This is a relative newcomer to the bag of surgical tricks gynaecologists use. It is looking likely to replace the old D and C, as it is used for similar reasons, and has the added advantage of being more accurate and in many cases more useful than D and C and endometrial sampling.

Aims. As for D and C, but also allows for visual inspection of the uterine cavity, and therefore more selective sampling or treatment of abnormalities than the ‘blind* D and C and endometrial sampling methods. Indications:

1. Diagnostic—abnormal menstrual bleeding, and to assess the shape of the uterus.

2.Therapeutic—the newer technique of endometrial ablation (or endometrial resection) is being used as an alternative to hysterectomy in some cases, and involves removing the endometrium, usually by laser or diathermy. The main indication for this is menorrhagia (very heavy periods).

Method. This procedure can be done either with or without local anaesthetic on a conscious patient, or under general anaesthetic. The patient is in lithotomy position, and a hysteroscope (a thin instrument, like a tiny telescope) is passed into the uterine cavity through the cervix. Usually carbon dioxide gas is used to gently open up the cavity so that the operator is able to see through the hysteroscope, which is used to check the lining of the cervix, the uterine cavity, and the openings of the fallopian tubes inside the uterus. Any abnormal areas can be identified, and small samples (biopsies) can be taken to be further examined under the microscope by pathologists. If there is a polyp it may be possible to remove this using an attachment on the hysteroscope.

Endometrial ablation is a relatively new procedure, performed with a hysteroscope (under general anaesthetic), in which the endometrium is treated with either laser or diathermy. This has the effect of limiting the future development of endometrial tissue, therefore decreasing menstrual bleeding. Varying success rates are being reported, and more information about its long-term usefulness as an alternative to hysterectomy should be available as experience with the technique grows.

Complications. Difficult to give accurate figures. In some ways comparable to D and C, but because it is done under vision, the likelihood of damaging the uterus is potentially less. Using gas to inflate the uterine cavity should not cause the same types of problems as inflating the pelvic cavity in laparoscopy, but there still may be a potential (very small) risk of the gas going in the wrong place (like into a blood vessel, for example). If a general anaesthetic is used, that carries some risk itself. If having an endometrial ablation, there are the added small risks associated with laser or diathermy treatment.

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This is unfortunately a fairly common disease in our community. Estimates place the incidence at between one in thirteen and one in fourteen Australian women. It is more common in older women, with most cases occuring in women between 40 and 80 years old. It is much less common, though still occasionally found, in women under 30.

Breast cancer can (very rarely) occur in men. About 1 per cent or less of all breast cancers occur in men. These would generally start with a lump in the breast tissue, and as the breast is small in men, it is usually not difficult to find. Men should have breast lumps investigated, too. (Generalized breast swelling, called gynaecomastia, is not uncommon. It is a side-effect of some medications, liver disease, and certain other conditions, and should probably be checked out as well.)

Risk factors. Researchers have found factors which appear to be associated with the development of breast cancer. These include:

• Family history. Even though about 80 per cent of women with breast cancer have no family history of it, a clear genetic tendency has been exposed. For the 20 per cent who have a family history of breast cancer, the risk increases with the number of first-degree (mother or sister) relatives who have the disease. For example, a woman who has one first-degree relative with breast cancer carries an increased risk of one and a half to two tunes that of the general population. If she has two first-degree relatives, the risk increases to four to six times. If a sister had breast cancer in both breasts, and was under 40 years of age, the risk may increase further.

• Early menarche (first menstrual period) and late menopause (last menstrual period). Starting menstruation under 12 years of age, and finishing after 55 may be weak risk factors, with relative risks of one and a half, and two times that of the general population, respectively.

• Never having had children (nulliparity), or having the first child late in life. These have been identified as risk factors.

• Having some forms of benign breast disease. Only some types of benign breast disease may increase the risk of developing breast cancer. The types which have been implicated are those where microscopic examination of biopsies show proliferation or atypical hyperplasia (overgrowth of some of the cells within the breast tissue). If there is none of this particular change, then benign breast disease (such as fibroadenomas, cysts, and simple fibroadenosis) does not significantly increase the risk of developing cancer.

