A: Even though the birth of a baby is viewed as a happy occasion, it is normal to be depressed for a short time. It’s difficult to pinpoint how common this is, but researchers estimate that a depressed mood affects anywhere from 50 to 75% of new mothers. Because of the dramatic hormonal changes that occur in a woman’s body after she delivers a baby, an even higher percentage of women may experience some sort of emotional letdown.

The most common syndrome is called “postpartum blues.” Mothers describe sadness (often worsened by the expectation that they “ought” to be happy), crying jags, anxiety, irritability, impatience, restlessness, and hypersensitivity. Typically, symptoms emerge on the third or fourth day after delivery and resolve on their own within 2 weeks.

A mood shift that starts later than the “blues” is called postpartum depression. Postpartum depression usually develops at least 1 week or so after delivery (mothers may feel relatively well until then) or anytime up to 6-8 weeks later, and it may last up to a year. This longer-lasting disorder is less common, affecting about 10-20% of new mothers. Symptoms include agitation, anger, fear, insomnia, decreased appetite, and depressive, obsessive, or racing thoughts. Postpartum depression can also involve changes in sleep patterns, panicky feelings, difficulty concentrating, guilt pangs, and thoughts of suicide. A much rarer mood disorder, postpartum psychosis, occurs only in about one out of 1,000 women who have recently given birth. A psychotic disorder is characterized by an absence of rational thinking in addition to other mood changes.

The time immediately after delivery is by definition one of great change for all mothers–a baby radically alters a woman’s personal, family, and home dynamics. This, in addition to the expected hormonal changes new mothers experience, can easily produce depressed feelings, most of which are short-lived and quite normal. If your symptoms do not improve or seem to worsen, you should discuss what you are feeling with your doctor.

Why are so many baby strollers, built for two or even three, rolling up and down the avenues of major cities? The short answer: infertility treatment.

During the past 20-25 years, largely due to such treatment, the incidence of triplets, quadruplets, and even higher-order multiple births has increased 400%. Medicine’s success in combating infertility is a boon to would-be parents, but it has come at a cost–medical, moral, and financial–that everyone considering it must evaluate.

This article describes the two types of infertility treatment that give rise to multiple births, explains the risks, explores the major ethical issues, and passes along practical advice on how to choose a reputable physician and program. The focus is on reaping the rewards of these technologies while minimizing their harmful consequences to mothers and their babies.

First There Were Seven and Then There Were Eight

Remember the McCaughey septuplets, the babies born to Bobbi and Kenny McCaughey? Everyone was captivated by a modern fairy tale that combined the wonders of technology with the kindness, warmth, and neighborliness of a 1940s movie. An army of medical personnel, on hand during the delivery and follow-up hospital care, was succeeded by an army of devoted neighbors and friends who coordinated meals, laundry, transportation, babysitting, and housecleaning. The babies appeared healthy. The McCaugheys really did seem to have “a wonderful life.”

Stories about the Chukwu octuplets, born in Texas about 1 year later, were very different in tone, and not only because one of the babies, who weighed a mere 10.3 ounces at birth, died a week later of heart and lung failure. The media reaction was less celebratory and more ambivalent. Media hesitation to discuss the medical risks involved in so-called high-order multiple births, which had been obvious when it dealt with the McCaugheys, evaporated within days of delivery.

The Twin Causes of Multiple Births

Both Bobbi McCaughey and Nkem Chukwu had taken fertility drugs. Such drugs are given for two reasons: ovulation induction (to enable someone who does not ovulate regularly to do so) and super ovulation (to enable a woman who does ovulate, but has had difficulty becoming pregnant, to produce multiple eggs). High-order multiple births are linked to both treatment goals, but primarily the first. When using such drugs, it is good medical practice to do ultrasound scans to monitor the number of eggs present. If the number is too high, the woman may be advised to refrain from sexual intercourse.

