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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The problem is that these suspect substances seem to be absolutely everywhere – in the food we eat, the air we breathe, and the things we use at work and at home. We can avoid many of them, and minimize our exposure to others. But we obviously cannot completely eliminate them, short of finding a non-polluted desert island to go and live on.

However, reducing your exposure is only part of the plan. There are plenty of ways to fortify yourself and your partner against the effects of unavoidable exposure and to ensure that toxins are successfully eliminated from your system. In my experience, dramatic results have been achieved by couples whose ‘unexplained fertility’ turns out to have been due to exposure to some of these substances.

Xenoestrogens

These are synthetic oestrogens which affect the fertility of wildlife and are causing some animals to grow both male and female sex organs. They come from pesticides and plastics and are stored in body fat and can affect men and women differently.

The massive proliferation of xenoestrogens has coincided with:

• A decrease in sperm counts of 50 per cent over the last ten years.

• An increase in testicular cancer.

• Earlier onset of puberty. (At the turn of the century the average age was 15. Now some girls as young as eight are growing breasts and pubic hair. It has been found that girls can enter puberty almost a year earlier if their pregnant mothers had higher levels of two synthetic chemicals, PCBs and DDE, while they were pregnant.)

• A doubling in the number of boys born with undescended testes (which means they may not produce sperm) between 1962 and 1981.

• Increasing numbers of male babies born with problems with their penis. Some boys are born with the opening of the urethra (where urine passes out of the body) on the side of the penis instead of the top. In extreme cases male babies have been born with both male and female organs.

Synthetic oestrogens, similar to those in use in the pesticides and plastics industry, have been linked to cancers and abnormalities.

Years ago women who suffered recurrent miscarriages were treated with a synthetic oestrogen called dithethylstilbestrol (DES). Now their grown-up daughters, who were exposed to DES in the womb, are showing high rates of cervical abnormalities that can lead to recurrent miscarriages or infertility. Some have developed a rare and sometimes fatal vaginal cancer (clear-cell adenocarcinoma).Their sons are not so severely affected but some have suffered mild genital abnormalities.

Further evidence comes from Professor Ana Soto in Boston, USA, who was studying breast cancer cells stored in large incubators. These cancer cells started to divide and multiply as if oestrogen was present. But when the laboratory changed the tubes on the incubators the cells stopped dividing. It turned out that nonylphenol, a synthetic oestrogen similar to those widely used in paints, toiletries, agricultural chemicals and detergents, had been used in the manufacture of the tubes.

In another example of the power of these chemicals, some male workers developed breasts after inhaling dust containing bisphenol A, a synthetic oestrogen used in a wide range of packaging (e.g. for soft drinks, bottled Water and even babies’ bottles).

Phthalates, found in PVC, food packaging and glues, are another class of chemical which has an oestrogen-like effect on humans.

Types of chemicals that affect hormone balance and fertility include:

• Pesticides (DDT, DDE, endosulfan, methoxychlor, heptachlor, toxaphene, dieldrin, lindane)

• Plastic compounds (Alkyphenols such as nonylphenol and octylphenol, biphenolic compounds such as bisphenol A, phthalates)

• Pharmaceutical drugs (Synthetic drugs like DES)

• Industrial substances (PCBs, dioxin)

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How do these problems arise? There are several possible factors involved. The work environment of the middle-aged man often involves increased pressures, particularly from younger men who are eager to fill their shoes. The prospect of retirement is often another factor – having to face a change in life style, with a reorganisation of interests and finances. Finally, the realisation that time is coming to be a most precious commodity and there is so little of it left – and has it all been worth while? Any or all of these factors can lead to depression, which can be compounded by children leaving home and developing their own life style, which often involves a completely different set of values. The couple is, in many instances, left alone for the first time in years, and, like the woman, the man suddenly becomes aware of this.

Any of these stresses may cause depression, tiredness and, ultimately, impotence. Impotence is also particularly aggravated by drinking alcohol to excess.

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