Going Abroad? Make sure to book an appointment with us at least 4 weeks before you travel. Contact clinic: 01-6314500

The D2 Medical Centre                 

Well Woman clinic 0830-1300 every Wensday with Dr Niamh Houston at the D2 medical, free smears for all women over age of 25.

Cervical Screening and cervical cancer vaccine at the D2 Medical.

Why are cervical screening tests advised?

The test checks the cells from your cervix. In most women the cells are normal. Abnormal cells are found in some women. An abnormal result does not mean cancer in the vast majority of cases. Abnormal cells indicate that cancer may develop sometime in the future. Treatment can be given to prevent cancer from developing in women with abnormal cells. So, the test aims to prevent cancer, and not to detect cancer.

Who should have a cervical screening test?

All women aged 25 to 64 should have regular tests. For women aged 25-49 it is usually done every three years. For women aged 50-64 it is usually done every five years. From the age of 65, most women do not need any more tests. However, women aged 65 or over who have not had a test since age 50, or have had recent abnormal tests, will still be advised to be screened. So, a test may be advised for some women aged 65 or more.

Why is the cervical screening test important?

Cervical cancer (cancer of the cervix) is not uncommon. In recent years the number of cases has fallen due to cervical screening tests. However, there are still over 2000 new cases of cervical cancer diagnosed each year in the UK. Cervical cancer can be prevented if you have regular screening tests.

Where do I go for a cervical smear test?

Most women have the test at the D2 medical, their local GP or at the rotunda hospital.

What do the results of the cervical screening test mean?

Normal result

About 9 in 10 routine cervical screening tests are normal. You will be sent a letter inviting you for another one in 3-5 years. (Note: a normal result means you have a very low chance of developing cancer of the cervix - not a 100% guarantee that it will not occur.)

Inadequate test

This sometimes occurs. This simply means no result can be given. For example, if the smear method was used, an inadequate test may occur because there was some blood or too much mucus on the slide and the cells could not be seen properly. Sometimes it is because a smear of cells was too thick or too thin to assess properly. You will be asked to attend for a repeat test. However, with the newer liquid based cytology method, the number of tests that are 'inadequate' and need repeating is much less than with the traditional smear method.

Abnormal result

Some changes in the cells are found in about 1 in 10 tests. There is a range of changes that may occur. In nearly all cases, these changes do not mean cancer.
Minor or borderline abnormal changes are quite common. These often clear away on their own and most mild changes do not progress to anything serious. However, any change needs to be monitored as some may progress to become more serious in the future. A repeat test after 3-12 months is commonly advised, depending on the type and degree of change. Often the changes will have gone when the test is repeated. If the changes do not go, or the changes are more marked, then a referral to colposcopy is advised. Rarely, a cancer of the cervix is diagnosed by a cervical screening test.

What is colposcopy?

Colposcopy is a more detailed examination of the cervix. In this test a speculum is gently put into the vagina so the cervix can be seen. The doctor uses a magnifier (colposcope) to look at the cervix in more detail. A liquid is used to 'paint' the cervix which shows up the abnormal cells. It takes longer than a normal screening test (about 15 minutes). It is done by a specialist at hospital. During colposcopy it is usual to take a small piece of tissue from the cervix (biopsy) to make a more detailed assessment of the cells.

Can abnormal cells be treated?

Yes. A minor abnormal change often goes away by itself. This is why a repeat test after 3-12 months may be all that is needed. If the cells remain abnormal, or the changes are more marked, then treatment is offered. This will stop cancer from developing in the future.

The types of treatments that are used include:

• Cryotherapy - freezing the affected area of the cervix which destroys the abnormal cells.
• Laser treatment - this destroys or cuts away abnormal cells.
• Loop Diathermy - a thin wire loop cuts through and removes the abnormal area of cells.

These treatments are done as an out-patient and do not take long. They are usually successful and are usually needed only once. Follow up and regular screening tests are needed for the next few years check that the treatment has been successful. It takes a few weeks for the cervix to heal after treatment. Once it has healed, a normal sex life can be resumed. Treatments do not affect fertility.

Some common questions about the cervical screening test

How effective is the cervical screening test?

The test is about 80% effective. This means that for every 10 women who would have developed cancer of the cervix, about 8 cases can be prevented. So, although it does not detect an abnormality every single time one occurs, overall it is a reliable test.

I have never had sex. Do I need a cervical screening test?

The test is recommended for all women - even if you have never had sex. However, the risk of getting cervical cancer is very low if you have never had sex with a man. This is because the main underlying cause of cervical cancer is a past infection with a virus called HPV virus. This is a very common virus that is normally passed on by having sex.

I have had a hysterectomy - do I need to have a cervical screening tests?

This depends on the type of hysterectomy, and why it was done. Get your doctor to advise. In general, if you have a total hysterectomy (removal of the uterus and cervix) for a reason not due to cancer, then you no longer need cervical screening tests. Some types of hysterectomy leave the cervix in place, and some are done to remove a cancer. In these situations, a test of the cells of the remaining cervix, or of the top of the vagina, may still be advised.

Does the cervical screening test really save lives?

Yes.

In summary

The 'take-home message' is:

• you are very unlikely to develop cervical cancer, IF....
• you have regular cervical screening tests at the times advised by your doctor, AND....
• you have treatment when advised if abnormal cells are detected.