Alternatively, by using in vitro fertilization (IVF), eggs can be fertilized outside the body. The resulting embryos are then implanted into the mother. Age is a factor here: Implanting more embryos in younger women increases the risk of multiple births. Generally, the better the technical abilities of the infertility specialist, the fewer the embryos required to be implanted.

The Risks

For individuals (and their mates) who really want to become pregnant, it can be difficult to coolly consider the risks that attend to giving birth to several infants–risks to both mother and babies. For women, overstimulating the ovaries can have medical complications. Carrying multiple fetuses increases the risk of potentially fatal blood clots during pregnancy and delivery, as well as the likelihood of miscarriage.

Premature babies face a broad range of increased risks, which include potential complications immediately after delivery and later problems such as learning disabilities, mental retardation, blindness, and chronic lung problems. For instance, doctors are currently evaluating whether two of the McCaughey septuplets may have cerebral palsy. There are also potential psychological effects of having parents who may be stretched beyond their capacity to cope.

Why Doctors and Patients Go Ahead Anyway

But many women (and couples), even knowing the risks, choose to take their chances. They have unprotected sex when they have produced many eggs, or they ask their doctors to implant four, five, or even six embryos after IVF. Both drugs and IVF are expensive and, for most people, these procedures are not covered by insurance. They therefore want to maximize their chances. And, of course, there is the intense desire to become a parent.

Clinics have incentives, too. Patients choose specialists with the highest success rates. However, giving too much of a drug or implanting too many embryos, which may not be in the best interests of mother and child, can result in deceptively good statistics for unwary consumers. Some physicians feel that if they are faced with a high-order multiple pregnancy, selective reduction–giving some fetuses a lethal injection of potassium chloride to increase the chances for the ones that are left–is a fallback position. For religious reasons, for Bobbi McCaughey and Nkem Chukwu, it wasn’t.

Ethical Issues

The April 21,1999, episode of Chicago Hope, “And Baby Makes Ten,” depicted multiple births as ethically problematic. There are many concerns, some of which are troublesome or have moral implications, including the following:

• First, informed consent: Before treatment begins, doctors must describe to couples the risks to mother and baby, as well as the likelihood of success and how that success is measured. The so-called take-home baby rate–the percentage of treatments that result in a healthy baby–is key. Various options should be fully and frankly explored.
• Second, selective reduction: Couples should be asked, before treatment, whether this could be an option for them. If not, more conservative treatment may be considered.
• Third, the doctor’s duty: Doctors have a responsibility toward the babies as well as toward their mothers (and fathers). A woman’s (and man’s) wish to maximize the chances for a pregnancy must be balanced against the babies’ welfare.
• Fourth, cost: The cost of caring for these children can be extraordinarily high. The cost for the octuplets had reached $2 million by the time they left the hospital. Although fertility treatment expenses are usually paid by the individuals undergoing treatment, the babies’ medical care is covered by insurance. Many people question whether it is reasonable for society at large to bear such high costs as a consequence of the decisions of individuals.

Questions to Ask When Choosing an Infertility Specialist

In addition to understanding the specialist’s approach to the ethical issues just described, there are other questions to ask. Eric Widra, MD, director of Reproductive Endocrinology, Georgetown University Medical Center, and an associate at Shady Grove Fertility Centers, suggests four criteria:

• Are there fellowship-trained reproductive endocrinologists working there? (These are doctors who have had obstetrics and gynecology training, along with additional training in infertility and developmental disorders of the reproductive tract.)
• Are the doctors board certified (after taking written and oral exams)?
• What are the success and complication rates?
• Can the practice offer complete services, including IVF, 7 days a week?

Diagnosis of endometriosis can be difficult. However, there are a number of symptoms that indicate that it may be present. If the following sound familiar, there are medical tests your doctor can do to see if you have the disease.

symptoms
While a small number of women with endometriosis have no symptoms at all, most suffer severe, chronic pelvic pain. Other symptoms include:

The only way to confirm endometriosis

is with a laparoscopy.

Medical Tests
Symptoms often indicate that a problem exists, and sometimes a doctor can feel growths during a manual pelvic exam. But because similar symptoms can be caused by other conditions, such as ovarian cancer, diagnosis needs to be confirmed before beginning treatment.

