PRECAUTIONS BEFORE HAVING A TUBAL LIGATION

The Story of Ruth
Some women can also benefit from injections of natural hormones usually on a temporary basis. Ruth was an example of this type of treatment.
Ruth looked tired and depressed as she slumped into the chair on the other side of my desk. The most obvious reason for her fatigue was probably that she had five children all under ten years of age. However, as she related the sequence of her symptoms, the jigsaw pieces started coming together.
Two and a half years ago, Ruth had undergone surgical sterilization from a surgeon who had used the outmoded technique of burning the tubes. She had not been told what technique the surgeon would use as the consent form she had signed did not explore the alternatives. Ruth had thought this was her only way out as she could not tolerate the oral contraceptive pill and her husband refused vasectomy.
Eighteen months after her sterilisation she developed heavy painful periods heralded by increasing pre-menstrual tension with severe mood changes. She felt resentful towards her husband who could not understand her unpredictable moods and loss of interest in sex. She experienced a constant dull throbbing pain in her pelvis and sexual intercourse was acutely painful on deep penetration.
Ruth was nearly 40 and felt that her hormonal problems may be due to an early menopause, especially as she felt she was ageing rapidly. Her rapidly
diminishing self esteem and confidence were not helped by her husband who felt that her symptoms were psychosomatic.
I asked her if she ever felt good. She replied that at the end of seven days of menstrual bleeding she felt a bit like her old self and said, ' That's when I wear high heels again, cook cakes and take the kids out, but I only feel normal for seven days, then the rotten pre-menstrual syndrome takes the wind out of my sails".
Ruth wanted to know if she could have her tubal ligation reversed. I said this was doubtful as her surgeon had used the burning method which often causes damage to the fragile tubes and the blood supply to the ovaries. Trying to reverse this damage would be no guarantee to cure her hormonal problems and would also involve more surgery and pain.
I encouraged Ruth to try hormonal therapy. Blood and urine tests revealed that Ruth's ovaries were not functioning well presumably because of damage to their blood supply induced by burning of the tubes and blood vessels at the time of sterilization.
Ruth started on natural oestrogen tablets (Progynova lmg twice daily) everyday and progesterone (Provera 5mg) for the first twelve days of every calendar month. The Provera tablets were necessary to balance the oestrogen and regulate her cycle and they would bring on a menstrual period around the twelfth day of every calendar month.
This treatment relieved her pre-menstrual tension, depression, pelvic pain and heavy bleeding and she started to get on top of things again.
Her flagging libido remained a problem and so we checked her level of male hormones which are necessary for a healthy sex drive, orgasmic ability and so called ' 'feminine virility''. We found that her male hormones were almost non-existent which explained why she felt asexual which she described as ' 'almost like a eunuch''.
Ruth and I decided that this was best overcome by giving her an injection of natural oestrogen and testosterone (Primodian Depot injection) every three months, with this injection being given at the end of every third menstrual period. This was to continue for nine to twelve months and would build up her body's male hormones to a degree sufficient to increase libido but without causing side effects such as facial hair or acne. The Primodian injection proved nothing short of miraculous and Ruth began to feel like a vital, sexual and happy human being for the first time in three years.
There are thousands of women like Ruth who are standing on the sidelines, struggling with their health and waiting for enlightened doctors to draw the curtains on the astounding benefits of natural hormone replacement.
Until more long-term studies of women after tubal ligation are available, we can only guess at the number of women having hysterectomies to relieve their post-sterilization symptoms. They should be given all the alternatives to hysterectomy and not be told that it is the only answer.

Precautions Before Having A Tubal Ligation
As has been seen, surgical sterilization or tubal ligation is not always free of hassles and should not be taken casually. I would not advise my patients to undergo tubal ligation unless a further pregnancy would be a catastrophe as in women with severe diabetes, heart, kidney or liver disease. I believe that with current non-surgical methods of contraception and the newer oral contraceptive pills, vaginal rings and contraceptive implants that are imminent, that the benefits of tubal ligation do not outweigh the risks. I would advise any woman with gynaecological problems such as heavy, painful bleeding, fibroids, endometriosis, pelvic pain, pre-menstrual syndrome or a past history of nasty, postnatal depression to avoid tubal ligation.
Until surgeons have perfected and standardised surgical techniques (preferably microsurgical) for tubal ligation, I think that younger women considering this operation should seriously think about the possibility that current techniques (which vary widely) may put them at risk for years of hormonal and gynaecological problems and reduced ovarian function.
Older women may have little to gain from tubal ligation. They already face the likelihood of diminished ovarian function in the pre-menopausal years and tubal ligation will give them less contraceptive time than younger women. Furthermore, they are less fertile anyway so that simple and safe contraceptive methods such as the progesterone only pill, diaphragms and vaginal rings and hormone implants are relatively more effective.
If you really want a tubal ligation, make sure that your personal life is stable and happy. I have seen many women who later wanted a reversal of their tubal ligation.
Before having a tubal ligation, have a thorough gynaecological examination, pelvic examination and pap smear and if you have abnormal bleeding, you should have a dilatation and curettage of the uterus. This will exclude the presence of cancer of the uterus or cervix or huge fibroids, that may require a hysterectomy in the near future, in which case a tubal ligation would have been an entirely unnecessary and unpleasant experience.
Finally, I believe that the consent forms for tubal ligation should be expanded to include all the potential complications and problems (including the increased risk of hysterectomy) that may occur in the long term subsequent to this procedure. The consent form should also state that more
research is needed to determine the real incidence of these problems. Then we could say that women are really able to give valid informed consent to a surgical procedure that may have a lasting effect upon their lives.
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