Healthpharmablog. About Health & Medicine

A conservative laparotomy for endometriosis is surgery which attempts to remove or destroy as much endometriosis and as many adhesions as possible while still retaining the uterus and at least one ovary and fallopian tube so that conception and pregnancy are possible. It will also try to correct any other problems of the reproductive organs if they are present.

Who is suitable for a conservative laparotomy?

The reasons for having a conservative laparotomy vary widely and they may include any of the following:

• moderate or severe disease

• endometriomas or cysts greater than two centimeters in diameter

• adhesions, especially if they are causing pain or distortion of the reproductive organs

• involvement of other organs such as the bowel or bladder

• moderate or severe symptoms that have not responded to other treatments

• inability or unwillingness to take hormonal treatment

• desire to conceive immediately

• desire to avoid hysterectomy

• woman’s preference

• gynaecologist’s preference.

A conservative laparotomy is often the most appropriate form of treatment for more severe forms of endometriosis, particularly if large cysts or adhesions are present. Some gynaecologists believe that a conservative laparotomy is of little benefit for those with minimal or mild endometriosis and that in those cases it should only be used as a last resort if hormonal treatment or laparoscopic surgery is unsuccessful.

Hormonal treatment has little or no effect on adhesions or large cysts and endometriomas greater than two centimeters in diameter as they are made up largely of scar tissue. Surgery is the only way to remove or destroy any adhesions or large cysts and endometriomas.

If your endometriosis involves nearby organs such as the bowel or bladder, surgery may be necessary to ensure the normal functioning of those organs.

Things to discuss before conservative laparotomy

Before your operation it is important that you discuss with your gynaecologist what is intended to be done during the operation. Also ask any other questions or voice any concerns that you may have. In particular, you should make sure that you both agree on the purpose of the surgery and you should discuss what procedures are proposed and you should make it clear if there are any procedures that you particularly do or do not want carried out. You also need to remember that, because each case of endometriosis is unique, until your gynaecologist actually starts the surgery it is difficult to be certain what procedures will be needed.

If your symptoms are manageable and if you are contemplating becoming pregnant soon it may also be worthwhile discussing the timing of your surgery with your gynaecologist. Most infertile women with endometriosis who conceive following a conservative laparotomy do so in the first 12 months after their surgery and you are more likely to conceive after the first bout of surgery than subsequent surgeries. Some gynaecologists believe that, if possible, a conservative laparotomy should be timed for when the woman wishes to become pregnant.

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Although each patient is different, there are certain typical errors of thinking that they usually fall prey to. Let me describe some of these errors.

Black-and-white thinking: By this I mean the “all or nothing” attitude. For the anorexic, fat is hell, the ultimate nightmare, the horror of horrors. Thinness, however, is heaven, bliss, a goal worth dying for. There is no middle ground. Did she gain a pound this week? Then obesity is just around the corner. “If I can’t be one hundred percent perfect,” she tells herself, “then I am a total failure.”

A bulimic sees certain foods as “good” and others as “bad.” Bad foods must be absolutely, totally banished from her diet. Her characteristic thought is, “If I eat a little of this food then I’ll lose control. I won’t be able to stop until I become extremely fat.” But if she gives in to temptation and takes even a single bite of the forbidden food, then all is lost. She goes ahead and stuffs herself until she can hold no more. For her, there is no such thing as eating in moderation. All or nothing. Black or white.

She thinks the same way about other areas of life. She considers a grade of “B” on a school assignment to be a failure, since it is not perfect. Becoming sexually involved with someone means she is a loose woman. One patient saw herself as an “angry monster- if I’m not totally in control, then I’m totally out of control.”

One clue to black-and-white thinking is the fact that many of the patient’s statements contain such phrases as “I must” or “I should.” A patient might remark, “I must eat the same foods every day or I’ll swell up like a blimp.” Another might say, “I should exercise at least three hours a day.” The psychoanalyst Karen Horney coined the phrase “the tyranny of the ‘Shoulds” to describe this state of mind.

When patients divide everything into such extreme categories, they reveal their need for certainty in their lives. Because they mistrust their own feelings, their own ability to judge, they look outside themselves for guidance. The drive to be perfect shows their inability to determine when they are good enough. In cognitive therapy we spot the “should” and “must” thought-tyrants and challenge their right to rule the patient’s life.

