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‘Subcutaneous’ means ‘beneath the skin’, and this is how the implant works. A tiny pellet, about the size of the tip of a lead pencil, is inserted under the skin of the lower abdomen. The technique is simple, takes about 5 minutes, and can often be carried out in a general practitioner’s surgery under a local anaesthetic, leaving little or no mark. The big advantage of an implant is that, once it has been inserted, you can forget about it for several months. No need to take tablets or change patches. Unlike other forms of HRT, it can also be combined with small quantities of the hormone testosterone if your doctor thinks this would help you. Although testosterone is the male hormone, it is also produced in the ovaries of women, so it is not unnatural to receive it. It can be helpful for women who have certain psycho-sexual problems, a drop in libido (interest in sex), much reduced energy levels or severe loss of confidence. Being a male hormone, it may cause a slight increase in facial hair.

Nearly all women with implants gain relief from hot flushes, and three-quarters gain relief from depression. Improved collagen levels lead to better skin and stronger bones.

As with the patch, the oestrogen is released straight into the bloodstream, and avoids the digestive system, so a lower dose can be used, giving fewer side-effects than oral HRT. There is no question of forgetting to take it, or of suffering the skin irritation some women get with the patch. It also avoids the necessity of ‘popping a pill every day’, which is what many women don’t like about HRT; until it needs replacing you can forget you are using it at all. It also offers good protection against osteoporosis, except at the lowest dosage.

The implant does not last forever, and it will need to be replaced every 4-6 months, depending on when the level of oestrogen in the implant falls and the menopausal symptoms return. You will need to return to your GP or gynaecologist for a replacement Although this may seem rather a nuisance, it does ensure that you are regularly monitored, and a check-up may also detect irregularities that might otherwise have gone unnoticed.

This condition is called tachyphylaxis, and has received unfavourable publicity following reports of some recent research into it One or two newspapers decided that it suggested the women were ‘addicted’ to oestrogen, because they needed ever-higher doses at ever-more-frequent intervals. This type of reporting is irresponsible and unjustified, but many newspapers seem unwilling to present HRT in a neutral light, choosing either to extol its ‘sexy forever’ image or to condemn it for exaggerated side-effects.

The problem of tachyphylaxis should not, however, be dismissed as irrelevant, because for the small minority of women affected by it, it can be a serious disadvantage, and one for which doctors can’t at present agree on a solution. Simply to refuse further HRT in any form produces a return of the symptoms and much suffering; it may also be a dangerous approach in women whose falling oestrogen is producing feelings of depression. However, to replace the implant at ever-closer intervals in a woman whose oestrogen level may be well above normal is not desirable either. It is obviously an area in which more research is needed. If you feel you are developing this condition, talk to your doctor about a gradual withdrawal from this type of HRT, as a different type might be the solution for you. He may decide to monitor your blood oestradiol level regularly, and to replace the implant when it falls to a certain level.

The second disadvantage of the implant concerns those women who still have a uterus and who need to take progestogen. The raised levels of oestrogen from an implant are eliminated from the body only very slowly, so that even once you have stopped using implants the lining of the womb continues to thicken every month and you need to continue taking progestogen until this stops happening.

Implants come in three different strengths (25, 50 and 100 milligrams); the higher dose lasts longer, and continues to relieve severe symptoms longer.

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Radical or Wertheim’s hysterectomy. A radical hysterectomy means that the surgeon removes the entire uterus including cervix and support structures, both ovaries, Fallopian tubes, nearby lymph nodes, and the upper portion of the vagina.

In some women, for example a patient with cancer that has infiltrated several reproductive organs, there may be no option but a radical hysterectomy. In other circumstances there may be more flexibility about the amount of tissue taken.

