Ovarian cancer in Australia

Incidence rates of ovarian cancer

Ovarian cancer is the eighth most common cancer in Australian females and the second most commonly diagnosed gynaecological cancer after uterine cancer.

Approximately 1,580 Australian women are expected to be diagnosed with ovarian cancer in 2017, accounting for 2.5% of all new female cancer cases. The estimated age-standardised incidence rate for 2017 is 10.8 cases per 100,000 females, up from 10.6 cases per 100,000 females in 2013 (Figure 1). The majority of these women diagnosed are likely to be diagnosed with an advanced stage of disease as early-stage ovarian cancer often does not present with symptoms.

The risk of ovarian cancer increases with age up until the age group 70 – 95+ where the incidence begins to decrease. The average age at diagnosis is 63 years, with a 1 in 122 risk of developing ovarian cancer before the age of 75, and a 1 in 81 risk before the age of 85.

Figure 1: Estimated incidence rates and mortality rates for ovarian cancer in 2017

Mortality rates for ovarian cancer

Ovarian cancer is the sixth most common cause of cancer death amongst Australian women, with an estimated 1,047 deaths (accounting for 5.1% of all female cancer deaths) expected in 2017. The age-standardised rate (ASR) for mortality was 6.8 deaths per 100,000 cases in 2014, a decrease from 9.3 deaths per 100,000 females in 1968 (Figure 1).

The 5 year survival rate between 2009-2013 was 44.4%, up from 34.1% between 1984-1988 (Figure 2). The prognosis (outlook for survival) depends on the type and stage of cancer at diagnosis as well as general health. Where ovarian cancer is diagnosed early, over 80% of women are likely to survive for over 5 years, however only approximately 30% of women diagnosed at advanced stages will survive for more than 5 years.

Figure 2: 5-year relative survival from ovarian cancer

Resources

Cancer in Australia 2017

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129559144

Summary of AIHW Cancer in Australia 2017 report

https://ovarian-cancer.canceraustralia.gov.au/statistics

Ovarian cancer

What is ovarian cancer?

Ovarian cancer occurs when cells in one or both of the ovaries begin to grow abnormally and develop into cancer. There are four main types of ovarian cancer that are named after the cell types where the cancer originates:

Epithelial ovarian cancer

• Originates in the epithelium (outer cells of the ovary) and accounts for ~90% of cases.

Borderline or low malignant potential (LMPO) tumours

• Less aggressive epithelial tumours with a generally favourable prognosis for the women affected.

Germ cell ovarian cancer

• Arises in the cells that mature into eggs (ova) and accounts for ~5% of ovarian cancer cases, particularly affects women under 30 years.

Sex-chord stromal cell cancer

• Begins in the ovarian cells that release female hormones, also accounts for ~5% of cases and can affect women of any age.

Cause of ovarian cancer

There are a number of factors which may increase a woman's risk of developing ovarian cancer, such as:

• Family history
• Being of Northern European or Ashkenazi Jewish descent
• Alterations in BRCA1 or BRCA2 genes
• Being over the age of 50
• Late menopause
• Early onset of menstruation (<12 years)
• Infertility, never having children or having their first child after the age of 30 years
• Never taking oral contraceptives
• Having fertility treatment or oestrogen-only hormone replacement therapy
• Smoking
• Obesity

Symptoms of ovarian cancer

Although there are no obvious signs of ovarian cancer, you may experience some of the following symptoms:

• Abdominal bloating
• Difficulty eating/feeling full quickly
• Frequent/urgent urination
• Constipation
• Indigestion
• Back, abdominal or pelvic pain
• Menstrual irregularities
• Fatigue
• Pain during sex

Diagnosis

There is currently no screening option for ovarian cancer in Australia. However, if you are experiencing symptoms associated with ovarian cancer it is advised that you discuss your concerns with your doctor who may suggest various tests to detect cysts, tumours or other abnormalities. These may include:

Physical examination

• External abdomen examination and internal vaginal examination.

Blood tests

• Your blood will be tested for tumour markers, in particular the protein CA125 which may be elevated in women with ovarian cancer.

Ultrasound

• A transvaginal ultrasound (TVU) where an ultrasound probe to be inserted into your vagina to relay an image of the ovaries.

Other Imaging scans

• Other tests may include CT scans, external ultrasounds, abdominal x-rays or an MRI

If the tests suggest that there are abnormalities present, a biopsy (tissue sample) may be taken to confirm cancer diagnosis.

Staging

There are often few signs of ovarian cancer in its early stages, usually only presenting once the cancer has spread. The stage of ovarian cancer is determined using the International Federation of Gynaecology and Obstetrics (FIGO) system. The FIGO system records whether the cancer remains contained within the ovaries or the extent of which it has spread to other pelvic structures or into the abdominal lining.

Treatment

Your treatment team generally consists of your GP as well as a number of specialists including a gynaecological oncologist and possibly a medical oncologist or radiation oncologist, as well as other healthcare professionals. The best treatment option depends on the type and stage of the ovarian cancer as well as general health.

