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What Women Need to Know
From Headaches to Heart Disease and Everything in Between
By Marianne Legato, Carol Colman
OPEN ROAD INTEGRATED MEDIACopyright © 1997 Marianne Legato, M.D., and Carol Colman
All rights reserved.
Q.I heard there is a new pill that can induce abortion so that a surgical abortion is no longer necessary. Is this true? Is it safe to use? Can I take it at home?
A. There are two different types of drug therapies that can terminate pregnancy; one is available in the United States and one is not. In my opinion, at this time, neither therapy is better than conventional surgical abortion.
RU 486, the so-called abortion pill, is widely used in France. When combined with oral prostaglandins (substances that cause the uterus to contract), RU 486 can induce abortion up to the ninth week of pregnancy. As of this writing, however, RU 486 is not legal in the United States; therefore, it is not an option for American women. Anti-abortion forces have so far been effective in their efforts to block the use of RU 486 as an abortion drug, and it is only available in the United States to medical researchers for experimental purposes. Recent studies have suggested that RU 486 may be an effective treatment against breast cancer and other diseases, and a handful of American scientists are conducting further research.
There is another drug regimen for abortion that is both legal and available in the United States, but it is very new and somewhat controversial. According to a study published in the New England Journal of Medicine, two other drugs commonly prescribed for other purposes can, when combined, also safely and effectively terminate pregnancy up to nine weeks. The first drug, methotrexate, is approved by the Food and Drug Administration (FDA) to treat some cancers as well as rheumatoid arthritis and psoriasis. The second drug, misoprostol, is an approved anti-ulcer medication that can also cause uterine contractions. For the past decade, methotrexate has been prescribed "off label" (not for its approved use) to terminate ectopic pregnancies (a potentially life-threatening condition that occurs when the fertilized egg lodges within the fallopian tube). Misoprostol is also commonly prescribed "off label" to soften the cervix when inducing labor.
In order to induce abortion, the patient must be given a shot of methotrexate, which terminates a pregnancy in two ways: It interferes with the growth of the embryo and the placenta by killing rapidly dividing cells, and it also blocks the action of folic acid, an important B vitamin that is critical to the normal growth and development of the embryo. Five to seven days later, the patient must return to the doctor for a vaginal suppository containing misoprostol. Typically, within two days after getting the suppository, the woman will begin to bleed and cramp, as she would with a miscarriage. In rare cases, the pregnancy may not terminate and a surgical abortion is required.
There are some advantages to this new abortion procedure over surgical abortions. For one thing, it can be performed in any doctor's office and does not necessitate a hospital stay or a visit to an abortion clinic, which many women may find upsetting (particularly if anti-abortion people are picketing outside). For another, unlike a surgical abortion, which is best performed at around six weeks, the drug-induced abortion can be performed as soon as the woman knows she is pregnant, which eliminates the days or weeks of waiting.
There are some disadvantages, however, to this procedure that women should be aware of. First, the drug-induced abortion takes considerably longer than the usual surgical procedure. During the first twelve weeks of pregnancy, abortion is usually done by vacuum aspiration, which takes between ten and fifteen minutes. In this procedure, the cervix (at the entrance of the uterus) is dilated and a blunt-tipped tube is placed in the uterus. The tube is connected to a small suction machine which draws out the contents of the uterus. A vacuum aspiration can be performed with either local or general anesthetic. In most cases, after an hour or two of rest, the woman can go home. Although there may be some residual bleeding for up to two weeks, the abortion is over quickly and efficiently. On the other hand, the drug-induced abortion can take up to two weeks before the abortion is finalized, which can be emotionally wrenching for many women. In addition, if unprepared, many women may be very distressed by the amount of bleeding and cramping, although most of the women who have had this procedure find that the pain is easily controlled with medications. In addition, since neither methotrexate nor misoprostol have been approved by the FDA for use for abortion, some doctors may be reluctant to administer them for this purpose. As of now, I personally would not recommend this procedure until it has been tested further.
Q.I had an early abortion when I was a teenager and my doctor said that everything went well. Now that I want to get pregnant, I'm having difficulty. I sometimes think that I'm being punished for the abortion. Could the abortion have caused my fertility problems?
A. A legal abortion performed by a doctor under sterile, medical conditions rarely results in fertility problems. Keep in mind that about 15 percent of all couples have difficulty conceiving for any number of reasons. If you are concerned about infertility, you should not assume that the abortion was to blame, but you should consult a fertility specialist for a complete diagnostic workup.
