Health News

Women and men who have completed their families, or who know they do not want any children, may want a permanent method of birth control.

Permanent methods may be appropriate for mature women and men who find that:

• their partners agree that their families are complete, and no more children are wanted

• they want to enjoy having sex without causing pregnancy

• they don’t want to have a child in the future

• they and their partners have concerns about the side effects of other methods

• other methods are unacceptable

• the woman’s health would be threatened by a future pregnancy

• they don’t want to pass on a hereditary illness or disability

• they are men who choose vasectomy to spare their partners the surgery and expense of tubal sterilization. (Sterilization for women is more complicated and costly.)

Permanent methods are not appropriate for women or men if:

• they want to have a child in the future

• they are being pressured by their partners, friends, or family

• they have marriage or sexual problems, short-term mental or physical illnesses, or financial worries, or are out of work. Permanent methods are not good solutions for temporary problems

• they have not considered possible changes in their lives such as divorce, remarriage, or the death of their children.

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In our sexually repressive culture, we have little concern for the well-being of women and men who have sex less often than mo people. But we have grave concerns about women and men who have sex more often than most people. Having sex very infrequently, or not at all, is called hypophilia. Having sex more often than most people is called hyperphilia. The desire for women to have sex very frequently with many different partners is called nymphomania. A similar desire in men is called satyriasis or Don Juanism.

Some mental health professionals consider nymphomania and satyriasis sexual compulsions, or sexual addictions, if the search for sex partners:

• results from an obsession that is like being in a trance and involves the development of rituals

to intensify sexual arousal

• interferes with important responsibilities and commitments, such as getting to work, home, or

school, maintaining good health, and forming nonsexual social relationships

• seems utterly hopeless to control

Recovery groups, such as Sexual Compulsives Anonymous, can be very helpful for women and men who want to control what they believe to be sexual addiction. However, accurate diagnosis and treatment for sexual addiction through psychosexual counseling may also be very important for people who are concerned that they may be addicted to sex.

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On the basis of clinical experience, surprisingly little of which has been systematically documented, testosterone has long been the treatment of choice to induce or restore sexual functioning and drive in hypo-gonadal or castrated men. Estrogens and certain progestogens which suppress testicular testosterone production and/ or compete with testosterone at the target-organ level, typically interfere with male libido and sexual functioning. The clinical data on the effects of other androgens on sexual behavior are too scanty to permit any reasonable conclusion. There is an increasing number of clinical studies, that show a beneficial effect of LH-RH administration on libido and potency in impotent, hypogonadal, and normal men. Although the data are suggestive, one has to reserve judgment at this point because the sample sizes are usually small, the methodology sometimes inadequate and the results inconsistent.

High-dose androgen treatment as it is used in estrogen-dependent cancer in women is known to have a strong, positive impact on sexual drive in many such patients. Analogously, female patients with abnormally high androgen levels due to adrenal tumors or other abnormalities, also show an increased sexual drive. A new report on endocrinologically normal women presented sizable correlations between their plasma testosterone levels, averaged over the menstrual cycle, and their “self-gratification scores” (a more appropriate label might be “self-rated sexual arousal”). Testosterone has been used successfully in the treatment of sexually unresponsive women. It has been shown—although without replication – that adrenalectomy, not ovarectomy, will decrease female sexual drive. Therefore, Money has called adrenal androgen the female “libido hormone.” It appears likely, however, that it is not the weak adrenal androgens, but the much more potent testosterone itself (which, in the female, is largely a conversion product of adrenal androstenedione) that is responsible for such effects. The role of female ovarian hormones, estrogens and progesterone, on female sexuality is even less clear, and menstrual-cycle studies of female sexual activity and desire have not produced a consistent body of data (McCauley and Ehrhardt). Estrogens clearly affect female attractivity to males via their effects on the secondary sex characteristics and facilitate female receptivity, at least indirectly, through their effect on the vaginal mucosa. However, Persky and others failed to show any relationship of plasma estradiol level to sexual behavior in young women. Data on the role of progesterone in female sexual behavior are not yet conclusive (McCauley and Ehrhardt), and data on behavioral LH-RH effects are not available.

