A Complete Sexual Health Information for Female

Women - Know Your Body

Most of us are familiar with the different parts of our bodies and have a working knowledge of what they do. But somehow, when it comes to the area 'down there', nobody's sure about the great unknown. It's a taboo subject. You can't ask your parents about it. Whatever little you know has been picked up from girlie magazines and steamy novels, which are not the most reliable source of information. And like you, your friends are pretty much groping in the dark. Read on to find out about that mysterious place between your legs.

External female anatomy 

The entire external sexual area in women is called the vulva. The soft, fatty pad of the female external anatomy covered with pubic hair is called the mons veneris or Mount of Venus. Pubic hair begins to grow around the age of 12 and varies in colour, texture, and density. In some women, the hair extends up to the navel. 

The labia majora are two soft folds of outer skin covered in hair that cushion and protect the vaginal opening. The labia minora are small, sensitive lips just inside the labia majora. They become engorged when a woman is aroused, providing a tighter grip around the penis. There are glands in the labia minora that secrete a small amount of fluid during sexual arousal. 

If you pull the labia majora apart with your fingers, you will see the clitoris at the top of the folds. It is a small rounded piece of tissue that is very sensitive to sexual stimulation. It becomes stiff and enlarged when a woman is sexually aroused. Touching other erogenous areas of the body like the breasts and the neck can also result in the erection of the clitoris. Directly below the clitoris is the urethral opening through which you urinate. 

The hymen, the guardian of your virginity, is a thin tissue-like membrane that partially covers the vagina, leaving a small opening for vaginal and menstrual discharge. Some women are born without hymens; some hymens tear during sport activities like riding and bicycling or when women have sex for the first time. 
 

Internal female anatomy 

The vagina is an elastic tunnel about 3-5 inches long that connects the cervix to the outside of your body. It performs serves several functions: the menstrual flow passes through it; so does sperm on the way to the uterus; this is where the penis is inserted during intercourse and it also serves as the birth canal during childbirth. The length of the vagina does not affect ease of delivery or the degree of sexual enjoyment. Since the entrance to the vagina is more sensitive than the back, the length of your partner's penis doesn't make a difference. In other words, size doesn't matter. 

If you insert your hands into your vagina, you may feel something hard and dimpled. This is the cervix, which is the mouth of the uterus. It is very small and will not allow a penis, a finger or a tampon to enter, but it can stretch enough to let a baby through at the time of delivery. 

The uterus is a muscular organ about the size of a fist. This is where the foetus grows for nine months during pregnancy. The contraction of the uterine muscles in a pregnant woman marks the beginning of the birth process. 

There are two openings at the upper end of the uterus that lead to a pair of fallopian tubes. This is where the sperm, after surviving the journey through the vagina, cervix and uterus meets the egg and fertilizes it. The inside of the tubes is lined with microscopic hairs that help the fertilized egg on its journey to the uterus where it becomes embedded in the uterine lining. 

The ovaries are a pair of almond-sized organs located on either side of the uterus adjacent to the opening of each fallopian tube. The ovaries produce eggs and the hormones oestrogen and progesterone. Normally, an egg is released once every month and travels down the fallopian tubes into the uterus. If it is fertilized, it is implanted in the uterine lining. If it isn't, it will be discarded in the menstrual flow. That is why one of the signs of pregnancy is a missed period. 

The Periodic Cycle of a Woman

What is the female periodic cycle?

The normal reproductive years of the female are characterized by monthly rhythmic changes in the rates of secretion of the female hormones and corresponding changes in the ovaries and sexual organs as well. This rhythmic pattern is called the female sexual cycle. The duration of the cycle averages 28 days.

Which hormones govern the female cycle?

The female hormonal system consists of five hormones - 

1. Luteinizing hormone releasing hormone (LHRH)
2. Follicle stimulating hormone (FSH): FSH stimulates the ovaries and growing follicles
3. Luteinizing hormone (LH): LH stimulates ovulation
4. Oestrogen: It is responsible for regulating and sustaining female sexual development and reproductive function
5. Progesterone: It prepares endometrium for implantation

How are ovulation and menstruation defined?

Ovulation is the end result of a complex series of events leading to the production and release of an egg. If that egg is fertilized and gets implanted in the lining of the uterus wall (endometrium) a pregnancy has commenced. If it is not fertilized then it is lost together with the endometrium as the menstrual blood flow at the beginning of your next period.  These events are collectively known as the Menstrual Cycle and are controlled by a pea-sized structure called the pituitary gland, which is attached to the under surface of the brain.
 

What happens during the menstrual cycle?

1. At the beginning of a period, a hormone called Follicle Stimulating Hormone (FSH) is released from the pituitary gland. FSH stimulates a follicle on the surface of the ovary to grow. Contained within the follicle is the developing egg.
2. During the next two weeks the egg grows and matures, and as it does, so a female hormone called oestrogen is produced in increasing quantities by the ovary. The oestrogen in turn enters the bloodstream and feeds back to a part of the brain above the pituitary gland where it is recognized by special receptors. If enough oestrogen has been produced, this feed back process decreases the production of FSH. 
3. Rising oestrogen levels also trigger the output of another hormone from the pituitary gland called Luteinizing Hormone (LH). This leads to the release of the mature egg from the follicle. The escape of the egg from the ovary is known as ovulation. 
4. After ovulation, the empty follicle forms a structure called the corpus luteum, which produces the second female hormone called progesterone. The progesterone levels go up after ovulation, and maintain the endometrium in a state of readiness to receive a fertilized egg. If the fertilized egg does not implant itself the progesterone level falls and a period commences. The whole cycle now begins once more.

Ovulation and Menstruation Problems

What are the various ovulation problems?