Cervical cancer - HPV vaccine FAQs

There has been strong interest in the development of two human papillomavirus (HPV) vaccines, one of which (Gardasil) has been available in Ireland for several years. Gardasil has also been confirmed for future funding on the National Immunisation Schedule for 12 and 13 year old girls only. A lot of information is available, and this article is to help you answer some of the frequently asked questions (FAQs)

FAQs

Who is eligible for the funded vaccine?

The HPV vaccine (Gardasil) is available at the D2 medical, the cost of the vaccine in 600 euro for 3 shots over a six month period.

Is the new vaccine really important?

Yes. The available HPV vaccine is 100% effective against disease caused by HPV types 6, 11, 16 and 18.

Why are these HPV types important?

HPV types 16 and 18 cause around 70% of high-grade pre-cancerous changes and cervical cancers as well as vaginal and vulval cancers. HPV types 6 and 11 cause an estimated 90% of genital warts. The currently available vaccine prevents you being infected with four different HPV types (6, 11, 16 and 18) and protects against pre-cancers, cancers and genital warts caused by these HPV types.

Does the vaccine protect against all HPV types?

No. The vaccine has been developed to protect against the four most common types of HPV.Therefore, it will not prevent infection with other less common types.

Is the vaccine useful for everyone?

The vaccine does not work for a particular HPV type in the vaccine if you are already infected with that HPV type - it prevents HPV infection through sexual activity. That is why the target is a young age group (females 9-26 years; males 9-15 years). However, if you have been infected with one HPV type that is in the vaccine, the vaccine will still prevent you being infected with the other types contained in the vaccine.

What does it not protect against?

It will not protect against 30% of cancers and 10% of genital warts, which are caused by other less common types of HPV not in the vaccine.

Why is the vaccine recommended for such young girls?

HPV is sexually transmitted. The vaccine is best given when you do not have an HPV infection from an HPV type in the vaccine. Therefore, people who receive the vaccine before sexual activity begins will receive the maximum benefit and protection against the HPV types in the vaccine. However, if you have been infected with one HPV type that is in the vaccine, the vaccine will still prevent you being infected with the other types contained in the vaccine.

Why is it only recommended for girls/women aged nine to 26?

The safety and efficacy data from studies are well established for this age group. Further research is awaited on women older than 26.

Will sexually active females benefit?

Yes. Sexually active females will also receive protection. They may not receive full protection if they are currently infected with one of the vaccine HPV types, but they will be protected against the other types covered in the vaccine.

What if I already have genital warts?

The vaccine only works to prevent acquisition of HPV virus. It does not work as a treatment for genital warts. However, the vaccine can still be given to protect against the other HPV types covered in the vaccine.

What if I already have had an abnormal smear?

The vaccine only works to prevent infection with HPV virus. It does not work as a treatment for cervical smear abnormalities. The vaccine provides some (about 25%) protection against progression of HPV infection to CIN 1 (the first pre-cancerous stage) and worse. However, the vaccine can still be given to protect against the other HPV types covered in the vaccine.

Is there a test to see which HPV types I may have, or a screening test before having the vaccine?

An HPV DNA test is not routinely available in general practice. It is not necessary to know whether someone already has HPV before giving them the vaccine. Those who have already acquired one HPV type that is in the vaccine will still benefit from the vaccine by protecting themselves from the other types.

What about vaccinating boys and men?

The available HPV vaccine (Gardasil) is currently indicated for boys aged 9-15 years. This may change to include older males as research is completed. It makes sense to vaccinate males as this will protect them from genital warts and will have indirect benefits for partners.

How is the vaccine given?

It is a three-dose schedule given over six months - you receive the first dose, the second is given two months later and the third is given six months after the first one (0, 2 and 6 months).

How long does it work for? Is a booster needed?

The vaccine gives protection for at least five years. Follow-up trial data will likely show the duration of protection is even longer. It is not yet known if a booster is required, but current data show the vaccine produces a high immune response and is unlikely to need a booster.

Is it possible to get infected by the vaccine?

No. The vaccine is not a live vaccine. It does not contain the complete HPV virus and cannot cause HPV infection.

What if I do not finish the three doses?

It is not known yet what level of protection is provided by only one or two doses.

Are there any adverse effects?

The HPV vaccine is safe and has been studied in over 20,000 women. The most common side effects are local reactions at the injection site and fever, which are mainly mild and usually disappear in a few days.

Is it safe in pregnancy?

There is no evidence to suggest adverse outcomes in pregnancy. However, the vaccine is not licensed for use in pregnant women. If a woman becomes pregnant after starting the vaccination schedule, she should give birth before receiving the next dose. The vaccine is safe for breastfeeding mothers.

Who should not be vaccinated?

People with allergy to yeast or components of the vaccine should not be vaccinated.

As cervical cancer is the second most common cause of cancer death in women on a worldwide basis, this vaccine represents a significant advance in preventive health.

3. Cholesterol screening, What factors affect the blood level of cholesterol?

In most people, your cholesterol level reflects the amount of fat that you eat. This is not the full story as different people who eat the same amount of fat can make different amounts of cholesterol. However, in general, if you eat less fat your cholesterol level is likely to go down.

