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1 Reproductive health

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Contents

Objectives

When you have completed this chapter you should be able to:

Introduction to reproductive health

1-1 What is reproductive health?

Reproductive health is defined as ‘a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system, and to its functions and processes’. Reproductive health, therefore, implies that people are able to:

In order to achieve this, both men and women have the right to:

Note
This definition, which builds on the WHO definition of reproductive health, was presented at the 1994 International Conference on Population and Development in Cairo. The definition together with a Programme of Action was accepted by 180 national governments who were represented at the conference.

1-2 What is women’s health?

Women’s health includes all health issues which are specific to women because of their anatomy, or which are different in women when compared to men because of biological, psychological or social factors.

Note
Research has shown that many illnesses affect women differently to men. Women may have different susceptibility to a disease, show different signs and symptoms and may respond differently to treatment. It has also been shown that in many healthcare systems, especially, but not only in developing countries, women receive poorer quality care when compared to men.

1-3 What is sexual health?

The World Health Organisation has defined sexual health as ‘a state of physical, mental and social wellbeing in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence’.

1-4 What factors threaten women’s reproductive health?

There are many conditions that affect women’s reproductive health. Some of the most important factors include:

Note
Maternal mortality is the death of women during pregnancy or up to 42 days after delivery.

1-5 What are the Sustainable Development Goals?

The Sustainable Developmental Goals (SDGs) 2030 replaced the Millennium Development Goals (MDGs) in 2016. Among other aims, the SDG envisions “a world in which every woman and girl enjoys full gender equality and all legal, social and economic barriers to their empowerment have been removed”. Goal 3 of the SDGs aims to “ensure healthy lives and promote well-being for all at all ages”. This includes reducing maternal mortality to less than 70/100 000 live births.

Note
The maternal mortality rate is South Africa is about 140/100 000 live births.

Routine cancer screening

1-6 What cancers should women be screened for?

Women should be screened for cervical cancer and breast cancer. These cancers are common, they can be detected early through relatively simple tests and they can be cured if they are diagnosed early and treated correctly.

Breast and cervical cancer can be cured if detected early and treated correctly.

Note
Unfortunately there is no effective method of screening for ovarian cancer. The symptoms of ovarian cancer are usually vague and may be caused by many other conditions.

1-7 Who is at risk of breast cancer?

All women are at risk of breast cancer, but the most important risk factors are:

Note
Atypical ductal hyperplasia, ductal carcinoma in situ and lobular carcinoma in situ may all progress to breast cancer.

1-8 How does breast cancer present?

It usually presents as a new lump in the breast or armpit or an old lump that changes (getting bigger or harder). It can also present with a change in the size or shape of the breast, flaky or red skin anywhere on the breast, and blood or any other fluid coming from the nipple in women who are not pregnant or breastfeeding.

Breast cancer may present with a new lump, any change in an old lump, or nipple discharge.

Any unexplained change in one breast should be investigated, as breast cancer can be cured if detected early and treated correctly.

1-9 How can breast cancer be detected early?

There are 2 ways which help to detect breast cancer early:

In low-resource settings breast awareness is one of the most important interventions to reduce mortality from breast cancer. Breast awareness is more successful than breast self-examination, as even well-educated women are known to rarely self-examine their breasts. Access to clinical breast examination and screening mammography is often limited in low-resource settings because of lack of appropriately trained staff, lack of radiological equipment and the cost of mammography.

All women should be taught breast awareness and should report any unusual changes.

Note
Many developed countries have population-based routine screening mammography programmes, although the benefit to women with normal or low risk for breast cancer is controversial. Some international guidelines recommend annual screening of all women from the age of 40, while others recommend 3-yearly intervals between the age of 50 and 70. Although mammography screening helps in the early detection of breast cancer it also quite commonly detects radiological changes that are not malignant. These need further investigation before the woman can be reassured that it is not cancer. Therefore an abnormal mammography does not necessarily mean that the woman has breast cancer.

1-10 What is the role of primary healthcare workers in the early detection of breast cancer?