A laparoscopy is the only way to positively confirm endometriosis. This is a minor surgical procedure where a laparoscope (a lighted tube) is inserted into an incision in a woman’s abdomen allowing the doctor to look for growths on the abdominal organs. At the same time, the surgeon can also remove adhesions and growths to provide much needed relief to the patient.

To significantly increase the chance of pregnancy you should pinpoint when ovulation occurs and have sex during that time.

Ovulation & your cycle
We are often told that ovulation happens between day 12 and day 16 of the cycle (day 1 being the first day of the period). This is only true for a 28 day cycle. Women with longer cycles ovulate later and those with shorter cycles ovulate earlier. Someone who normally has a period every 35 days for example, will most likely ovulate between day 20 and 24 and with 21 day cycles the fertile time is as early as day 6-10.

When is your fertile time?
The way to estimate your fertile time when you have regular cycles (whether long or short), is to subtract 16 days from the number of days in the cycle which gives the earliest day ovulation could happen. Within the four days after that day, ovulation is most likely to occur.

For example, if you have a 31 day cycle, then subtract 16 from 31 which gives 15. Start having sex on day 15 of your cycle (ie count to 15 from the first day of your period). If you’d like a hand to find the best days to start having sex or even get a reminder (very discrete reminder, that is!)

Physical changes around ovulation
There are some physical signs around ovulation time and being aware of those can help you identify when you are about to ovulate or have ovulated:

• Just before ovulation, the vaginal discharge becomes clear and stretchy like egg-white
• Body temperature rises approximately 0.5 degrees after ovulation
• After ovulation the vaginal discharge becomes thick and white
• Some women experience abdominal pain around the time of ovulation

Ovulation testing
There are commercially available home urine tests which can help you to detect ovulation. These tests measure the LH hormone in the urine and when the level of this hormone rises 1-2 days before ovulation, the test shows positive. These tests are available from a chemist and can be helpful in predicting your fertile time of the month.

Sperm can survive up to five days in a woman’s reproductive system but to optimise the chance of pregnancy it is best to have sex during or very close to the time of ovulation.

If you suspect you are not ovulating
Some women don’t have periods or have very infrequent or irregular periods. This most commonly indicates that they are not ovulating. If you suspect that you are not ovulating, you should see a fertility specialist who will be able to determine the cause.

Anatomy :
The heart pumps blood out around the body through arteries. These become smaller and smaller until they are only one cell in diameter, when they are known as capillaries. In the capillaries, the oxygen and nutrition are removed from the blood, which then travels back to the heart through the veins. Two systems of veins are used in the legs to move the blood from the feet back to the heart. One system is deep inside the muscles of the calf and thigh, the other system is outside the muscles and just under the skin. It is this superficial system that causes varicose veins. The contraction of the muscles in the leg supplies the force to move the blood out of the legs. The muscle movement squashes the veins, and with the aid of one way valves scattered through the superficial venous network, the blood is steadily pushed back towards the heart.

Cause :
Pregnancy (because of the growing baby putting pressure on the veins in the pelvis) and prolonged standing (in jobs like hairdressing and shop assistant) make it difficult for the blood to move up from the legs into the body. The veins then become swollen with blood, and the one way valves can become damaged. The damaged valves then allow more blood to remain in the veins, dilating them further and eventually causing the grossly dilated varicose veins.

Incidence :
Very common in certain occupations where prolonged standing is required. More common in women than men due to pregnancy. Worsen steadily with age.

Prevention :
Reducing the amount of standing, wearing elastic support stockings and regularly exercising the muscles in the legs while standing may prevent varicose veins.

Investigations :
Ultrasound examinations and rarely x-rays after injection of dye, may be performed before surgery to determine the appropriate areas for correction.