In some people, a high cholesterol level is due to another condition. For example, an underactive thyroid gland, obesity, drinking a lot of alcohol, and some rare kidney and liver disorders can raise the cholesterol level.

In some people, a very high level of cholesterol runs in the family due to an inherited genetic problem with the way cholesterol is made. One example is called familial hypercholesterolaemia.

Risk factors

Everybody has some risk of developing atheroma which then may cause one or more cardiovascular diseases. However, certain 'risk factors' increase the risk. Risk factors include:

• Lifestyle risk factors that can be prevented or changed:
  • Smoking.
  • Lack of physical activity (a sedentary lifestyle).
  • Obesity.
  • An unhealthy diet - including eating too much salt.
  • Excess alcohol.
• Treatable or partly treatable risk factors:
  • Hypertension (high blood pressure).
  • High cholesterol blood level.
  • High trigliceride (fat) blood level.
  • Diabetes.
  • Kidney diseases that affect kidney function.
• Fixed risk factors - ones that you cannot alter:
  • A strong family history. This means if you have a father or brother who developed heart disease or a stroke before they were 55, or in a mother or sister before they were 65.
  • Being male.
  • An early menopause in women.
  • Age. The older you become, the more likely you are to develop atheroma.
  • Ethnic group. For example, people who live in Ireland with ancestry from India, Pakistan, Bangladesh, or Sri Lanka have an increased risk.

However, if you have a fixed risk factor, you may want to make extra effort to tackle any lifestyle risk factors that can be changed.

Note: some risk factors are more 'risky' than others. For example, smoking and a high cholesterol level probably cause a greater risk to health than obesity. Also, risk factors interact. So, if you have two or more risk factors, your health risk is much more increased than if you just have one. For example, a middle aged male smoker who has high blood pressure and a high cholesterol level has a high risk of developing a cardiovascular disease such as a heart attack before the age of 60.

What is a 'high' cholesterol level?

The following levels are generally regarded as desirable:

• Total cholesterol (TC) - 5.0 mmol/l or less. However, about 2 in 3 adults in Ireland have a total cholesterol level of 5.0 mmol/l or above.
• Low-density lipoprotein (LDL) cholesterol after an overnight fast: 3.0 mmol/l or less.
• High-density lipoprotein (HDL) cholesterol: 1.2 mmol/l or more.
• TC/HDL ratio: 4.5 or less. That is, your total cholesterol divided by your HDL cholesterol. This reflects the fact that for any given total cholesterol level, the more HDL, the better.

As a rule, the higher the cholesterol level, the greater the risk to health.

However, your level of cholesterol has to be viewed as part of your overall cardiovascular health risk. The cardiovascular health risk from any given level of cholesterol can vary, depending on the level of your HDL cholesterol, and on other health risk factors that you may have.

Assessing (calculating) your cardiovascular health risk

A 'risk factor calculator' is commonly used by doctors and nurses. This can assess your cardiovascular health risk. A score is calculated which takes into account all your risk factors such as age, sex, smoking status, blood pressure, cholesterol level, etc.

The calculator has been devised after a lot of research that monitored thousands of people over a number of years. The score gives a fairly accurate indication of your risk of developing a cardiovascular disease over the next 10 years.

Who should have their cardiovascular health risk assessed?

Current Irish guidelines advise that the following people should be assessed to find their cardiovascular health risk:

• All adults aged 40 or more.
• Adults of any age who have:
  • A strong family history of early cardiovascular disease. This means if you have a father or brother who developed heart disease or a stroke before they were 55, or in a mother or sister before they were 65.
  • A first degree relative (parent, brother, sister, child) with a serious hereditary lipid disorder. For example, familial hypercholesterolaemia or familial combined hyperlipidaemia. These diseases are uncommon.

If you already have a cardiovascular disease or diabetes then your risk does not need to be assessed. This is because you are already known to be in the high risk group.

What does the assessment involve?

A doctor or nurse will:

• Do a blood test to check your cholesterol and glucose (sugar) level.
• Measure your blood pressure and your weight.
• Ask you if you smoke.
• Ask if there is a history of cardiovascular diseases in your family (your blood relations). If so, at what age the diseases started in the affected family members.

A score is calculated based on these factors plus your age and your sex. An adjustment to the score is made for certain other factors such as strong family history and ethnic origin.

What does the assessment score mean?

You are given a score as a % chance. So, for example, if your score is 30% this means that you have a 30% chance of developing a cardiovascular disease within the next 10 years. This is the same as saying a 30 in 100 chance (or a 3 in 10 chance). In other words, in this example, 3 in 10 people with the same score that you have will develop a cardiovascular disease within the next 10 years. Note: the score cannot say if you will be one of the three. It cannot predict what will happen to each individual person. It just gives you the odds.

You are said to have a:

• High risk - if your score is 20% or more. That is, a 2 in 10 chance or more of developing a cardiovascular disease within the next 10 years.
• Moderate risk - if your score is 10-20%. That is, between a 1 in 10 and 2 in 10 chance.
• Low risk - if your score is less than 10%. That is, less than a 1 in 10 chance.

Who should be treated to reduce their cardiovascular health risk?

