Decongestants work by shrinking blood vessels, thereby relieving the effects of an allergic reaction, particularly in the mucus membranes of the nose. They can be taken as tablets or as nasal sprays (e.g. Otrivine, Afrazine and Sudafed). They can be effective against hay fever and rhinitis, but their major drawback is that they lose their effectiveness as time goes on. Moreover, they can actually make symptoms worse when their use is stopped. The blood vessels react to this cessation by expanding again, which causes congestion once more, even if the allergen is absent and you are not reacting.

The best advice is not to use decongestants continuously for more than three to five days, and to avoid prolonged use. You should use them on doctor’s advice rather than buy them over the counter.

Some decongestants are combined with anti-histamines (eg. Congesteeze, Haymine, Sudafed Plus).

Decongestants can be dangerous if you have a history of high blood pressure or heart disease. Consult your doctor.

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Many people with chemical sensitivity find that they can tolerate bottled water better than tapwater. But some bottled waters can upset people, even with minute levels of contamination of chemicals. Particular brands of bottled water are consistently better tolerated by chemically sensitive people and, if you are thinking of switching to bottled water, it is a good idea to try these ones first. The well-tolerated brands are Malvern, Buxton and Evian. Carbonation – adding carbon dioxide to water to make it fizzy -has no effect on people’s tolerance of bottled water.

If you are very sensitive to plastic, try to obtain bottled water in glass bottles. Evian is not generally available in glass; it is worth trying in plastic since even very sensitive people are often unaffected by it.

If you or your family and friends drink a lot of bottled water, it may be worth buying wholesale. Suma, wholefood wholesalers, stock a number of brands. Natural Foods deliver bottled waters in the London Area. Malvern is sold by wholesalers supplying the pub trade, and Buxton and Evian are sold by wholesalers and cash and carry merchants supplying grocers, confectioners and newsagents. Look for these in Yellow Pages.

If you react even to these brands, or to reverse osmosis water, you can try rotating waters. Set up a four-day rotation for waters, allocating one type or brand of water to each day, Brand One to Pay One and so on. Use just that water for drinking and cooking on that day, and change waters on each of the four days.

Neutralisation, a form of de-sensitisation, can sometimes be effective with bottled water. It can help if you are desperate.

Another method that sometimes helps is to pass bottled water through a jug filter. Again it is worth a try if you feel desperate.

If you are sensitive to tapwater, your symptoms should be clear or improve after four days. You may feel worse with withdrawal symptoms initially if you are extremely sensitive to water, but these will clear fast.

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If you are allergic to moulds or house dust mites, you should take care if buying a car secondhand. If a car appears very dusty and damp, or smells fusty, it will probably have house dust mites and moulds. You may be better buying a new car or one of more recent date.

If you are allergic to pets and animals, and buying a secondhand car, check with the owner whether any animals (or people in close contact with them) have travelled regularly in the car, even if the owner does not have pets. (Even traces from clothes, or from the rear of a car can upset the very sensitive.) Look for traces of pet hair, often difficult to remove.

If you are sensitive to tobacco smoke residues, check when buying a car secondhand whether anyone has ever smoked in the car. A good tip is to look in all of the ashtrays – these are virtually impossible to clear of smells and ash. You will be able to detect any traces of smokers from the ashtrays even if the owner or dealer cannot say whether the car has been exposed to smoke. When you travel by taxi, ask for a non-smoking taxi.

If you are very sensitive to chemical cleaners and air fresheners, sniff the car carefully to see if any strong agents have been used. Fumes from air fresheners – often stuck to the dashboard, in or under the glove compartment – take a very long time to wear off: avoid a car which has had these recently, if you can. If you buy privately, rather than from a dealer, it is often easier to find out what has or has not been applied to the car. This applies also to recent repairs, rust-proofing or service treatments as well.

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There are three leading brands of peroxide system in the UK: 10/10, Oxysept and Perform. They differ in the neutralising agent used in the second step of the system. In 10/10, the neutraliser contains sodium pyruvate; this is a chemical produced naturally in the body as a byproduct of metabolism and is well tolerated. The neutraliser in Oxysept is an enzyme called catalase; in practice, few problems arise with this, In Perform, the neutraliser is sodium thiosulphate. This is a less powerful agent than sodium pyruvate or catalase. Follow the manufacturer’s instructions carefully and it should prove acceptable.

Some other modern preservative-free systems use as their germ-killing agent chemicals which release free chlorine in the process. These type of systems do not require a neutralising agent; they are cheaper to buy and less time-consuming to use. In theory, the chlorine released should disperse during soaking overnight and not cause problems in the morning. In practice, most people do not have problems with this type of system but even some people who are not chemically sensitive find that they get irritation from the minute traces of chlorine left on the lens.

On balance, the more expensive and less convenient peroxide plus neutralising agent systems, such as 10/10 and Oxysept, are a better choice for the chemically sensitive.

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If you are sensitive to many foods, or even to a small number of basic foods, it can be virtually impossible to avoid everything to which you react. If you have come through exclusion dieting and found this to be the case, do not despair. Except for some very rare individuals, it is quite possible to manage your diet and live with multiple sensitivity. Food intolerance and mild allergies respond to dietary management -eating foods seldom and in small quantities will help you to keep them in your diet and maintain some kind of balance.

With food intolerance and mild allergy, the severity of reactions often declines markedly if you do not eat a food constantly or in large quantities. The body seems able to build up a certain level of tolerance. Therefore, a doctor may recommend that you keep a food to which you are sensitive in your diet, but eat it in moderation.

You may also be recommended to leave a food out for a long time -say, a few months or even a year – and then try it again, even if you had severe reactions to it on testing. (Doctors are only likely to recommend this where you have food intolerance rather than allergy.) The reason for trying this is that many people find that they regain tolerance for a food to which they been sensitive after leaving it out for a long time. You can then include the food in your diet, but again eating it in moderation and at intervals.

A rotation diet will also help to maintain the body’s level of tolerance to foods, and to prevent you developing new sensitivities.

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If you are exceptionally sensitive, you may continue to react even to very tiny levels of fumes once things are aired off, and you may have to avoid some chemicals totally, but this is extremely rare. For most people, taking care with specific situations means they can live happily with substances that upset them.

If you investigate for yourself what chemicals are found in anything you use, it is also worth remembering that chemicals are usually only troublesome when they are given off as vapour or released into the atmosphere. If a chemical has been used in the manufacture or finishing of a product, it may not be released as free vapour at all and it will not bother you. Formaldehyde, for instance, is commonly a troublesome chemical when it is released as free formaldehyde. It is used in the manufacture of many products, but in some circumstances is not released after manufacture as free formaldehyde and should pose no problems. Formaldehyde resins are used in the making of plywood, for instance, but, if manufacture has been correct, no free formaldehyde is given off at all, and plywood should not give problems. Formaldehyde resins are also used in the manufacture of chipboard but, in this case, free formaldehyde continues to be released after manufacture is complete, and chipboard is known to cause some people persistent reactions.

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Pure cotton underwear is relatively easy to find in High Street shops. Cotton jersey vests and pants are commonly sold by all the major clothing chains, as are warmer knitted cotton winter underwear. Flocky knitted cotton underwear can sometimes irritate sensitive skin where cotton jersey (also called cotton interlock) does not. If you are very sensitive, stick to cotton jersey. You may need to beware of trimmings, lace and elastic upsetting you

Nightwear can be harder to track down. Some chemically sensitive people react to cotton poplin, cotton lawn and winceyette, because of fabric treatments. Again, cotton jersey can be safer. Most High Street chains usually have a selection of cotton jersey nightwear for women and children. Marks and Spencer commonly stock 100 per cent cotton poplin men’s pyjamas. Mail order sources for cotton jersey nightwear are given below. Finding 100 per cent cotton bras can also be tricky. Specialist underwear shops or departments usually stock light cotton jersey sports bras which are practicable if you need only light support. Playtex make a 100 per cent cotton support bra, the ‘Whisper* bra. Natural Fibres supply 100 per cent cotton bras by post, with a size range up to 115 cm (46 inches). David Nieper also supply 100 per cent cotton bras by post. Schmidt Natural Clothing sell a silk and cotton blend bra top. Maternity bras are commonly available in pure cotton. Even if not pregnant, you may find them useful, since they are designed for proper support.

