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YOUR VISITS TO THE DOCTOR

Your First Visit
I suggest you consult a doctor or gynaecologist who has a special interest in women's health and a Menopause Clinic or Women's Health Centre is usually your best bet. Your History
Before beginning HRT or deciding that it is not for you, your doctor must take a medical history and perform a full physical checkup and a battery of tests. She will want to know if there are any risk factors in your family history that could influence the decision to begin HRT. For instance, a strong family history of breast cancer occurring in close relatives, especially if diagnosed before the age of the menopause, would cause your doctor to be more conservative in giving you oestrogen replacement. Conversely, a family history of osteoporosis or cardiovascular disease would probably influence her to advise you more strongly to take oestrogen replacement on a long-term basis as this would reduce your chances of following in your female relatives' footsteps. Particular attention should be paid to your menstrual pattern. If you have had irregular bleeding or bleeding after twelve months of stopping regular menstruation then you will need a dilatation and curettage of the uterus before commencing HRT. This will rule out the presence of uterine or cervical cancer which, if discovered, would require urgent treatment.
Your contraceptive needs should also be discussed because, if you are premenopausal and wanting to begin HRT before the real onset of the menopause, then theoretically there is still a slight risk of pregnancy. Modern day natural HRT cannot guarantee 100% protection against pregnancy as it is not as effective in suppressing ovulation as the oral contraceptive pill. Thus, in pre-menopausal women or those in the very early stages of menopause while there is still a slight chance of ovulation, the mini pill (progesterone only pill) could be taken every day along with natural oestrogen or a low-dose oral contraceptive pill could be continued until one is certain that menopause has arrived. Alternatively, mechanical methods of contraception such as the diaphragm, intra-uterine contraceptive device or condoms can be used until the menopause has definitively arrived.
A previous history of gynaecological cancer is very significant. If you have had successful treatment of a previous cancer of the ovaries or cervix, then HRT should not be a problem. If you have had successful treatment of a cancer of the inner lining of the uterus (endometrial cancer) taking oestrogen could theoretically stimulate a recurrence. If this applies to you, check with the gynaecologist and cancer specialist (oncologist) who treated your cancer and then make a decision regarding HRT.
Your past history is also worth scrutinizing because, if you have had a problem with high blood pressure, heart disease or blood clots, special care will be needed in deciding the type of HRT that is best for you. In such cases the oestrogen patch is likely to be the safest form of HRT. Your doctor will also want to know about your lifestyle and daily habits as well as your expectations and needs concerning your sex life. Ideally, before starting HRT you should stop smoking, begin to exercise regularly and if overweight, slim down.
Menopausal women who are enjoying an active and fulfilling sex life can optimistically be told that HRT can ensure a lasting quality to this pleasure. It will definitely help vaginal and vulval lubrication, the ability to achieve a satisfying orgasm and prevent shrinkage of the breasts, uterus, vagina and clitoris. Most women want to remain sexually active way beyond the menopause.
Your doctor will also quiz you about your symptoms such as hot flushes, obviously with the intent of assessing your level of oestrogen deficiency. Why not make it easy for him by taking along your completed oestrogen level score chart. That Vital Physical Examination
It should take about twenty minutes and will be a complete strip off. Your heart, blood pressure, blood vessels and weight will be checked. The thyroid gland which is that soft fleshy mound in the front of your Adam's apple is pressed along with a thorough feel around in the neck and armpits for lumps and assorted swellings. The breasts should be painstakingly felt for any tenderness, lumpiness or thickenings. The skin and nipples of the breast are also checked. The abdomen is checked, followed by the pelvic examination. The vagina and vulva should be checked for signs of oestrogen deficiency or disease processes. In a woman with oestrogen deficiency the vaginal secretions are scanty and alkaline (non-acidic) and the mucous membrane lining the vulva and vagina may be thin and fragile. Understandably, in such cases the taking of a pap smear may be extremely uncomfortable in which case
The use of a vaginal oestrogen cream for one month will be required to restore the vaginal tissues to normal so that a pap smear and pelvic examination can be done comfortably.
You will be asked to cough or bear down while your doctor views the vaginal opening as this reveals any tendency to prolapse of the uterus and bladder. Next comes what I affectionately call the "squeeze test" as the doctor palpates with two hands your uterus, ovaries and surrounding pelvic organs. This is a vital part of your checkup as presently the only early evidence of a cancer of your ovary is a swelling or lump in the pelvis, so try to relax and breathe deeply as it makes the pelvic examination far more accurate. Making sure you have emptied your bladder before your examination is also a great help, especially when your doctor is squeezing around in your pelvis, checking the size and consistency of your uterus.
If your uterus is enlarged or your ovaries are enlarged or difficult to feel because you are overweight or tense, it is wise to have an ultrasound scan of your pelvis. This can reveal uterine fibroids (fibrous growths) or tumours and cysts on the ovaries. Cancer of the ovaries becomes more common during the post-menopausal years and carries a very high risk of death because it produces few symptoms in the early stages. Presently, ovarian cancer is the fifth most common cancer in women and kills twice as many women as cancer of the cervix. It is usually first discovered in women over 45 at a stage when it has spread extensively and can be considered generally as a slow-growing cancer which is not diagnosed until late. An ultrasound scan helps to discover growths on the ovaries in the early and curable stages. The more frequent use of ultrasound scans of the pelvis to check the ovaries in women over 45 will reduce these currently pessimistic statistics.