Course :
Large, ugly, blue, knotted ropes straggling across the surface of once shapely legs like a blue-water seaman�s nightmare! Tired, aching, swollen legs, that make their owner wish that medical science had developed a way of transplanting firm and supple limbs onto an otherwise well-tuned body. Varicose veins never kill their owner, but they certainly cause a great deal of discomfort, and a significant drop in ego and self-esteem, when their owner finds others staring at the patterns they describe across the blotchy, red and sometimes ulcerated skin.

Treatment :
Unfortunately, there are no magic cures for this very common problem, but doctors do have ways of reducing the symptoms and removing the veins. Once present, there are tablets (eg: Paroven - see Medication Table) that can reduce the aching that may be present in the dilated veins, but only surgical procedures can permanently remove the veins. Injections may be used to destroy small, fine, spider-like networks of veins. This is rather like injecting a special type of glue into the veins, to stick the walls together. Larger isolated veins can be removed one at a time by a nick and pick procedure, with a small cut being made over each vein to allow its removal. The most major procedure is stripping, where most of the superficial veins on one side of the leg from the groin to the ankle, are removed. This procedure may be combined with a nick and pick . After all these procedures, the leg must remain firmly bandaged for several weeks. It is sensible to discuss the matter with your general practitioner sooner rather than later if varicose veins worry you, so that referral to a surgeon can be arranged before too many of the tortuous veins develop.

Diet :
A loss of weight in the obese may reduce the discomfort of varicose veins, improve the chances of surgical success, and reduce the risk of recurrence.

Complications :
Varicose veins may rupture to cause severe bruising, or be cut and bleed profusely. In these situations, the bruised or cut area must be bandaged firmly, the patient should lie down, the leg must be elevated for an hour or so, and ice applied.

Outcome :
The operations are successful in most people, but they do not prevent the development of veins elsewhere in the legs, and the skin staining caused by the varicosities is usually permanent.

Introduction :
Fungal infection by Candida albicans.

Types :
Thrush is most common in the vagina, but may also occur in the mouth, around the anus, and rarely in the nose.

Cause :
Thrush is a fungal infection caused by Candida albicans. It is a distant cousin to the fungus that can grow on rotting food. Candida can cause infections in many different areas, but the most common are the mouth and vagina. The mouth infections usually occur in babies, but it is the vaginal form that causes the greatest problem. Candida albicans normally lives in the gut where it causes little or no trouble. Usually when it comes out on to the skin around the anus, it dies off; but if that skin is warm, moist and irritated, it can grow and spread forward to the lips of the vagina (the vulva). A warm climate and the aggravating factors listed below, give the area between a woman’s legs the right degree of warmth, moisture and irritation to make the spread of the fungus relatively easy. Antibiotics aggravate the problem because, as well as killing infecting bacteria, they can kill off the good bacteria in the gut which normally keep the number of fungi under control. Entry of the fungus into the vagina from the skin outside is aided by the mechanical action of sex, and the alteration in the acidity of the vagina caused by the contraceptive pill.

Incidence :
Almost every woman catches thrush at some time in her life.

Prevention :
Tight jeans, panty hose, the contraceptive pill, nylon bathers, antibiotics and sex. These are the common aggravating factors involved in catching the modern woman’s curse of vaginal thrush. You can prevent infections by wearing loose cotton panties (or no panties at all at home and when socially acceptable), drying the genital area carefully after swimming or showering, avoiding tight clothing, wiping from front to back after going to the toilet and not using tampons when an infection is likely.

Investigations :
No investigation is normally necessary, as the diagnosis is obvious when a woman is examined, but if there is any doubt, a swab can be taken from the affected area and sent to a laboratory for culture and identification.

Course :
Once established, thrush causes an unpleasant white vaginal discharge, intense itching of the vulva and surrounding skin, and often inflammation of the urine opening so that passing urine causes discomfort. The almost irresistible, but socially unacceptable itch is what drives most patients to the doctor.