Nice Irma’s sell Indian cotton dressing gowns. Women’s slips and petticoats in cotton are sold by post by David Nieper.

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It is difficult to detect whether you are sensitive to building materials already used or applied in your home or other environments. Changes in your symptoms when you go into different places, or if you stay away from home, can be indicative, but not always conclusive, evidence of sensitivity to materials.

You can be tested by patch testing or sublingual tests for allergy or sensitivity to specific chemicals. There are also two environmentally controlled units in the UK, which are as chemical free as possible, where rigorous testing for chemical sensitivity can be done.

You can use the Tile Test (opposite) to test specific materials to see if these induce symptoms, but the only reliable way of finding out in your own environment whether materials around you upset you is to remove and replace potential hazards. However, for most people this is impracticable, as well as costly and disruptive. At work or school, it is invariably impossible. Unless you are absolutely confident that materials are the key source of trouble for you, it is wiser first to reduce chemicals from other sources around you – cleaning materials, toiletries, personal hygiene products, clothing, furniture, bedding, flooring before you make significant changes to your decoration or building.

If, thereafter, you determine that you need to change the materials, or if you are obliged to redecorate or do repair work, use low-hazard materials as suggested below and see, after a period of airing, whether your symptoms improve.

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When You Come Back In

If you have been close to high sources of pollen, it can help to shower and wash your hair on returning home. Changing clothes can also be a help. If a dog has been out in long grass or near trees, brush or wash it down before it comes indoors.

When Indoors

At the height of pollen seasons, keep doors and windows closed as much as you can. Surprisingly high levels of tree and grass pollens have been monitored inside buildings. Keep them closed, especially at peak hours, and above all keep bedroom windows closed during the day and early evening. A good time to open windows is overnight, between 10.00 p.m. and 6.00 a.m., although on some hot nights there can be pollen peaks at around midnight.

Using an air filter can help. It will not remove all traces of allergens, but people report that using a filter can make enough difference to make life bearable indoors.

Some people also report that hanging damp butter muslin or damp net curtains at windows helps trap pollens, and reduce their level indoors. It may not be possible to keep windows and doors closed as much as you would like at work or school. Sitting away from a window will help a little, as will holding a damp cloth to your nose.

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In its commonest and most effective form the Pill contains the synthetically produced female hormones, oestrogen and progesterone. Because these two are combined in one pill it is called the ‘combined Pill’. The hormones these Pills contain are very similar to the natural ones produced by a woman’s body but are different enough to allow absorption from the stomach and intestines. Natural hormones would not be absorbed if taken by mouth. The Pill’s constituents are, after absorption, so similar to the natural hormones that they influence chemo-receptors (specialised monitors of blood hormone levels) at the base of the brain in the same way as natural hormones. If they were not identical or nearly so they would not work because

chemo-receptors are highly specific. Because of this it is not quite right to think of them as totally alien chemicals, which is how they are sometimes represented. The reason the Pill works so well is that it copies Nature. Its effect is to convince the pituitary gland that a pregnancy has already occurred and in this state the pituitary suppresses the release of the hormones which normally make the ovaries release an egg each month. It is a form of false pregnancy.

It sometimes happens that whilst a woman is on the Pill an egg is produced, but conception still does not occur because one effect of the progesterone in the Pill is to make the mucus in the passage through the cervix so thick that no sperms can penetrate it. A further effect of the combined Pill is to prevent the development of the lining of the uterus, the endometrium, so that even if conception were to occur the embryo could not implant and grow there. Although there have been tremendous advances in oral contraception some improvement is still possible.

There are 24 different brands of the Pill available and the principal basis on which one is chosen rather than another is to administer the lowest doses of hormones that suit the particular needs of the woman. In some cases the medical and family history may make the Pill an unsuitable choice. Starting and administration instructions vary. The phased Pills, in which the ratio of oestrogen to progesterone varies throughout the pack so as better to imitate what happens in the natural cycle, are different from the 21 tablet formulations. Instructions about what to do if a pill is taken late or missed, or if it is desired to postpone a period, also vary so instructions for a particular Pill must be followed carefully.

What seems to be a period for the woman on the Pill is not one in fact. It is a withdrawal bleed due to the supply of hormones being stopped.

The Pill’s constituents are broken down by the body over twenty-four to thirty-six hours and are excreted via the urine and stools. Some women metabolise the Pill more rapidly and so need higher doses. Others who are on certain drugs such as some anti-tubercular, anti-epileptic, or anti-fungal drugs and some antibiotics also metabolise the Pill more rapidly, as may vegetarians. This could mean that they need a higher-dose Pill to be safe. If these women are on a

normal-dose Pill, it, so to speak, ‘runs out’ before the next one is due. Women who, perhaps for the psychological reasons mentioned earlier, ‘forget’ the Pill or who are very late taking it are also exposed to the Pill running out. In all of these cases the sign to go by is the spotting of blood or even a full withdrawal bleed. If a pill has only been taken, say, six hours late, spotting is not inevitable, but if it does occur it happens two or three days later. In other words it is a ‘mini’ withdrawal bleed. The reason why a full bleed does not occur as a rule is that the woman continues to take the Pill. The correct reaction to repeated spotting or withdrawal bleeding at unexpected times, provided it is not caused by interference from other drugs, is not to change the Pill you are on, as many doctors and clinics suggest, but rather to be scrupulous in taking it within, say, an hour of when it is due.

The Pill is a very safe and efficient contraceptive but problems can and do sometimes occur. Problems mostly arise in those who are found on psychosexual investigation to have unconscious difficulties about accepting their sexuality, as we mentioned earlier. These should be cleared up before a change in method is seriously considered, simply because all other methods are less efficient. Depression, irritability, and bad dreams can be due to unconscious self-detestation for Pill-taking and depression often results in a loss of sex drive, a failure to have orgasms, and

over-eating, leading to the marked weight gain sometimes reported on the Pill. This is not to say that all Pill symptoms are emotional or psychological but many are and can be prevented or cured by psychosexual counselling alone. It is interesting that in studies in which women were given a dummy tablet yet were told it was the Pill, the women had Pill-like symptoms which went on until they stopped taking the tablets!

Medically the Pill has both advantages and disadvantages. It is thought that statistically the former outweigh the latter. Although it can (rarely) lead to blood clots and may or may not (the evidence is conflicting) increase the chance of breast cancer and cancer of the cervix, it reduces benign breast disease, produces a two to three fold reduction in the chance of having an ovarian or endometrial cancer and, in older ex-Pill takers, protects against osteoporosis. Its lesser benefits, such as reducing pains associated with menstruation thereby, perhaps, reducing the consumption of pain relievers which can be harmful in themselves, are very considerable.

Obviously careful medical supervision is advisable because this ensures correct usage, is reassuring for the woman, provides an opportunity to disentangle psychosexual factors which may greatly benefit the woman and her partner in other ways, and provides a basis for regular health checks including cervical smears. Most of the things which are found to be wrong when doctors carry out routine Pill checks are nothing to do with the oral contraceptive.