Nurses and doctors working in primary healthcare have 3 important roles:

  1. To educate all women about breast awareness.
  2. To perform clinical breast examination in any woman who complains of a change in her breast or any breast-related complaint.
  3. To promptly refer any woman who reports any unusual change in her breast or who has any breast lump discovered on clinical examination to a family physician, surgeon or breast specialist.

Refer the following women who are at high risk for breast cancer:

Note
Ideally women on hormone replacement therapy (HRT) should have regular mammographic screening for the duration of the treatment.

1-11 What causes cervical cancer?

Nearly all cervical cancers are caused by a high-risk human papilloma virus (HPV). HPV infection is very common. It is estimated that more than half of sexually active people will have had genital HPV infection at some stage in their lives. In most cases the infection does not cause any signs or symptoms and goes away by itself, but in some women the infection persists and can cause cancer. Because HPV infection is so common, it causes cancer in many women.

Cervical cancer is caused by a genital infection by the human papilloma virus.

Note
HPV is a group of over 200 virus types of which about 40 infect the genital tract. They are divided into high-risk and low-risk types. Genital HPV is spread by skin-to-skin contact, including through sexual activity. There is no cure for HPV infection, but in most people the infection goes away on its own. Only persistent infection with high-risk viruses (HPV 16, 18, 31, 45 and 56) is associated with cervical cancer.

1-12 Who is at risk of cervical cancer?

All women who are, or have been sexually active, are at risk of cervical cancer. Although it is possible to get high-risk HPV from a single partner, the risk is greater if women have many sexual partners, or if their partners have many partners. It can occur in young women, but it is more common in women over the age of 40. It is also more common in women who are HIV positive and in women who smoke.

1-13 How does cervical cancer present?

Early cervical cancer is often asymptomatic. This is why Pap smears (cervical cytology) are so important as they detect changes in the skin of the cervix before these changes develop into cancer. More advanced cervical cancer usually presents with an offensive vaginal discharge or abnormal vaginal bleeding (bleeding after intercourse, irregular or heavy bleeding, and bleeding after menopause).

Abnormal bleeding and vaginal discharge can be a sign of cervical cancer.

1-14 Who should be screened for cervical cancer?

All women should be screened for cervical cancer. Many countries have cervical cancer screening guidelines which state from which age women should be screened and how often.

According to South African guidelines all asymptomatic women should have 2 Pap smears in their lifetime, with a ten-year interval between each smear, starting at the age of 30.

In addition women that are HIV positive, regardless of their clinical stage or whether they are on antiretroviral treatment or not, must be screened after the age of 20 years.

Some women may however need earlier or more frequent Pap smears because they are at high risk, such as women who are HIV positive, or because they had a previous abnormal Pap smear. While unnecessary Pap smears should be avoided, it remains the decision of the health worker when to do a Pap smear.

1-15 What is a Pap smear?

A Pap smear is a test which takes cells with a wooden spatula from the surface of the cervix through a speculum. The smear is put onto a glass slide, immediately fixed with a spray and then sent to a laboratory for examination under a microscope.

The report will take about 3 weeks and will state one the following results:

Note
The Pap smear is named after Dr Georgios Papanicolaou who described the test in the 1920s in New York.

All women should be screened for cervical cancer.

Note
Women with an indication for a Pap smear who are bleeding at the time should have a speculum examination to exclude a macroscopic lesion on the cervix.

1-16 What action should be taken after a Pap smear?

The most important action is to ensure that the woman gets the result of her Pap smear and understands the result.

If the Pap smear is normal she should be informed of her next smear date according to the local screening programme. If the smear is inadequate it should be repeated.

The following action should be taken if the smear is abnormal:

Note
A colposcope lights up and magnifies the cervix. It allows the health worker to determine if the woman has a healthy cervix, precursor stages of cervical cancer or cervical cancer.

1-17 Can cervical cancer be prevented?

Yes. Cervical tissue which contains precursor stages of cervical cancer can be removed through a relatively simple procedure at the time of colposcopy. This prevents the precursor stage from turning into cancer.

Women can also be immunised against HPV infection before they become sexually active. It is recommended that all girls should be immunised at 13 years of age. The vaccine is widely used in the private sector and is being given to grade 4 girls in the South African public sector.