Treatment to reduce the risk of developing a cardiovascular disease is usually offered to people with a high risk. That is:

• People with a risk assessment score of 20% or more. That is, if you have a 2 in 10 chance or more of developing a cardiovascular disease within the next 10 years.
• People with an existing cardiovascular disease (to lower the chance of it getting worse, or of developing a further disease).
• People with diabetes. If you have diabetes, the time that treatment is started to reduce cardiovascular risk depends on factors such as: your age, how long you have had diabetes, your blood pressure and if you have any complications of diabetes.
• People with certain kidney disorders.

The following people should also have drug treatment to lower their cholesterol level, regardless of any calculated risk. The risk calculator may not necessarily take these people into account who have a high risk of developing atheroma.

• People with a total cholesterol to high density lipoprotein ratio of 6 or more (TC/HDL = 6 or more).
• People with familial (hereditary) lipid disorders.

What treatments are available to reduce the risk?

If you are at high risk of developing a cardiovascular disease then drug treatment is usually advised along with advice to tackle any lifestyle issues. This usually means:

• Drug treatment to lower your cholesterol level, usually with a statin drug. No matter what your current cholesterol level, drug treatment is advised. There are several brands of statin drug. They work by blocking an enzyme (chemical) which is needed to make cholesterol in the liver. The aim is:
  • to reduce total cholesterol to less than 4.0 mmol/l and LDL cholesterol to less than 2.0 mmol/l, OR
  • a 25% reduction in total cholesterol and a 30% reduction in LDL cholesterol.

Whichever is the biggest reduction.

• Drug treatment to lower blood pressure if it is high. This is even if your blood pressure is just mildly high.
• A daily low dose of aspirin - depending on your age and other factors. Aspirin helps to prevent blood clots from forming on patches of atheroma.
• Where relevant, to encourage you even more to tackle lifestyle risk factors. This means to:
  • stop smoking if you smoke
  • eat a healthy diet - including keeping your salt intake to under 6 g a day
  • keep your weight and waist in check
  • take regular physical activity
  • cut back if you drink a lot of alcohol.

If available, and if required, you may be offered a referral to a specialist service. For example, to a dietician to help you to lose weight and eat a healthy diet, to a specialist 'stop smoking clinic', or to a supervised exercise programme.

Can diet lower my cholesterol level?

Changing from an unhealthy diet to a healthy diet can reduce a cholesterol level. However, dietary changes alone rarely lower a cholesterol level enough to change a person's risk of cardiovascular disease from a high risk category to a lower risk. However, any extra reduction in cholesterol due to diet will help. A healthy diet has other benefits too apart from reducing the level of cholesterol.

Briefly, a healthy diet means:

• AT LEAST five portions, and ideally 7-9 portions, of a variety of fruit and vegetables per day.
• THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables.
• NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads.
• INCLUDE 2-3 portions of fish per week. At least one of which should be 'oily'.
• LIMIT SALT to no more than 6 g a day (and less for children).
• If you eat meat it is best to eat lean meat, or poultry such as chicken.
• If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.

In addition, foods that contain plant sterols or stanols can reduce blood cholesterol level. For example, a daily dose of about 2 g of plant sterols or stanols can reduce LDL cholesterol by about 10%. Plant sterols and stanols are available in margarine spreads, yoghurts, milk drinks and other foods sold in stores. Food products containing plant sterols and stanols are generally designed to provide about one third of the recommended daily dose per meal. However, always read the labels and follow the manufacturer's advice about portion sizes. Recommendations from the Food Standards Agency include the following:

• You should not not eat more than 3 g per day of plant sterols and stanols.
• Pregnant women, breast-feeding women, and children under the age of five years should not eat foods with added plant sterols or stanols.
• Foods with added plant sterols or stanols should be eaten as part of a balanced diet.

How much benefit do I get if my cholesterol level is reduced?

If you have an increased risk of developing an atheroma related disease, your risk can be reduced by up to 30% if your cholesterol level is lowered to a target level.

If you already have an atheroma related disease, lowering the cholesterol level reduces your risk of further problems.

4. Thrush.

Thrush is an infection caused by a yeast called Candida. Small numbers of Candida commonly live on the skin and around the vaginal area. These are usually harmless. The immune system and the harmless bacteria that also normally live on the skin and in the vagina usually stop Candida from thriving. However, when conditions are good for Candida, it multiplies and may invade the vagina and cause symptoms.

The conditions Candida likes best are warm, moist, airless parts of the body. This is why the vagina is the most common site for Candida infection. Other areas of the body that are prone to Candida infection include the groin, the mouth, and the nappy area in babies.

What are the symptoms of vaginal thrush?

Thrush is the second most common cause of a vaginal discharge. (The most common cause of vaginal discharge is bacterial vaginosis.) The discharge from thrush is usually creamy white, but is sometimes watery. It can cause itch, redness, discomfort, or pain around the outside of the vagina (the vulva). Sometimes symptoms are minor and clear up on their own. Often symptoms can be quite irritating and will not go without treatment.

Thrush does not damage the vagina, and it does not spread to damage the uterus (womb). If you are pregnant it will not harm your baby.

Who gets vaginal thrush?