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Anyone can copulate with a willing member of the opposite sex, as we saw earlier, but the act is not necessarily based upon an intimate knowledge of the sexuality of the partner and, although it can be exciting and gratifying, in reality it amounts to no more than masturbation using the genitals of the opposite sex. A lot of couples, married or not, spend much of their sexual lives copulating with one another and not having intercourse, let alone making love. They have never communicated about their sexual needs and preferences. This can come about because of shyness, inhibition, lack of courage, or a lack of knowledge or imagination.

For most couples the desire to please and to give pleasure, along with the desire to experiment, leads to the elaboration of simple copulation into intercourse. This elaboration expresses the needs and the sexual personalities (sexualities) of that particular couple. As they develop and grow together as a couple they develop a pattern of sexual behaviour which is unique to them. Copulation at its most basic is almost entirely a physical experience but intercourse is much more. It involves the personalities and intimate needs and desires of the people involved. Love is certainly not a prerequisite for enjoyable and fulfilling intercourse-but it helps. Some people, however, find it difficult to express themselves sexually with someone they love. This is one of the many ironies of sexual dysfunction.

Some women are so excited by the thought of intercourse that they have an orgasm at or soon after penetration. Many men have the same experience but if they can develop an attitude of mind which thinks of penetration, at least initially, as being a continuation of their foreplay techniques, they find they can make intercourse last as long as they or their partner wishes. It is possible to do this by accepting the pleasurable sensations in the penis and, instead of trying to suppress awareness of them by thinking of something non-sexual, trying to focus attention on the partner and her responses. When they finally decide to ‘let go’, perhaps on some mutually agreed signal from the woman such as, for example, her stroking him in some particular way, they can unleash their sexual desires and start to move in a way which produces maximum penile pleasure. At this stage the man often becomes relatively unaware of the woman’s reactions because his own pleasure is so intense. On the other hand his mounting passion, tension and vigour may be more than sufficient for his partner to obtain an (or another) orgasm. Trying to obtain a simultaneous orgasm by any other means can all too easily reduce what should be a spontaneous pleasure to a series of predetermined goals which have to be worked hard for. Most people find this takes the fun out of sex, even if on occasions it results in them climaxing together.

From the point at which he ‘lets go’ the man is no longer concerned with how long he lasts, and the time it takes him to have an orgasm is likely to be somewhere between a half to three minutes. The average man on the majority of occasions ejaculates within two minutes or less, unless he learns to control the situation. Exceptions are those men who suffer from a form of impotence known as retarded ejaculation. Any man can teach himself to establish ejaculatory control and there are several well-tried techniques available. These include the determination of a frequency of ejaculation reasonable for the individual man (if he goes too many days between orgasms he will be too ‘trigger-happy’); the rehearsal in fantasy of the technique we have just described when he masturbates; and the practice of semi-masturbation in which he rubs his erect penis with accompanying fantasies but does not allow himself to reach orgasm. By doing these things the average man can easily get used to maintaining an erection for long periods without ejaculating and can then ejaculate at will. Most experts would agree that being able to do this is valuable because most, if not all, women enjoy some prolongation of the act and many complain that their men are too quick. Premature ejaculation as such is a somewhat different problem and is discussed later.

Women too can train themselves through masturbation to develop attitudes and practices of value in intercourse. For many women their desire for intercourse rises with the amount they masturbate. Through masturbation and appropriate fantasy a woman can train herself to increase her excitement during intercourse and so reduce the time it takes to have an orgasm. As far as we know, those women who have a capacity for multiple orgasms establish it first by masturbating. The ability to masturbate well is basic to intercourse, just as learning to talk is the basis of the ability to converse. In a way successful and enjoyable intercourse could be described as two masturbators comparing notes and then making it perfect for each other. In fact, unless you know exactly what your partner likes when masturbating you will not get the best out of intercourse.

But this view of intercourse reveals a common difficulty. For reasons discussed elsewhere in the book, some men find that they perpetually prefer to adopt a passive role in intercourse. This may be one reason why prostitution is popular — the man can pay a woman to do things to him. In some cases all that can be done to help such couples is to suggest that they each take it in turns to be active and passive. Most men have occasional masturbation fantasies of the woman taking charge and most women have occasional fantasies of being in charge. So most couples are likely to enjoy occasional role reversal in intercourse and this of course doubles their repertoire. Some women, on the other hand, have a need to be totally passive, since to behave in any other way would raise their sense of guilt to a point where they can no longer enjoy themselves. Such women can often be unsatisfactory partners, especially for the older man who needs prolonged stimulation from the woman if he is to function well.

To some degree we are all reared with inhibitions about intercourse. One effect this has is to raise anxiety, which in turn tends to make men ejaculate earlier than would otherwise be the case and to delay orgasm in women. Good masturbation can help to master and dispel these inhibitions but both sexes also need their partner’s help to abolish them. So, a woman who understands her sexuality and the needs of her body should educate her partner, and her partner, by encouraging her to develop her capabilities, can liberate her from her inner inhibitions. After all, between the two of them there should be complete openness and a willingness to do what the other wants.

The trouble with inhibitions is that they tend to increase one’s awareness and vigilance. The individual, so to speak, ‘watches’ him or herself for any infringement of the unconscious ‘rules’, and this is exactly the opposite to what is needed for good intercourse. What we need to do is to cut off our earlier taught restraints so that we can totally lose conscious control of what we are doing during intercourse. In this sense, good intercourse is a kind of regression to babyhood and this may be the reason why some couples indulge in baby-like talk and noises when making love. After a certain point in the proceedings rational talk reimposes awareness of the real world and undermines the other-worldiness so vital for good intercourse. Some people, especially women, fearing total sexual abandonment, continue to talk, as a defence against this loss of control. The same end can be achieved if a woman self-consciously concentrates on having an orgasm instead of relaxing and letting it happen. An inhibited man too may over-concentrate on the state of his penis, his partner’s physiological responses, or the mechanics of intercourse. Although he achieves his unconscious inhibiting aim of pleasure reduction by doing these things, the consequence is likely to be poor performance and early ejaculation with a poor-quality orgasm.

So much for the background factors so vital to success in enjoyable and fulfilling intercourse. Realising they exist, recognising them and dealing with them can help a man and a woman help each other. The overwhelming principle, contrary to what most sex books would have you believe, is that attitudes are more important than techniques. The most powerful sex organ of the body is the brain. Too many ‘experts’ have put far too much emphasis on genital technique and positions during intercourse. The vast majority of couples with good, enjoyable and lasting sexual relationships do not spend their lives changing techniques but eventually learn to make love in a few tried and tested ways that they find mutually enjoyable and satisfying.

Having said this, it is helpful to be aware of some of the many ways in which it is possible to have intercourse, because most couples want to experiment from time to time and need to be aware of the alternatives there are at special times of life, for example, during pregnancy.

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The ovaries are paired organs about the size of walnuts lying one each side of the pelvis. They have two functions. First, they release a ripened egg each month and, second, they produce progesterone and oestrogen — two important female hormones. The ovaries are remarkable organs — when a baby girl is born she already has all the eggs (30,000—40,000) in her ovaries. After puberty the eggs begin to ripen or mature under the influence of complicated hormonal changes that occur cyclically. This usually happens every month (unless the woman is pregnant or on the Pill; nor does it happen for some of the time she is breastfeeding) until the end of her reproductive life, the menopause, intervenes. In practice, several eggs begin to mature each month but for some unknown reason only one usually ripens. The average woman has 400—450 cycles in a lifetime. The ripening and release of an egg each month is called ovulation.

