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it at the bottom of the list; the risk ranges from 1 in 44,000 cases of post-coital bleeding in women aged 20–24 to 1 in 2,400 in 45–54-year-olds.6

       Does removing a fallopian tube affect my fertility?

      Sometimes fallopian tubes may need to be removed in cases of severe infections (see Chapter 9 on STIs) or due to an ectopic pregnancy (a pregnancy in the tube). You can still get pregnant with one tube (see here), but if both are removed it does mean that you would need IVF to get pregnant. Removing either one or both tubes also does not affect the function of your ovaries and does not cause you to go into the menopause.

       Why do I have a cyst on my ovary?

      Ovarian cysts are very common and about 1 in 10 women will need surgery for one at some point in their lifetime. Most arise as a result of the normal workings of the ovary (see here). We get tonnes of referrals to the gynaecology clinic for ovarian cysts that have been found incidentally during a scan for something else. Ultrasound is the best way to look at your ovaries initially, preferably an internal scan using a small probe inside the vagina because it gets closer to the action. Most cysts will disappear on their own within a couple of months. You may need a follow-up ultrasound, depending on the size and type of cyst.

      Larger cysts may need to be removed because there is a greater risk that they may twist the ovary which cuts off its blood supply, and if not untwisted will cause the ovary to die. This is called ‘ovarian torsion’, and you’ll definitely know if you have it because it is incredibly painful, to the point where even morphine won’t touch the pain. It requires emergency surgery to untwist the ovary and remove the cyst. In most cases the ovary itself can be saved if the blood supply returns on untwisting.

      The biggest ovarian cyst I’ve ever seen was in a young woman and was 24cm across. She was supermodel-slim, and finally went to her GP after spending a fortune on pregnancy tests, because she couldn’t understand why they were all negative, yet she looked seven months pregnant. A big tummy is a slightly unusual way for a cyst to present. More common symptoms include:

       abdominal pain – this may be constant, occasional or during sex

       constipation – due to pressure on your bowel

       wanting to pass urine more often – due to pressure on your bladder

       a change in your periods – irregular, heavier or lighter.

       The risk of a cyst being cancerous in a pre-menopausal woman is very low, ranging from 1 to 3 in 1000.7 (See Chapter 4 for more about polycystic ovaries.)

       Should I be worried about ovarian cancer?

      Ovarian cancer is so rare before the menopause and ovarian cysts do not increase your risk.

      An estimated 5–15 per cent of ovarian cancers are inherited, most often caused by mutations in the BRCA1 and 2 genes, which are also associated with breast cancers. If you have close family members (e.g. mother, sister, grandmother) affected by ovarian cancer, particularly at a young age, you may be eligible for genetic testing, which should be discussed with a genetic counsellor.

      An estimated 21 per cent of cases of ovarian cancer are directly related to lifestyle factors including smoking, poor diet and lack of exercise,⁸ so keeping active and eating well is one of the best ways to prevent the disease.

      There isn’t currently any screening for ovarian cancer, as there isn’t yet a test that is accurate enough. Remember that screening means identifying women who may have a disease but do not have any symptoms.

      If you experience any of the following symptoms more than twelve times per month, you should be investigated:

       Persistent bloating

       Feeling easily full after eating and/or loss of appetite

       Pelvic or abdominal pain

       Needing to pass urine more often, or as a matter of urgency

       Change in bowel habit

      THE GYNAE GEEK’S KNOWLEDGE BOMBS

      I hope you have found this chapter more fascinating than when you studied female anatomy in that awkward biology lesson at school. These are the key facts that you may not have learned back then that I want you to keep in mind:

       Your uterus can face forwards or backwards and contracts during your period to help the blood get out, which is what causes period pain.

       It also doesn’t like being poked very much, which is why it can be normal to get a bit of an ache after sex.

       Bleeding after sex is rarely caused by the big C.

       Your fallopian tubes are pretty flexible guys, flapping around like a Mexican wave, so that they can pick up an egg from either ovary.

       Ovarian cysts are very common (often a result of the normal functioning of your ovary) and do not increase your risk of ovarian cancer.

      Periods are one of society’s biggest taboos. Over half of the population has had or will have one at some point during their lifetime. Yet we barely talk about them.

      I’ve noticed an interesting three-way split in the way women feel about periods. In the first group are women who are ambivalent; they don’t mind either way whether they come or not. The second group hate them and would do anything to make them go away (‘Give me anything you’ve got to make them stop!’). The third group love them and are horrified at the thought of not having their period every month – some, because they see it as a sign that their bodies are working, and many because they feel like it’s ‘cleaning their body from the inside’ (although I’m always quite keen to point out that having a period doesn’t clean your body of germs or toxins; in fact, I think period blood often has a ‘dirty’ connotation, which is probably one of the reasons we’re so reluctant to address the issue).

      There are some types of contraception – for example, the hormonal coil – that will stop your periods (see Chapter 7), and if that happens it’s not a bad thing. It doesn’t mean your uterus will become ‘unclean’. The medication is simply preventing the lining from building up, so there’s nothing to shed. I once offered the hormonal coil to a lady whose periods were so heavy that she’d had several blood transfusions. However, for her the possibility of having no period at all was unacceptable and she declined, explaining that she ‘wouldn’t feel like a woman any more’. I really like the fact that some women appreciate their period as a sign that their body is working. This is so true, and I always tell my patients that their period is a reflection of what’s been going on in their bodies for the last month, even slightly longer.

      The next three chapters will cover the basics of periods, the menstrual cycle and what can, and commonly does go wrong.

CHAPTER 3

       Periods – the basics

      Me: How long is your menstrual cycle?

      Patient: Three to four days.

      Many

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