More than half of all women have at least one bout of thrush in their life. In most cases it develops 'out of the blue' for no apparent reason. However, certain factors can make thrush more likely to develop. The vagina contains mucus and some harmless bacteria which help to defend the vagina from Candida (and other germs). These natural defences may be altered or upset by certain situations. For example: when you are pregnant, if you have diabetes, or if you take antibiotics.

People with a poor immune system are also more likely to get thrush. For example, people on chemotherapy, people taking high dose steroids, etc.

Do I need any tests?

Usually not. The diagnosis is usually based on the typical symptoms and signs.

However, do not assume that a vaginal discharge is thrush. There are other causes of vaginal discharge. If you have never had thrush before, then see a doctor or nurse to confirm the diagnosis and for advice on treatment. The doctor or nurse may examine you. No tests may be necessary if the symptoms and signs are typical. However, the doctor or nurse may take small samples of the discharge with swabs if the cause of the discharge is not clear. These is sent to the lab to confirm the cause of the discharge.

What are the treatment options for vaginal thrush?

Topical treatments

These are pessaries and creams which you insert into the vagina with an applicator. They contain anti-yeast medicines such as clotrimazole, econazole, fenticonazole, or miconazole. Commonly, a single large dose inserted into the vagina is sufficient to clear a bout of thrush. However, you may also want to rub some anti-yeast cream onto the skin around the vagina (the vulva) for a few days, especially if it is itchy. You can get topical treatments on prescription.  Side-effects are uncommon, but read the product label for full information. You can use topical treatments if you are pregnant.

Tablets

Two options are available. Fluconazole, which is taken as a single dose, or itraconazole which is taken as two doses over the course of one day.  Side-effects are uncommon, but always read the product label for full information. Do not take these if you are pregnant or breastfeeding. You may also want to rub some anti-yeast cream onto the skin around the vagina for a few days, especially if it is itchy.

Tablets and topical treatments are equally effective. Tablets are more convenient, but are more expensive than most topical treatments.

What if the treatment does not work?

If you still have symptoms after a week from starting treatment, then see your doctor or nurse. Treatment does not clear symptoms in up to 1 in 5 cases. Reasons why treatment may fail include:

• The symptoms may not be due to thrush. There are other causes of a vaginal discharge. Also, thrush can occur at the same time as another infection. You may need tests such as vaginal swabs to clarify the cause of the symptoms.
• Most bouts of thrush are caused by Candida albicans. However, about 1 in 10 bouts of thrush are caused by other strains of Candida such as Candida glabrata. These may not be so easily treated with the usual anti-thrush medicines.
• You may not have used the treatment correctly.
• You may have had a quick recurrence of a new thrush infection. (This is more likely if you are taking antibiotics, or if you have undiagnosed or poorly controlled diabetes.)

Some other points about vaginal thrush

• 'Natural' remedies for thrush include: live yoghurt inserted into the vagina; adding vinegar or bicarbonate of soda to a bath to alter the acidity of the vagina; tampons impregnated with tea tree oil. However, there is little scientific evidence to show that these remedies work.
• Thrush is not a sexually transmitted infection. Candida is a yeast germ which commonly occurs on the skin and vagina. For reasons not quite clear, it sometimes multiplies to cause symptoms.
• Male sexual partners do not need treatment unless they have symptoms of thrush on their penis. Symptoms in men include redness, itch, and soreness of the foreskin and the head (glans) of the penis. Women do not 'catch' thrush from men who have no symptoms.
• Thrush occurs more commonly in pregnant women, and can be more difficult to clear. It can take several days of topical treatment to clear thrush if you are pregnant.
• Some women develop recurring thrush. This is defined as four or more times a year.

Do I need to see a doctor if I get vaginal thrush again?

If you have had thrush in the past and the same symptoms recur, then it is common practice to treat it without an examination or tests. Many women know when they have thrush and treat it themselves. You can buy effective treatments (discussed above) from pharmacies without a prescription.

However, remember, a vaginal discharge or vulval itch can be due to a number of causes. So, do not assume all discharges or itch are thrush. The following gives a guide as to when it may be best to see a doctor or nurse if you think that you might have thrush. If you:

• Are under 16 or over 60 years of age.
• Are pregnant.
• Have abnormal vaginal bleeding or lower abdominal pain.
• Are unwell in yourself in addition to the vaginal and vulval symptoms.
• Have symptoms that are not entirely the same as a previous bout of thrush. For example, if the discharge has a bad smell, or it you develop ulcers or blisters next to your vagina.
• Have had two episodes of thrush in six months, and have not consulted a doctor or nurse about this for more than a year.
• Have had a previous sexually transmitted infection (or your partner has).
• Have had a previous bad reaction to anti-thrush medication or treatments.

5. Planning to become Pregnant, Folic acid supplements

You should take folic acid tablets for at least the first 12 weeks of pregnancy - even if you are healthy and have a good diet. Folic acid is a vitamin which occurs naturally in certain foods. However, you need a good supply of folic acid when you are pregnant. If you take folic acid tablets in early pregnancy you reduce the risk of having a baby born with a spinal cord problem such as spina bifida. You can buy folic acid tablets from pharmacies.