There are five main categories of ovulation problems:

1. Oligomenorrhoea (very erratic periods): There is a defect in the feedback of oestrogen from the ovary to the brain. In spite of this, levels of F.S.H., L.H. and oestrogen are normal, but there is usually a menstrual disorder with either Oligomenorrhoea or secondary amenorrhoea. 
2. Amenorrhoea (never have a period or periods have stopped): The pituitary gland fails to produce F.S.H. and L.H. This, in turn, affects the ovaries, which fail to produce oestrogen. Amenorrhoea is usually the representing symptom. 
3. Menopause-like condition: The ovaries fail to respond or may be resistant to F.S.H. As is the case in menopause, the F.S.H. levels are very high and the oestrogen level very low.
4. Polycystic Ovary Disease: This is a condition where there are multiple tiny cysts in the ovaries. The L.H. level is characteristically high with normal F.S.H. and oestrogen levels. There is often Oligomenorrhoea or amenorrhoea. 
5. Hyperprolactinaemia: The level of the hormone prolactin is very high while the levels of F.S.H. and oestrogen are lowered. This condition is known as hyperprolactinaemia. There is either Oligomenorrhoea or amenorrhoea. Discharge from the nipples is also a symptom of this condition as this is the hormone responsible for milk production. 

If you have amenorrhoea, your specialist may recommend a test
called the Progesterone Challenge Test before the commencement of the”fertility drug" treatment. This involves taking progesterone tablets for five days. If the ovaries are producing oestrogen, a withdrawal menstrual bleed should occur after progesterone tablets have been stopped.
 

Are ovulation problems reversible?

With the exception of ovarian failure for which there is no treatment, all the other causes of ovulation disorders are treatable. If an ovulatory disorder lies at the root of your infertility, you can expect that with the appropriate treatment, the chances of your having a baby will be elevated almost to the levels enjoyed by the fertile population.
 

Is ovulatory disorder a major cause of infertility?

At least 20% of the women attending an Infertility Clinic will have a problem relating to ovulation.

Your menstrual history may indicate the likelihood of an ovulatory disorder for example: 

1. You may never have had a period, a condition called primary amenorrhoea; 
2. Periods which were once present have now stopped altogether (known as secondary amenorrhoea);
3. Your cycle is so erratic. E.g. periods occurring every 1-4 months, that even if you are ovulating, ovulation is completely unpredictable (known as Oligomenorrhoea).

Sometimes a woman's B.B.T. Chart, day-21 progesterone assay or endometrial biopsy may show that despite the fact that she has an apparently normal and regular cycle, definite problems exist. Either she is not ovulating (anovulatory cycles), or the luteal phase of the cycle is too short, perhaps combined with lowered progesterone levels from the corpus luteum after ovulation. (Inadequate luteal phase). 
 

Predicting Ovulation

How do I know when I am ovulating?

When you are planning a baby, it is important to know whether you are going to be ovulating in that cycle, and if so, when are you ovulating.  There are a few ways of determining ovulation:

(a) Ovulation Predictor kits:
Ovulation predictor kits are the most convenient method for predicting ovulation.  Although slightly expensive, they offer you that luxury of testing in the privacy of your home. They simply require you to collect a few drops of urine and test them on the stick over a period of about 7-10 days of your likely ovulation time.  The day the stick changes colour to a shade darker than the previous days, you are likely to ovulate within the next 48 hours.  If you have run out of all the sticks in the pack without detecting a colour change, you may have to buy another test kit and continue testing. It could mean that either you have not yet ovulated, or that you may not be ovulating in this cycle.

(b) Basal Body Temperature (BBT): 
This method requires the woman to keep a chart of her daily temperature readings.  The temperature needs to be taken from the woman is anus first thing in the morning while she is still in bed.  It can be recorded using either special test kits available in the market, or a regular thermometer.  The basis for this method is that a woman’s basal body temperature drops briefly and then raises half a degree following ovulation, and remains elevated until the start of the next period.  Normal BBT is between 96 and 98 degrees, and after ovulation rises to 97 to 98 degrees.  A rise in temperature that persists for at least 3 days indicates that ovulation has occurred.

(c) Mucus method:
Another method that is more recent depends on the analysis of the vaginal mucus. A few days before, also called the dry period, there is very little mucus in the vagina. When there is white vaginal discharge in the vagina, it indicates the beginning of the wet period.  At the time of ovulation, the mucus becomes clear, sticky and stringy in nature, and can sometimes stretch to over a couple of inches between your two fingers.

(d) Ultrasound Scan: 
Another way of determining your ovulation is through an ultrasound scan.  An ultrasound scan is also usually used when it is critical for fertilization to take place at the precise time of ovulation, such as for artificial insemination.  This method of predicting ovulation, although very reliable, is quite expensive.

Fertilization

How does fertilization take place?

During each month of the female sexual cycle, there is a cycle increase and decrease of FSH and LH

Pre-ovulatory Phase:
The pre-ovulatory phase is the time between menstruation and ovulation. During the first few days after the beginning of menstruation, concentrations of FSH & LH increase several fold. These hormones cause accelerated growth of 6-12 primary follicles each month.  When under the influence of FSH, the group of follicles continue to grow and secrete oestrogen. One dominant follicle becomes mature graafian follicle i.e. continues to increase its oestrogen production under the influence of increasing level of LH. Small amounts of progesterone are produced by the mature follicle a day or two before ovulation. 

Ovulatory Phase:
Estrogens liberated stimulate repair of endometrium and thicken it. New ovulation occurs on the 14th day i.e. there is rupture of mature graafian follicle. Post ovulatory is the period between ovulation and next menses. A single ovum is expelled from an ovarian follicle into the abdominal cavity in the middle of each monthly cycle. This ovum then passes through one of the fallopian tubes into the uterus and if it is fertilized by a sperm, it implants in the uterus where it develops into a fetus. 