In conclusion, the evidence described above names testosterone as the major hormone for sexual motivation and behavior in human males and possibly in females, while hardly anything is known in humans about a facilitory or contributing role of adrenal androgens, and there is only inconsistent but suggestive evidence for such a role of LH-RH in males. Estrogens and progestogens inhibit male sexual behavior, at least when used in pharmacologic dosage. Their role in female sexual motivation is not well established; it is probably much less prominent than in the case of lower mammals, but the available studies on women are not sufficient for ruling out facilitory effects of estrogens or inhibiting effects of progestogens as they have been observed in nonhuman primates.

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During the first several years of life, the infant’s relationship to others centers mostly on relationships with the mother (or a mother substitute) and having physiological needs met, especially the need for food. Feeding is necessary for survival, but it is also an occasion for intimate contact with other persons as a part of the infant’s exploration of the environment. Objects are experienced by putting them in the mouth, by sucking, touching, eating, and biting. This basically autoerotic stage lasts for the first five or six months of life. From as early as two months of age onward and increasingly through the first year of life, infants are not so much passive and receptive as active in seeking interaction. Most infants show the need for the proximity of others sometime during the first quarter of the first year.

Attachment is a two-way process. Attachment behavior between mother and infant consolidates the affectional relationship. In studying the interaction of twenty-eight babies with their mothers, Ainsworth catalogued thirteen patterns of attachment besides those associated with feeding—the rooting response, sucking, and search for the breast. On the infant’s side, the thirteen include differential crying, smiling and vocalizing, visual-motor orientation, crying when the mother left, following, scrambling, burying the face, exploring from a secure base, clinging, lifting the arms and clapping the hands in greeting, and approaching through locomotion.

Preference for the mother is not present at birth; it must develop out of the feeding and caring experience. The infant’s earliest posture is one of undiscriminating responsiveness. In the first few weeks of life it can be assumed that the infant experiences the mother, and particularly her breast, as part of itself. The first few weeks of life can be characterized as an around-the-clock time of sleep alternating with waking periods in which the infant’s contact with the mother is directed by hunger rather than by any other drive or appetite. But the mother and the infant are two independent psycho-physiological systems. They interact through specific mechanisms of stimulation and pacification. In the process, circular social interaction becomes more discriminating, and the relations between the two become numberless and infinitely varied.

Most mothers in the nuclear family do not share the intimate care of their offspring with another adult (although more and more fathers are becoming involved) and are in a position to develop an unusually close relationship with their babies. Caldwell and Hersher found that such mothers, in contrast to mothers who shared care of the infant with others, were less intellectualized in their relationships with the baby, were more sensuous in their touching and handling, were more likely to vocalize, were more active and more playful with their six-month-old babies. At one year of age they were rated as more dependent upon their babies for the achievement of their own need gratifications. In general, the data suggests a comfortable relationship between infant and mother in the cases in which the mother had exclusive responsibility for the child.

Infants show differing personality traits, strengths in their aggressive instincts, for example. Some are placid. Some are quiet. Some are noisy and active. These temperaments stay with them as they grow. There are also male-female behavioral differences present at birth, though research findings are still sparse. The male infant has greater muscular strength at birth, but the female is in no way less active or expressive. The female infant from birth shows more oral sensitivity, engages in more frequent mouth-dominated approaches, and is a more frequent and more persistent thumb-sucker. Newborn females also exhibit greater cutaneous sensitivity than do males.

Parents treat male and female infants differently right from the start, hence there is constant parental reinforcement, not only of innate differences but also of differences in what society regards as gender-appropriate behavior. In other words, the infant’s unique male or female characteristics, as well as cultural expectations, may affect the nature of parent-infant interaction from the day of birth and onward. Moss found, for instance, that mothers had significantly more contact with infant boys than with girls on such variables as “attends” and “stimulates-arouses.”

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Clearly, the kind of person a man happens to be will have some bearing on the way he and his son get along together and on his son’s readiness to identify with him. For example, a father who is cold or weak may not invite close relationships with his son or seem very interesting or important to identify with. In this regard, studies have described the fathers of homosexual males as passive and ineffective family members who leave major decisions to their wives.

The homosexual men tended to describe their fathers as persons who would presumably be poor objects for identification:

It should be noted that the homosexual respondents did not differ from their heterosexual counterparts in how masculine or feminine, independent or dependent, active or passive, or relaxed or up-tight they said their fathers had been.