A woman’s body functions in a cyclical way, each cycle lasting about a month. It is important to remember that this is only an average and that there can be large variations in cycle length that are still quite normal. In a classical ‘text-book’ cycle the events run as follows. The first day of the cycle is taken as the first day of menstruation. This is the day when the lining of the womb, now that it is not going to be needed for pregnancy, starts to be shed in the form of clots, cells and blood. The brain (particularly the hypothalamus) influences a tiny gland that lies near it (the pituitary gland) to produce a hormone called follicle-stimulating hormone (FSH) which

stimulates the ovary to ripen an egg that month. Another hormone, luteinizing hormone, (LH) is produced by the pituitary during the whole cycle. A surge of LH is produced around the middle of the cycle (day 14) which helps release the ripened egg. This release of the egg is called ovulation and it is at this stage that a woman is most likely to conceive. Some women experience abdominal discomfort at this time.

Each month, then, an egg is released from one of the ovaries and is ‘collected’ by the tube. It takes at least three days for an egg to pass along the tube. While this is going on, the ruptured egg sac on the ovary turns into a functioning gland called the corpus luteum which produces another hormone called progesterone. Progesterone, together with oestrogen, acts on the lining of the uterus. Oestrogen produced in the first half of the cycle primes the endometrium and encourages growth. Without it, progesterone produced in the second half of the cycle could not act properly to ripen the endometrium ready to receive the fertilised egg. If the egg is not fertilised, the corpus luteum which has a lifespan of only about fourteen days, begins to cease functioning. Progesterone and oestrogen levels then fall, causing the lining of the womb to shed thereby starting a menstrual period.

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Marriage, or any other close man-woman relationship, offers a whole range of wonderful options as a way of life. Provided expectations are not set too high and the couple keep their feet firmly on the ground, marriage can be a friendship; a source of attachment; an alliance against a hostile world; a source of companionship; a mutual admiration society; a therapy group of two; a work group with each member specialising in jobs they do best; a source of tender, loving care; a means of keeping adolescent romance alive; a secret society with its own language and history; a child-rearing group; and a means by which we can increase the love we feel for ourselves indirectly by putting someone else first in life.

Although marriage is a personal contract between two people it is also a social act because it is the way in which society chooses to organise men and women in family units to bring up children. Around the world different cultures have very different ways of organising family life but in the West we have arrived at the nuclear family in which, typically, two adults live alone with their children. The heart of this type of family structure is the parents, not only because they are the starting-point but also because they are the only consistent source of adult company for the children. The vast majority of people still think that children should ideally be raised within the context of marriage. Many young couples throughout the Western world live together, but once they decide to have children they usually get married.

There is no need to ‘sell’ marriage. It is as popular as ever even at a time when its failures are so apparent and seemingly inevitable. Of all those of marriageable age in the UK 95 per cent will be, are, or have been married at some time in their lives. Marriage is, unfortunately, still portrayed as some kind of fairy-tale ideal rather than the reality of two people living together and sharing their lives for a very long time. The thing is that today, with age expectancy rising all the time, a couple married in their twenties can expect to be together for fifty years or longer, which is more than twice as long as they would have only a hundred years ago.

Statisticians and analysts looking at the mid-life peak in divorces (second only to the

first-five-year peak) suggest that it could be a sort of natural break point for many people. After all, they argue, had they lived a few centuries ago they would have been ‘divorced’ by death.

Many, if not most people, (and especially girls) go into marriage with expectations that are far too high. What most people do not realise is that by idealising marriage as an institution they trivialise the man-woman relationship. This comes about because it is intrinsic in our culture to regard marriage as the ideal manifestation of the man-woman relationship. Until recently it was the only social structure within which men and women could enjoy each other’s company and have intercourse. Reliable contraception and the women’s movement have changed all that, probably for ever, and now most people don’t get married solely to have intercourse or to have a close, meaningful relationship with someone of the opposite sex. Even so, most people still see marriage as their preferred life-style, even if children are not involved. The one in ten couples who live together in the UK (many with children) as if they were man and wife without in fact being so go to show how conventional we all are, even in these so-called enlightened times.

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1 One (or both) of the individuals is too immature in his or her personality development and simply is not ready to settle down. Such a person finds that he or she resents the thought of becoming linked to one person exclusively, talks a lot about the loss of freedom and wants to continue to play the field.

2 Often, a person will say, T love her (or him) a lot and we’d make a good couple, but do I really want to be married to him or her for years and so lose my freedom?’ Such doubts are probably universal but fleeting. When they persist the couple are not keen enough on each other to want to make an exclusive commitment and should not get engaged.

3 Not uncommonly, because boys mature later and more slowly, the girl is ready, willing and able to go ahead with the serious commitment involved but the boy is not.

4 Unfortunately, some potentially very good relationships fail at this stage because they are unrealistically based from the start on romantic, instead of realistic, notions.

5 Some people are so indecisive that they simply cannot make important decisions of any kind and so back away from engagement.

6 Often one or other of the couple feels that the relationship is nearly right but is not quite good enough in some ways. This is a real dilemma because no one is perfect, and this goes for the person doing the agonising. There are two useful questions to ask yourself. The first is, ‘Given that I’m not perfect, have my faults and am certainly not «ideal», have I the right to demand that someone else is all these things?’ The second is, ‘Given that I know of these faults and shortcomings in the relationship, am I sufficiently flexible to be able to adjust?’ In other words, ‘Can I love him or her, warts and all?’

7 Engyesis (‘marriage sickness’) is a medical term used to describe a cluster of symptoms (anxiety, depression and doubt) about one’s partner which occur during courtship and engagement. When it was first described in 1888 it was thought that it was the sexual tensions of this group of people that caused these very real psychological problems. The main symptoms are inability to sleep, loss of appetite, weight loss, headaches, a feeling of tension and a lack of concentration. Almost all such people are insecure about their proposed marriage. Some people become suddenly struck with one or more of these symptoms on making specific wedding arrangements. The ill one then often says, ‘You can see how ill I am, it wouldn’t be fair to go on with the marriage’, to which the well partner says, ‘I love you, I’ll stand by you.’ At this point the ill one becomes worse and goes to a doctor. The idea that sexual tensions are the cause of these problems is probably not true because in one survey at least half such couples were having intercourse. This same survey found that about half the patients had had a previous psychiatric ailment or illness for which they had sought medical advice.

The question is what to do in such cases. One survey found that the illness subsided more or less completely with the breaking of the engagement or on marriage but that about a third continued to have symptoms after marriage. Medical opinion differs as to what should be done. Some doctors say that any relationship that produces illness must be basically unsound in some way and so should be abandoned and others that given that two-thirds seem to do well after marriage, perhaps it is simply a way of reacting to the common stresses of courtship and engagement, which go once the couple settle down together.

8 Parental opposition is, and always has been, a factor in the breaking off of courtship and engagements. Very often in our experience, parents do know best and usually have their child’s future at the heart of their suggestions. Of course, by no means all such advice is lovingly given and some parents have all kinds of motives for wanting to put their children off marrying anyone, let alone any one particular person. It really is up to the individual to decide. Parents, it seems from research, approve of over 80 per cent of all engagements, so this is not a widespread problem.

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If you’ve been inhibited from using a condom because of stories about tearing, experts agree that your concerns are virtually unwarranted. Research has revealed that condoms are almost always uncommonly sturdy, and will endure rather severe treatment before tearing. In fact, the chances of a popular brand of condom tearing are very remote.

To ease your concerns, experts say that American brands, especially the thicker brands of condoms, are perhaps the safest when it comes to the likelihood of tearing. Some foreign brands, such as Japanese brands, are sometimes thinner than American brands, and as a result may be less sturdy.

If your concerns won’t go away, you might actually try to tear a condom. Buy a popular brand and tear several of them. Stretch them as much as you can, clamp one around a water faucet and fill it with water until it bursts. The idea is to see exactly what it takes to tear a condom. After «sacrificing» three or four condoms, you should know whether or not your concerns are warranted.