Note
HPV immunisation is a form of primary prevention of cervical cancer as it prevents infection with high-risk type HPV. There are 2 types of HPV vaccines. One vaccine prevents infection with 2 types of high-risk HPV. The other also prevents infection by the types that cause genital warts.

Overweight and obesity

1-18 What is a Body Mass Index?

The body mass index (BMI) is a measure of how much a person weighs in relation to his or her height. The BMI is calculated by dividing body weight in kg by the square of height in metres. The BMI is used to define normal weight, underweight and overweight:

Note
The BMI is a useful way to screen women for overweight, but it does not take into account the distribution of fat tissue. Most people store excess fat around their waist or hip. Research has shown that people who carry a lot of fat around their waist (apple shape) have more health problems than people who have excess fat around their thighs (pear shape). Using a measuring tape to measure the waist circumference (at the smallest section of the natural waist, usually just above the belly button) and the hip circumference (around the hips and the widest part of the buttocks) allows you to calculate the waist-hip ratio. In women a waist-hip ration of over 0.8 is associated with increased health risks.

1-19 What causes overweight and obesity?

A chronic imbalance between the amount of energy (food) intake and energy used up (through physical activity).

Women who are overweight or obese typically:

Poor eating is the most important reason for overweight and obesity. It is often influenced by other factors including urbanisation, cultural, environmental and socioeconomic factors.

Obesity is usually caused by excessive eating and too little exercise.

Note
What is important is the total calorie intake. A kilojoule is a unit of energy supplied by food. A kilojoule is a kilojoule irrespective of its source. Many food products provide information about kilojoule content on the food package. The more kilojoules the more fattening is the food. Animal fats are particularly high in kilojoules. Endocrine causes for being overweight are rare.

1-20 Are overweight and obesity common?

Yes, overweight and obesity have become very common both in wealthy and poor communities. According to data from 2008, 1 in 2 adults in the world is overweight and 1 in 9 adults is obese. In South Africa it is estimated that 50% of women are overweight and 25% are obese. People who are overweight are at risk of becoming obese.

1-21 How does overweight and obesity affect the reproductive health of women?

Overweight and obesity have detrimental effects on the reproductive health of women. The following reproductive health problems are significantly more common in overweight and obese women:

Most of these reproductive health risks can be reduced if the woman loses weight. Although achieving a normal BMI may be the ultimate goal, even a small reduction in weight (5–10% of the BMI) can result in improvements in reproductive health.

1-22 What are the general health dangers of being overweight or obese?

Obesity has become a major cause for illness and death in all countries of the world. The following conditions are much more common in people who are overweight or obese:

Obesity may also lead to social discrimination, resulting in low self-esteem, social isolation, depression and poor social functioning. It is therefore important to prevent and treat overweight and obesity.

Being overweight or obese is dangerous.

Note
Central obesity with an increase in abdominal circumference and waist-hip ratio due to excessive intra-abdominal fat is associated with the metabolic syndrome characterised by insulin resistance, hypertension and raised serum lipids.

1-23 How can overweight and obesity be managed?

Women who are overweight or obese need a lot of support from the health system to help them lose weight. They need information on how obesity affects their general and reproductive health, encouragement and practical advice on a regular basis. Short-term diets do not usually result in long-term weight changes. Instead, women need to be encouraged and motivated to change their lifestyle.

A healthy lifestyle includes:

Referral to a dietician at a community health centre is of great help.

1-24 How can overweight and obesity be prevented?

All women should be educated about nutrition so they can eat healthily and make healthy food choices in their homes. It is particularly important to decrease and prevent overweight and obesity in children. Children should be encouraged to be active, to drink lots of water and to have regular meals with healthy portions of food that is low in fat, sugar, salt and calories.

Education on healthy eating is a very important part of health education. It should be promoted not only in clinics but also in families, schools, communities and the media. Healthy eating habits should be aimed at the whole family and community. Promoting a healthy, balanced diet and regular exercise is a major challenge in both wealthy and poor communities.

1-25 Why is regular exercise important?

