DEALING WITH UNPREDICTABLE PERIODS: COULD JOGGING AFFECT MY MENSTRUAL PERIOD?Ever since I graduated from college and started working, I’ve been sitting behind a desk. At twenty-five years old, I felt myself getting out of shape. I started jogging a year ago and now I run five miles on weekdays and eight or nine miles on weekends. At first, my periods were lighter, and I liked that, but for the past two months they have disappeared completely. I also seem to have a vaginal discharge which comes and goes, and I’m beginning to wonder what’s going on. Jogging is supposed to make me healthy but it seems to be making me sick.—S.C.Washington, D.C.Some exercise can enhance the menstrual cycle by alleviating stress and cramps and reducing the flow. However, excessive physical activity, such as jogging, cycling, strenuous dance, can result in complete amenorrhea. Women athletes and professional ballet dancers are known to consider amenorrhea an occupational hazard. Periods probably stop because the constant exercise results in weight loss and a change in hormonal balance, which blocks the release of the brain hormones LH and FSH. Women who are physically active need high blood counts to carry added oxygen to their muscles, and a woman who is not menstruating usually has a blood count that is higher than average. So, nature is adjusting to bodily need. Female athletes find the change especially good for them since there is no menstrual fatigue when they are training and competing.Ms. C. has no reason to worry. Menstrual absence is common to athletes, and the return of menstruation is practically a sure thing once physical activity is slowed down or stopped. She is not ovulating right now, so there is no buildup of her uterine lining, and that does not mean she is sick. It is perfectly normal for a woman doing as much strenuous exercise as she is to stop having ovulations.Her vaginal discharge, however, may be due to a hormonal change inside her vagina. Since she is not ovulating, her estrogen level is lower, and a diminished estrogen level can dry the vagina and make it more susceptible to infection. And if she is wearing nylon jogging shorts, she is providing a hot, damp, airless climate in which germs can breed with ease.This woman might attempt to restore a healthy vaginal environment by wearing cotton underpants and cotton shorts. If a change of attire does not alleviate her condition, she should consult a physician for treatment of her vaginitis.*47\333\2*

It is important to note at the outset that studies of sexual behaviour are a relatively recent phenomenon in human history, one reason being that many people have reservations about studying something they regard as intrinsically private. The upshot is that much of the information we have on sexual behaviour comes from groups of volunteers who may not be representative of the population in general. It is important to remember this in drawing conclusions from such studies.

The studies of Alfred Kinsey and his associates in the 1940s and 1950s were more wide-ranging than most studies before or since. His team asked more than 5900 White American women and 5300 White American men about their sexual practices and found, among other things, that women and men reported a decline in sex drive as they got older. Sexual activity in old age was related to sexual activity earlier in life, with those having an active sex life in old age more likely to have been sexually active during their youth and middle years.

Some people place enormous store on maintaining an active sex life into old age, while for others it is neither here nor there. Views on this are diverse, and we do not wish to suggest that sex is a requirement for a happy and satisfying life. People who have no desire for, or interest in, sex or who have deliberately chosen a lifestyle in which sexual activities play little or no part, have every right to their decision. The obverse is also true. Older people who enjoy sex, or who want to enjoy it in a mutually satisfying relationship, should be given information to help them achieve this.

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Who Should Have It?

If you have been given a diagnosis of unexplained infertility, you are under the age of 35, and there seems to be no medical or physical reason why you and your partner are not conceiving, IUI should be the first assisted conception treatment offered.

IUI can be used if you have a problem with ovulation because stimulatory drugs can be given at the same time. Stimulatory drugs are often used anyway to encourage two or three eggs to mature and to increase the chance of the technique working.

IUI can also be used if the man produces an anti-sperm antibody which usually means that his sperm will not penetrate the cervical mucus of the woman.

Again, IUI can be used if a post-coital test has shown that your mucus is hostile to your partner’s sperm.

IUI can be used with donor sperm if your partner is infertile or has a hereditary disease. However, donor insemination is an emotional issue -particularly for your partner who may feel he has ‘failed’ as a man. There may also be religious concerns and you should be counseled if donor insemination is required to enable you to conceive. Using a friend or family member as a donor is not usually advised because of the possibility of future problems as the child grows up.

