In the UK, 8 in 10 people have at least one headache each year. The majority of headaches last for only a few hours, but some persist for weeks.

Pain may occur in only one part of the head, such as above the eyes, or it may be spread across the entire head. The type of pain varies, it may be sharp and sudden or dull and constant. Sometimes, other symptoms, such as nausea, occur at the same time.

What are the causes?

There are many possible causes of headache that determine the site and nature of the pain. About 3 in 4 of all headaches are caused by tension in the scalp muscles. Tension head-aches tend to recur frequently and cause moderate pain that affects both sides of the head. Other types of headache, including migraine and cluster headaches, have a variety of possible causes.

Very few headaches have a serious underlying cause, but those that do require urgent medical attention. For example, a severe headache may be a sign of meningtitis, a condition in which the membranes covering the brain an spinal cord become inflamed, or subarachnoid haemorrhage, in which there is bleeding between the membranes covering the brain. In an elderly person, a headache with tenderness of the scalp or temple may be due to temporal arteritis, an inflammation of the blood vessels in the head. Occasionally, headache results from prolonged use of strong painkillers.

If your headache is severe, lasts more than 24 hours, or is accompanied by other symptoms, such as problems with your vision or vomiting, should seek medical advice without delay.

What might be done?

You will be physically examined by your doctor. If it appears that an underlying disorder is causing your headache, you may have tests, such as CT scanning or MRI of your brain.

Treatment depends on the cause of the headache. A tension headache will usually clear up with rest and painkillers. Cluster headaches and migraine headaches can be treated with a specific drug. Such as a triptan drug or ergotamine

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Pain is the body’s response to an injury or disease that results in tissue damage. Pain usually functions as a protective warning mechanism that helps to prevent further damage, although chronic (long-term) pain often seems to serve no useful function. Everyone has experienced pain, but its type and severity depend to some extent on the cause. For example, pain that results from a sports injury may be less severe than that of a similar injury caused by a violent assault. Mood and personality also affect the way we perceive pain. For example, fear or anxiety can make pain worse, while relaxation may help to relieve it to a certain extent.

The brain and spinal cord produce their own painkillers, known as endorphins, in response to pain. Endorphins, are natural chemicals that are closely related to morphine and act as highly effective pain relievers for short periods but are less effective for chronic pain.

Most forms of pain can how be controlled as a result of improvements in treatment, and it is rare for someone to have to live with persistent pain.

What are the causes?

When tissue is damaged by trauma, infection, or a problem with its blood supply, specialized nerve endings called pain receptors are stimulated. Electrical signals travel along the nerves and through the spinal cord to the brain, which interprets them as pain. While this is happening, the damaged tissues release chemicals known as prostaglandins, which cause inflammation and swelling. The prostaglandins further stimulate the pain receptors. The skin and other sensitive parts of the body, such as the tongue and the eyes, have a large number of pain receptors and are therefore very sensitive to painful stimuli. The internal organs of the body have fewer pain receptors and are insensitive to most types of injury.

What are the types?

Although each individual may describe the character or the site of pain in a different way, there are some types of pain that usually result from specific problems. For example, throbbing pain is often due to increased blood flow, either as a result of widening of the blood vessels, as may occur in migraine, or because of an increase in blood flow through injured tissues. Severe, shooting pains, such as sciatica, can be caused by pressure or irritation of the nerve at the point where it emerges from the spinal cord. Colicky pain is caused by intermittent stretching and contraction of muscles in the walls of the intestines, or in other parts of the body such as the bile ducts, which lead from the liver to the intestine.

The location if the pain usually acts as a good guide to its source. However, in some cases, overlapping nerve path-ways can result in a confused message, causing pain to be felt in a different area of the body from the site where it originates. This type of pain, known as referred pain, occurs when nerves carrying the sensation of pain merge with other nerves before they reach the brain. For example, hip problems may be felt as knee pain, while problems with a tooth may be felt as earache. Heart problems, can cause pain across the chest, into the neck, and in one or both arms. Pain due to problems in the intestines tends to be felt in the centre of the abdomen and is felt locally only when the abdominal wall is affected, as in the late stages of appendicitis.