It is true, however, that illegal abortions, typically performed under less than sanitary conditions, could cause problems that might make it difficult to conceive. For example, infection, a common complication of illegal abortions, could cause scarring in the Fallopian tubes, thus closing down the passages the sperm must pass through to reach and fertilize the egg. In rare cases, an illegal abortion could cause a more serious complication, like a perforated or torn uterus, which is a medical emergency that often requires a hysterectomy. Fortunately, since abortions are legal and done in medical settings, these complications rarely, if ever, occur.
Q.I had an abortion over twenty-five years ago. Since then, I have had one child and am happily married. Although I know that I made the right decision at the time, I still feel very bad about the abortion. In fact, lately I have been waking up at night crying. Is this normal? I'm becoming menopausal, and wonder if I'm just being "over-emotional."
A. I frequently see women who, having had an abortion many years earlier, apparently without any ill effect, suddenly and inexplicably begin to grieve about it years later. Often the grief surrounds the loss of reproductive ability, as in the case of menopause, or the death of a child, or some other severe blow that makes them believe they are being punished for their past "sin" of abortion. If the patient is really suffering, I usually refer her to a psychiatrist. Very often, simply talking about the issues that may have provoked the reawakening of regret and guilt may be enough to bring the patient relief. If the obsession over the abortion continues, the psychiatrist may prescribe an antiobsessive or antidepressant medication like Prozac.
I do not believe there is such a thing as being "overemotional." However, I tell patients who feel unable to deal with their emotions, whether they be of unbearable internal pressure, grief, sorrow, or simply anxiety, to get help early. Check with your family doctor first: She probably knows you the best and can refer you to the appropriate consultant if you need psychiatric care or medication.
Acquired Immune Deficiency Syndrome (AIDS)
Q.I read that women are now at greater risk of getting AIDS than men, and when we do get it, it is a more serious form of the disease. Is this true?
A. At one time, AIDS was considered a disease that primarily afflicted gay men. We now know that this is simply not true, and, in fact, the fastest-growing method of transmission of the AIDS virus is through heterosexual contact. Today, more than 40,000 women in the United States have been diagnosed with AIDS, and depending on whose figures you believe, anywhere from 120,000 to 400,000 women are believed to be infected with HIV. AIDS is now the fourth leading cause of death of women between the ages of fifteen and forty-four.
Due to anatomical differences, women may be more likely to contract the HIV virus than men; in fact, women are twice as likely to get AIDS from a male partner than men are from a female partner. For one thing, semen contains greater quantities of HIV than do vaginal secretions, which makes unprotected vaginal intercourse riskier for women than for men. In addition, a vagina contains more surface area than a penis, so there is more of a chance that the virus will find a place within the vaginal wall or cervix to infiltrate into the bloodstream. And since the semen remains in the vagina for several hours after intercourse, there is also more time for the virus to inoculate the bloodstream.
When women first began contracting AIDS, it was widely believed that they were not only harder hit by the disease, but that they actually died more quickly than men. In fact, statistics bear this out: Men who were diagnosed with AIDS live up to six times longer than women with the disease. Similar studies have also shown that African Americans with AIDS have a poorer prognosis than do whites. Perplexed by the starkly different prognoses of AIDS patients based on gender and race, researchers began to investigate whether there were any physical differences in women and African Americans that made them particularly vulnerable to the ravages of HIV. Recent studies, though, show that the disparity in survival rates have little to do with race and gender and everything to do with quality of care. In one study, for example, researchers found that patients who received drugs to prevent AIDS-related infections in the early stages of their disease had a higher survival rate than those who did not, regardless of gender or race, or any other factors. In other words, AIDS patients who had access to good quality health care fared better than those who did not. For whatever reason, women and African Americans with AIDS did not have the same access to health care as men.
It is also important to note that until recently, physicians knew very little about the progression of AIDS in women. Nearly all of the earlier studies had been performed on men, and there was little information about the way HIV affected women's bodies. For example, physicians were unaware that HIV could manifest itself in women in the form of an abnormal Pap smear, genital ulcers, or recurrent vaginal yeast infections. As a result of this ignorance, many women were diagnosed late, or never diagnosed at all, and therefore never received the medical treatment they so desperately needed. In 1993, based on new information, the Centers for Disease Control (CDC) expanded its definition of AIDS to include on their list of warning signs previously excluded conditions, including cervical cancer and other genital infections, and particularly stubborn, recurrent, or unusually virulent vaginal yeast infections.
