DEALING WITH UNPREDICTABLE PERIODS: SPOTTINGEvery time my husband and I have intercourse I notice that I stain afterwardsI am not in any pain during sex so I don’t understand why I’m bleeding.-K.Q.Poughkeepsie, New YorkA woman who spots after sex should immediately see a doctor. She might have a lesion or an erosion on her cervix, an active sore that is irritated during sex. There are also cases where spotting after sex has turned out to be a cervical growth—a cancer or a polyp. So a woman should make an appointment with her doctor to have a Pap smear and put her mind to rest that she does not have cancer. A cervical sore can be treated with medication, or eliminated with electrocautery or cryosurgery, a freezing technique. A cervical polyp must be surgically removed.If she has no cervical abnormalities, then her spotting might mean that her uterus is being irritated during active sex. In that case it is usual to experience some cramping and subsequent spotting.Every so often during masturbation, orgasm, or for no apparent reason, a woman feels a cramp and notices a slight stain which is usually the shedding of a few blood cells from the uterine lining. Sometimes an inadequate progesterone level during the last two weeks of a woman’s cycle might result in mild uterine contractions which cause bleeding. Most of the time this type of spotting is not dangerous, but if it happens two months in a row, a woman should visit a doctor who could treat her condition with progesterone in the form of tablets or suppositories.*51\333\2*

If the front (anterior) vaginal wall is slack the bladder and urethra may slump backward, into the vagina. The position of the urethra and the bladder play a part in controlling flow out of the bladder, so when that is disturbed, the result may be incontinence (lack of bladder control). The capacity of the bladder and how well it empties may also be affected, leading to a tendency for bladder infections.

If the back (posterior) wall of the vagina is weakened, the structures behind it which can slump into the vagina are the rectum and small bowel. This can lead to problems with the bowels, such as constipation, and difficulty in actually passing poo.

The causes of prolapse include damage during childbirth (stretching of the vaginal wall supports, the pelvic floor muscles, or the uterus-supporting ligaments), or a congenital (born with it) tendency to have slacker connective tissues. The prolapse may not be apparent until the intra-abdominal pressure is increased, as it may be in pregnancy, or (more rarely) if there is a significant swelling within the abdomen, or with the passage of time and gradual progression (it is more common in older women).

Aggravating or compounding factors for prolapse include being overweight, having a chronic cough (smoking), or chronic straining (constipation). Adjusting these factors may in fact help alleviate the symptoms considerably. Pelvic floor exercises may also be helpful, and if oestrogen deficiency is noted, replacement either locally or with hormone replacement therapy may be worth trying. However, if the symptoms are troublesome, surgical prolapse repair can be performed.

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Breast tissue often feels like rice pudding in balloons. It can have a globby, slippery, grainy texture. Of course there is enormous variation, and some women have very soft smooth breast tissue, while other women’s breast tissue feels much harder.

The hard smooth lumps you may feel, particularly near the edge of the breast tissue, are ribs. You need these.

The idea of breast self-examination is to get to know what your breasts normally feel like, so if there is something different, like a pea, or a rock, in the rice pudding, or a bit of the pudding which feels different altogether, you might notice it, and get it checked out.

The only way to become familiar with what breasts should feel like is by doing lots of examinations. It takes a while to get used to the feel. It is the same when you are examining your own breasts. Once you have felt them a few times you get used to what they feel like. It does take practice to feel confident with breast self-examination.

Ask your doctor to show you how to do it, and if you want to practice. Try doing it after every period. If you are concerned about anything you may feel, ask your doctor to check. You can ask your doctor to check your breasts any time, or when you have a routine pap smear, even if you do examine your own breasts.

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Generally you need to talk over some issues with your doctor before you can know if you can have a vasectomy or not. Some things that may make vasectomy more difficult, at least under a local anaesthetic, could be: medical problems such as diabetes, epilepsy, bleeding disorders or if you are on anticoagulant therapy, or if you have any lumps in your testes that have not yet been diagnosed.