*193\27\8*

Many common household pests, such as houseflys, spiders, wasps, and mosquitoes, represent a potential health risk if not controlled. The key to keeping such household pests away is to deny them food, water and shelter.

Here are several proven methods of keeping common household pests at bay:

1) Keep food stored in tightly sealed glass or plastic containers.

2) Clean up all crumbs and spills immediately.

3) Keep sink areas clean and dry.

4) Clean garbage cans regularly, and secure their lids.

5) Fill all cracks and crevices, and repair all torn screens.

6) Cover chimney and flue openings with spark-arresting screening.

7) Electric bug zappers, while virtually ineffective against most stinging and biting insects, such as wasps and mosquitoes, do lure other flying insects away from the patio, pool and picnic areas at night.

Sprinkle a few broken up bay leaves on windowsills to combat invading ants. If the ants head straight for your flour and sugar bins, place a couple of bay leaves inside. Replace the leaves every month.

9) Don’t use «all-purpose» pesticides. They often lack the one ingredient needed to kill a specific pest. For information and advice on how to select the safest and most effective pesticide, contact your local Cooperative Extension Service.

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Many medical experts say that person under stress can easily «pass on’ their tension and anxiety to people around them— especially to those people who tend to get caught up in the problems of others. Although being sensitive to another person’s anxiety and tension is not a weakness, it can make us vulnerable to unnecessary stress which could then lead to serious health problems.

Since we all have our own fair share of stress to cope with every day. it is important that we know how to avoid «catching» stress from other people. Here are several expert tips on how to protect yourself from «contagious stress»:

1) While it may seem harsh or unfeeling, you should, if at all possible, try to avoid people who seem to exude tension and anxiety. For example, if you seem to be coming into contact with such a person at the same time and place —at lunch or on the bus— rearrange your schedule so you are not constantly meeting him or her. After all, avoiding potentially unhealthy situations is an important part of proper health maintenance.

2) If you can’t avoid «stress carriers», distract yourself so that you don’t get caught up in their problems. Try to remind yourself that their problems are not yours. It’s o.k. to sympathize, and even offer a few words of encouragement as long as you don’t allow yourself to be swept away in their misery.

Try to distract yourself by thinking of peaceful images when you are in the presence of a stressed-out person. Visualize the most relaxing setting you can imagine—a sunny beach or a picnic in a lush, green meadow. This type of distraction should serve as a protective barrier against intrusive tension and anxiety.

3) A sense of humor may be one of your best defenses against contagious stress. Try to make yourself laugh as soon as possible after an encounter with a stressful person. Seek out a friend who can always make you laugh, or go see a funny movie. Research has proven that laughter can be a potent antidote to stress.

4) Another proven method of reducing stress is exercise. If possible, do some exercise—walking or running—after dealing with a stressful person. Exercise will be helpful, even if you simply walk around the block once or twice at lunchtime.

5) Keep your personal and professional environment as «stress-resistant» as possible with flowers, plants, posters, or pictures of relaxing scenes. In other words, try to surround yourself with proven «stress-busters».

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You can be «true» to a low-fat diet even when you eat out by following these tips:

1) Choose a restaurant which features a good salad bar, or one that is known for its delicious, healthful salads.

2) Lime or lemon juice is a good low-fat salad dressing substitute available at most salad bars. Seafood coctail sauce is another excellent low-fat substitute dressing.

3) Ask the waiter, or the chef to prepare your vegetables without butter, sour cream, or cheese sauces.

4) Order chicken broiled instead of fried.

5) Try a low-fat entree, such as cooked chopped broccoli, on your potato.

6) Don’t give in to temptation. Most chefs will prepare your food exactly as you request.

News About Nutrasweet

The artificial sweetener Nutrasweet, found in many diet soft drinks, begins losing sweetness after about three months. To avoid getting «sweetless» diet soda, look at the code on the bottom of the can or bottle. Many diet sodas containing nutrasweet have codes which usually begin with a number that corresponds to the last number in the current year. For example, 2 for the year 1992. That number is followed by three digits that signify the day of the year. For example, a drink canned on January 1 (the first day of the year), 1992 would be stamped with the code 2001— and may taste watery before the end of April.

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Thanks to new labeling regulations, consumers, for the first time, will be able to compare the nutritional value of every packaged food available in the supermarket.

The new federally required labels on all processed foods will have to list calories, total fat, saturated fat, cholesterol, carbohydrates and protein, and sodium content, and show them in the context of a daily diet featuring 2,000 calories and 65 grams of fat. The idea is to show the consumer how much of a day’s total of each individual

ingredient he or she is getting from a particular food. Also, designations such as «low-fat», «high-fiber» and «light» are to have federally imposed definitions under the new labeling regulations.

Here are the federal govenrment’s definitions for some of the terms most commonly used to describe calories, sodium, sugar, fiber, fat, and cholesterol in food:

1) Free— fewer than 5 calories; less than 0.5 gram of sugar; less than 5 milligrams of sodium; less than 0.5 gram of fat; less than 2 milligrams of cholesterol, and 2 grams of saturated fat per serving.

2) Low— less than 140 milligrams of sodium; fewer than 40 calories; 3 grams or less of fat per serving size.

3) High— provides more than 20 percent of the amount recommended for daily consumption, as in «high_fiber».

4) Source of— provides 10 to 19 percent of the amount of a specific nutrient recommended to be consumed each day.

5) Reduced, or less— at least 25 percent less than the original product in sodium, calories, fat, saturated fat or cholesterol.

6) Light— if the product has more than 50 percent calories from fat, this designation means at least a 50 percent reduction in fat. However, if the product has less than 50 percent calories from fat, it can be either 50 percent reduced in fat or have 1 /3 fewer calories.

7) Light in sodium— reduces the sodium content of the original product by 50 percent.

*34\27\8*

Heart disease is the foremost killer in the Western world, thanks to smoking, high blood pressure and fatty diets. Although a heart attack is predictable in many people because they collect risk factors like football cards, for many it comes as a bolt out of the blue. Coronary artery bypass surgery is now more commonplace than having your tonsils out, but that is not to say it’s a breeze. Quite often a heart attack or heart surgery is the first time a person comes face to face with their own mortality, or faces the prospect of losing their partner. During the early weeks after the event, the foremost thing on your mind has to be your immediate survival and even if the question of resuming sex did occur to you, it’s hard to get the opportunity to ask.

Ward rounds before discharge from hospital have to be seen to be believed. You might have the surgeon, the registrar, a resident or two, the physiotherapist,», dietician, occupational therapist, ward pharmacist, nurses, spouse and assorted relatives crowded around the bed discussing anything from your latest cardiac echo to a warning about never smoking again. ‘Any questions, Mrs Jones?’ ‘Well, Doctor, my husband and I were actually wondering whether a big orgasm might bust my stitches and kill me?’ is probably not the first question to spring to your lips under the circumstances. Many people are sent home wondering whether they will ever be able to have sex again.

Jack is a man in his late sixties. Married for forty years, he had recently undergone heart surgery. He told me, ‘We had always enjoyed a good, relaxed sex life. In fact the last twenty years have been better than the first twenty. After the operation I knew I would be able to do it, but I didn’t know if it would be normal. For the first few weeks I was too tired to really even think about it but as I got stronger we thought it was time to give it a go. I had to reassure my wife that it wasn’t going to hurt me. You see, I had asked my doctor if it would be alright, and he said that when I could walk up two flights of stairs I wouldn’t have any problems with sex. At first the chest wound made sex uncomfortable in some positions, so we tried out some different positions to see what was best. Anyway, we took it slowly and now after a couple of months things are pretty much back to normal.’ He smiled warmly at his wife. ‘Yes, we’re doing alright.’