Menstrual Phase:
If fertilization does not take place, this ovum gets released in the menstrual phase.  During the menstrual phase, follicles in each ovary begin to enlarge. Menstrual flow from the uterus consist of 50-150ml blood, tissue fluid, epithelial cells derived from endometrium. 
 

When is fertilization and pregnancy most likely to occur?

Fertilization of an egg can only occur if you have intercourse around the time of ovulation, the so-called 'fertile phase' of the cycle. If you are ovulating, this takes place l4 days before the onset of a period. This is a reasonably predictable event if you have a regular cycle but may be very unpredictable if you have a very erratic cycle. 
 

What is necessary in order for pregnancy to occur?

1. Ovulation is essential;
2. Intercourse must take place during the fertile phase of the cycle;
3. Your partner's sperm count must be adequate to ensure that a sufficient number actually reach the egg;
4. The mucus in the cervix must not be unfavourable and/or hostile to the sperm;

There must not be any mechanical barrier preventing fertilization from taking place, such as blocked fallopian tubes or adhesions around the ovaries preventing the egg from gaining access to the tube and sperm.

Various Forms of Contraception

What are the various forms of contraception?

There are various forms of contraception, ranging from natural family planning methods which are least invasive, to intrauterine devices which require a doctor's intervention:

(a) Natural family planning methods:
These methods are based on the principle that conception can be avoided by abstaining from sex during the woman's most fertile period.  The two most popular methods are the temperature method and the rhythm method.  These have a very high success rate when combined with other forms of contraception.

(b) Artificial barriers:
These methods mechanically block the sperm from entering the uterus.  These include condoms, diaphragms (soft rubber cup-like devices used with sperm-killing cream, inserted into the woman's vagina before intercourse), intrauterine devices or IUDs (inserted into the woman's vagina and kept there for the entire time she does not wish to conceive), vaginal insert contraceptives, etc. In addition to contraception, the advantage of these barrier methods is that they prevent the spread of AIDS and other sexually transmitted diseases. 

(c) Spermicidal:
Creams, foams, jelly and similar substances with special spermicidal chemicals can be useful contraceptives.  These substances are inserted into the vagina before intercourse, and essentially immobilize the sperms and make them ineffective. 

(d) Birth control pills:
Birth control pills are specially designed to control the hormone levels of the woman.  These pills need to be taken daily, for the entire duration that the woman is sexually active and does not wish to conceive.  If taken correctly, success rate is close to 100%, but the drawback is that one needs to remember to take it daily; else it loses its effectiveness.
 

How effective are these various contraceptive methods

The table below indicates that the success rates are higher for contraceptives that are more invasive:
 

Rhythm method	80% on average
Foam	80% on average
Diaphragm	85% on average
Condom	90% on average
Combination pill	97% on average
IUD	99%

Natural Family Planning

What is natural family planning?

Natural family planning, i.e. without the use of drugs or contraceptives, can be achieved by abstaining from intercourse during the fertile period.  There are many methods that help in determining the woman's fertile period (ovulating phase).  The two popular methods are: the Temperature method; and the Calendar method.
 

What is the Temperature Method?

A woman's basal body temperature (BBT) drops briefly and then rises half a degree following ovulation, and remains elevated until the start of the next period.  Normal BBT is between 96 and 98 degrees, and after ovulation rises to 97 to 98 degrees.  A rise in temperature that persists for at least 3 days indicates that ovulation has occurred.  The safe period begins from the fourth day to the last day of your next period.  In order for this method to be effective, a chart of your daily temperature reading needs to be kept.
 

What is the Calendar method ('rhythm' method?)

Regardless of the length of your cycle, ovulation always occurs 14 days before the start of your next period.  The safe period is generally three days after ovulation has occurred.  For a woman with a 28-day cycle, the first 2-3 days after menses are also safe.  Note, however, that using this as a sole method of contraception is unreliable for women with longer or unpredictable cycles.  This method works best for women with regular cycles, and has an average success rate of 80%.

The Birth Control Pill

What are birth control pills?

Birth control pills, also called oral contraceptives, contain hormones like oestrogen and progesterone.  There are two kinds of pills, combination pills and mini pills.  The mini pill is so called because it contains only progesterone.  However, 99% of all pills are combination pills, which contain both oestrogen and progesterone.  If you are starting on birth control pills, you should start them on the fifth day of your period, regardless of whether bleeding has stopped.
 

Should one take these pills during menstruation?

All combination birth control pills come in packages of 21 or 28 pills. If the pack contains 21 pills, then the woman should take the pill each day, at roughly the same time, for 21 days.  She should then stop taking the pill for 7 days (during which time she will most likely menstruate) and then start again on the next pack of 21 pills. If the pack contains 28 pills, the woman is expected to have a pill for 28 days, and then without missing a day, start with the next pack (regardless of her periods).  The reason is that the pack of 28 pills contains not only 21 hormone pills, but also 7 'blank' pills with no active ingredients.
 

What if I forget to take the birth control pill one day?

If you forget to take one pill then take two pills the next day.  If you miss two pills in the third week of the pill pack, then start a new pack immediately because this is your fertile period.
 

Can I take the birth control pill if I am breast-feeding?

You should not take the combination birth control pills if you are breast-feeding because it may decrease the quantity of milk supply.  The doctor can prescribe you the mini pill instead.

Side Effects and Risks of the Pill

What are the possible side effects of the birth control pill?

Although over 85% of women have mild to no side effects to the pill, it is important to know the serious side effects so that appropriate measures can be taken in time:

• Mild side effects: Nausea, weight gain (about 2 kgs), fluid retention, breast tenderness, spotting between periods.  These side effects usually subside in the first three months

• Moderately serious side effects: Breast pain, discharge or engorgement; rash, itching or jaundice; reduced tolerance to contact lenses; headaches or migraines; nervousness or depression.  If you experience any of these side effects, you should inform your doctor.  The doctor may be able to prescribe another brand of the birth control pill that may be more suitable for you. He may also ask you to stop the pills completely and resort to a different form of contraception.