What Happens?

The aim is to get your partner’s sperm high into your womb at ovulation when you are most fertile.

You will both have to go to the clinic and your partner will be asked to produce a fresh semen sample. His semen may be ‘washed’ in a special fluid and centrifuged so that the weaker sperm are filtered out. Alternatively a ‘swim up’ test can filter out weaker sperm. Sometimes a ‘split ejaculate’ is used because the first part of the ejaculate contains many more sperm.

Ultrasound is used to track the development of the follicles so that the sperm can be inserted at precisely the right time. This tracking is also important so that, if there is over-stimulation from any of the drugs and the possibility of a multiple birth, the procedure can be abandoned.

IUI may be a bit embarrassing but it is not at all painful. No anesthetic is needed and the sperm is placed high in the womb through a fine catheter. You will have to rest for a little while afterwards.

Success Rate

When there are no medical reasons for infertility IUI has a good success rate – around 15 per cent before the age of 35.

If you have been given a diagnosis of unexplained infertility, and you know your tubes are clear and that your partner’s sperm is healthy, IUI may be the first assisted conception treatment you are offered.

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No sooner have you felt relief when confusion and perhaps fear take hold. While your doctor is talking about your options, you may become overwhelmed about what is ahead. How do you explain the disease simply to family and friends? Isolation follows when there is a feeling that there is nobody out there who understands.

Then there may be guilt and anger. Could I have done something to avoid this disease? Why don’t loved ones understand and help?

Some women experience depression. How can I cope with this disease – the drugs, the pain, and the unknown?

Many women go through these stages before being able to finally meet endometriosis head on and accept the disease and make decisions about how they want to manage its treatment.

Frustration

Before you were diagnosed many questions no doubt regularly crossed your mind, including:

• am I neurotic

• are these symptoms all in my head

• is there anything really wrong with me

• do I have a low pain threshold

• why am I unable to cope with period pain when my friends have no trouble

• why do I have to spend so much time laid up in bed suffering

• will I have to suffer and tolerate this period pain until I reach menopause.

These questions probably bring a wry smile now, but when we consider the difficulty many women with endometriosis had in getting a doctor to acknowledge that something was really wrong, it can be seen that pre-diagnosis is an extremely difficult and emotional time.

Those suffering dyspareunia often ask what causes them to have pain during intercourse. Those who are infertile cannot understand why they cannot get pregnant.

Some women have also thought the pain of endometriosis was in fact a life-threatening disease such as cancer and have lived in fear for months until a correct diagnosis is made.

It is common to feel frustrated with your partner, family and friends before endometriosis has been diagnosed because you are unable to tell them what is wrong with you, why you are in so much pain, why you are feeling tired and depressed.

Some women are in pain for just a few days each month and look perfectly well for the rest of the time, and it can be difficult for those close to you to accept that there is something wrong. They may not take your pain seriously or may misinterpret your inability to take part in social gatherings and leisure activities, labelling you as lazy or trying to opt out. Sometimes your pain may have been interpreted as a quest to get sympathy and attention. Some may have accused you of being lazy because your pain has rendered you tired and incapable of doing your usual daily chores.

Students have found that they have been accused of trying to get out of school work, study or exams. Few of us have been lucky enough to escape those days when the pain has disrupted time at work, school or home. Unfortunately, teachers, employers and partners may not be sympathetic to your illness and you feel frustrated and isolated.

There are also times when doctors have frustrated us because they have refused to take our symptoms seriously by saying: ‘It’s a woman’s lot’ or ‘You’ll just have to learn to live with the pain’ or ‘It will get better once you have a baby’. Then there is always: ‘You won’t have any more period pain once you reach menopause’. Not reassuring news!

None of these quotes will be of any comfort to those wanting an answer to a problem that could well plague them for their reproductive years.

Partners too can be frustrating at times. Even those who are understanding and have the best of intentions can drop the odd stinging remark here and there. Some ask if you really love them because you have refused intercourse – yet again – because you are simply in too much pain. Or perhaps you are not in pain and would like to keep it that way for at least one night!