Treatment :
The treatment of vaginal thrush revolves around antifungal vaginal pessaries, vaginal creams and an expensive oral tablet (Diflucan -see Medication Table). These can give rapid relief, and are given in a course that can vary from one to ten days depending on the severity of the infection and the method of treatment used. Unfortunately, many women have repeated attacks, and this is due to inadequate treatment, contamination from the gut, or reinfection from their sex partner. The husband/boyfriend must also be treated with a cream, because although he may show no signs of the infection, it may be present under his foreskin, and he can give the thrush back to the woman after she has been successfully treated.

Diet :
There is no evidence that any particular diet aggravates, or treats, thrush effectively.

Complications :
Thrush rarely causes serious medical problems, but because of it troublesome nature, it should always be treated promptly and effectively

Outcome :
Most thrush infections can be cured quickly, but recurrences are common.

Related conditions :
Fungal Infections.

1. Hypothalamus
A higher thinking centre of the brain (the hypothalamus) sends a messenger chemical called a hormone to a gland in the centre of the brain (the pituitary gland). This messenger chemical is called GnRH and its role is to release a second set of messenger hormones from the pituitary gland which will travel to the ovary.

2. Pituitary gland
The pituitary gland is a small 1 1/2 cm diameter gland situated in the centre of the brain. It releases hormone messengers that control many functions in the body such as the thyroid gland, the adrenal gland, and breast milk production. It releases two important hormones which control both egg production and release in the ovary.

These are:

• FSH (follicle stimulating hormone) . This messenger hormone travels from the pituitary gland to the ovary and tells the ovary to grow an egg or eggs.

• LH (luteinising hormone) . For 2 days out of every 28 days this hormone is produced in large quantities and travels from the pituitary gland to the ovary and tells the ovary to ripen and then release the egg. LH levels only increase in the bloodstream 36 to 40 hours prior to egg release. The sudden spike of LH released by the pituitary gland is called a “surge”. It’s rather like a “sneeze” of hormone being released. Daily blood levels can be used in patients to predict this LH surge and therefore predict the time of egg release to within a couple of hours. This technique is widely used to help infertile patients become pregnant by telling them when to time their intercourse or artificial insemination.

3. Ovaries
All the eggs present in the ovary for a woman’s lifetime are actually produced when she is still a foetus inside her mother. As she enters puberty she has approximately 400,000 eggs in her two ovaries. When all the eggs are used up and there are none left to proceed to maturity each cycle, the female goes into menopause. This happens at an average age of 52 years.

From puberty, at the start of each menstrual cycle 30 to 100 eggs are stimulated by the release of FSH from the pituitary gland. In the context of the normal 28 day cycle this usually occurs between Day I and Day 5 of the cycle, often the period is still occurring. Each of the eggs develops in a very small cyst called a follicle. These follicles all begin to grow under the influence of FSH. However, it would clearly be very undesirable for 30 to 50 eggs to be released every cycle. This would make the risks of multiple pregnancy far too high. The body and the ovary therefore have a mechanism of selecting only one (and sometimes two) follicles to become the selected egg which will grow onto maturity for that month. This process of egg selection and its subsequent growth to a mature egg occurs between Day 5 and Day 12 of the average 28 day cycle. As this dominant follicle and egg grow, the other numerous little follicles which started to grow fade away and the primitive eggs die off, never to be used.

During this phase of egg development and maturation, cells in the wall of the developing follicle/cyst start to produce a hormone called oestrogen. Oestrogen is the most important female hormone and it is possible to measure its daily rise in the bloodstream from Day 5 to Day 14 in parallel with the egg development. Typically a single follicle producing a single egg will have a peak oestrogen level about one day prior to ovulation of 400- to 1400 p.mols per litre.

4. Ovulation
The release of the now mature egg occurs usually between about Day 12 and 15 of the average 28 day cycle. The pituitary gland releases a rapid spike of LH messenger hormone which travels to the ovary and starts a complex series of chemical actions which ripen the egg, detach it from the wall of the cyst/follicle in which it is growing so that it is now floating free in the fluid within the follicle. Finally the follicle splits open to release the egg.