Some time ago, researchers devised an ingenious experiment that revealed black-and-white thinking in action. They asked a group of dieters to drink milk shakes and then eat some ice cream. What the dieters didn’t know was that the “milk shake” was actually a ringer-it had a relatively low calorie content. Surprisingly, the dieters who were told that the shakes were high-calorie went ahead and ate more ice cream than those who were told the truth. Why? Well, the researchers called the dieters’ action “counterregulation.” The dieters felt that drinking a high-calorie shake had caused them to “blow” their diet. They had already failed, so why bother holding back while eating ice cream?

Magnification: This word describes the patient’s tendency to blow things, especially negative things, all out of proportion. Most prominent in their minds, of course, is body size. Many of my patients say they know perfectly well they are thin-they can see it in the mirror, their friends all tell them-but they feel fat. That feeling overrides and distorts any logical arguments to the contrary.

Similarly, patients distort their impressions of food itself. A case in point: A twenty-one-year-old, eighty-six-pound woman named Ondine swore up and down that at home she always ate three good-sized, nutritionally balanced meals, plus snacks, a day. I admitted her to the hospital. Yet when the first tray was brought to her, Ondine panicked. “I can’t eat all this!” she cried. “This is more than I eat in a week!” Obviously, her perception of a “good-sized” meal was somewhat skewed.

Magnification occurs in other areas as well. A certain homework assignment temporarily becomes the be-all and end-all of the girl’s life. An interest in sports turns into the compulsion to jog ten miles a day and play tennis to the point of exhaustion. A broken date becomes a billboard announcing the patient’s un-desirability to the world.

Personalization: A fifteen-year-old bulimic told me she had been too afraid to go to the beach during the previous summer. “I knew they’d all be staring at me and thinking that a whale had washed up on the beach.” This patient was personalizing-assuming that everyone’s undivided attention was focused on her and her alone.

Patients sometimes personalize an otherwise innocent remark. “You’re looking good,” an office colleague might say. The patient twists this to mean, “You looked so bad before.” The idea that people might observe and comment on a patient’s appearance can occupy her mind the rest of the day, and trigger a binge when she gets home that night.

Magical thinking: Examples include such statements as, “Bread is poison,” or, “With my metabolism, everything I eat after lunch turns into fat.” One patient told me, “If I eat one Oreo cookie at ten o’clock at night I’ll be all right, but if I give in and eat it earlier I know I’ll binge.” Magical thinking about eating, exercise, or interpersonal relationships is very common, especially among anorexics.

Sensory distortions: A lot of patients report that their senses become keener during their illness. One patient fought constantly with her brother because he kept his stereo turned up too high. Maybe he did, but there was no doubt that her hearing had become much sharper during starvation. Some patients wear sunglasses, even indoors, because average light has become too bright. Many report that colors are more vivid, smells more potent. Often, these cognitive distortions are direct, physical consequences of starvation itself.

Errors of attribution: These are mistakes in figuring out the relationship between cause and effect. For example, a patient may gain a pound and believe it is because she ate a chocolate-chip cookie the week before. When we look at the facts, however, we may find that her weight gain is actually the result of premenstrual water retention.

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A little black dress hung from Dinah Burnette’s closet door, reminding her of the past and showing her what the future might hold. But at 245 pounds, she couldn’t even pull the dress over her hips.

Being overweight was a new experience for Dinah. When she was a teenager, she stayed trim despite hearty meat-and-potato meals and midnight pizza sessions. And as a young woman, her figure always snapped back after the birth of each of her four children.

But when Dinah was in her late twenties, she added 100 pounds to her frame in just 2 years. During that time, she had started taking a prescription medication that sometimes causes weight gain. But she also suspected that her metabolism had just slowed down.

Even though the clothes in her closet grew bigger and bigger, Dinah didn’t acknowledge just how much weight she’d accumulated until she saw photographs of her 1996 nursing-school graduation. “I was in this fantasy world that there were several girls in my class bigger than me,” she says. “When that class picture came, I was the biggest. I just remember being so embarrassed.”

