There is a list of relative contraindications to HRT, that is those conditions in which you and your doctor will need to consider the balance between the risks and the benefits:

• Migraine responds unpredictably to HRT, and your doctor may suggest you try it for a month or two to start with to see how it affects you. If you develop migraine for the first time during or after the menopause, then it may be

Some women find it returns during the days in each month when they are taking progestogen. Unfortunately, in these cases, changing to a different type of progestogen will probably not bring much improvement.

• Women who are overweight can usually take HRT, but very overweight women have a higher-than-average level of oestrogen, and increasing this level with HRT can increase the risk of breast cancer. However, these women, because of their higher oestrogen levels, tend to be less troubled by menopausal symptoms, and are at low risk of developing osteoporosis.

• There is no reason why smokers shouldn’t take HRT, although some doctors advise them to give up smoking while they are on it. Smoking reduces oestrogen levels.

• Varicose veins are not usually connected with deep vein thrombosis, and if this is so for you then there is no reason why you can’t take HRT unless they are acutely inflamed (phlebitis). Superficial inflammation of varicose veins is not a contraindication.

Between 10 and 20 per cent of post-menopausal women have significant contraindications to HRT, and the majority of them have menopausal symptoms that cause them long- or short-term embarrassment or distress. They need treatment to cope with the hot flushes, etc, and to increase their sense of wellbeing, yet many doctors aren’t particularly helpful.

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Any major gynaecological surgery, such as an open myomectomy which entails a large incision and a general anaesthetic, will put sex off the agenda for at least six to eight weeks. This does not mean you cannot enjoy each other in intimate ways. The opportunity to give pleasure to each other through massage can help the recovery process. It can also help the sexual relationship in the longer term by allowing partners to communicate their sexual needs to each other and learn about each other’s sexual responses before sexual intercourse resumes.

One type of activity that most couples find enjoyable, starts with partners giving each other a general body massage. Hand cream or body oil, and an atmosphere that is warm and relaxed, will add to the experience. As the massage occurs, the partner who is being stroked and rubbed describes his or her feelings and desires. In this way each partner learns how the other likes to be stimulated and caressed and unexplored areas of communication and fantasy may be unearthed. The activity may continue to climax.

After a hysterectomy, hysteroscopy, laparoscopy, endometrial ablation or endometrial resection, the desire to give and receive love remains. Most people want to continue with intimacy — the challenge is to be flexible enough to manage this when some of the old ways of being intimate are on hold. Giving and gaining pleasure may be achieved by caressing, cuddling and enjoying each other’s company. The use of a hand-held vibrator on many parts of the body can arouse sensations in areas we do not usually think of as pleasure zones, such as the soles of the feet, the face and the lips. Intercourse can be resumed when bleeding or discharge has stopped and the pelvis feels normal. Depending on the type of procedure and the speed with which your body heals this may be anything from a fortnight to several months. A slow start to the resumption of love-making is usually the best approach, with genital touching and gentle penetration later. If you have any concerns, wait until the postoperative check-up to get the all clear.

Drug treatments which induce a temporary menopause may reduce a woman’s interest in sex and may cause intercourse to become less pleasurable because of a decreased output of secretions in the vagina. Fatigue due to hot flushes and sleep disturbances may also reduce sexual responsiveness. Overcoming these adverse effects calls for lateral thinking as outlined above. It will not occur overnight, so a medium- to long-term approach is vital.

Treatments for excessive bleeding, such as the Pill, progestogens, NSAIDs, danazol, and GnRH agonists are a mixed bag as far as sexual function is concerned. Some, notably progestogens and GnRH agonists, can cause a marked reduction in interest in sex; while others, such as the Pill, may produce little change.

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Ordinary stress is pressure exerted on us in our normal daily life. My car breaks down, my boss misunderstands me, I lose some money in my investment, 1 have an argument with my friend, I am going to sit an important examination tomorrow, and so on; these are normal events that we may have everyday. I am jealous, I am disappointed, I regret, I am frustrated, I feel guilty, I am frightened, and so on; these are feelings and reactions we can have in our everyday lives.

When we are under stress, a normal reacting mechanism in our body works to counteract the stress applied to us. Our body feels threatened, and we put ourselves on battle alert. We respond in two ways: with a biological reaction and with a psychological reaction. These two ways go hand in hand with each other, and both are protective mechanisms against the threat of imminent danger.

Biological reaction. Our body is immediately geared up for the stress, ready for Tight or flight’. Plenty of adrenaline is circulating, and our muscles are all tensed, our heart pumping hard, our blood pressure high so that our body is ready for the flight, our blood thickened and able to clot easily just in case we are injured or bleed in the fight, and our eyes wide open with the pupils dilated and staring at every move of the enemy. There is little chance of falling asleep when

there is imminent danger as we are on guard all the time.

The biological reaction to stress developed way back in the course of evolution, but is still very important in present day life; for example, in a boxing competition or when soldiers are fighting in combat Or when attacked by a burglar, we have to either ‘fight’ or ‘flight’.

However, in most modern stress situations the biological reaction becomes a burden. Physical action is normally not required. If your boss misunderstands you, you become very uptight and are ready to explode. But in most cases, even if you want to, you are not going to give him a black eye, as this is a civilized world. This biological reaction generates a lot of energy, which we are unable to release. We feel distressed. Continual, chronic, modern stress can be harmful to the body. We are flooded with excess adrenaline, and we have a greater chance of falling victim to a heart attack or stroke. This is because, during the biological reaction to stress, the blood pressure is high to increase the energy supply through circulation, and the blood will clot easily to stop bleeding if this is necessary. Some authorities recommend an aspirin a day to thin the blood, so as to prevent heart attack or stroke, as both can result from a clot in a vital blood vessel; in the case of a heart attack, it is a clot in the coronary artery supplying the heart muscle, and, in the case of a stroke, it is a clot in an important artery supplying the brain.

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