In addition, the homosexual respondents’ more-frequent description of their fathers as cold persons appears to be consistent with others’ theoretical expectations. It should be noted, however, that when fathers and mothers were compared, the majority of respondents of both sexual orientations reported their fathers made fewer decisions in the family, and that their fathers were not much colder than their mothers.

Our findings suggest that a father perceived as relatively cold by his son is less likely to get along well with him and offers a less-appealing figure for identification. The influence of paternal traits, however, seems limited to familial relationships; their ultimate effect on a son’s adult sexual preference is at best tenuous.

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The problem may lie in one of these areas:

• The woman—70 to 75 per cent of infertile couples have a female factor.

• The man—30 to 35 per cent have a male factor.

• The couple—40 per cent of infertile couples have more than one factor. In some couples no cause will be identified.

However, the most common causes of infertility are:

• Anovulation (not producing an egg)—about 30 to 40 per cent of infertile couples have this problem.

• Having blocked fallopian tubes—about 20 per cent.

• Sperm problems—about 20 to 30 per cent.

Rarer causes include problems with the uterus, cervix, chromosomes and male anatomy.

Tube problems. Not only do the sperm need to travel up the tube to meet the egg, but the fertilised egg must also make it down through the tube to the uterus. If the tube is kinked or narrowed it is less likely that a pregnancy will result. If the tube is completely blocked, then it’s pretty unlikely indeed.

Things that muck up tubes, such as the most common causes, infection and endometriosis. Chlamydia and gonorrhoea are the main causes of sexually transmitted pelvic inflammatory disease (PID). Non-sexually transmitted PID, for example infection following an abortion or other gynaecological operation, or related to an intrauterine contraceptive device (1UD), accounts for some cases. Scarring following pelvic surgery or appendicitis can also affect the tubes.

Endometriosis can damage the tubes if it causes scarring. It can also slow the rate at which things travel through the tubes, by exerting a type of hormonal effect.

Having an ectopic pregnancy (a pregnancy which settles in the tube or ovary rather than in the uterus) can damage the fallopian tube, as an operation is usually performed to remove the ectopic pregnancy. Generally that means removing some or all of the tube on that side. Surgeons try to be as careful as possible, and in some cases are able to conserve the tube.

Another reasonably common cause of tube problem is previous surgery. Some women who have had their fallopian rubes operated on (either cut and tied, or had clips applied), will request reversal of their operation to restore their fertility. Men who have had a vasectomy may also change their minds, and seek a reversal operation. Reversal may work, but success rates would vary depending on the surgeon and the degree of damage to the tube from the sterilization procedure. You should never have a sterilisation operation thinking you can change your mind later, because the results of reversal are so unpredictable.

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There are several ways of working this out. The most common is by dates. The first day of your last period is counted as day 1, and an average pregnancy is about forty weeks. The ‘expected due date’ is calculated in this way. Most babies arrive between thirty-eight and forty-two weeks, not necessarily on their ‘due date’.

If your first missed period was two weeks ago, you would be about six weeks pregnant, because it is counting from your last real period, (only thirty-four weeks to go!). This method assumes that most people have cycles of about four weeks and regular periods, as most people do.

However, if you have a usual cycle of five weeks, and your missed period was two weeks ago, you may not be seven weeks pregnant (which you would be by counting from your last real period). You are more likely to be six weeks, because most women ovulate about two weeks before their period, regardless of how long it is between periods. If you have irregular cycles it may be impossible to tell the gestation (stage of development of the pregnancy) from the dates alone.

It is generally not absolutely necessary to know the exact gestation. If it is, then an early (less than ten weeks) ultrasound can be used to assess gestation. This measurement will be accurate to within a few days.

Less accurate, but still useful, is a physical examination. The size of the uterus can give an idea of how far the pregnancy has progressed. The limiting factors in this method are the experience of the doctor performing the examination and the fact that the uterus may not be that easy to feel.

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Again, some blood tests will tell you:

• if you have ever been in contact with the bug, and have developed antibodies

• if you still have the infectious part of the virus, the ‘antigen’, floating around your blood stream, and are infectious to other people—a carrier

• if your liver has been damaged by the virus, if you are a carrier.