Sudden (acute) severe pain may be associated with other symptoms, such as pale skin, sweating, nausea or vomiting, rapid pulse, and dilated pupils, and may even result in fainting. Prolonged period of severe pain that continue for weeks or months may lead to depression, loss of weight as a result of decreased appetite, and disturbed sleep.

What might be done?

If you experience severe or recurrent unexplained pain, you should see your doctor who may be able to establish the cause of pain after a physical examination. Further investigations, including blood tests and imaging tests such as ultrasound scanning, may be necessary if there is no obvious cause.

Since it is difficult to measure the severity of pain, your doctor may ask how the pain affects your sleep and your ability to cope with daily activities. You may also be asked to describe the severity of the pain on a scale of 1 to 10 for almost unbearable pain.

The most effective remedy for pain is treatment of the underlying cause, if possible. However, pain relief is also important until treatment of the cause takes effect. There are many different ways to relieve pain, including drugs and physical methods. The form of pain relief chosen depends on the cause and type of pain you experience.

Since pain, especially persistent pain, is influenced with other factors such as personality and levels of stress, treatment has to be tailored to the individual.

Drug treatment: virtually all short-lived pain and much long-term pain can be relieved by painkillers. When pain is caused by local prostaglandin release, treatment with a non-steroidal anti-inflammatory dugs such as ibuprofen often works well because these dugs limit the release of prostaglandins.

Opioid drugs, such as morphine and codeine, act directly on the part of the brain that perceives pain and are usually highly effective. Opioid drugs may be needed to relieve intense pain, such as that following surgery, and the severe pain associated with some cancers. The risk of addition to these drugs is small when they are used for short periods, and dependence is not a cause for concern when they are used in caring for a terminally ill person.

In addition to painkillers, a number of other drugs are prescribed for certain types of pain. These include local anaesthetics and drugs that affect the transmission of nerve impulses, such as anti-depressant drugs and anti-convulsant drugs. Pain that is caused by muscle tension may be relieved by small doses of anti-depressants. Anti-convulsant drugs are often used to treat pain associated with neuropathies, such as trigeminal neuralgia.

Physical treatment: a wide range of non-drug therapies is available to help to relieve pain, including gentle massage and the use of hot or cold compresses. These treatments both after blood flow through damaged tissues and stimulate other nerve endings, blocking pain.

Acupuncture is helpful for some types of helpful for some types of pain and may be used to relieve pain after operations or for persistent pain that does not respond to other types of treatment. Acupuncture is believed to work by causing the brain to release endorphins or by stimulating nerve endings near the site of the pain so that they stop sending pain messages.

If your pain is due to damaged ligaments or muscles, your doctor may offer ultrasound treatment, in which sound waves produce vibrations in the tissues and generate heat. Transcutaneous electrical nerve stimulation uses electric impulses to reduce pain by stimulating the nerves and is sometimes used for lower back pain or during labour.

What is the prognosis?

Almost all pain can be relieved to some degree, even if the underlying cause of the pain cannot be definitively treated. However, persistent pain is often more difficult to control than acute pain.

PAIN RELIFE USING TENS

Transcutaneous electrical nerve stimulation (TENS) is sometimes useful for relieving severe, persistent pain, such as back pain. In TENS, electrical impulses are relayed from an impulse generator to electrodes placed on the skin in the area of the pain. After about 30 minutes, pain may be significantly reduced. Relief may last for several hours. TENS can be used while pursuing normal activities.

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Fibroids are abnormal growths in the uterus that consist of muscular and fibrous tissue. Fibroids are found in up to 1 in 3 women of childbearing age in the UK and are more common black women. Fibroids occur singly or in groups and may be as small as a pea or as big as a grapefruit. Small fibroids may not cause problems, but larger ones may affect menstruation or fertility.

What are the causes?

The cause of fibroids is unknown, but they are thought to be related to an abnormal response by the uterus to the female sex hormone oestrogen. Fibroids do not occur before puberty, when the ovaries begin to increase oestrogen production, and they usually stop growing after the menopause. They also increase in size at times when there are increased levels of oestrogen in the body, such as during pregnancy and when taking the combined contraceptive pill or hormone replacement therapy.

What are the symptoms?

Most small fibroids do not cause symptoms, but the common symptoms of larger fibroids include:

- Prolonged menstrual bleeding.
- Abdominal pain during periods.
- Heavy bleeding during periods.