Special Tests
To help determine your individual requirements for HRT, it is best to have some simple tests. The most important is the breast X-ray or mammogram. If you have an undiagnosed cancer lurking in your breast, taking HRT could theoretically increase its rate of growth. Thus, it is most important to exclude the presence of a breast cancer before beginning HRT and a mammogram is the most accurate means of doing this. Your doctor will examine your breasts very carefully for signs of cancer but even the best doctor in the world can miss a tiny cancer because it is just too small to humanly feel. A good quality low-radiation-dose mammogram can reveal very tiny cancers, as small as one to two millimetres in size long before your doctor can feel them. In Sweden, studies have proven that screening women aged 45 years and over with regular mammograms can reduce the risk of dying from breast cancer by up to 60%.
Routine blood tests to measure your Follicle Stimulating Hormone (FSH), oestrogen level, a full blood count, blood sugar level, liver function tests and blood cholesterol should also be checked. If you have a past history of forming blood clots (thrombosis), then blood should be taken for a clotting factor profile.

Follow-Up Visits
Your doctor will usually make a decision regarding HRT at your second visit during which you can both review and discuss the results of all your tests. The most pressing reason to begin oestrogen replacement without delay would be a poor result on your bone mineral density test. If you feel you need time to think about it or seek a second opinion, you may take several months to sort out your attitude and feelings about HRT. If you decide to start HRT straight away watch its effects by keeping a weekly record of your symptoms on your oestrogen level score chart
After starting HRT see your doctor after two months, six months and twelve months; thereafter at twelve-monthly intervals. This will enable him to fine-tune your HRT to suit your individual needs. Your general physical examination, pap smear and mammogram should be repeated every twelve months. If your initial bone mineral density test was satisfactory, this can be repeated every three to five years, whereas those women with a low calcium content in their bones should have a bone mineral density test done every one to two years.
If irregular unexplained vaginal bleeding occurs at any time while on HRT, a dilatation and curettage of the uterus should be done by a gynaecologist. Some experts feel that all women on long-term HRT should have more than a pap smear every twelve months. They recommend the addition of a test to take a sample of cells from the lining of the uterus called an endometrial cell sample. This can be done easily at the time of your pap smear and checks for pre-cancerous cells higher up in the uterus above the cervix.
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EPILEPSY AND PREGNANCY

Women with epilepsy are quite often concerned about getting pregnant. There appear to be five reasons for this concern. They wish to know:
if they are likely to hand their epilepsy on to their children;
whether their fits will get worse during pregnancy;
whether it is safe for the baby that the mother should take anticonvulsants drugs during pregnancy;
if there will be any problems in the newborn baby from these drugs;
if they can safely breast feed the baby.
With regard to handing on epilepsy to one’s children – as mentioned earlier, if one parent has epilepsy, the chances of one of the children having epilepsy are no greater than in the population at large. If both parents have epilepsy, it would appear that the risk of a child having epilepsy is about 10 per cent. So in fact the chance of a child inheriting epilepsy, particularly idiopathic epilepsy, is negligible.
As far as seizures during pregnancy are concerned, the situation is not as clear as it might be. There is evidence that for some women, seizure control may deteriorate, while for others there may in fact be no change or even an improvement. A patient told me recently that “she would like to remain pregnant forever” as she had not had a single fit during her pregnancy, compared with six fits in the preceding nine months!
As a general working rule, it is suggested that people who have more than one grand mal fit a month are those who are most likely to have a deterioration in seizure control during pregnancy. The deterioration, if it occurs, is most likely during the first three months of pregnancy. There are a number of theories why this may happen, but none has been proved. It may be of value to check the blood anticonvulsant levels during pregnancy, especially if there is a deterioration in seizure control. The blood levels may fall, necessitating an increase in dosage during the pregnancy.
The main concern for parents is whether the anticonvulsants can harm the unborn baby (foetus). It is known by most people with epilepsy that this is a potential hazard. The effects include physical abnormalities in the baby, a process known as teratogenesis. Abnormalities have been reported in the offspring of mothers on all the commonly used anticonvulsants with the exception of carbamazepine. This is particularly applicable to phenytoin, barbiturates and sodium valproate. Babies born to mothers who have been on carbamazepine have not been shown to have any physical abnormalities, but have a smaller head size than other babies. This has not been shown to be any handicap to the babies who have been followed up for five years.
The risk of abnormalities in the baby is difficult to assess, but it seems to be most common in mothers on polytherapy (receiving numerous drugs), especially if they are on three or more anticonvulsants. The risk in mothers on phenytoin, with or without other medications, appears to be about a 10% chance of the baby showing features of the ‘foetal hydantoin’ syndrome. This syndrome consists of cleft palate, abnormalities of the fingers, possible heart abnormalities and mild mental retardation. Thus, at present, if it is possible, it would seem wise to try to change patients over to carbamazepine before conception. This may not be possible in all patients and, of course, many women will first visit their doctor when already pregnant, at which time there is no purpose in making the change.
Anticonvulsants taken by the mother during pregnancy may have some effects on the baby immediately after birth, as they are transmitted to the baby across the placenta. These include the possibility of a mild bleeding tendency and some drowsiness. In mothers who have been taking barbiturates, the infant may occasionally show features of a withdrawal reaction with irritability, jitteriness and poor sucking. None of these features is [...]

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