• You should start taking folic acid tablets before becoming pregnant (from the time you plan to become pregnant). If the pregnancy is unplanned then start taking folic acid tablets as soon as you know that you are pregnant.
• For most women the dose is 400 micrograms (0.4 mg) a day.
• If you have an increased risk of having a child with a spinal cord problem then the dose is higher (5 mg a day - you need a prescription for this higher dose). That is, if:
  • you have had a previously affected pregnancy
  • your partner, or a first-degree relative, have a spinal cord defect
  • you are taking medication for epilepsy
  • you have coeliac disease, diabetes, sickle cell anaemia, or thalassaemia.

Alcohol

Advice from the the HSE is that you should not drink at all if you are pregnant or trying to become pregnant. It is known that if you drink heavily you have an increased risk of miscarriage, and it may cause serious harm to the baby's growth and brain development. A condition called fetal alcohol syndrome develops in some babies born to mothers who drink heavily. A baby with this syndrome can have severe physical and mental problems.

However, the exact amount of alcohol that is safe during pregnancy is not known. This is why the advice is not to drink at all. If you do chose to drink when pregnant then limit it to one or two units, once or twice a week. And never get drunk. If you find it difficult to cut down or stop drinking alcohol, then seek advice and help from your practice nurse or GP.

Smoking

If you smoke, you are strongly advised to stop smoking before getting pregnant. Tobacco smoke contains poisonous chemicals which pass into the baby's blood and can slow the baby's growth. The risk of having a miscarriage, premature birth, or stillbirth are higher if you smoke. Babies born to mothers who smoked when pregnant also have an increased risk of developing attention deficit hyperactivity disorder (ADHD) when they are older. Also, after the birth, children of smoking parents have an increased risk of developing chest infections, asthma, 'glue ear' and sudden infant death syndrome (cot death).

For many women who smoke, planning to become pregnant is a good incentive to stop smoking. It is often a good time to persuade partners to give up too. If you find it difficult to stop smoking then seek advice and help from your practice nurse, GP, or pharmacist.

Food and diet

Eat a healthy balanced diet

Aim to eat a 'healthy diet' (which everyone should be eating!) Briefly, the bulk of most meals should be starch-based foods (such as bread, cereals, potatoes, rice, and pasta), with fruit and vegetables. Eat protein foods such as meat, fish, pulses, chicken, etc, in moderation.

Don't 'eat for two' and over-eat when you become pregnant. Too much weight gain increases your risk of developing problems later in the pregnancy. Also, extra weight is difficult to lose after the birth. If you are already obese or overweight, try to lose some weight before becoming pregnant to reduce the risk of pregnancy complications.

Include foods with plenty of iron, calcium and folic acid

A growing baby needs these nutrients right from the start of the pregnancy.

• Iron is mainly in red meat, pulses, dried fruit, green vegetables and fortified cereals.
• Calcium is mainly in dairy products such as milk, cheese, and yoghurt. (Low-fat milk, cheeses and yoghurts usually contain just as much calcium as the full-fat varieties.)
• Folic acid is mainly in green vegetables, brown rice, and fortified cereals.

Foods and drinks to avoid

You should not eat the following if you are pregnant or trying to become pregnant.

• Anything with a lot of vitamin A. You need a small amount of vitamin A to keep healthy. However, large amounts can harm an unborn baby. So, avoid:
  • Liver and liver products such as liver p?t? and cod liver oil supplements.
  • Vitamin tablets or supplements which contain vitamin A.
• Food which may have high levels of listeria. This bacterium (germ) does not usually cause problems in people who are not pregnant. However, pregnant women are more likely to become infected with listeria, and it sometimes causes miscarriage, stillbirth, or infections in the baby after birth. Foods which are most at risk of carrying listeria are:
  • Undercooked meats and eggs. For example, this may occur in some pre-cooked meats and pre-prepared meals. Make sure all meat foods are cooked until piping hot. Eggs should be cooked until both the white and yolk are solid.
  • Soft cheeses such as brie. (Hard cheeses and processed cottage cheese are safe.)
  • Shellfish and raw fish.
  • Unpasteurised milk. Note: goat's milk is often unpasteurised, and goat's milk products such as cheeses are often made from unpasteurised milk.
• Fish which may contain a lot of mercury. A high level of mercury can damage the developing nervous system of an unborn baby. So:
  • Do not eat shark, marlin, or swordfish.
  • Limit tuna. You should eat no more than two medium sized cans (drained weight = 140 gm per can), or one fresh tuna steak per week. (This would be about six tuna sandwiches, or three tuna salads per week.)
• Limit the amount of caffeine to no more than 300 mg per day. Having a lot of caffeine increases your risk of having a miscarriage and a baby with low birth weight. The main sources of caffeine are coffee, tea, chocolate, cola. It is also added to some 'energy' drinks and to some cough and cold remedies. As a rough guide:
  • One cup of instant coffee has about 75 mg caffeine
  • One cup of brewed coffee has about 100 mg caffeine.
  • One cup of tea has about 50mg caffeine.
  • One 50g chocolate bar has about 50 mg caffeine.
  • One can of cola, and half a can of an 'energy' drink has up to 40 mg caffeine.
• Peanuts. If you have an atopic disease such as asthma, eczema, or hay fever, or if a close family member has one of these conditions, then you may wish to avoid eating peanuts when you are pregnant. This may reduce the risk of your child developing peanut allergy in later life (which can be a serious and life-threatening allergy). This advice about peanuts in pregnancy is precautionary and further research is needed to clarify this issue.