The egg is hopefully picked up by the waiting fallopian tube and if intercourse or insemination occurs around this time, sperm and egg may meet together in the fallopian tube and a pregnancy may result.

5. Corpus luteum
After ovulation the follicle reforms and the cells in the lining of a follicle change their chemical structure and begin to produce a hormone called progesterone. The follicle which has just released the egg is now called a corpus luteum. Progesterone is a very important hormone which travels from the corpus luteum to the uterus and changes the lining of the uterus preparing it to receive a pregnancy. This second half of the menstrual cycle is therefore called the luteal phase of the menstrual cycle and would typically run from Day 14 to Day 28 of the normal cycle.

If the female does not become pregnant in this particular cycle the corpus luteum cyst will degenerate around 14 days after ovulation (Day 28 of the cycle) and as the progesterone levels drop the lining of the uterus becomes unstable and the period will begin.

If however pregnancy has occurred the pregnancy itself begins to send special hormonal messengers to the corpus luteum telling it not to degenerate. The corpus luteum continues to produce progesterone past Day 28 of the cycle and no period occurs. The lack of the menstrual period therefore serves as a marker that the patient may be pregnant and several days later a pregnancy lest can be performed.

In some cases, it may be appropriate to start an infertility investigation after 6 months of trying to conceive. Reasons to start the investigation sooner include:

• If the woman is over 35 years of age
• If she has irregular periods or no periods at all
• If she has had pelvic surgery or a pelvic infection in the past
• If the man has a past history of genital surgery, genital infection or trauma to the testes.

The initial tests in a fertility investigation may be done by your GP but for more advanced tests it is best to be referred to an infertility specialist. You should see both your GP and the specialist as a couple so that both partners can be investigated simultaneously. Another important reason for participating as a couple is to give each other support throughout the process, which at times can get frustrating and stressful.

At the first consultation the doctor will usually do a physical examination of both the woman and the man and take a thorough history. The questions asked will sometimes give clues to what may cause the infertility.

Questions to expect
This list gives an idea of the kind of questions you can expect and explains why they are asked:

• Your age, because it affects fertility, particularly the woman’s, but to an extent also the man’s age
• The regularity of the woman’s periods - this gives important information about how frequently ovulation occurs (so keep a record of your period dates)
• If periods are very painful, because this may point to endometriosis
• Questions about previous pregnancies and the outcome of those are always asked
• If either of you have had surgery or physical trauma in the past that may have involved the reproductive organs, this could point to a problem related to that surgery or trauma
• If the woman has had a pelvic infection or used an IUD in the past, this might suggest that the Fallopian tubes are blocked
• If the woman’s Body Mass Index (BMI, the relationship between height and weight) is very high the reason for infertility could be Polycystic Ovarian Syndrome
• If the man’s occupation involves hazardous chemicals this may affect sperm production
• How often and when in the cycle you have intercourse is important to know - the problem may simply be that pregnancy does not happen because you try at the wrong time
• Questions about life style- smoking, alcohol intake, diet, etc - will be asked because some life style factors affect fertility and chance of pregnancy

When all the information has been gathered the doctor will order some tests.

Tests & investigations

The man will be asked to have one and sometimes two semen analyses. If the test result is abnormal, the doctor may order blood tests to uncover the reason.

For the woman, many more tests and investigations are often needed to find the cause of infertility. These include:

• Hormone tests to monitor ovulation. Some doctors also ask the woman to take her temperature each day (BBT, Basal Body Temperature) and record it. Just before ovulation the body temperature often rises slightly and this indicates ovulation. However, it is quite stressful to do BBT over several months and it is of limited value because some women ovulate even when no temperature rise shows up.
• A vaginal ultrasound examination by a specialist ultrasonographer can be a very good diagnostic tool. Things like PCOS (”Polycystic Ovary Syndrome), fluid filled fallopian tubes, fibroids and polyps, endometriosis or other cysts can be detected with an ultrasound scan.
• A hysterosalpingogram is an x-ray examination which gives information about the inside of the uterus (uterine cavity) and whether the Fallopian tubes are open or blocked
• A hysteroscopy allows the doctor to inspect the uterine cavity
• A laparoscopy is a surgical procedure where an optic instrument is inserted close to the navel giving the doctor the opportunity to examine the uterus, Fallopian tubes and ovaries for any abnormalities. You need a general anaesthetic and a day in hospital to have a laparoscopy.