There are some conditions that need to be treated before you can have a vasectomy. They include high blood pressure, a tendency to bleed, and any infection or dermatitis on the skin of the scrotum.

Why would I want to choose a vasectomy? You may want to choose a vasectomy if you have all the children you want and you feel sure that no matter what happens, you would not want to have any more children. You may choose vasectomy even if you have never had children if you feel absolutely convinced that you won’t ever want a child, or if there is a genetic reason why you should not father any children.

If you and your partner have decided that sterilization is the best contraceptive option for you as a couple, and you have to choose between vasectomy and tubal ligation, vasectomy is often a better choice. Compared to tubal ligation, vasectomy is more effective. The procedure takes a shorter time as an outpatient or in a clinic, and recovery is usually quicker. But it’s important that you feel comfortable with the decision, and you are not agreeing to do it just to please your partner.

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How do you use the Calendar method? You will need to write down the length of each menstrual cycle for six months, or however long it takes you to have six cycles. A menstrual cycle is measured by counting the first day of a period as day one. The next day is day two. You keep on counting like that even when your period finishes. Count each day until your next period starts. That is one cycle. Write down the number of days in that cycle. When the next period starts, you start at day one again and count die days of that next cycle.

An average menstrual cycle is about 28 days, but your cycle may be only 21 days or it could be as long as 35 days (or even longer). This is usually nothing to be worried about, you just need to know what is normal for you. Some women will find they have cycles of different lengths from month to month. Most women will need to get some help from a Natural Family Planning specialist in working out their fertile days if they want to use this method effectively—but here’s a guide to how it’s done.

If you have sex during the time that you are recording the length of your cycles, you should use another method of contraception like condoms, or avoid having vaginal sex. You should definitely not be using the Pill, the contraceptive injection or contraceptive implant, because you do not have normal cycles while you are using a hormonal method of contraception.

At the end of six cycles you can calculate your fertile time. Write down the length of the shortest cycle. Let’s say it was 26 days. Now take away 20 from that number, in this case we’ve said it is 26, and that leaves 6.

Then write down the length of your longest cycle. Let’s say that was 30 days. Take away 10 from that number, we said it was 30, and we have 20. Look at the two numbers, 6 and 20. They mean that your unsafe days are from day 6 to day 20 of your cycle. So, some time between the sixth day after your period starts and the twentieth day after your period starts, you might be ovulating so it is not safe for you to have unprotected sex during that time.

Of course, you will not be fertile all that time, but you cannot be sure exactly when you are going to ovulate, so this covers you for most possibilities. Some other systems use slightly different numbers, and that is why it is best to go and see someone who has taught the method a lot and can explain it to you properly.

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Some women may get headaches or sore breasts. Some women put on weight because the progestogen in the minipill increases their appetite and they eat more, but this is not very common because of the very low dose of hormones in the minipill.

Some women don’t have any side effects at all.

Are there any reasons why I could not use the minipill? There are very few women who shouldn’t ever take the minipill. However, it probably isn’t a good choice for someone who has had cysts on the ovary or a pregnancy in the tube (also called an ‘ectopic pregnancy’) since the minipill can increase the chance of these happening again. There are also some things you should talk over with your doctor before you decide to use it. If you have unusual bleeding from your vagina that hasn’t been diagnosed, or if there is any chance you could be pregnant, both these issues need to be sorted out before you start taking the minipill. You should also tell your doctor if you have liver disease, breast cancer or a disease of your ovaries.

Are there any other things that could cause a problem if I take the minipill? If you have any illness that causes you to vomit or have diarrhoea, you should talk about this too. And tell your doctor if you are on any medication in case it could react with the minipill. But don’t worry, antibiotics don’t lower the effectiveness of the minipill.

There is some evidence that if you weigh more than 70 kilograms the usual dose of the minipill may not be as effective, but you can ask your doctor if this is an issue.

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