So the Winston-Salem, North Carolina, woman began a self-styled regimen of healthy meals, a gallon of water a day, and lots of exercise. “When I started walking, I couldn’t even do a half-mile,” she says. “But in 6 months, I worked my way up to 3 miles every day.” For motivation, Dinah hung her expensive black dress, the only piece of small-size clothing she’d kept, on her closet door. The last time she had worn it was to a wedding in early 1989.

“I would try it on every 4 weeks and see how close the buttons were getting. Gradually, I could get it on, but the buttons were 4 feet apart,” she laughs. One year later and 100 pounds lighter, she could once again fit into the size-12 dress—this time with room to spare.

Now, her closet contains only one larger-size garment, which she keeps around so she’ll stay inspired to maintain her present weight of 145 pounds.

It’s the size-24 white dress that she wore in that graduation photo.

WINNING ACTION

Measure your progress with your wardrobe. Keep one article of clothing handy that will fit when you reach your ideal weight. Try it on from time to time to measure your progress. Use your try-on as motivation—and don’t let yourself get depressed if it doesn’t fit for weeks or months. Remember Dinah: The buttons on her black dress didn’t close at first, but she persevered. Now, she has room to spare.

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- What causes night sweats, and how are they linked with hot flushes?

Night sweats are probably hot flushes with the bedclothes on. Flushing and sweating attacks tend to go hand in hand and peak in the years after menopause. The sweating sensation usually takes longer to subside than flushes do.

- Will my hot flushes return with a vengeance if I stop HRT too soon?

HRT does not seem to affect the duration of hot flushes. If you stop HRT, and you are still in the flushing phase after menopause, your flushes will return. Every woman on HRT for control of hot flushes reaches a point where she wonders if it’s time to take a break and see how her body responds. Going off HRT may indicate that the phase of flushes is over or, if not, it will remind you of why you started on HRT in the first place. After a while, of course, the flushes will subside normally — just as they would if you had no HRT.

- I’m told many women give up HRT after a year or two. Why would they do that?

For a variety of reasons, such as bleeding, a dislike of being on medication for an extended time, and concerns about the long-term possibility of increased risks of breast and endometrial cancers.

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BLADDER DISEASE Hormone replacement therapy undertaken by such women may change the composition of bile and increase the incidence of gallstones. If you have gallstones and want HRT, be cautious about it and give preference to the patch format. Hormone therapy is suitable for women who have had their gall bladders removed, provided there are no other reasons against it.

WOMEN WITH DIABETES Hormone replacement therapy may be prescribed for women with diabetes. However, if you have diabetes you should realise that your blood sugar levels are likely to be disrupted during the first few months of hormone use. This may necessitate changes in the dosage and timing of your medications, particularly if you use insulin. Patches or implants are the preferred form of HRT for women with diabetes. Although some research has been conducted on the impact of oestrogen on blood glucose levels, there is relatively little information on the effects produced by hormone combinations such as oestrogen and progestogen.

*76\38\8*

The HRT dosage prescribed depends on a number of factors such as its purpose (for example, mainly for symptom control or mainly for reducing the risk of later heart or fracture problems) and a woman’s individual response to it. The oestrogen dosages needed to relieve symptoms may be higher or lower than those required to provide long-term protection against heart disease and osteoporosis, depending on the severity of symptoms. Women on HRT before menopause is confirmed cannot rely on it for contraception as hormone dosages are insufficient to prevent pregnancy. As explained previously, a low-dose combined Pill is one way of obtaining both the benefits of HRT and contraceptive protection.

Whether it is taken every day or for ten to fourteen days per cycle, the total monthly dose of progestogen in HRT is similar to that given to a woman on the Pill. The dosage used by Tessa, who is taking progestogen daily, was arrived at by lowering the daily dose until she had breakthrough bleeding, then adjusting upwards.

Individual variability in the body’s capacity to deal with the hormones of HRT is another reason why a dose that relieves symptoms in one woman has little effect on another. In the case of hormone patches and implants, the position on or in the body affects the amount of hormone the body absorbs and therefore the dosage required.