• Previous cancers. Having had cancer of the uterus (endometrial carcinoma), or a previous breast cancer places a woman at higher risk of developing breast cancer.

• Environmental and dietary factors. Research has not yet identified specific factors, but there are suggestions in the geographic and sociological distributions of breast cancer which make environmental and dietary factors likely suspects. In particular, high-fat diets, alcohol, and obesity have been looked at, but there are no clear cut answers so far.

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Micro-inserts are very small, flexible devices that are placed inside the Fallopian tubes to prevent pregnancy.

Are there different types of micro-inserts? There is only one type of micro-insert procedure available at present. It is called the Essure pbc procedure. The letters pbc stands for permanent birth control. The Essure pbc procedure involves micro-inserts that look like little spirals and are made of a material that has been used in heart surgery and other surgical procedures for a long time.

How do micro-inserts work? When the micro-inserts are in place, body tissue grows into them and blocks the Fallopian tubes. It takes about three months for the tubes to be completely blocked. This prevents an egg from meeting any sperm and being fertilised.

How effective are micro-inserts? Micro-inserts are very new and so far no woman with micro-inserts has become pregnant. However, you should be aware that there is always a chance that any method can fail.

Why would I want to choose micro-inserts?

The reasons for choosing micro-inserts are similar to the reasons people choose any permanent method of contraception. The special thing about micro-inserts is that you do not need a general anaesthetic, and the procedure does not involve cutting through your skin so there will be no scars. Your Fallopian tubes are not cut, clipped or cauterised either, so the procedure is a bit easier on your body and you will tend to recover more quickly than with other methods.

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Is there anything else that may be a problem if I want to use a Progestogen IUD?

There are some things you should talk over with a doctor so you can decide how you feel, before you choose a Progestogen IUD. One issue to discuss is if you have not had a child, but you may want to have one in the future. There are some risks with an IUD that we have talked about already, but it is best to consider all the possibilities and discuss them with a doctor before you make a choice.

Some other things that may need to be sorted out are, if you have had an abnormal Pap test that has yet to be treated, or if you have a medical condition, such as rheumatic heat disease, that makes it very risky for you to get an internal infection. Any condition that means you have to take steroids or other medications that stop your immune system from working properly can be a problem.

If you have already had an IUD and it came out by itself tell your doctor. If the space inside your uterus is fairly small or unusually large, this might mean you are not suitable for an IUD. The doctor will be able to tell you about this when you are examined. And if you are going away somewhere where you won’t be able to have follow-up checks after the insertion, it may not be a good idea to choose a Progestogen IUD right now.

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Are there any reasons why I could not use the Pill? You cannot use the Pill if you have had a deep vein thrombosis, which is a blood clot in a vein, or if you had a stroke or a heart attack. You cannot take it if you have severe liver problems, focal migraine, which is a special severe kind of migraine, or uncontrolled high blood pressure.

If you have any unusual bleeding from your vagina that hasn’t been diagnosed you will have to wait until you know what is causing it before you can take the Pill. You will probably not be able to take the Pill if you have cancer in your breast, uterus or ovary, because the hormones in the Pill could affect the cancer, making it spread.

If you are breastfeeding and you want to keep breastfeeding you won’t be able to use the combined oral contraceptive pill because the oestrogen reduces milk production, but you can probably take the minipill or one of the other hormonal types of contraception that doesn’t contain any oestrogen.

Are there any other things that could cause a problem if I want to take the Pill?

You may not be able to take the Pill if any of the following things apply to you. If you have common migraine, diabetes, are being treated for tuberculosis (TB), a strong family history of thrombosis (blood clots in veins), or severe depression you will need to talk it over with your doctor.

If you are taking other medications you should also tell your doctor in case they could react with the Pill and make it less effective. If you are over 35 and smoke, or you are under 35 and smoke more than 15 cigarettes a day, this should be discussed too. If there is a chance you could be pregnant, you will probably need to wait until you can have a pregnancy test to be sure you are not pregnant before you start the Pill.

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