Animals

Avoid contact with sheep and lambs at lambing time. This is because some lambs are born carrying the germs that cause listeriosis, toxoplasmosis and chlamydia. These may be passed on to you and your unborn baby. See below about cats and kittens.

Medication

The effects of some prescribed drugs have been well studied and it is known that certain drugs are safe in pregnancy. For example, paracetamol at normal dose is safe and useful for headaches, backache and other aches and pains that may occur during pregnancy. However, some drugs are not safe, and may be harmful to a developing baby, particularly if you take them in the early weeks of pregnancy.

Therefore, always tell a doctor or dentist who prescribes you medication that you are pregnant, or intend to become pregnant. Also, don't take drugs that you can buy (including herbal remedies) unless they are known to be safe in pregnancy. The pharmacist will advise.

If you already take regular medication, (for example, for epilepsy), it is important to discuss this with a doctor before becoming pregnant. If you have an unplanned pregnancy, discuss any medication that you take with your doctor as soon as possible.

Infections

Rubella (German Measles)

If you plan to become pregnant for the first time, you should check that you are immune to rubella before becoming pregnant. See your practice nurse for a 'pre-pregnancy' blood test. Most women are immune to rubella as they have been immunised as a child. However, childhood immunisation does not work in every child and you may not be immune. If you are not immune, you can be immunised.

Note: you should not become pregnant for one month after the injection, and ideally until your immunity has been confirmed by a further blood test.

The rubella virus causes a mild illness, but can seriously damage an unborn baby, especially in the early stages of growth. So, until you know that you are immune (from the result of the blood test), you should avoid anyone who has rubella, especially in the first 16 weeks of pregnancy.

Toxoplasmosis

This germ is commonly found in raw meat, sheep, lambs and cat faeces. It can sometimes cause serious harm to an unborn baby. To avoid it:

• Wash your hands after handling raw meat.
• Do not eat raw or undercooked (rare) meat.
• Wash salads and vegetables as any dirt may have been contaminated by cat faeces.
• Wash your hands after handling cats and kittens.
• Get someone else to clean out any cat litter trays when you are pregnant.
• Always wear gloves when gardening.
• Avoid sheep, especially during the lambing season.

Chickenpox

Having chickenpox when pregnant can be a nasty illness, and there is some risk to the developing baby. A vaccine is offered to healthcare workers (doctors, nurses, etc) who have not previously had chickenpox and so are not immune and may catch chickenpox. (About 1 in 10 adults have not had chickenpox as a child.) Therefore, non-immune healthcare workers should consider having this vaccination before getting pregnant.

If you are not sure if you have had chickenpox, a blood test can check if you have previously had it.

Hepatitis B

A mother who is infected with hepatitis B has a high risk of passing it on to her new-born baby. If you are at high risk of catching hepatitis B you should be immunised against this virus before becoming pregnant. You are at increased risk and should be immunised if:

• Your job puts you at risk of contracting hepatitis B. For example, health-care personnel and staff at day care or residential centres.
• You inject street drugs.
• You change sexual partners frequently.
• You live in close contact with someone infected with hepatitis B.

Screening blood tests

Ideally, you should have a blood test before you become pregnant to screen for hepatitis B, syphilis, and HIV. Ask your practice nurse for a 'pre-pregnancy' blood test.

Consider your working environment

If you think that your occupation may pose a risk to a pregnancy, then ideally you should discuss this with your employer before becoming pregnant. For example, if you work with chemicals, fumes, solvents, etc, which may pose a risk, or if you work with animals such as cats or sheep which may be carrying germs

Medical conditions

Women with certain medical conditions may benefit from other advice before becoming pregnant. See your doctor if you have concerns about a medical condition which may affect pregnancy. For example:

• For some conditions, the medication or treatment may possibly affect the pregnancy or the unborn child. For example, epilepsy.
• For some conditions, the condition itself may require special attention during the pregnancy. For example, diabetes.
• If a hereditary condition runs in your family, you may benefit from genetic counselling.

Summary and checklist

Most pregnancies go well and without any major problems. But it is wise to reduce any risks as much as possible. So, a reminder of things to consider before becoming pregnant, or as soon as you realise that you are pregnant ...

• Things you should do
  • Take folic acid tablets before you get pregnant until 12 weeks of pregnancy.
  • Have a blood test to check if you are immune against rubella, and to screen for hepatitis B, syphilis, and HIV.
  • Eat a healthy diet. Include foods rich in iron, calcium and folic acid.
  • Wash your hands after handling raw meat, or handling cats and kittens.
  • Wear gloves when you are gardening.
• Things you should avoid
  • Too much vitamin A - don't eat liver or liver products, or take vitamin A tablets.
  • Listeriosis - don't eat undercooked meat or eggs, soft cheese, p?t?, shellfish, raw fish, or unpasteurised milk.
  • Fish which may contain a lot of mercury - shark, marlin, swordfish, or excess tuna.
  • Sheep, lambs, cat faeces, cat litters, and raw meat which may carry certain infections.
  • Peanuts - if you have a personal or family history of eczema, hay fever, or asthma.
• Things you should stop or cut down
  • Caffeine in tea, coffee, cola, etc, - have no more than 300 mg per day. This is in about three cups of brewed coffee, or four cups of instant coffee, or six cups of tea.
  • Alcohol - you are strongly advised not to drink at all.
  • Smoking - you are strongly advised to stop completely.
  • Street drugs - you are strongly advised to stop completely.
• Other things to consider
  • Immunisation against hepatitis B if you are at increased risk of getting this infection.
  • Immunisation against chickenpox if you are a healthcare worker and have not previously had chickenpox and so are not immune.
  • Your medication - including herbal and 'over the counter' medicines.
  • Your work environment - is it safe?
  • Medical conditions in yourself, or conditions which run in your family.