Again, there is a ‘window period’, as explained in the previous section on AIDS—HIV infection, so sometimes a repeat test may be necessary to exclude infection.

Treatment. Unfortunately, there is no effective cure. Being a virus, it doesn’t respond to antibiotics. The best we can do is try to stop it spreading, and give symptomatic relief to those who are in the ’sick’ phase of the disease.

There are drug treatments being tried on people who have chronic hepatitis, with varying success. Ultimately some people will be treated for liver failure, as the chronic stage progresses, and they will sometimes be candidates for liver transplants.

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The drug companies realized that there would be ‘gold in them there pills’, and consequently there are lots on the market. This breeds a bit of confusion among the pill takers, when they realize they are on one type of pill, and all their friends are on different ones. Are some better than others? Generally no. In fact some of the ‘different’ pills are in fact identical, but made by a different company, so have a different brand name and packaging. Some have different doses and some contain different types of progesterone, but they all work in the same way.

There are many presentations of the pill. All contain combinations of oestrogen and progesterone. Some of the commonly prescribed ones include:

• 30 microgram oestrogen—stable dose—21-day or 28-day (which includes seven ’sugar’ tablets as well as the twenty-one hormone tablets). The idea of the sugar tablets is so the taker gets into a routine of taking a pill every day. The sugar pills do not make you fat. You don’t actually have to eat them if you don’t want to. Trade names: Microgynon 30, Microgynon 30 ED ‘every day’, Nordette 21 and Nordette 28.

• 35 microgram oestrogen—stable dose—21-day or 28-day package. Trade names: Brevinor, Brevinor-1.

• 50 microgram oestrogen—stable dose—21-day or 28-day packets. Trade names: Microgynon 50, Microgynon 50 ED, Nordette 50, Nordiol, Nordiol 28, Norinyl-1, Ovulen.

• Triphasic and Diphasic packets—21 -day or 28-day. These vary the amount of hormone taken throughout the month, but work in the same way to prevent ovulation. Some triphasic preparations have a lower overall dose of hormone when added up for the month. Trade names: Triphasil, Triphasil 28, Triquilar, Triquilar ED, Synphasic 28-day (35 microgram oestrogen), Biphasil (50 microgram oestrogen), Sequilar ED (50 microgram oestrogen).

• Preparations with other progesterones are also available. These specific progesterones may be more suitable for some people, as they are less likely to adversely affect skin (acne and hair growth). Trade names: Diane 35 ED, Marvelon.

When starting the pill for the first time, often the lower dose (30 microgram) pill, or a triphasic preparation will be prescribed. If ‘breakthrough bleeding’ occurs regularly, a higher dose may be prescribed. Breakthrough bleeding or spotting is not uncommon when first starting any pill, and will usually settle down within three months. If it doesn’t it may be worth trying a different pill.

The higher dose (50 microgram) pills may be better for people with certain problems, such as acne, breakthrough bleeding, or people taking certain medication already. Tablets for epilepsy, among others, can interfere with the effectiveness of the pill, so a higher dose is required to provide adequate contraception. If you are on a regular or frequent medication, check with your doctor about interactions with the pill. Together, a woman and her doctor can work out the alternatives. It is not uncommon for women to find they tolerate one type of pill better than another. Women may try several different ones before finding a pill they are happy with.

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Then there are the bits we can’t see, like hormones. Hormones are chemical messengers which float around in the blood stream, telling different bits of your body to do their jobs. Like little floating supervisors, there are hormones which control a variety of body functions. For example, growth hormone tells the various growing cells to multiply at a particular pace, mainly during childhood and adolescence. Without sufficient growth hormone we do not grow at the usual rate. Insulin is a hormone, made in the pancreas, which controls the sugar level in the blood. Diabetes is the condition which arises when insulin it not made, or stops having its effect, and blood-sugar levels rise. There are many hormones floating around the body at any particular time, regulating the many functions of the body. The ones are the ones which affect the reproductive organs.

There are two major female sex hormones. One is oestrogen (also spelled estrogen). Progesterone is the other. There arc other hormones related to reproduction, with poetic names like follicle stimulating hormone (FSH), luteinising hormone (Ml), and women also possess the ‘male’ sex hormone testosterone.

These hormones are produced by, and act on, a variety of organs.

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