• Serious side effects: Blood clots are a serious side effect of the pill.  Blood clots will exhibit different symptoms depending on the part of the body where they form.  Some of these symptoms are leg tenderness or swelling; sudden chest pain or shortness of breath, partial or complete loss of vision or blackouts; numbness in any part of the body.  If you experience any of these symptoms, you should immediately stop the pill and consult your doctor.

For whom is the birth control pill not advisable?

The pill is also not advisable for the following women:

• Women over 35 who smoke;
• Women with high blood pressure, high cholesterol, or a family history of heart disease;
• Women with past or present breast, uterus or liver cancer;
• If a pregnancy is suspected

There are also other reasons when a pill is not advisable.  Your gynaecologist would be in the best position to make this decision since she would know your and your family's medical history.

Birth Control Pill and Conception

When should I stop taking the pill if I want to get pregnant?

The pill should be stopped at least 2-3 months before deciding to get pregnant, so that the chances of foetal malformations are reduced.  During this time, other forms of contraception, like condoms or creams, should be used.  It is important to note that women who have had irregular cycles before starting the pill will have a significant delay  (six months or more) in getting their first period
 

Is it true that the birth control pill causes infertility?

Contrary to popular belief, the pill does not cause infertility, nor does it reduce the sex drive.  There is also no benefit to going off the pill for a while (rest period) and then restarting it either.

Vaginal Contraceptives

What are vaginal insert contraceptives?

Vaginal foams, creams, gels, and suppositories contain spermicides and are 80% effective. Creams and jellies are usually used in conjunction with condoms thus increasing their contraceptive effectiveness and enhancing protection against venereal disease. Foam comes in a pressurized container with a nozzle or a plastic applicator. You should insert the nozzle or applicator deep into your vagina to ensure that the foam is ejected as close to the cervix as possible. Foam has an immediate effect. Vaginal suppositories, on the other hand, take ten to fifteen minutes to dissolve.
 

How do vaginal contraceptives work?

Vaginal contraceptives need to be placed in the vagina just 4-5 minutes before intercourse.  The spermicidal action of a vaginal contraceptive lasts for about 1 hour after insertion.  The sperm is first immobilized by soluble base and the spermicide then prevents pregnancy from occurring by acting on the sperm and killing it immediately on contact. 
 

What are the advantages of vaginal contraceptives?

The main advantages when compared to other methods of contraception are:

• No loss of natural feeling when compared to condoms.
• No side effects such as vomiting, headaches and weight gain when compared to oral pills.
• No bleeding or pain when compared to the Loop.
• No interference of a third party because it is do-it-yourself method.

The Male Condom

The condom is a rubber sheath that fits over a man's erect penis. In this way, it serves as a barrier, preventing the sperm from entering the uterus. It is 90% effective as a method of birth control. It also offers the best protection against venereal disease, including AIDS. Condoms are available at any chemist. 

The condom should be used every time you have intercourse. There may be some decrease in the sensation during sex. The man should put it on prior to any genital contact. You should avoid the use of oil-based lubricants like petroleum jelly, cold cream or baby oil as these can weaken latex condoms causing them to break. If necessary, use water-soluble lubricants like K-Y Jelly. Some condoms are lubricated with spermicide, which increases their effectiveness. 

Half an inch of the condom should be left at the tip of the penis to collect the semen. The condom must be removed carefully because if the semen spills, it could enter the vagina. Thus, the male partner should grasp the condom firmly at the base after climaxing to prevent it from slipping off and withdraw promptly before he loses his erection.

The Female Condom

The female condom is a disposable device that has two flexible rings at either end of a soft, loose-fitting polyurethane sheath. It is 75% effective as a birth control method and as a preventive measure for venereal disease. It is inserted like a tampon, with the inner ring covering the cervix and the outer ring remaining outside. After intercourse, the condom should be removed by first squeezing and twisting the outer ring to hold the semen in the pouch.

Injectable Contraceptives

• Injectable contraceptives are used as a temporary method of contraception by females. They have been in use in India since 1992.
• They are widely accepted in USA, Europe and parts of Asia, especially in Thailand and Indonesia.
• Injectable Contraceptives (ICs) are made up of progestational compounds. Progesterone is one of the female sex hormones. This hormone is normally present in healthy, adult women during the latter half of their menstrual cycle.

There are 2 types of ICs available in the market. They are: 
 

1. Noristerat (Chemical name - Norethindrone Enanthate, also called Net-en)
   Noristert is to be given every 2 months.
2. Depo Provera (Chemical name - Medroxyprogesterone acetate)
   Depo Provera is to be given every 3 months.

Both are available as single dose ampules. Either of the two can be used. The choice is yours or your gynaec's!
 

Mode of Administration

Deep intra-muscular injection, preferably gluteally, with usual the antiseptic precautions.

This injection is NOT to be massaged. However, you could apply light pressure to the injected area for 1-2 minutes.

The first IC injection is to be given: 

a) Between the 1st and 5th days of the menstrual cycle. It can be given during or immediately after the menstrual period. 

b) Anytime during the menstrual cycle, if the woman and her doctor are sure that she is not pregnant. 

c) Postpartum - 6 weeks after normal delivery or Caesarian delivery.

d) Post abortion - immediately or within 7 days after abortion.

The second injection should be taken exactly after 2 months in case of Noristert, and after 3 months in case of Depo Provera. Upto 4 days earlier or upto 4 days later than the stipulated date is permissible.
 

ICs can be given in most cases where Estrogen containing oral pills are contraindicated or not tolerated.
 