Heavy blood loss may lead to anaemia, cause pale skin and tiredness. Large fibroids may distort the uterus, which can often result in infertility or in recurrent miscarriages. During pregnancy, a large fibroid may cause the fetus to lie in an abnormal position. Fibroids may also press on the bladder, causing a need to pass urine often, or on the rectum, causing back pain. Rarely, a fibroid may become twisted, resulting in sudden pain in the lower abdomen.

How are they diagnosed?

The doctor will perform a pelvic examination. You may also have ultrasound scanning of the uterus or a hysteroscopy, in which a viewing instrument is inserted into the uterus through the cervix. A sample of the fibroid will be removed during the hysteroscopy to check that the growth is not cancerous. Sometimes, fibroids show up on X-rays that are taken for other reasons.

What is the treatment?

Small fibroids often do not need treatment but should be checked regularly by your doctor to make sure that they have not grown. If treatment is necessary, fibroids may be removed during a hysteroscopy if they are on an inner wall. Rarely, fibroids are treated using an in injection of a substance that blocks the blood vessels supplying them, causing the fibroids to shrink.

Large fibroids can be removed via an incision in the abdomen. Before having the surgery, you may be prescribed hormones that suppress the production of oestrogen so that the fibroids shrink. If you have persistent, large fibroids and do not want children, you may consider having a hysterectomy. Removal of fibroids usually results in regained fertility, but in about 1 in 10 women fibroids recur. Fibroids usually start to shrink after the menopause, when oestrogen levels in the body fall.

HYSTEROSCOPY

A hysteroscope is an instrument used to see inside the uterus and fallopian tubes. Hysteroscopy is used to diagnose disorders such as uterine polyps and can be performed under general or local anaesthesia in an outpatient clinic. Minor surgery, such as the removal fibroids, may also be carried out through the hysteroscope. The procedure usually lasts 15 minutes or less.

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Cancer of the ovary is the fifth most common type of cancer in women and causes about 4,300 deaths each year in the UK, more than any other cancer of the reproductive tract. This high death rate is usually explained by the fact that symptoms do not develop until late in the progress of the disease, which delays the diagnosis and treatment.

The cause of cancer of the ovary is not known, but the tumour sometimes develops from an ovarian cyst. There seem to be hormonal and genetic risk factors for developing the disease. Women who have never had children or have had a late menopause are more likely to develop cancer of the ovary. Women with a close relative who developed ovarian cancer before the age of 50 are also at greater risk.

What are the symptoms?

Ovarian cancer rarely produces symptoms in the early stages, although there may be symptoms similar to those of an ovarian cyst, such as irregular periods. In most cases, symptoms occur only if the cancer has spread to other organs and may include:

- Pain in the lower abdomen.
- Swelling in the abdomen caused by excess fluid.
- Frequent need to pass urine.
- Rarely, abnormal vaginal bleeding.

There may also be general symptoms of cancer, such as loss of weight, nausea, and vomiting. Left untreated, the cancer may spread to other organs in the body, such as the liver or lungs.

How is it diagnosed?

If a close relative has had cancer of the ovary, you should consult your about screening for this type of cancer. Screening may detect cancerous changes before symptoms develop and allows treatment to be given in the early stages of the disease. You may be offered ultrasound scanning (through the vagina to look for a tumour or blood tests to look for a specific protein that is produced by this cancer. Otherwise, if your doctor suspects cancer of the ovary, he or she will examine your abdomen for the presence of swellings or lumps. You may have an ultrasound scan of your ovaries and a laparoscopy. Other tests that may be carried out include a chest X-ray and CT scanning of the lungs or liver to see if the disease has spread.

What is the treatment?

If cancer of the ovary is diagnosed in a woman who wishes to have children, usually only the affected ovary and fallopian tube are removed. If the cancer has spread to other parts of the reproductive tract or the woman does not wish to have children, a total hysterectomy may be performed, in which the uterus and both the fallopian tubes and ovaries are removed. Surgery is followed by chemotherapy to kill any remaining cancer cells. If the caner has spread to other organs in the body, radiotherapy may also be given. After treatment, blood tests and physical examinations are carried out regularly to check for recurrence.