Q.Can you get AIDS from oral sex with a man? What about using sex toys like vibrators on each other? (I heard that was "safe" as long as you did not have intercourse.) How about open mouth kissing?
A. AIDS is caused by the human immunodeficiency virus (HIV), which is transmitted in either of two ways:
1. through blood or blood products, such as a blood transfusion, or sharing a needle with an infected person
2. through the exchange of body fluids, such as semen or vaginal secretions during sexual activity.
Oral sex In women, the virus passes through the skin into the body through tiny tears or sores in the vagina, mouth, or rectum. Latex condoms offer good protection against HIV, especially when combined with the spermicide nonoxynol-9. It is definitely possible to get infected through oral sex if the man ejaculates into your mouth. Keep in mind that even the "pre cum," the drops of fluid that are discharged from the penis prior to ejaculation, can contain HIV. Therefore, it is advisable to insist that your partner use an unlubricated condom during oral sex.
Anal sex Anal sex can be particularly risky because the muscles that ring the rectal area do not stretch readily and as a result, when under pressure from an entering penis, can easily tear or break, thus allowing the virus to enter the bloodstream. If you practice anal sex, be particularly careful about using a condom and spermicide.
Sex toys Many people tell me that they are using so-called sex toys such as vibrators and dildos, particularly for anal sex, because they believe that the AIDS virus cannot be transmitted unless there is direct contact between the penis and the vagina, rectum, or mouth. Theoretically, the use of sex toys are safe if you use them on your partner and do not use the same toy on yourself. If, for example, a woman uses a vibrator on her partner, and then penetrates her vagina with the same vibrator, she could very well be infecting herself with HIV if her partner carries the virus.
As far as kissing is concerned, although HIV may be present in the saliva of infected individuals, it is not present in a high enough quantity to be considered a major threat. Blood-to-blood transmission of HIV from kissing may be possible if both people have open, bleeding sores. There was recently a reported case of AIDS being transmitted via a bite that penetrated the skin; however, the saliva was not the means of transmission. The person who did the biting had open sores in her mouth, which exposed the other to her blood.
Q.I heard that lesbians do not get AIDS. Is this true?
A. There is an extremely low incidence of AIDS among the lesbian population, which has led some people to believe that lesbians are somehow "immune" to this disease. In reality, there has not been very much research done in this area, but based on what we do know, it appears as if lesbians would be as vulnerable as anyone else to contract HIV if they engage in risky behavior. Studies show that many lesbians are actually bisexual and may very well have sex with men as well as women. Some also use IV drugs. Since the AIDS virus can be transmitted through vaginal fluid, and even menstrual blood, it is very possible that AIDS can be transmitted by sexual contact between women.
Q.When I was in college twelve years ago, I was not as careful as I should have been about sex. I was on the pill, and since I was not worried about pregnancy, I had sex with several partners without using a condom. I recently discovered that at least one of these individuals may have used heroin. Now that I am older and wiser, I'm worried that I may have contracted HIV. Should I be tested? What is the use of knowing you are HIV positive if AIDS is an incurable disease? I might add that I'm in perfect health. If I was HIV positive, wouldn't I be sick by now?
A. Most people who contract the AIDS virus (HIV) begin to develop symptoms—so-called HIV disease—within eight to ten years of their initial exposure. HIV dampens the immune system's ability to work effectively. The role of the immune system is to fight against viruses and bacteria to prevent infection, and to identify potentially dangerous cells in the body that, if allowed to grow unfettered, could develop into cancer. In particular, HIV knocks out important cells called CD4, which are essential for the body to wage an effective battle against unwanted invaders. In time, HIV-infected women usually develop telltale symptoms of a compromised immune system, such as chronic and intractable yeast infections, severe respiratory infections, weight loss, skin rashes, night sweats, swollen glands, and cervical cancer. The Centers for Disease Control defines "full-blown" AIDS as the presence of two or more AIDS-related illnesses in persons who test positive for HIV.
Excerpted from What Women Need to Know by Marianne Legato, Carol Colman. Copyright © 1997 Marianne Legato, M.D., and Carol Colman. Excerpted by permission of OPEN ROAD INTEGRATED MEDIA.
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