ADVANTAGES

A. Contraceptive Benefits
  They have a 99% rate of efficacy during the first year of use, and are thus very effective. 

1. Their effect is rapid. They start working within 24 hours after administration. 
2. A pelvic examination is not required prior to use.
3. They do not interfere with intercourse.
4. They do not affect breast-feeding. They can be given to lactating women without any effect on the baby or on the amount of breast milk.
5. They have minimal side effects. There is no nausea, rise in blood pressure or any clotting disorder associated with their use. In fact, these risks are associated with oral pills. However, cases of mild headaches or dizziness should be reported to the doctor.
6. They provide you with protection for 2 to 3 months. There is no need to use any other form of contraception during this period. 

Sexually Transmitted Diseases

Paying the price

It's a fact that you have to pay a price to enjoy all the good things in life, whether it's chocolate, french fries, a chilled beer and yes, even sex. The difference is that while chocolates, french fries and beer usually take their toll when indulged in excess, it takes just one unprotected sexual encounter to make a baby or get a disease. And we're not just talking about AIDS. There are other diseases that are transmitted through sexual contact that cannot be ignored. Contracting a sexually transmitted disease is embarrassing as well as being uncomfortable and even painful.
 

What are STDs?

Sexually transmitted diseases, STDs for short, are "infections transmitted from one person to another during intercourse or other intimate contact." AIDS is the big daddy of them all, but that's not the only one. There are others which you must have heard of like genital herpes, genital warts, gonorrhoea, syphilis, Chlamydia and hepatitis-B. 

People often labour under the misconception that STDs are something that affects the poorer classes. The fact is that STDs can affect men and women from all backgrounds. It's just a question of who's having unprotected sex and sex with multiple partners. Often people who have contracted STDs show no symptoms, but as long as they are infected they can pass the disease on to their sexual partners. It's not just adults who get affected. Mothers infected with a STD can pass on the disease to a baby before, during or immediately after birth. While some of these infections in newborns can be treated, others can have serious repercussions causing a baby to become permanently disabled or even to die. 
 

Warning signs

Here are some indications that you might have contracted a STD and it's time you went for a check-up to the doctor. 

In the case of women, look out for the following signs: 

• Unusual discharge from the vagina 
• Pain, burning or itching around the vagina 
• Pain in the pelvic area or abdomen, sometimes with fever or chills 
• Bleeding other than your usual period 
• Sores or blisters on the genitals or in the mouth 

In the case of men, the following symptoms could indicate that they have contracted a STD: 

• Discharge from the end of the penis 
• Pain or burning when urinating 
• Swelling around the groin 
• Sores or blisters on the genitals or in the mouth 
• Flu-like symptoms such as fever chills, aches in the joints or muscles 

So if you have nightmares about being caught creeping stealthily into a 'Sex and V.D. Clinic' after contracting one of these diseases, it's better to put your mind at rest by informing yourself about the causes, symptoms and prevention of sexually transmitted diseases. Except for AIDS, STDs can be treated if caught in the early stages, but prevention is better than cure. So if you're going to have sex, remember that it's not all fun and games. Have a responsible approach to your sex life; else the consequences could be serious.

B. Other non-contraceptive benefits
  May decrease menstrual cramps.

1. May decrease menstrual bleeding.
2. May improve anaemia.
3. Protects against some causes of pelvic inflammatory diseases.
4. Decreases chances of ectopic pregnancy.
5. Decreases benign breast disease.
6. Protects against endometrial cancer.
7. Any nurse or trained non-medical staff can administer the injection. There is no need to book an appointment with your gynaec every time you need a shot.

DISADVANTAGES

1. Menstrual Irregularities - Spotting, breakthrough bleeding and sometimes skipping of your periods are the side effects of these contraceptives. However, skipping of your periods is natural when you are on the IC and it does not cause any harm… and, of course, it helps in cases of anaemia!
2. Planning or postponement of the period is not possible when the woman is on ICs.
3. One cannot accurately predict the timing of the period, which may create a slight problem, especially when planning a holiday or even religious function. 
4. There may be a delay in return to fertility after discontinuing ICs. Pregnancy may not occur immediately. On an average it takes 2-3 months after you stop taking the pill or removing a Copper T to resume fertility. If you are using injectable contraception, this period is longer, and can be 4 to 5 months. 
5. ICs do not provide protection against STDs or HIV. Neither do oral pills for that matter. Only condoms or any other barrier method of contraception can provide this protection. 

Taking Precautions

Safer sex

The bad news is that there is no such thing as safe sex. The only way to avoid surprise pregnancies and nasty diseases is to abstain from sex. Most people are not willing to even consider this option. So if you can't exercise any control over your libido, the next best thing is to practice safer sex. But just like it takes two people to make love, it takes two people to practice safer sex. This is something that you have to discuss with your partner.

Contrary to popular belief, sex is not just about penetration. You and your partner could explore other forms of sexual expression like kissing, cuddling and caressing each other. There's no harm trying it out. You'll be surprised how pleasurable it can be. 
 

Tips for playing it safe

It is understandable if this is not a viable option for most people because people in a relationship are bound to want to move on to the next step sooner or later. In that case, you should take the following precautionary measures:

• Buy your own condoms and don't forget to check the expiry date. And this applies to women too. Remember that your body is your responsibility. It is up to you to look out for yourself and take the necessary precautions.
• Make sure that you or your partner knows how to use a condom properly and use it every time you have sex.
• You are not going to be in a condition to make a sensible decision about safer sex under the influence of alcohol or drugs. Make your stand clear to your partner before you indulge yourself in these substances.
• Promiscuity could mean trouble. Be picky about your sexual partners and try to avoid having intercourse with people who have multiple partners. 
• Birth control pills, diaphragms or IUDs do not provide adequate protection against STDs. Spermicides provide a small degree of protection against STDs, but it is advisable to use them in combination with other methods of protection.
• Keep yourself informed about the symptoms of different STDs so that you can check with the doctor if you have the slightest suspicion that you have contracted a STD.
• If you are sexually active, it is a good idea to routinely check for STDS even if you don't have any symptoms. 
• Tell your partner if you have been diagnosed as having a STD so that he or she can get tested.
• If you or your partner have been infected with a STD, you will have to abstain from sex. 
• Don't let any feelings of embarrassment stand in the way of your visiting the doctor if you suspect that you may have contracted a STD. 