For those women who already have children, endometriosis can put a strain on their relationship. No child likes to see its mother unwell and in pain. For younger children it is difficult to understand why mummy is grumpy and moody; for the older ones it can be annoying when mum is out of action and not available to tend to their needs.

It is important that you continue to seek a correct diagnosis. You know your own body, and you are the best person to recognize if there is something wrong. Do not be fobbed off. Try not to be discouraged. Keep searching and exploring until you have an answer.

And if that means that you have to insist on investigations and tests to reveal the problem, insist!

You must remember that severe period pain, painful intercourse, backache and heavy bleeding are not normal. You do not have to put up with it.

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What is it? Pelvic inflammatory disease is just that. It means that some or all of the organs and tissues in the pelvis, like the fallopian tubes, uterus, ovaries, and pelvic lining (peritoneum), become inflamed. Inflammation means that the tissue becomes red and hot and sore.

What causes it? This particular inflammation is due to infection with bugs. The most common bug to do this is chlamydia, being responsible for anywhere between 20 and 60 per cent of cases. Other sexually transmitted bacteria, particularly gonorrhoea, can also cause infection in the pelvis. There are other bacteria and organisms which are not your typical STDs, like mycoplasma, but can infect the pelvis. Some of the bacteria which usually live in the bowel, like E coli and streptococci, can cause PID. Sometimes there may be more than one bug causing it.

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If this is an unplanned pregnancy, you may have some thinking to do. Despite the fact that every person’s situation is different, the bottom line is you have to make a choice: to continue with the pregnancy or not. This is rarely an easy decision to make, and you may want to seek help rather than making it alone. You do not have to make this decision immediately. If you are considering termination of a pregnancy, it is best done before ten to twelve weeks, so you usually have a little time after finding out you are pregnant. It is a good idea not to leave it till the last minute, but don’t feel you have to rush into action prematurely. You might like to talk to your doctor, or a counsellor, a friend or relative. There are agencies set up specifically for helping people in this situation. Family planning clinics can often help, or direct you to local help.

If this is a wanted pregnancy, there are still things to do and plan. You can make arrangements for your care during the pregnancy and delivery, based on your situation, history and wishes.

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Symptoms

Again, the only sign is a smelly vaginal discharge. This is usually watery, and is said to smell a bit fishy (although if fish smelt like gardnerella). There is usually not much itch or pain, but sometimes the excess discharge can lead to discomfort.

Diagnosis

The look of the discharge is often characteristic, but swabs can confirm that the cause is gardnerella, or some of its other bully mates.

Treatment

Various antibiotics and creams have been used to try to get the normal balance of bugs back again. Frequently the same tablets are used as for trichomoniasis. Creams and douches that change the acidity of the vagina are sometimes recommended, with varying success. Sometimes it seems to go away without treatment. No real benefit has been shown in treating sexual partnets.

This sort of bacterial overgrowth is a nuisance, because it often comes back. Some women will notice symptoms as often as monthly, as it can coincide with the hormonal changes of the menstrual cycle. Some women get it when they are on the oral contraceptive pill, others when they are not taking it, so it is difficult to recommend a sure-fire solution.

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It is fairly effective (failure rate about 2 to 3 per cent, apparently), but it should not be relied upon as a regular form of contraception if you are having frequent intercourse.

The MAP (usually two 50-microgram oestrogen and 250-microgram levonorgestrel combined oral contraceptive pills in each ‘dose’), is often preceded by an anti-nausea pill, as the relatively high oestrogen load can tend to induce nausea or vomiting. If you do vomit within two hours of taking a dose you may not have absorbed the hormones, and you will need to take another dose, preceded by an anti-nausea tablet.

It seems that the nastier side-effects of high-dose hormones don’t seem to happen with the occasional sporadic dose, like taking the MAP. Women do often experience some menstrual disturbance, like an early or late period or spotting. It is wise to have a pregnancy test if the next period is abnormal or delayed, as the method does have a failure rate. It may also be a good idea to consider a more reliable longer-term contraceptive, if you are needing one, and perhaps a check for STDs if you have had unprotected intercourse.

Post-coital IUD insertion. If an IUD is the method of choice for a particular woman, insertion within five days of unprotected intercourse can provide protection against that potential pregnancy. This has about the same failure rate as the MAP, but is much less commonly used.

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