Exercise, such as walking or cycling, for 30 minutes 5 times a week improves the quality of life. It increases fitness, helps to prevent overweight and reduces the risk of depression. Regular, enjoyable exercise should be part of a healthy lifestyle.

Smoking

1-26 Why is smoking harmful?

Cigarette smoke contains over 250 chemicals which are toxic or carcinogenic, meaning they can cause cancer. The toxic substances in cigarette smoke reach every part of the body including the genital organs. They are also found in breast milk and even in the urine of newborn babies born to mothers who smoke.

Smoking causes addiction through a substance called nicotine. Nicotine is a psychoactive drug which is as addictive as alcohol, heroin and cocaine.

Cigarette smoking is harmful.

Note
Apart from nicotine, the most harmful substances include carbon monoxide, polycyclic aromatic hydrocarbons (PAHs) and nitrosamines. Carbon monoxide reduces the ability of red blood cells to carry oxygen. Nicotine and carbon monoxide cause most of the harmful effects in pregnancy. PAHs and nitrosamines cause cancers, especially lung cancer.

1-27 How does smoking affect the reproductive health of women?

There are many reproductive health problems associated with smoking:

The risk of these conditions is often proportional to the amount of cigarettes smoked, but even smoking very few cigarettes or smoking only occasionally is harmful. Women who are passive smokers because of other people smoking in their home or workplace are also at increased risk of these conditions.

Many infants and children are passive smokers. They are at increased risk of:

Pregnant women that smoke are at increased risk of having miscarriages, preterm births, stillbirths, or babies that die within the first 4 weeks after birth.

1-28 What are the other health dangers of cigarette smoking?

Smoking cigarettes is very dangerous for the general health of both women and men. Smoking increases the risk of:

Smoking is the cause of death in 50% of lifelong heavy smokers and reduces the average lifespan by 10 years.

Smoking remains a common habit in South Africa, especially among young women. According to a study nearly 40% of women giving birth were smokers.

Many women die of health dangers caused by their cigarette smoking.

1-29 Are the reproductive health problems caused by smoking reversible?

Many risks can be reduced and some may be avoided altogether if the woman stops smoking. Stopping smoking reduces the risk of early menopause and delays in conception. Stopping smoking before pregnancy avoids all pregnancy-related risks and stopping smoking at any time during pregnancy helps to reduce the harmful effects. Women who stop smoking also greatly improve their life expectancy. The earlier in life a woman stops smoking the better, but there are benefits of stopping smoking at any age.

1-30 How can women stop smoking?

Because smoking is addictive, many smokers find it difficult to stop. Health workers should consistently educate their patients on the dangers of tobacco addiction and encourage them to stop smoking. It is important to remain supportive and to understand that a person may take multiple attempts to stop smoking. Research has shown that a combination of counselling and medication achieve the best results. There is a range of nicotine replacement products such as gums, inhalers and patches and many of them do not require a prescription.

Aging and menopause

1-31 What can women do to remain healthy when they get older?

Lead a healthy lifestyle. Stop smoking, eat a healthy, balanced diet and avoid or limit alcohol intake. Reduce stress where possible, ensure adequate rest at night and do regular, weight-bearing exercise such as walking. It is also important that older women do not become lonely and isolated. Families and communities play an important role in caring for the elderly, and at the same time older people should try and remain active and involved in family and community life.

1-32 What is menopause?

Menopause is the time when a woman reaches the end of her reproductive life and her periods stop permanently. It usually occurs between the ages of 45 and 55 years when a woman’s ovaries stop producing the hormones oestrogen and progesterone. Commonly the terms ‘menopause’, ‘change of life’ or ‘climacteric’ are used by lay people to describe the years around the menopause.

1-33 What are the symptoms of menopause?

Menopausal symptoms can start several years before menopause and may last for several years afterwards. Women are affected very differently by menopause, with some women having very few symptoms while others may suffer a lot.

1-34 What are the health consequences of menopause?

Although menopause is a normal part of aging, the hormonal changes put women at increased risk of:

Note
Before menopause women are partially protected from cardiovascular disease by their oestrogen hormones and they are less likely than men to suffer a heart attack or a stroke. After menopause women have similar risks for cardiovascular disease as men.

1-35 What is hormone replacement therapy?