What to expect at the doctor's clinic

The doctor will probably ask you what symptoms you have that prompted you to think that you may have contracted a STD. He will ask you questions about your sex life and if your partner displays any symptoms of a STD. 

Once he has made a note of your history, he will conduct a physical examination. He will probably need you to undergo some tests to confirm his diagnosis. Tests will be run on blood samples, urine samples and any swabs that the doctor takes from the affected area. The results may take a few days to come in so abstain from having sex in the interim to be on the safe side.

Did You Say, AIDS?
The lady on the phone sounded really frantic. It was the principal of a well-reputed English medium school. Ever since a series of articles on AIDS had been run in the local newspapers, she and the biology teacher of the school had been inundated with questions from the students. And they found to their horror that most of the facts about the subject were unclear to them too. A simple one-hour affair explaining the basics of the condition so that all confusion was clear, once and for all. She also wanted a question and answer session following the deliberations.

Well, AIDS being my favourite topic, I just could not resist the invitation. The talk was fixed for the following week.

Here is a summary of the topics discussed that day [The questions that followed my talk, stretched the session to almost 2 hours - so much so that a subsequent talk had to be scheduled just for the questions]. 

The condition of AIDS could not have been more aptly named. 

Acquired - opposed to congenital, 

Immune Deficiency - indicating the weakened immune system of the patient, 

Syndrome - conglomerate of numerous signs and symptoms involving a multitude of organ systems.

AIDS is caused by a virus now called the HIV (Human Immunodeficiency Virus). Three strains have been confirmed, HIV-I, HIV-II, HIV-III. Viruses basically are extremely small (20 - 300 nanometres) parasites, which multiply inside the cells of human beings who act as their hosts. Structurally they consist of a nucleic acid core (which carries the virus genetic information) surrounded by a coat of protein. [When the virus was discovered way back in 1982 by two independent groups of researchers, it was known by other names HTLV-III and LAV - terminology which has now been rejected].

The HIV is made up of two concentric glycoprotein spheres with a RNA (Ribonucleic Acid) core. The outer surface of the outer sphere has certain special proteins that help the virus to attach itself to the body’s immune defence cells - the T4 cells. After the virus enters the blood stream, it attaches itself to the said defence cells and its outer surface fuses with that of the cell. The RNA core then enters the cell and commandeers the reproductive machinery of the cell to replicate itself many times, These new viruses burst out of the host cell - killing it in the process - and go on to infect fresh T4 Cells. All such infected T4 cells are useless for the body and thus the human defences get crippled, leaving it open to even minor infections.

Though the HIV is present in all the body fluids, namely - blood, semen, saliva, tears, breast milk, urine and vaginal secretions, evidence available till now has implicated only blood, semen and vaginal secretions in transmission. (See Box - I for infectivity risk). There still is no conclusive proof as regarding breast milk / saliva transmitting AIDS. 

After the virus enters the blood stream (known as exposure in medical parlance), in almost all cases a fixed sequence of events occurs (see Box-II). A virus coming in contact / or deposited on intact skin / mucous membrane - poses no danger. But even if there is a micro abrasion (often unseen by the naked eye), the risk increases dramatically. 

Unlike many medical conditions where certain typical features characterise a particular disease, AIDS is completely different. AIDS by itself does not have any peculiar symptoms - but depending on the organ system involved it can present itself in numerous garbs. (Hence the question what are the symptoms of AIDS? is technically a wrong question).

However as a rough guide, one should keep this disease in mind (even the term AIDS is now no longer in vogue - more preferred is the term HIV) as one of the probable diagnosis if a patient presents with any of the following symptoms. Unexplained weight loss   (more than 10 % of body weight), persistent fever (more than 1 month), diarrhoea (more than 1 month), recurrent apthous (oral) ulcers, unexplained night sweats and recurrent herpes (A viral infection). All these just make a loose framework for one to suspect HIV positivity. You must remember that the presence of these need not always indicate AIDS, and neither are these symptoms mandatory in confirmed positive HIV patients. 

The diagnosis of HIV, just clinically, both in adults and children is difficult under normal circumstances because the usual signs and symptoms are non - specific and resemble many common illnesses. 

Apart from the general diseases that affect any normal individual, HIV patients often are susceptible to a group of infections called Opportunistic infections.

Organ systems most frequently afflicted by opportunistic infections include the respiratory, gastrointestinal, the skin and the nervous system (See Box - III). The reason that such infections are called opportunistic infections is that, in an HIV positive case, because of lowered immunity, certain rare and specific organisms get an opportunity to cause infection not usually available in a healthy person. As a rough benchmark, if any commonly occurring disease state presents in a widespread, flared up and rapidly progressive form in addition to it, being resistant to conventional treatment, one should suspect HIV infection. 

Despite universal similarities, there are certain geographical differences, in which AIDS has been presenting itself in different parts of the world. 

Especially in India, it’s usually a drug resistant and widespread TB and severe diarrhoea, which have been most frequently seen, in HIV positive cases. In the US, it is pneumonia (a rare variety of it), which is the most common clinical presentation. And finally in Africa severe diarrhoea is the most common symptom, which is also known as the Slim disease because of the acute weight loss it causes. Though certain findings mentioned earlier can lead one to suspect HIV infection, some tests are necessary to confirm the diagnosis.

