You have probably noticed in life that every silver lining has a cloud! In the case of HRT, the cloud is called progestogen (a synthetic form of the hormone progesterone).

Up to now it has all looked pretty good: whether you have hot flushes, vaginal and bladder problems, mood changes, or even feelings of insects crawling over your skin, replacing oestrogen gives you a good chance of ending these troublesome symptoms of the menopause. HRT even protects you against osteoporosis, and reduces your chance of having a heart attack. It all sounds too good to be true.

If you have had a hysterectomy, you can skip this slightly depressing chapter, because progestogen is not a word that need bother you. But if you still have a uterus (womb) and are considering taking HRT.

Progesterone is produced in the ovaries after the ovulation phase of the menstrual cycle, and in pregnancy. Its main function is to prepare the womb for a fertilised egg, and to maintain the pregnancy. It also thickens the lining of the womb, reduces secretions from the cervix (the neck of the womb), prevents ovulation, contributes to the retention of water and salt, and works with oestrogen to stimulate milk cells in the breasts. During a menstrual cycle that doesn’t result in pregnancy, it is the production of progesterone that contributes to the pre-menstrual feelings of bloatedness, breast tenderness, and general irritability. So although it has an important role to play in the menstrual cycle and pregnancy, progesterone is not exactly an unmixed blessing, and its presence in HRT causes the single most important reason why women who have not had a hysterectomy either don’t want this form of treatment at all, or don’t stay on it for more than a few months.

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Various procedures have been developed in recent years which aim to destroy the endometrium in women experiencing excessive bleeding that is resistant to control by drug therapy. The heavy or prolonged bleeding may be caused by fibroids, adenomyosis, postmenopausal hormone therapy or drugs designed to thin the blood (anticoagulant therapy). These procedures do not appear to be helpful in relieving pain associated with menstruation.

The destruction process is carried out using a hysteroscope, an instrument described previously in this chapter. A fibre optic camera threaded through the hysteroscope records the view which is seen by the surgeon on a video screen. The surgeon, who needs good hand-eye coordination, watches the image on the screen, enabling him or her to guide various instruments in the confined space of the uterus. These instruments can include a ball heated by an electrical current (called a rollerball), an electrically heated wire loop (called a resectoscope) or a laser. The procedure is referred to as an endometrial resection when the electrically heated ball or wire loop is used to produce electrocoagulation (also called diathermy) of the endometrium, and an endometrial ablation when heat from a laser is used. The rollerball method of endometrial resection destroys the endometrium by rolling the coagulating ball over it like a paint roller, the electrocoagulation loop removes or ploughs several furrows in it, and the laser vaporises it. In the case of endometrial ablation, light from the laser passes down an optical fibre inserted into the hysteroscope and the surgeon moves the tip of the laser to draw a fine beam of light across the endometrium. In radiofrequency ablation, high energy radio frequency waves are applied to the endometrium instead of the high energy laser beam. A thermal method of removing the endometrium which involves passing hot water into the uterus is also being developed. Early studies suggest it is just as effective as methods using laser or electrocoagulation and may have advantages over them in terms of safety.

Comparisons of the resectoscope and the laser suggest that the former is cheaper, more readily available in hospitals, faster to use, takes less time for doctors to become competent with, is more robust and results in fewer complications. As the techniques alter, however, claims to superiority may be short-lived. A study comparing the newer ablation technique of radiofrequency with endometrial resection claims the former is simpler to perform, less time-consuming and possibly safer. However its cost is higher and the success rate is comparable.

Women having these procedures can receive either a general anaesthetic or a local anaesthetic with light sedation, although, for the laser treatment, a general anaesthetic is currently the norm. A few women bleed heavily immediately after the operation; but, for most, light post-operative bleeding gradually turns into a light discharge that disappears completely over about four to six weeks. Periods may continue, and in most cases they are light. Most women are in hospital for a day or overnight, and many have resumed work within a week or two. A year after an endometrial ablation or resection, about 85% of women report having reduced their use of sanitary pads or tampons by more than half; some have no bleeding at all, while for others heavy bleeding is still a problem. Looked at over a ten-year time frame, there is still a dearth of data.

The endometrium is well-known for its regenerative powers, provoking speculation that removing the endometrium is just ‘one more operation of doubtful value* that women are being encouraged to have. One study of more than 400 women who had endometrial resections for fibroids, endometriosis or adenomyosis found that about 20% developed a recurrence of heavy bleeding within four years, in some cases within a few months of the procedure.10 Some of these women chose to have the procedure repeated but, after a second try, about 40% of this group were still having bleeding problems. Overall, about one in every eight women who had an endometrial resection ended up having a hysterectomy within four years. Women who had a repeat resection were even more likely to resort to hysterectomy, with more than one in three such women eventually having the operation.

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NREM sleep represents three-quarters of the time spent in sleep. Although a great deal of study has been carried out on the psychology of dreams, no one has yet studied the psychology of NREM sleep, but I will try to make amends here. Biologists and physiologists like to classify our state of awareness into two main types, the conscious state and the unconscious state. This grouping should not be confused with Freud’s concept of the conscious and unconscious mind.

The unconscious state is a state in which we are not aware of anything and from which we are not easily aroused. It includes such experiences as a black-out after a head injury, the complete blank while under general anaesthetic, and so on.

The conscious state, on the other hand, is a state in which we are continuously aware of what goes on around us or of what we are thinking. We can account for all events continuously. So we can describe how we got out of bed in the morning, got dressed, had breakfast, went to work, said hello to the pretty secretary, worked hard, had a wonderful lunch with the secretary, went back to the office to work even harder, came home, had dinner, watched television, went to bed (still thinking about the wonderful lunch) … and then there is a blank, until we get out of bed again the next morning. (For the lady readers, please change ‘pretty secretary’ to ‘handsome assistant’, but note that the pretty secretary here just happens to be my wife!)

An interesting feature of the above is that we are able to give a continuous account until after our thoughts of ‘the wonderful lunch’. A blank follows. We are not unconscious, as we can be aroused easily. However, we are not conscious either, as there is a blank in the continuous account of the day’s event. This blank is NREM sleep, during which there is no thinking, no memory, and no account of what goes on, very much like the blankness we have when undergoing general anaesthetic. NREM sleep is classified under the conscious state because it is arousable, but it is much more like the unconscious state, as we have no thinking or memory and cannot give a continuous account of what goes on.

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