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It’s amazing how many people say they had their first experience of intercourse when they were drunk or lost their inhibitions under the influence of recreational drugs. Improving your libido is one thing but if your inhibitions go out the window, so do all the promises you make to yourself about safer sex. The morning after can find you with more than just a nasty hangover. Interestingly though, hitting the bottle in a big way interferes both with a man’s erection (brewer’s droop) and a woman’s capacity to orgasm. Some recreational drugs like cocaine will reduce pain and this can be downright dangerous with some sex games, particularly the ones that involve toys and implements. Without the limits of pain you can do a lot of damage that will be an unpleasant surprise when the drug wears off.

Prescribed medications can affect your sexual responses too, so it’s important to know the possible side effects of any of your drugs in case they are responsible. If erection problems come on

after you start a new medication it’s always worth checking whether the drug is the problem. Some blood pressure tablets fall into this category and it would be easy to explain away the erectile failure as an inevitable part of getting older. There is a long list of other drugs that can affect sexual ability too, like the oral contraceptive pill and some antidepressants.

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As pregnancy progresses, continuing your sex life might take a bit of experimenting with your technique. Many couples remember pregnancy as the time they discovered a few new positions and techniques that became a part of their wider sexual repertoire after the baby was born. Lisa said, ‘In the last few months intercourse was difficult if he was on top. I grew so big I think he’d have to be exceptionally well-endowed to be able to reach. Lying side by side or me on top was best for us. We actually found that me on top was the position we both enjoyed even after the baby was born, so we do it that way a lot now. Right at the end of the pregnancy with the baby’s head pressing down there was just no room in my vagina for intercourse, but that was okay. There were plenty of other things we could do sexually that didn’t involve intercourse. We both had to use our imaginations more.’

Julia continued to enjoy sex right through her pregnancy too. ‘The only position I found comfortable in the end was with him entering from behind. You know, doggy-style. I hadn’t realized the impact it had on him until the first time we made love after the new baby, and he looked into my eyes and said, «Gee it’s nice to see your face again!»

There are women who never enjoyed sex before pregnancy, for whatever reason. Sex therapists speak of a ‘Queen Bee syndrome’; a situation where, for this group of women, sex is for procreation only. That means that for the few months it takes them to get pregnant they are highly interested, but once they conceive it’s a very different story. Once the Queen Bee has mated with a drone in flight, she has no further use for him. There’s the analogy. For men in this situation it is terribly confusing. The period of high sexual interest highlights the contrast when sex is turned off again. He may feel the best he can hope for is trouble conceiving. The difficulties with the sexual part of the relationship are likely to be a pointer to deeper problems with the whole relationship. These couples will often need extensive sexual and relationship counselling to see if the problems can be overcome.

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While some relationships do stay together for life, the divorce rate currently stands at one in three. It is difficult to estimate the rates of separation for longterm relationships that are not legally counted but it is clear that not all sexual relationships are forever. Some people marry for the promise of companionship and support but being married is not necessarily an antidote to loneliness. Some of the loneliest people you meet are in emotionally desolate marriages, devoid of any real emotional communication. Some people call it ‘Staying together for the kids’ sake’ or ‘Better the Devil you know’ or ‘He can be so nice when he hasn’t been drinking.’ You hear a lot of talk about how lightly people take marriage and the evils of easy divorce but I have yet to see a divorce which was anything but painful for everyone concerned. People marry expecting that it will work out, but for many of them, the concept of marriage has been seriously oversold.

A large part of the responsibility for this comes down to the fact that men and women speak a different emotional language to each other. This gets back to the way boys have been brought up to contain their emotions and believe that talking about feelings like love and sadness is ‘girl’s stuff. The majority of divorces are instigated by the woman (only about one in five is instigated by the man), and while this is not the only scenario, there is one pattern you see over and over again. The woman is dissatisfied, unhappy, feeling as though she is not getting the emotional support she needs from her husband. The sorts of lines you hear that are warning bells in a marriage are: ‘You never listen to what I’m saying’; ‘You don’t appreciate me’; ‘My opinion doesn’t matter to you’; and of course ‘I think we need some counselling.’

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Perhaps even more importantly, it helps to know that there is no way of spotting the person in the crowd most likely to be carrying an STD. It won’t necessarily be the most attractive or the most ugly person, not the best dressed or the sloppiest, it will have nothing to do with income or personality. Anyone who has vaginal or anal intercourse or oral sex can catch an STD. Anyone. Clearly some sexual behaviors will put you at more risk than others but thinking you can predict the risk beyond doubt is naive.

Women who have sex with other women have traditionally thought that they were exempt from any safer sex messages. Now while these women are still statistically in what we call a low risk group for HIV/AIDS, there is real concern about a false sense of security. The reality is that some women who have sex with other women will be HIV positive, some will also have sex with men, and some will use intravenous drugs so there is the possibility of exposure to the virus. An HIV positive person can transmit the virus through cuts or ulcers in their mouth by oral/vaginal contact. Menstrual blood and vaginal secretions are also potentially infectious, so unprotected oral sex during a period, or unprotected hand and vaginal contact (when you have cuts, dermatitis, or broken skin around your nails) could transmit infection. The trouble is, until the research is conclusive and the risk is perceived to be significant, it’s going to be difficult to sell this safer sex message. The biggest risk people seem to perceive at the moment is choking on the dental dam mid-gasp. The prospect of using a condom to cover sex toys like vibrators or dildos is not such a problem. Using a sheet of rubber (like a condom cut lengthwise) or a dental dam for oral sex, or latex gloves for genital touching might be stretching the friendship at this stage. Still, there are some health researchers who are starting to recommend safer sex between women to prevent the whole range of STDs from HIV/AIDS to warts and herpes simplex. Of course, the same applies to male partners of women. Maybe the total body rubber suit is the only answer.

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Some other STDs cause genital ulcers that may be mistaken for the ulcers of syphilis or genital herpes. These are chancroid, Lymphogranuloma venereum (LGV) and Donovanosis, which are mainly found in impoverished parts of the world. In the case of Donovanosis, this includes northern Australia.

These three infections are caught by sexual contact with a partner’s lesion. The germs that cause them get into the body, as usual, through a small surface break. They are diagnosed by taking a scraping from the ulcer and identifying the organism in the laboratory. They are all cured by antibiotics.

If chancroid, LGV or Donovanosis is suspected or proved, you will be advised to have tests for other STDs, which are often picked up at the same time.

Trichomoniasis

This infection is caused by Trichomonas vaginalis (TV), a single-cell parasite like an amoeba. It has a tail that it lashes to move itself along, and a wavy membrane along one side of the cell. Trichomonads feed by wrapping themselves around their food, including bacteria, which can sometimes be seen inside them under the microscope. TV infects the vagina, urethra, bladder and sometimes the Bartholin’s glands and the glands near the opening of the urethra.

How do you catch trichomoniasis?

It is transmitted mainly through sexual intercourse. It’s also possible for TV to be passed by a fomite such as a towel recently used by someone infected or from contaminated water splashing out of a toilet, though this sort of transmission is believed to be rare. However, I’ve seen TV infection in virgins so I know it can get into the vagina other than by sexual penetration. It is also the only STD regularly seen in women who only have sex with other women.

Here is a brief outline of how to strengthen your pelvic floor.

• While seated, contract your pelvic muscles as if you were trying to lift your genitals from the seat. Hold the contraction for three seconds at least. Then relax. Repeat until you’re tired or up to 10 times, trying to contract the muscles a little more forcefully each time.

•While standing, contract your muscles as if you are trying to stop the flow of urine midstream, or trying to stop a tampon from being pulled from your vagina. Relax and repeat 10 times as above. This exercise can also be done lying on your back with your knees bent or lying face down.

• Try a fast version of the exercises, contracting and relaxing at one-second intervals.