Specific tests like the ELIZA include the detection of antibodies (or chemical agents with a fixed structure, which are formed in the body against any foreign agent - in this case the HIV is called the antigen. The foreign agent can also be a bacteria or an organ) against the HIV. There are also some other rapid fluorescence tests, which are routinely done in laboratories. And finally there is the confirmatory test - the Western blot test. However a HIV test, done with three different antigens is confirmatory enough. It is extremely important to remember here, that the tests become positive only 6-12 weeks after exposure. The latest reports say that this period might be as long as 6 months also. Before that (window period) practically nothing can help us to diagnose or suspect the condition.
 

The present status Of treatment

PREVENTION IS NOT BETTER THAN CURE. IT IS THE ONLY CURE

RISK OF INFECTION (from a HIV +ve source)

Sexual Intercourse (Vaginal/Anal)	0.1 % - 1.0 % (male to female is 7- 10 times more than female to male) Having STD increases the risk.
Blood Transfusion	90 - 95 %
Pregnant Mother to Child	20 - 40 %
Intravenous Drug Abuse & Others (*)	0.5 - 1.0 %
Breast Milk	Controversial (but if present, benefits definitely outweigh risks)
Saliva	Controversial (just anecdotal reports till now been presented in its favour).

(*)  - Surgical accidents

 -needle stick injuries

- Unsterilised instruments/ equipment.

YOU   DO   NOT   ACQUIRE HIV by:

1. Casual contact (sitting together, sharing clothes/ utensils).
2. Casual kissing, shaking hands (deep kissing when there are oral ulcers could be risky).
3. Mosquitoes
4. Swimming Pools/ Door knobs/ Railings/ Toilet Seats
5. Donating blood

[Apart from ways mentioned in the BOX, there is no other route by which HIV can be transmitted].

SEQUENCE OF EVENTS

Infection (exposure)	Sexual Intercourse. Blood transfusion, Intravenous drug abuse, Mother to unborn child.
Influenza like illness	2 - 3 weeks after infection (fever, fatigue, rash). Subsides on its own, often without the patient noticing it. So transient it is that the very occurrence of this is being doubted.
Seroconversion	6 - 12 weeks. HIV test now becomes positive. Patient absolutely fit and normal. Till this stage only the most advanced tests can help diagnose AIDS. (This period can be as long as 6 months also
Enlargement of lymph nodes. AIDS related complex (weight loss, fever, diarrhoea, oral ulcers, and herpes).	Depending on the patients own immunity and how severe the initial infection is, these related stages come at roughly around 5 years (but this is variable - a long period if infection is through intercourse and short if by blood transfusion)
AIDS (Symptomatic HIV)	20 % of those infected develop it in 5 years and 50 % in 10 years. Till this stage the patient is merely HIV positive. AIDS is labelled when the patient has        I) Opportunistic Infections ii) A malignancy called Kaposi’s Sarcoma and iii) some neurological deficit. After this the patient soon succumbs. (See Note � 6.)

Note:

1. A patient is infectious to others right from the moment of infection. A receiver can /may manifest symptoms much earlier than one who hands over the infection.
2. Infection can only occur, (essentially) if the viruses enter the blood stream and not merely surface contact.
3. Only recently has it been confirmed that a few cases despite being HIV positive 13- 14 years ago have not as yet developed AIDS.
4. There have been reports of some Caws/ patients not acquiring AIDS despite continuous exposure to the virus. [Active research is going on this direction also, as to why are some persons naturally resistant to HIV]
5. Doubtful reports talk of spontaneous reversal of HIV status.
6. Present terminology is symptomatic HIV (i.e. AIDS is now more properly called Symptomatic HIV) and asymptomatic HIV. Terms like AIDS or full-blown AIDS are no longer in vogue.

HOW AND WHY EXACTLY DO AIDS PATIENTS DIE

Depending on how severe the infection at exposure is, patients usually develop symptoms at around 7 years after the entry of the virus.

Symptoms can be in the form of any single or multiple system involvement. Infection occurs which either does not respond to routine treatment because of resistant strains or, if it responds, it does so after a long time only to recur. Such repeated infections debilitate the body leading to death. The drugs too, often produce rare reactions in AIDS patients not commonly seen otherwise. Some of the commonly encountered symptoms in HIV positive patients would be as follows.  RESPIRATORY	GASTROINTESTINAL	NERVOUS	SKIN
Cough	Persistent diarrhoea (by common and rare pathogens)	Headache	Xerosis (Dry Skin)
Breathlessness	Difficulty in swallowing or eating	Altered Personality	Purpuric Spots
Rapid Breathing	Perianal discomfort	Lethargy	Hair loss/ Greying of hair
Blood stained cough		Dementia
Effusions in Lung cavity		Convulsions	Bacterial Viral infections Fungal
		Meningitis
		Visual Impairment

[It is the causative organisms of these common symptoms, which are important in HIV positive]. 

There are a few conditions, which were extremely rare till now, the occurrence of which almost confirms AIDS and are called markers.

A) Few of these could be
a)Recurrent/ widespread Herpes Zoster
b)Oesophageal Candidacies
c)Kaposi’s Sarcoma in a young person
d)Oral Hairy Leucoplakia

HOW TO PROCEED WHEN YOU SUSPECT INFECTION
(Especially for those with high-risk behaviour)

• RELAX. DONT PANIC
• Get an ELIZA test done at a laboratory after 12- 14 weeks of the suspected exposure. In an Indian set-up nothing can help diagnose AIDS before this. Meanwhile assuming that you are infected takes care and do not infect others. (E.g. No blood donation, no unprotected intercourse, no pregnancy). 
• If the test is negative - learn a lesson not to repeat the mistake.
• If positive - get a repeat test done and if possible a Western blots.
• If Western blot too is positive, not everything is lost. Get professional help at counselling centres. Contact the nearest Government hospital. Get advice as to the drug therapy to be started.
• Lead a regular, hygienic and a fit lifestyle. [Healthy nutritious food, no vices]. Avoid stress. In short, avoid anything that can lead to an infection affecting the body. On the other hand, anything that boosts the body's general immunity helps.
• Yoga, Relaxation, Meditation are said to help a lot.
• Conquer fear.