Hormone replacement therapy (HRT) is the use of hormones to treat menopausal symptoms.

Hormone replacement therapy treats menopausal symptoms.

1-36 What drugs are used in hormone replacement therapy?

Usually a small maintenance dose of oestrogen is effective in controlling the symptoms. However, in women with a uterus, progesterone must be added, because oestrogen-only treatment may result in cancer of the uterus (endometrial cancer). Oestrogen alone can be used in women without a uterus.

HRT is mostly taken in the form of daily tablets. Other forms such as creams, gels, patches, and vaginal rings, but are usually not available in primary-health clinics because of cost. Subdemal contraceptive implants have been introduced in South Africa.

Women with a uterus must receive both oestrogen and progesterone when taking hormone replacement therapy.

1-37 Who should receive hormone replacement therapy?

Any woman who suffers significantly from hot flushes, night sweats, mood swings and sleeplessness may benefit from HRT.

HRT is also effective in treating vaginal dryness. If there are additional menopausal symptoms, vaginal oestrogen cream may be better than systemic, oral HRT.

Note
HRT also helps to reduce bone loss, but the decision to manage osteoporosis with HRT should always be made by a specialist. HRT does not reverse established cardiovascular disease. Women who need HRT but are at risk of cardiovascular disease or have established cardiovascular disease must be managed by a specialist.

1-38 Does HRT cause vaginal bleeding?

Women who do not have a uterus will not bleed on HRT. They can be treated with oestrogen only, as they do not need progesterone to protect their uterus from cancer. Examples of oestrogen-only pills include Premarin and Estrofem.

Women who have a uterus must take both oestrogen and progesterone. Many standard forms of HRT which contain both oestrogen and progesterone will cause regular menstrual bleeding. These products are called combined, cyclical HRT. Examples are Trisequens, Prempak, and Postoval. Usually the bleeding is lighter than normal periods and many women find it acceptable.

Women who have been post-menopausal for 2 years and who do not want to menstruate can be treated with combined, continuous HRT in which oestrogen and progesterone are balanced in a way that does not cause vaginal bleeding. Examples are Angeliq, Activelle and Premelle. Some women may however have some irregular spotting when starting this treatment. If the bleeding is heavier than normal or it does not occur in an expected cyclical pattern, investigation is required.

1-39 Are there any risks in taking HRT?

Yes. Women who take HRT have:

1-40 Who should not take HRT?

HRT should not be used in women with:

In very specific circumstances HRT may still be given but these women must be closely monitored by a specialist.

1-41 For how long is HRT given?

For as long as the woman suffers from menopausal symptoms. For most women this means 2 to 5 years. The use of HRT should be reviewed annually.

When thinking of discontinuing HRT the woman can stop for a month or 2 to see what happens. If she is still symptomatic without HRT she can continue treatment for another year or longer until she feels comfortable without HRT.

Women who are on long-term use of HRT (over 5 years) should be seen intermittently by a specialist.

Case study 1

A woman of 42 years attends a well women’s clinic and asks the doctor about screening for breast cancer. She is overweight and reports that her sister died of breast cancer.

1. Should this woman be screened for breast cancer?

Yes. She is at increased risk of breast cancer because she has had a close relative with breast cancer. Her risk is further increased by being over the age of 40 years and being overweight. However, all women should be regularly screened for breast cancer.

2. How does breast cancer usually present?

Usually with a breast lump that had not been noticed before or an old lump which has become bigger or harder.

3. Who should screen her for breast cancer?

She should examine her own breasts regularly. In addition, she should have her breasts examined by a trained doctor or nurse every year as she is at high risk of breast cancer.

4. Does she need a mammogram?

Yes. She should have an annual mammogram starting 10 years before the age at which her sister was diagnosed with breast cancer.

5. What should the clinic doctor do if a breast lump is found?

The woman must be referred for further investigation and management. Many breast lumps are not cancer but this can only be decided by further tests.

6. Can breast cancer be cured?

Yes, if it is detected early and treated correctly.

7. Can she reduce her risk of getting breast cancer?

Yes, by losing weight.