What is the prognosis?

A complete recovery from cancer of the ovary is possible only if the condition is diagnosed and treated while in the early stages. However, the disease has spread in up to 3 in 4 women by the time of diagnosis. In these women, chemotherapy can prevent further spread of the cancer, sometimes for years, but it can rarely eliminate the cancer completely.

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In polycystic ovary syndrome, both of the ovaries become enlarged with multiple, fluid-filled cysts. The condition is thought to be caused by an imbalance of sex hormones, sometimes by a relative excess of luteinizing hormone, produced by the pituitary gland, and of the male sex hormone testosterone. This imbalance may prevent ovulation (egg release), thus reducing fertility, and sometimes leads to the excessive growth of body hair.

This syndrome is the most common female reproductive disorder, affecting about 1 in 20 women of childbearing age in the UK. The condition sometimes runs in families.

What are the symptoms?

The symptoms of polycystic ovary syndrome are variable. The condition may go unnoticed until a woman is tested for infertility. Symptoms include:

- Infrequent or absent periods.
- Obesity.
- Excessive hair growth.

Women with polycystic ovary syndrome have an increased risk of developing resistance to the action of the hormone insulin and this resistance may lead to diabetes mellitus. Women who are affected by the condition are also more likely to develop hypertension, coronary artery disease, and myocardial infraction.

What might be done?

If your doctor suspects that you have polycystic ovary syndrome, he or she will take blood samples to measure your levels of sex hormones and see if you have an imbalance. You may also have ultrasound scanning to look for ovarian cysts.

Treatment depends on the severity of your symptoms and whether you want to conceive. Infertility can be treated with drugs, such as clomiphene. If you do not want to have children, abnormal periods can be treated with a combined oral contraceptive pill.

To treat insulin resistance and reduce your risk of developing diabetes mellitus, your doctor may prescribe drugs such as melformin, which may also help to make

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Ovarian cysts are fluid-filled sacs that grow on or in the ovaries. Most ovarian cysts are noncancerous and not harmful, but a cyst may sometimes become cancerous. Cancerous cysts are more likely to develop in women over the age of 40.

What are the types?

There are many types of ovarian cyst. The most common type is a follicular cyst, in which one of the follicles, where eggs develop, grows and fills with fluid. This type of ovarian cyst may grow to 5 cm (2 in) in diameter and usually occurs singly. Multiple small cysts that develop in the ovaries are thought to be caused by a hormonal disorder, and this condition is known as polycystic ovary syndrome.

Less commonly, cysts may form in the corpus luteum, the yellow tissue that develops from a follicle after the release of an egg. These cysts fill with blood and can grow to 3 cm.

A dermoid cyst is a cyst that contains cells that are normally found elsewhere in the body, such as skin and hair cells. A cystadenoma is a cyst that grows from one type of cell in the ovary. In rare cases, a single cystadenoma can fill the entire abdominal cavity.

What are the symptoms?

Most ovarian cysts do not cause symptoms, but when there are symptoms, they may include:

- Discomfort in the abdomen.
- Pain during sexual intercourse.
- Irregular periods, which sometimes have heavy blood loss.
- Postmenopausal bleeding.

Large cysts can put pressure on the bladder, leading to urinary retention or a frequent need to pass urine.

Are there complications?

If an ovarian cyst ruptures or becomes twisted, severe abdominal pain, nausea, and fever may develop. Cysts may grow so large that the abdomen is distended. In rare cases, a cyst producing the sex hormone oestrogen may develop before puberty, which leads to early sexual development. Some ovarian produce male sex hormones, which can cause the development of male characteristics, such as growth of facial hair.

What might be done?

Sometimes, ovarian cysts are only discovered when a pelvic examination is carried out during a routine checkup. If you have symptoms of a cyst, your doctor will perform a pelvic examination.

You may also be sent for ultrasound scanning or for a laparoscopy to confirm the diagnosis and the size and position of the cyst. You may also have blood tests to see if a cyst is cancerous.

Ovarian cysts may disappear without treatment, although the size of a cyst may be monitored with regular ultrasound scans. Large or persistent cysts may be drained or removed. If there is a chance that the cyst is cancerous, it will be removed, leaving the ovary and fallopian tube if possible. Ovarian cysts may recur if the ovary is not removed.