When a doctor is deciding on the most suitable dosage or hormone format for you, your individual response will be crucial. The hormones used initially may not relieve your symptoms adequately, or they may have unwanted effects. It may then be necessary to change the kind of oestrogen or progestogen used, or to alter the dose.

*41\38\8*

An artificial menopause can also be caused by chemotherapy, the drug treatment used against many types of cancer. Chemotherapy directed at any part of the body prior to menopause may result in a chemical menopause, but regrettably many women are not warned about this possibility. Marcia was upset to learn while having chemotherapy for leukaemia that her ovaries would no longer function after the treatment. ‘It was the last thing on my mind at the time I started chemotherapy, and the hot flushes I experienced some weeks later came as a most unpleasant surprise,’ she recalled. ‘Fortunately I have three children and wasn’t intending to have any more. However, I would have appreciated being told earlier about this effect of chemotherapy.’ Menopause may also be caused by radiotherapy to the ovaries, when x-ray treatment is given for a cancer in the pelvis.

Early natural menopause in the absence of any medical intervention is more likely in women who smoke (smokers experience menopause one to two years earlier, on average, than non-smokers and ex-smokers, the reason being that smoking reduces the availability of oestrogen to body tissues). Later menopause is more likely in woman with many children, and women who are heavier than average. Genetic and nutritional factors also seem to play a part: the menopause for Asian women apparently occurs earlier than for those with northern European backgrounds.

Sometimes none of these reasons accounts for spontaneous premature menopause, which on rare occasions can be found in women in their thirties or, even more rarely, in their teens or twenties. Studies suggest that the egg supply of most of these women has run out, but it is not clear whether this is due to a shortage of eggs at birth or, as is more likely, some unknown factor.

*7\38\8*

These are very similar to stomach ulcers, but occur in the first part of the small intestine – the duodenum. The main symptom is pain, several hours after eating. This pain is usually felt in the upper abdomen, although sometimes it appears to be in the back.

Most duodenal ulcers result from excessive acid production in the stomach. All the causative factors described above for stomach ulcers are also operative in duodenal ulcers, particularly anxiety, tension, smoking and drinking too much alcohol. Wine and spirits are the main offenders. Duodenal ulcers also seem to be linked with eating a lot of pickled food, and eating refined carbohydrates that is, sugar and white flour. Duodenal ulcers tend to heal themselves, provided the original causes are removed.

Again, a small minority of patients with duodenal ulcers may be suffering from food allergy or food intolerance – but there is little hard evidence to support this belief, only individual case-histories.

*137\180\8*

Try this way of life as an experiment either during your holidays or when you are convalescing from an illness. Instead of going out in the evenings on some social occasion that may last far into the night, take the opportunity to enjoy some natural sleep several hours before midnight. If, during our holidays, we accustom ourselves to this way of life, perhaps when we return home we may succeed in cancelling our social obligations on two or three weekday nights in order to enjoy the regenerative power of natural sleep. Our business and social life will actually benefit, for our energies and strength will be renewed. If, on the other hand, we behave like most people on holiday and stay up all hours of the night indulging in social life to the full, then we should not be surprised if our body and mind are still tired once it is over.

*1213/28/1*

I am always reminded of visiting a hospitable desert Bedouin in his tent whenever someone complains about a hot summer’s day in my native Switzerland, where cold and rainfall are well known but not real drought. In the shade of his black goat’s-hair tent the temperature must have been around 40 °C (104 °F) and the air outside was shimmering in the heat. In spite of this the bearded man, whose deeply lined face betrayed his advanced age, served me hot tea. I was astonished and wanted to know the reason. His answer was quick. It was completely wrong, he said, to drink cold water in the intense heat; it would only increase the thirst instead of quenching it. And so would sweet drinks, he added. It would be asking for trouble and not healthy either. At the time of our conversation I was still doubtful about his conclusion, but eventually it was confirmed by my own personal experience. It is really true that a hot drink or juicy fruit are better than anything else to quench one’s thirst in the heat. What is more, they may prevent you from catching a cold, but there is no guarantee for that if you gulp down ice-cold beverages.

It is also important to breathe through the nose when it is very hot, not only when you are in the cold. The nose is equipped with a built-in air-conditioning system, or temperature control, which warms up the incoming air in the winter and cools it down in the summer.

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