the experience of menopause to countless women, the majority of whom have experienced some signs of change in their body chemistry – hot flushes, headaches, depression, mood swings, sleeplessness. Some are less concerned about these difficulties than about future health problems caused by a possible inherited high risk of heart disease or cancer. Still others have broken a bone soon after menopause and show early signs of reduced bone density (osteoporosis). The questions they ask vary accordingly. Will HRT settle my symptoms? Will it reduce or increase my risk of future disease? Can it stop my existing medical problems getting worse?
We are the first to admit that the women with whom we have discussed the menopause and HRT do not necessarily represent all women. We certainly do not want to stereotype menopause in an excessively negative way. But it is believed that about three out of four women in countries like Australia experience some physical signs associated with menopause, even though only one in four feels she needs medical help to deal with them. Maybe women who don’t seek medical advice consider their symptoms to be unimportant, maybe they have not been told about the kinds of help available, or perhaps they are coping perfectly well regardless.
As your GP will tell you, you can be sure menopause has occurred only when you have had no menstrual bleed for twelve months. Three or so months without a period are not enough: about one in five women near menopause menstruates again after that.
Raise the issue of menopause at any gathering of women, and it is clear that the term has come to mean more than just the end of monthly bleeds. Menopause has become shorthand for the many changes occurring during the transition from regular periods to no periods at all. It is a quick way of summing up hormones in flux, children leaving home or returning, ailing parents needing help, changing relationships with partners, and altered responsibilities in the workplace. An alternative catch-all term for this time of midlife change is the perimenopause.
The last menstrual period for most Australian women occurs between the ages of forty-eight and fifty-three (and can happen quite normally five or so years earlier or later than this). It is less tied to age, however, than at any time in human history due to developments in surgery and cancer treatment. These medical procedures can result in a woman having an artificial menopause (that is, one caused by removal of or damage to the ovaries) from the age of puberty onwards.
*4\38\8*
For the past 15 years, John had suffered from regular bouts of mouth ulcers. Sometimes these were so painful that he could not eat for several days. Eventually the ulcers would clear up, only to come back again a few weeks later. During a long holiday in Southeast Asia, John’s mouth ulcers were much less of a problem, and this made him wonder if food might be the culprit, because he was eating a very different diet on holiday. Soon after his return, the mouth ulcers began to trouble him again. His doctor suggested that being on holiday, and free from stress, could have effected the cure, but John
pointed out that they had never got better on holiday before. The foods he had eaten very little of in Southeast Asia were bread, milk, butter and cheese, so he decided to try cutting these foods out for a while. There was no improvement, so the doctor suggested that John should also cut out other foods containing wheat, such as biscuits, pastry and pasta. When he did so John’s mouth ulcers improved considerably but did not disappear. The doctor then advised a gluten-free diet, cutting out oats, barley and rye, as well as wheat. On this diet, John has not suffered from mouth ulcers for over two years.
*134\180\8*
The question of how much sleep a person really needs has occupied the minds of many clever people who, try as they might, have never arrived at a satisfactory answer. Some say that seven or eight hours sleep are necessary if one wants to be rested and ready for work, while others seem to think that they can manage quite well with four or five hours. Regarding those who sleep fewer hours, it is questionable whether the nerve cells will have sufficient time to become regenerated and whether, in time, some deficiency will become apparent. An unusual failing of strength, shorter attention spans and becoming easily tired are definite indications that one is not getting enough sleep, no matter what kind of theories anyone has on the subject.
When should we sleep and for how many hours? There are many different answers to these two questions and it is better if we ask, not other fellow humans, but nature itself – the most appropriate teacher. Nature sets before us a splendid example in the lively, ever-active world of birds. What can we learn from our feathered friends? When and for how long do those cheerful little singers sleep? Well, we all know the answer, don’t we? They begin their songs at the break of dawn when the average person is wasting the sunny hours of an early spring morning lying asleep in bed. They are already about their business and do not return to rest until the last traces of twilight have gone. For the birds this seems to be a natural and proper way of life and, indeed, primitive man adopted it.
*1210/28/1*
Even if you are healthy you should not expose yourself to the sun’s rays indiscriminately if you want to avoid trouble. You will have to be patient and adjust your body gradually, staying in direct sunlight for only short periods at a time. And another thing: it is much better for you to move around in the sun rather than lie in it passively. Sunbathing in half-shade is far healthier and can even be recommended for the sick.
In low-lying areas the sun has little power in the winter months and more and more people prefer to spend their holidays in the mountains. High up in the mountains amidst the snow and ice it is quite common to see girls and young women in their bathing suits. They hope to get an even better tan in winter through the reflection of the snow than they would in summer. Watching this effort could really be a great comfort to the dark-skinned populations of the earth, especially those among them who strive to look as light-coloured as possible and escape the contempt they think white people might have for them because they are dark!
*1141/28/1*
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