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The lining of the uterus, known as the endometrium, is normally shed once a month during menstruation and the regrows. In endometriosis, some pieces of the lining become attached to organs in the pelvic cavity, such as the ovaries and the lower intestine. The misplaced pieces of lining react to the hormones of menstrual cycle and bleed during periods. The blood cannot leave the body through the vagina and causes irritation of the surrounding tissues, leading to pain in the abdomen and eventually scarring. Irritation of the ovaries may lead to painful cysts.

Endometriosis is a common condition, affecting as many as 1 in 5 women of childbearing age. Women who do not have children until they are in their 30s and those who remain childless are more likely to develop the condition. Severe endometriosis can often cause problems with fertility.

The exact cause of endometriosis is not known, but there are many theories. One theory is that fragments of endometrium shed during menstruation do not leave the body in the usual way through the vagina. Instead, they travel along the fallopian tubes, from where they may pass into the pelvic cavity and become attached to the surfaces of nearly organs.

What are the symptoms?

Endometriosis may not produce symptoms. If symptoms do develop, their severity varies from woman to woman. Symptoms may also vary depending on which organs are affected by the condition. They may include:

- Pain in the lower abdomen, which usually becomes more severe just before and during menstrual periods.
- Irregular periods or very heavy menstrual bleeding.
- Pain during sexual intercourse.
- Lower abdominal pain on urination.

If the endometrium grows on the lower intestine, you may develop diarrhoea or constipation, pain during bowel movements, and in rare cases, bleeding from the rectum during menstruation.

What might be done?

In women who do not have symptoms, endometriosis may only be suspected following investigations for infertility. To help make a diagnosis, your doctor will carry out a pelvic examination. The diagnosis may be confirmed with a laparoscopy (left), in which the organs in the pelvic and abdominal cavities are examined using a viewing instrument.

There are many different treatments for endometriosis, and the one chosen depends on your age, which organs are affected, the severity of symptoms, and whether you wish to have children in the future. You may be offered hormonal or surgical treatment. In mild cases, treatment may not be necessary.

If your symptoms are troublesome, your doctor may prescribe one of several different hormonal treatments that stop menstruation for several months. These drugs may include the synthetic hormone gonadorelin, gonadorelin analogues, and danazol, all of which suppress production of the female sex hormone oestrogen and have the effect of stopping menstruation. Alternatively, you may be given the combined oral contraceptive pill. This treatment is usually given for approximately 6 – 12 months, during which time the endometriosis should improve. If the condition does recur, it is usually milder than before.

Small fragments of endometrial tissue that do not respond to a period of hormonal treatment may be destroyed by laser surgery during a laparoscopy. However, endometriosis sometimes recurs after this treatment, and further operations may be necessary.

If you have severe endometriosis and you do not plan to have children or have gone through the menopause, your doctor may recommend that you have a hysterectomy to remove the uterus. Both ovaries will also be removed, together with other areas that are affected by endometriosis. If the ovaries are removed before you have reached the menopause naturally, you will develop menopausal symptoms. To alleviate these symptoms, your doctor will probably recommend hormone replacement therapy.

What is the prognosis?

Although treatment is usually successful, endometriosis may recur until the menopause occurs and the menstrual cycle ends. Endometriosis is unlikely to recur if the ovaries are removed.

LAPAROSCOPY
During laparoscopy, a rigid viewing instrument called a laparoscope is used to view the inside of the pelvis and the abdomen through small abdominal incisions. Laparoscopy may be used to look for disorders of the female reproductive organs, such as endometriosis, and to investigate other abdominal disorders, such as Appendicitis. Some types of surgery, such as female sterilization, may also be carried out during the procedure. Laparoscopy is always performed under general anaesthesia. Recovery is faster than after normal surgery due to the smaller incisions.

FEMALE STERILIZATION
Sterilization, by a method known as tubal ligation, is a permanent means of contraception for women who do not want any more children or for whom pregnancy would be harmful. The operation can be performed through two small incisions in the abdomen (laparoscopic sterilization) or single incision in the pubic area (minilaparotomy). The operation seals the fallopian tubes, usually by using clips or by cutting and typing them, so that sperm cannot travel through the tubes to fertilize eggs.

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