By the time Robyn turned thirty-seven her medical history included a myomectomy and an endometrial resection. Both procedures were undertaken to control heavy bleeding due to fibroids, but neither provided lasting relief. She had decided to accept the advice of her gynaecologist and have a hysterectomy, but was uncertain which sort would be most appropriate. The doctor proposed removing her ovaries and Fallopian tubes, along with her uterus, because of the possibility that ovarian cancer could develop some time in the future. This form of cancer tends to evade detection until it is advanced; treatment prospects are then poor. Robyn asked about the short- and long-term implications of ovary removal at her age and was told that her menopause would occur earlier than expected. Acute menopausal symptoms such as hot flushes and vaginal dryness were likely to accompany an early menopause, and hormone therapy would then be advisable. Long-term implications included an elevated risk of osteoporosis and heart disease. Even if the ovaries were left it was possible that she might experience a somewhat earlier than expected menopause, although this was by no means certain. As Robyn’s family had a tendency for heart disease, but not for ovarian cancer, she declined to have a total hysterectomy with bilateral salpingo-oophorectomy. Instead, a total hysterectomy was performed, and care was taken to preserve her ovaries intact.

There may also be some flexibility when it comes to the question of removal of the cervix. Women who have asked doctors about the implications of losing their cervix and the upper part of their vagina have received varied responses according to whether they were pre- or post-menopausal. Pre-menopausal women whose ovaries are to remain may be told to expect a reduced amount of lubricative cervical mucus around the time of the month that they ovulate. This might be one factor contributing to reduced sexual satisfaction for them and their sexual partners. At other times of the month when the output of cervical mucus is minimal, the impact of cervical secretions on sexual satisfaction would be negligible. Although recent studies do not show a reduction in vaginal size after the cervix has been removed, the absence of the cervix itself might be expected to alter the sensations experienced during intercourse. For postmenopausal women loss of the cervix would not affect lubrication, but its absence might alter sexual satisfaction for one or both partners if tapping it during intercourse was important for orgasm. On the other hand, removal of the cervix might be seen to have convenience value for some women as it would do away with the need for repeated Pap smears. It has become increasingly common to offer women the option of preservation of the ovaries and cervix and upper part of the vagina during hysterectomy.

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Bed-wetting at night during sleep is technically known as nocturnal enuresis. Bed-wetting is a nuisance to parents, and hence toilet training begins at an early age. After the age of four, when they start going to school, most children are dry at night. However there are some that continue to wet their beds at night even to a much older age.

In the past, a lot of people believed that children wet their beds while dreaming. Now, with the advent of the sleep laboratory, we are certain that they wet their beds during NREM sleep, especially in stages three and four of deep sleep. Children who sleep deeply lose control of their bladders in NREM deep sleep. As the children grow older, it is normal for them to sleep less deeply and this increases their bladder control. Ultimately, as these bed-welters become older,

bed-wetting cures itself. Most parents seek medical advice if their children still bed-wet at about school age. The doctor will make sure there is no urine infection or sugar diabetes. Diabetes mellitus, having sugar in the urine, is known to cause excessive urination, although few sufferers of diabetes bed-wet. If the doctor is satisfied that there is no physical illness, normally no treatment is required before the age of eight, as bed-wetting is a self-limiting condition. We are quite sure that the majority of bed-wetters are of normal intelligence and parents need not be worried or concerned about their child’s future development. These children should be rewarded when they have a dry night, and when they have a wet night it should be ignored. Do not punish them, as this will only give them a feeling of guilt which may be harmful to their future personality and may make their bed-wetting worse.

If treatment is required, two methods are commonly used. The first is a medicine called imipramine. This can be given to children when they need to be dry for a night or more as when they stay overnight at a friend’s home or go away to a school camp. It is only a temporary measure, as relapse is common once the medicine is stopped.

A second well-known method is the pad and alarm system. This is an electrical device consisting of two electrical pads separated by a small piece of cloth, and it is placed under the bed sheet. When the child wets the cloth between the pads, a short circuit is created which switches on a battery-run alarm which then wakes the child up. This trains the child to wake up once bed-wetting begins. This training may take anything up to 12 weeks before bed-wetting stops.

Bed-wetting sometimes runs in families and seems to be an inherited characteristic. It has been shown that an identical twin has double the chance of bed-wetting if the other twin bed-wets. Bed-wetting can also be caused by emotional factors; for example the addition of a new baby to the family may be perceived as a threat to the older child. In these cases of stress induced bed-wetting, most of the children have been dry for a period of months or years after toilet training, but bed-wetting begins again when they experience emotional stress. This is called secondary bed-wetting and is commonly stress related. This is less common than primary bed-wetting, in which the child has not gained bladder control at night since birth.

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