• You should go through one of these routines every waking hour of the day. It’s tiring at first, and you may not manage many contractions. Keep trying: you’re bound to improve. Aim for 10 each session. The routine takes about a minute of each hour, and it could change your life.

• No one can detect that you’re doing these exercises, so they may be done while waiting for traffic lights to change, during television commercials, while the dentist is drilling, or at any other spare moment.

• To prevent leakage, remember to contract your pelvic-floor muscles just before you cough, sneeze or lift, and before you get out of bed to empty your bladder in the morning.

• You can check your progress (and whether you’re using the right muscles) by digital vaginal assessment. This means inserting two fingers into your vagina and feeling the force of
the contraction. Make this assessment before you start and then once a week. If you keep up the exercises, after a week or so you will be pleased with the improved grip on your fingers. Women used to be advised to assess control of these muscles by occasionally trying to stop the flow of urine mid-stream. This is no longer recommended, as it can lead to bladder infection and other problems. Within three months your stress incontinence should be a thing of the past (if not, see an urologist). After you’ve gained control, keep your muscles in good shape by going through the routine at least four times a day.

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Endometriosis can cause a wide range of symptoms, which may be quite differed from one sufferer to the next. Some women have no symptoms at all, and the condition is discovered by chance during surgery for some unrelated condition (including sterilisation, showing that endometriosis isn’t always associated with subfertility). Other women have few or no symptoms except subfertility. Unfortunately some affected women suffer many symptoms such as period pain, painful sex, pelvic pain, bleeding problems, bowel problems and subfertility.

• Period pain (dysmenorrhea) is the most common symptom. The pain may be mild, moderate or severe and described as nagging or sharp, constant, throbbing, deep or gnawing. It may be in the centre or on either side of the lower abdomen, and may spread out of the genitals, groin, inner thighs, lower back, rectum and buttocks. It differs from period cramps by usually starting a day or so before the onset of bleeding and continuing throughout the period.

• Painful sex (dyspareunia) can have a devastating effect on a woman’s self-esteem and sexual relationship. It may be felt as sharp jabbing during sex and deep aching afterwards.

• Pelvic pain may be unrelated to periods or sex. It may be sharp or dull and can occur in attacks or be more or less constant. It may be made worse by certain movements and postures, a bowel movement or passing urine.

• Bleeding problems include heavy, prolonged periods with clotting, spotting before periods, irregular periods and sometimes bleeding between periods. Many women with endometriosis ovulate irregularly or not at all, and it is believed that the bleeding problems result from the hormonal state associated with disturbed ovulation. Repeated heavy periods can cause anaemia.

• Bowel symptoms such as diarrhoea, constipation, painful bowel movements, rectal pain, wind pain and abdominal bloating seem to be more common than was thought in the past, perhaps because some sufferers, unless asked, haven’t mentioned these symptoms to gynaecologists.

• About four out of ten women with endometriosis will have problems with conception, but eventually at least half of these will become pregnant. The subfertility may result from failure to ovulate, adhesions that block the release of the egg or its passage along the tube, hormonal imbalances and perhaps less intercourse because sex is painful.

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Bartholin’s cyst and abscess

If the duct of one of these glands becomes blocked, its secretions are trapped to form a Bartholin’s cyst, which will be felt as a swelling, usually painless, beside the entrance to the vagina. Often the cyst remains small and soft and needs no treatment. If it becomes large and tense it may cause local discomfort and interfere with intercourse.

The cyst is treated by making a permanent opening in it to allow drainage. This simple procedure, called marsupialisation, can often be done with local anaesthetic. There is little postoperative pain, and healing is complete within a few weeks. Marsupialisation of Bartholin’s gland doesn’t interfere with lubrication of the introitus during intercourse.

If a cyst becomes infected it becomes a Bartholin’s abscess – a tense, hot, red, very painful swelling, usually with swollen groin glands on the affected side. Treatment is by antibiotics: pain relievers. It’s often necessary to make an incision in the abscess to allow pus to drain. Opening the abscess brings immediate reduction of pain.

If Bartholin’s abscess occurs more than once, marsupialisation of the gland, as described for Bartholin’s cysts, will prevent further recurrences.

Sebaceous cysts

There are many sebaceous glands in genital skin. If the duct of one of these glands becomes blocked, sebum is then trapped farming a sebaceous cyst. Sebaceous cysts in genital skin grow slowly and rarely become larger than 5 mm diameter. A cyst is usually discovered by chance as a firm, painless swelling. No treatment is usually necessary and sometimes sebaceous cysts will go away by themselves. Occasionally a sebaceous cyst becomes infected to form a painful abscess. Opening and draining the abscess brings quick relief, but the infection is inclined to recur. Surgical removal of the gland may be the only way to prevent recurrences.

Vulval ulcers

Vulval skin can become ulcerated by chafing from sanitary pads or tight clothing, or from sexual activity when the vulva isn’t sufficiently lubricated. These simple ulcers heal quickly as soon as their cause is removed. Any ulcer that persists for more than two weeks should be checked by a doctor to rule out the possibility of infection or vulval cancer.

Cancer of the vulva

Vulval cancer is uncommon (about three out of each hundred pelvic malignancies). It can occur anywhere on the skin of the labia, clitoris or vestibule, and mostly affects women well past the menopause.

The most common symptom is persistent itching, which must always be checked in older women to rule out the possibility of cancer. Because vulval cancer often begins in skin affected by atrophic vulvitis, treatment of this condition with oestrogen cream may help to prevent malignancy.

Very rarely, a genital mole may become malignant (melanoma). Any mole that darkens, enlarges or changes shape should be checked without delay. Some doctors advise removal of benign genital moles because it’s difficult for you to keep an eye on them.

Treatment of vulval cancer is by surgery; the results are usually very good if diagnosis is early. Additional radiotherapy may be needed if the malignancy has spread.

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• If you think you’ve reached the menopause, see your doctor about the possibility of HRT. There are menopause clinics in all the large women’s hospitals, and most doctors in private practice have up-to-date knowledge about the menopause.

• Look after your general health.

a     Whether or not you decide to take hormones, have regular general and gynaecological checkups, including a breast check and Pap smear.

b     Eat well. Follow the Australian Dietary Guidelines. You need extra calcium after the menopause. Low-fat dairy foods are an excellent source of calcium. Watch your weight.

с     Exercise is important to maintain
your fitness and figure and to enhance physical and mental well-being. Keeping active also helps to
maintain bone health. Walking and swimming are recommended for older women.

What health conditions can cause problems in pregnancy?

Any chronic health disorder can make pregnancy more difficult. Antenatal supervision needs to be more frequent and detailed in conditions such as diabetes, disorders of the blood or blood clotting, chronic heart disease and lung disorders, and kidney problems. Women on long-term medication may need a different dosage during pregnancy. Abnormalities of the lower spine, pelvis and hips can lead to problems during labour. Ill health can make it harder to care for babies and young children, too.

If you have a chronic health problem, it’s best to ask your doctor before you conceive how pregnancy might affect your health and vice versa.

Are there any dangers from competitive sport, athletic training and strenuous exercise in pregnancy?

Because our bodies run at a different rate during pregnancy, moderate exercise has the same effects as vigorous exercise in non-pregnant women. There are theoretical arguments that very strenuous exercise may not be a good idea because:

• the extra blood flow required by the mother’s muscles during exercise may reduce the blood flow to the placenta and thus the amount of oxygen and nourishment available to the foetus

• the mother may not eat enough to make up for the energy consumed by exercise.

These arguments are supported by the fact that women who have regular strenuous exercise during pregnancy tend to have babies with a low birth weight.