An infertility investigation should take no more than 3-4 months. Male and female causes of infertility are equally common. Of couples who go through an infertility investigation a female cause is found in about 40% and a male cause in 40% of cases, but for 20%, no cause is found. Very rarely is the infertility absolute, meaning that there is a small chance of conception occurring naturally every month. That’s why it is useful to try to have intercourse around ovulation time. even when you have started an infertility investigation.

Introduction :
Dilated vein(s) around the anus that may be painful and bleed.

Types :
Internal and external forms, depending on which vein becomes damaged and dilated.

Cause :
Piles (or haemorrhoids as they are more correctly known) can occur very suddenly, or build up over many years. Around the anus is a circular vein, close to the skin surface. The anal canal is about two centimetres long, and at the inner end of the canal, another vein circles around it, close to the surface. When a motion is passed, the anal canal dilates to let it pass. If this dilation is excessive, due to constipation, these fine veins can be stretched, then rupture and form piles. If the outer vein ring is damaged, an external pile results; if the inner vein ring is damaged, an internal pile is formed.

Incidence :
Very common, and more likely to occur in men and with advancing age.

Prevention :
The best treatment for this distressing problem is prevention. Two things cause piles - hard large motions, and straining with heavy lifting. Piles are a common complaint amongst Olympic weight lifters. Keeping the bowels regular and soft is the most important preventative measure. This involves diet (see below) and habit. The habit of opening the bowels at a regular time each day, and not suppressing the urge to pass a motion, will ensure that no extra stress is put on those fine veins around the anus. Once piles are present, it is even more vital to prevent further stresses to the sensitive area.

Investigations :
If there is any concern that bleeding from the anus is caused by a problem other than piles, a colonoscopy (examination of the bowel through a thin flexible tube) must be performed to check for any bleeding sites higher in the bowel.

Course :
Haemorrhoids can vary dramatically in their appearance and effect. They may appear as an intermittent, painless swelling beside the anus, or they can be excruciatingly tender and painful, more than one centimetre across, and bleed profusely.

Get Rid of Piles

Treatment :
Treatment follows several steps. Initially, the soothing creams available over the counter from chemists can be used, but if relief is not rapidly obtained, assistance should be sought from your general practitioner. After examining the area to determine exactly what damage has occurred, the doctor will prescribe appropriate treatment. This usually takes the form of anti-inflammatory and antiseptic creams that can be used directly on the haemorrhoids, and soothing suppositories. These are bomb shaped tablets that are inserted through the anus into the rectum, where they dissolve to help internal piles. If there is a clot of blood in the dilated haemorrhoid, it may be cut open to allow the congealed blood to escape. Although momentarily painful, this is usually followed by significant relief. If the piles fail to settle on simple treatments, further intervention is necessary. This can vary from simply clipping a rubber band around the base of the pile, to a full scale operation to cut away part of the anal canal. Piles may also be injected or electrically coagulated. The operation can be rather uncomfortable and painful for some days afterwards, and so conservative measures are used whenever possible. If an operation is necessary, it is normally successful in permanently removing the problem.

Diet :
The diet should be high in fibre (bulk), and low in refined foods such as sweets, cakes, white bread and sugar. High fibre foods include unrefined cereals, wholemeal breads, green vegetables, fruit and unpolished rice.

Complications :
Once a pile is develops, a weak area will always be present, and even though one attack may settle, the same pile may flare up time after time.

Outcome :
Although rarely serious, piles can be a distressing condition, and should be treated sooner rather than later. If the appropriate creams and suppositories are used soon enough, it may be possible to avoid surgery for many years.

Related conditions :
Constipation.

Now you know how to get rid of..