Case study 2

A mother of 2 children is asked to return to the local clinic as the result of her Pap smear is not normal. She is 42 years old, smokes and is not married. Each of her children has a different father.

1. Is she at an increased risk of cervical cancer?

Women over 40 years, women who have or have had multiple sex partners, women who are HIV positive and women who smoke are at increased risk. Being infected with HIV would be an additional risk factor. However, any woman who is, or has been, sexually active can develop cervical cancer.

2. What causes cervical cancer?

Infection with the human papilloma virus (HPV), which is a sexually transmitted infection.

3. Does cervical cancer commonly present with clinical signs?

No. The clinical signs of cervical cancer (vaginal discharge or abnormal vaginal bleeding) only present when the cancer is advanced. This is why screening with Pap smears is so important.

4. Who should be screened for cervical cancer?

In South Africa it is advised that all women should be screened every 10 years starting at the age of 30 years.

5. What does it mean if her Pap smear is graded as low-grade SIL?

She has a squamous intraepithelial lesion (SIL) which shows very early changes that could later develop into cervical cancer. She should have a repeat Pap smear in 6 to 12 months, time to assess whether the test has become normal, remained the same or has progressed to a more advanced stage. If it is not normal she should be referred for colposcopy.

6. Can cervical cancer be prevented?

Yes. There are 2 ways of preventing cervical cancer. By immunising young girls at 13 years of age with HPV vaccine before they become sexually active, and by diagnosing and removing abnormal cells in the cervix before they turn into cancer.

Case study 3

While visiting her general practitioner, a women mentions that she has been overweight since her child was born a few years before. She also gives a history of cigarette smoking. The doctor calculates her BMI to be 27.

1. What is a BMI?

The body mass index (BMI) is a way of assessing a person’s weight for their height. It is a good screen for identifying people who are overweight or obese. A normal BMI is 19 to 25. Her BMI indicates that she is overweight. Obese people have a BMI above 30.

2. Why is she overweight?

She is likely to have a poor diet consisting of refined foods and high-calorie foods such as sweets, animal fat and soft drinks. She doesn’t exercise.

3. Is being overweight a common problem?

Yes. In South Africa it is estimated that 50% of women are overweight and 25% are obese.

4. What are the dangers of being overweight?

Being overweight is associated with many general health problems. The most important dangers are diabetes, hypertension, coronary artery disease, stroke and cancer.

5. What are the reproductive complications of being overweight?

There are many, including abnormal vaginal bleeding, infertility, cancer, miscarriage and other pregnancy complications.

6. Is cigarette smoking harmful?

Yes. Cigarette smoking also has many harmful effects both on general and reproductive health. Smoking is the cause of death in 50% of lifelong heavy smokers. She needs to be helped to eat a healthy diet, exercise regularly and stop smoking as this will reduce many of these dangerous complications.

Case study 4

A woman of 52 years who has recently stopped having periods presents at a clinic complaining of hot flushes and night sweats. She avoids sex with her partner because she has vaginal dryness.

1. Why is she having hot flushes and night sweats?

These are typical symptoms of the menopause and are caused by her ovaries no longer secreting oestrogen.

2. What other symptoms should her doctor ask about?

Sleep problems, mood changes and headaches, which are common.

3. What medical problems may develop due to the menopause?

Osteoporosis and cardiovascular disease.

4. How can her symptoms be treated?

By giving her hormone replacement therapy (HRT).

5. Are there dangers of this treatment?

Yes there is a small risk of breast cancer, deep vein thrombosis and cardiovascular disease. Therefore the use of HRT in women with diabetes or hypertension, who are overweight and smoke, or who have a family history of breast cancer should be started and monitored by a family physician or a specialist. HRT must not be used at all in women with breast cancer, liver disease or a past history of deep vein thrombosis.

6. What form of HRT should she take?

She must take a form of HRT that contains both oestrogen and progesterone because she still has a uterus. Because she has recently stopped menstruating she should take a form of combined, cyclical HRT. If she had had a previous hysterectomy she could take oestrogen-only therapy, but in a woman with a uterus this can cause endometrial cancer.

7. Is there another treatment of her vaginal dryness?

Vaginal oestrogen cream.

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