High Risk Behaviour: More than one sexual partner (any sex)

• Anal Intercourse
• Drug addiction
• Patient of STD's
• Blood Transfusion Recipients

WHAT EXACTLY IS HINDERING THE DISCOVERY OF DRUGS AND VACCINES AGAINST HIV

• As with all viral infections HIV too has a very small armamentarium of drugs against it. Since viruses multiply within living human cells, drugs to act on them, have to damage the human cell as well.
• Viruses being extremely small and having a very simple structure, drugs have a few sites to act on (unlike as in bacteria, where they can act on the cell wall, the nucleus, the cytoplasm, the organelles etc.) to disable them.
• As for the vaccines, they help us fight diseases by acting on the immune system. Unfortunately in AIDS it is this immune system itself, which is under attack. Secondly, the virus (like the common cold virus) is known to alter its structure when inside the body thereby rendering the vaccine useless. This is so because the vaccine is very specific and only on a fixed and similar structure. Even a minute change renders the vaccine ineffective. Naturally it is difficult to synthesise vaccines against all the structural variations. 

 

 

HOW TO AVOID ACQUIRING HIV
(What all should you do, so as not to get infected)

1.  Avoid sex with multiple partners or even with a single partner who in turn has multiple partners (ideally speaking stick to one single, absolutely faithful partner).
2. If sex is unavoidable, always wear a condom (though there is no guarantee, at least this offers the best protection) - e.g. during sex with a Community Sex worker. Other methods of contraception provide NO protection.
3. Avoid unnatural modes of sex (anal/ oral)
4. Avoid intravenous drug abuse - and if unavoidable at least don’t share needles and syringes you can use disposable ones.
5. Take blood transfusions, only when you must and that too from a blood relative / friend and after getting it thoroughly tested.
6. Pettings, Masturbation, Mutual Masturbation are the safest alternatives to sex.
7. Insist that your barber use a fresh blade every time he shaves / cuts your hair.
8. Always insist on disposable needles and syringes when taking shots.
9. Contact your local AIDS Counselling Centre / Government hospitals for any further clarifications.
10. Remember even a single act of unprotected intercourse (forget the complete act, even unprotected penetration without going the whole way) with an infected partner can lead to infection.

Note:

• Active research is going on at such a rapid rate that a few of the concepts (true at the time of going to print) might turn out to be invalid in days / months to come.
• The write-up is an extremely simplified picture of the very complex disease process. The above stated points are accepted by the majority. However not all doctors/ specialists might be in agreement with all the points.

Premenstrual Syndrome (PMS)

Are you one of those women for whom having a period is almost torture? There you are getting on quite blissfully with the business of living - and then the big M - menstruation, blights you. And this happens on a regular basis. You rail against the laws of nature that have gifted the 'curse' of menses to women. Your head aches, your stomach cramps, your tummy feels bloated, you feel like crying for no apparent reason, and you bite everyone's head off at the slightest provocation. Most of all, you hate it when people shrug and patronizingly mouth, "PMS!"

This syndrome was first recognized and given a name - premenstrual syndrome or PMS in 1931. There was official recognition of symptoms that have plagued women for centuries. Feminists were ambivalent about the acceptance by doctors that PMS was a problem that they needed to take cognizance of. They felt that this would just give men another opportunity to point a finger at the "weaker sex" and their physical and mental inability to cope.

The onset of menstruation signifies that a girl has stepped across a biological threshold into puberty. For some women, menstruation is merely an inconvenience. Others really dread that time of month. The latter are usually women who are plagued by premenstrual syndrome (PMS). For these women it is not the five days of actual menstruation that bothers them so much as the symptoms of PMS that manifest themselves any time from two to ten days before menstruation begins. 

As its name signifies, the symptoms of PMS begin after ovulation, peak just before menstruation begins, and then vanish at the start of menstruation. The symptoms can be both physiological and psychological. There are a large number of symptoms of which the most common are: tender breasts, bloated abdomen, appetite changes and cravings, pimples, headaches, stomach upset and swollen hands and feet. Women afflicted with this problem also display mood swings, depression, fatigue, irritability, lack of concentration, oversensitivity, crying jags, and social withdrawal.

Tips for relieving the symptoms of PMS

• Try to avoid stressful situations and get some rest.
• Mild exercise like walking can help relieve PMS.
• Control the intake of alcohol and caffeine contained in tea, coffee, soft drinks, etc.
• Reduce salt intake. Salt absorbs water and increases water retention. 
• Vitamin B6 also helps in reducing premenstrual tension and water retention.
• Eat less at every meal, but more often. This will minimize the fluctuations in blood sugar. It may also help to eat more green leafy vegetables, whole grains and cereals, fish and poultry.

Sometimes the symptoms of PMS are so severe that they require medical treatment. Psychologists describe this as Premenstrual Dysphonic Disorder (PDD). In cases of PDD, the depression and mood swings of the woman are so severe that they disrupt her normal functioning. In such situations, the woman might have to be treated medically. Doctors may recommend painkillers, diuretics for fluid retention, and anti-depressants in extreme cases. 1.5 gms of Evening Primrose Oil taken twice daily has been found to alleviate painful and tender breasts. Both the physical and mental emotional symptoms of PMS have a biochemical basis that can be linked to the level of certain hormones in the blood. Hence, some doctors may even prescribe birth control pills to alleviate menstrual cramps and pre-menstrual tension on occasion. The ingredients of the pill probably even out any hormonal imbalance.

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