Sexually Transmitted Infection Screening

Sexually transmitted infections are common. Remember any sexually active person may be exposed to a sexually transmitted infection. If you suspect you have an infection get it checked out as soon as possible. Most treatments are simple and painless and you do not have to be admitted to hospital. Treatment is confidential, non judgmental and free. The staff in the clinic are trained to treat sexually transmitted infections in an understanding and helpful way so there is no need for you to feel embarrassed. If you are pregnant and think you may have picked up a sexually transmitted infection it is particularly important to get it checked out and treated as soon as possible.

Contraceptive Services

The D2 medical centre provides a full comprehensive contraceptive service. There are many different contraceptive methods available, and different methods suit different people at different times of their lives.

Combined Pill	The combined pill combines two hormones, oestrogen and progestogen. Tests show that for every 100 women who take the pill correctly for one year, less than one will get pregnant. It is a prescription drug requiring regular surgery reviews.
Progestogen-Only Pill	There are also pills which have progestogen only and no oestrogen. Tests show that for every 100 women who take the progestogen-only pill very carefully and consistently, one will get pregnant in a year. The progestogen-only pill is a possible alternative for older women or others who cannot use the combined pill. It is suitable for women who are breastfeeding as it does not reduce the milk flow.
Injectable Contraception	Only one type is available in Ireland, it is called Depo-Provera. This contains a similar hormone to that in the progestogenonly pill. It can be used by women who cannot use other methods of hormonal contraception. One injection gives 12 weeks protection.
Intrauterine System (IUS / Mirena)	The Mirena coil is a small T-shaped plastic device with a sleeve, which releases the hormone progestogen into the cavity of the womb. The Mirena coil provides a highly reliable method of contraception, particularly for older women and it is also shown to be highly effective for treating heavy periods. The Mirena coil is inserted day 3-7 of your menstrual cycle.
Diaphragm or Cap with Spermicide	These are barrier methods of family planning which fit inside the woman's vagina. They form a barrier at the entrance to the womb which stop the man's sperm getting through to join an egg. Vaginal diaphragms are circular domes made of thin rubber.
Contraceptive Patch	There is only one type of contraceptive patch available at this time. It is called Evra. A new patch is applied every week for three weeks. When used correctly and according to the instructions it is as reliable as the oral contraceptive pill, that is over 99 per cent effective.
Emergency Contraception	If you have had sex and did not use contraception, or if you think your contraception did not work you can use emergency contraception. If you act quickly, emergency contraception will usually prevent pregnancy. Emergency contraception is only available by prescription. All the advice and treatment you receive is confidential. Emergency contraceptive pills contain a progestogen hormone which is similar to the natural progesterone women produce in their ovaries. They should be started within three days (72 hours) of having unprotected sex. They are more effective the sooner they are taken.

Breast Screening Service

It is important that every woman is breast aware. This means knowing what is normal for you so that if any unusual change occurs, you will recognise it. The sooner you notice a change the better, because if cancer is found early, treatment is more likely to be successful.

The 5 point breast awareness code;

1.     Know what is normal for you

2.     Know what changes to look for

3.     Look and feel

4.     Discuss any changes with your GP without delay

5.     Attend for routine breast screening if you are aged between 50 and 64

What to do if you find something ?

If you do notice any change in your breasts, see your GP as soon as possible. Remember that most breast changes are not cancer and are harmless. When your GP examines your breasts she or he may be able to reassure you that there is nothing to worry about. If the change could be connected with your hormones, your GP may ask you to come back at a different stage in your menstrual cycle. Alternatively, you may be sent to a breast clinic for a more detailed examination.

Don't worry that you may be making an unnecessary fuss and remember that nine out of ten breast lumps are harmless.

At the D2 medical  we recommend that women examine their own breasts at least monthly and become breast aware. They should request a breast examination six monthly to get an objective assessment. Between the ages of 50 and 64 we support women getting a mammogram every 2 years at the request of their local breast check service.

Menopause and HRT Service

The term menopause means last menstrual bleed. During the menopause the production of the female hormone oestrogen declines. The menopause can cause a range of symptoms, including hot flushes and night sweats, tiredness, difficulty sleeping, headaches, vaginal discomfort and a range of emotional symptoms. These symptoms vary from woman to woman but can be treated and will eventually pass.

However, women can now be expected to live well into their eighties. Hand in hand with this increase in life expectancy comes a number of potential health risks that can serious affect women in the years after the menopause.

                                                                                                 Dr John J Ryan Medical Director