Until we know more about how strenuous exercise may affect them, pregnant women are advised to take moderate exercise (in addition to antenatal exercises) such as swimming or walking to keep fit and feel good. If you want to continue vigorous exercise or training, discuss its safety with your doctor, midwife or physiotherapist.

What about air travel?

There are no restrictions up to 28 weeks. From 29-34 weeks, a doctor’s certificate of fitness to travel is required by commercial airlines. After 34 weeks, air travel is generally restricted, except in special circumstances.

If you’re planning pregnancy or are pregnant and are also planning a trip, speak to your doctor or pharmacist about prevention of infection while travelling. Vaccinations and medication to prevent malaria should be avoided during pregnancy, and it may be best not to visit places where such precautions are necessary.

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There are certain circumstances under which special consideration needs to be given to the means of contraception.

Disability

Disabled women have special contraceptive needs. Most disabilities don’t impair fertility. However, some methods of contraception may be unsuitable depending on the nature of the disability and other medications or treatments used. If you are disabled, discuss contraception with your doctor. The Family Planning Association provides special services in all states for physically and intellectually handicapped people. Contact the head office of the Association in your State for information about these services.

Adolescence

Once periods have become regular, most young women are very fertile. Though some young women don’t ovulate for a year or more after the first period, this can’t be relied on for contraception.

Many adults believe that it’s wrong to teach teenagers about contraception, thinking that it will encourage them to start sex earlier. Many studies in the UK and Scandinavia have shown just opposite: young women who’ve learned about sex and contraception generally have their first intercourse later than those who haven’t, and are better able to say ‘No’ if asked to have sex when they’re not ready for it. Condoms and the Pill are usually the most suitable methods, though the latter needs medical prescription.

Breast-feeding

Many women have used breast-feeding a natural form of birth spacing, as it’s well known that breast-feeding delays the turn of fertility after childbirth. The duration of this delay seems to depend on infant feeding practices such as the frequency and length of each feed, the time between feeds, and when other milk and liquid or solid feeds are introduced.

If you’re nursing five or more times per day, are not giving any supplements or solids and if you haven’t started menstruating, you have less than two chances in a hundred of conceiving within first six months after birth. However, if you don’t want to risk pregnancy until after the baby has been weaned, discuss contraception with your doctor or midwife. Barriers and the mini-Pill are chosen, and for some women an IUD may be suitable.

Around the menopause

Though fertility declines rapidly after mid-forties, this is a time of life when most women won’t want to take any chance on an unplanned pregnancy. Contraception is recommended for 12 months after the last menstruation. Choice of a method is the same as for younger women, according to your health, circumstances and preferences.

Until the mid-1980s it was thought that taking the Pill after the age of 35 was a health risk. This has now been proved wrong and healthy women up to the age of 50 who wish to and who don’t smoke may now take the Pill.

Rape

Any woman who is raped when she is at risk of pregnancy should be offered ‘morning-after’ contraception. This is the usual practice in rape referral centres.

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Advantages of the Pill

• It is easy to use and obtain.

• It is very effective if used properly.

• It is relatively cheap.

• It is a reversible method of contraception.

• Its use is not related to the time of sexual intercourse.

• It has some good side-effects for some women, particularly reduced blood loss, relief of menstrual cramps and improvement of acne.

• The need for a medical visit once per year (to renew the prescription) means that women on the Pill are more likely to have regular Pap smears and other; health checks.

• It reduces the risk of some health disorders, including some cancers.

Disadvantages of the Pill

• Some women can’t remember to take it regularly.

• Some women don’t like taking hormones.

• It
needs medical prescription.

• It
can’t be used by women with certain health histories or conditions.

• It can’t be used during breast-feeding.

• It has annoying side-effects for some, particularly breast tenderness and increased pigmentation of sun-exposed skin.

• It
has been associated, though rarely, with adverse effects on health.

• Any association between long-term use of the Pill and increased risk of developing breast cancer is still uncertain, though on present knowledge it seems unlikely.

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Once the XX or XY genetic combination has led to the development of ovaries or testes in an embryo, the sex hormones produced by the gonads take control of the development of the embryo’s female or male external genitals and internal reproductive organs. These sex hormones (also called sex steroids) are the main factor in sexual maturation at puberty, in the sexual behaviour that leads to conception (this is where sexual intercourse comes in), in preparing the female for pregnancy and for nurturing the newborn infant through lactation, and for parenting. So the sex hormones affect not only the form and function of our female and male bodies but also many aspects of our behaviour and social structure.

What are hormones?

Hormones are substances manufactured in special cells for the purpose of affecting the function of other cells. Most hormones are released into the blood so that they can travel around the body to influence cells far distant from their site of manufacture. In other words, hormones are the means of sending signals from one part of the body to another via the circulating blood. Cells that make hormones are usually arranged into organs called endocrine glands.

How do hormones work?

Cells that are influenced by hormones are equipped with special receptors either on their surfaces or within the cell. These receptors have a chemical structure that can combine with a particular hormone. When receptor and hormone combine, the cell is stimulated to function in one way or another. For example, a hormone may cause a cell to produce glycogen (a complex sugar), other hormones, or may stimulate cells to divide so that the tissue grows. Cells may have more than one type of receptor, so they may be influenced by more than one hormone.

A single hormone may stimulate more than one activity in the same cell. For instance, oestrogen makes the vaginal lining cells divide and also produce more glycogen. A hormone can also cause different activities in different cell types. Progesterone makes the cells lining the uterus produce more sugars and protein, and makes the cells lining the cervix produce thick, sticky mucus.

The sex hormones made by the ovary and testis are not the only ones essential for health. Other important hormones include those produced by the thyroid and parathyroid glands, the adrenal hormones (adrenalin and the corticosteroids), and insulin from the pancreas. And we all have a pituitary gland that makes a number of hormones; these hormones control the other endocrine glands.

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Heavy periods Heavy bleeding can happen early in puberty while periods are still irregular. This can occasionally lead to embarrassing ‘overflow’ from pads and tampons (see Helen’s story).

Helen’s story

Helen, aged 15, had no problems with menstruation except an occasional bit of heavy bleeding during the first 24 hours. During her last period this happened during the night. In the morning she found that blood had overflowed onto her nightgown and the sheets, and when she got up she left a few drips on the floor between her bed and the bathroom. A few weeks later, around when her next period was due, Helen was invited to stay overnight at her friend Jenny’s home. Jenny’s mum was very houseproud and a fussy housekeeper. What if Helen’s period started and stained the snow-white sheets! Although her mother assured her that this was unlikely, she decided to take no chances. Before leaving home she slipped a couple of old bathtowels into her overnight bag. Before going to bed at Jenny’s, she put a layer of newspapers and one towel under the bottom sheet and a towel between herself and the sheet. Then she put on two thick pads and two pairs of underpants. Next morning she found that her period still had not started, but that during the night her nose had bled!

It happens because, before ovulation begins, there is no progesterone in the second half of the menstrual cycle to change the blood vessels in the endometrium. Without the effects of progesterone there is less control on the amount of bleeding when the endometrium dies and is shed. The bleeding tends to be heavy for several days of the period. Heavy periods for this reason settle down when ovulation becomes regular. However, if it’s gone on for a year or more it could make you quite anaemic. See your doctor about it if you think you’re losing too much blood, if menstrual blood forms clots, or if you become pale, easily tired and lacking in energy.

After regular ovulation and menstruation are established, some women continue to have a day of heavier flow (often the day after the period starts) but this is usually no problem if you’re prepared for it.

Painful periods Pain with periods is called dysmenorrhoea (pronounced dis-men-o-ree-a). From about the mid-teens some young women experience cramp-like lower abdominal pain for a day or so during menstruation. This is usually due to primary dysmenorrhoea, which typically occurs in young women who haven’t had children and who have normal reproductive organs.