Surgery

• Surgery is usually the main treatment option for ovarian cancer, particularly when the cancer is still localised. The initial operation is known as a laparotomy, where a long vertical cut is made in the abdomen in order for the surgeon to locate and remove as much of the tumour as possible. At the start of the laparotomy a biopsy (known as a frozen section) is taken to confirm diagnosis. During the operation most women will have their ovaries, Fallopian tubes, uterus, omentum (fat pad around the abdominal organs), appendix and some lymph nodes removed, as well as part of the bowel in some instances. Biopsies from the removed tissues are examined to enable the gynaecological oncologist to learn more about the type and extent of the cancer and determine the best course of action for further treatment.

Chemotherapy

• Most women with ovarian cancer also undergo chemotherapy to slow or cease the growth of remaining cancer cells. Chemotherapy is most effective when the cancer is small and the cells are actively growing and is commonly used soon after surgery to remove remaining cancer cells. It may also be used as a first line of treatment in cases of widespread disease, or in situations where ovarian cancer has returned. Chemotherapy can damage non-cancerous cells and cause side effects. Advice for reducing of managing these side effects can be found here.

Radiotherapy

• Radiotherapy is less often used as a treatment for ovarian cancer but may be used in cases where the cancer is confined to the pelvic cavity, or in cases of advanced ovarian cancer to reduce the size and relieve symptoms.

Palliative care

• Palliative care may also be used in an attempt to alleviate symptoms, improve quality of life and slow the spread of ovarian cancer

Useful resources

Cancer Council Australia

http://www.cancer.org.au/about-cancer/types-of-cancer/ovarian-cancer.html

Ovarian Cancer Australia

https://ovariancancer.net.au/about-ovarian-cancer/

Uterine cancer in Australia

Uterine cancer is the most commonly diagnosed gynaecological cancer in Australia and is expected to remain the 5th most commonly diagnosed of all cancers amongst females in Australia for 2017.

In 2017 it is estimated that 2,861 new cases of uterine cancer will be diagnosed in Australia, accounting for approximately 4.6% of all new female cancer diagnoses. Over the last 35 years the number of new cases of uterine cancer has increased from 942 in 1982 to the estimated 2,861 new cases expected for 2017.

The incidence rate for uterine cancer increases with age from age group 20-24 until age group 65-69 after which it begins to decrease again (Figure 1). Overall, the age-standardised incidence rate for uterine cancer is 19 cases per 100,000 females, an increase from 14 cases per 100,000 females in 1982 (Figure 2). The risk of a female being diagnosed with uterine cancer by the time she turns 85 years old is estimated to be 1 in 42 for 2017.

Figure 1: Estimated incidence rates and mortality rates for uterine cancer in 2017

 

It is estimated that uterine cancer will be the 13^th leading cause of cancer death for females in Australia in 2017, down from the 12^th leading cause in 2014. This corresponds with a decrease in the number or deaths resulting from uterine cancer from 494 in 2014 to an estimated 453 deaths in 2017, which will likely account for 2.2% of all female cancer deaths.

Likewise, the age-standardised mortality rate is estimated to decrease from 3.4 deaths per 100,000 females in 2014 to 2.8 deaths per 100,000 females (Figure 2). However, mortality rate for uterine cancer generally does increase with age, particularly for those over the age of 60 years old (Figure 1), with an estimated risk of 1 in 259 for a female dying from uterine cancer by her 85^th birthday in 2017.

Figure 2: Age-standardised incidence and mortality rates for uterine cancer

From 2009-2013 females diagnosed with uterine cancer had a 5-year survival chance of 83.2%, an improvement on the 5-year relative survival of 75% between 1984-1988.

Figure 3: 5-year relative survival from uterine cancer

Resources

Cancer in Australia 2017

http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129559144

Summary of AIHW Cancer in Australia 2017 report

https://endometrial-cancer.canceraustralia.gov.au/statistics

Uterine Cancer

Uterine cancer (or cancer of the uterus) is the most commonly diagnosed gynaecological cancer in Australia, particularly in women over the age of 50 years old. There are two main types of uterine cancer: endometrial cancer which initiates in the uterus lining (endometrium) and uterine sarcomas which develop in the muscle tissue of the uterus (myometrium).

Symptoms

Although these symptoms can occur for reasons other than uterine cancer, it is recommended that you talk to your GP if you experience any of the following (particularly if you are postmenopausal):

• Unusual vaginal bleeding
• Watery discharge
• Smelly discharge

What causes uterine cancer?

When a woman does not ovulate, her ovaries continue to produce oestrogen but no longer produce progesterone. The exposure of the endometrium to 'unopposed oestrogen' can lead to a benign condition known as endometrial hyperplasia (thickened uterus wall lining) which with continuing exposure to oestrogen may later develop into endometrial cancer.

Circumstances which lead to a continuous exposure to 'unopposed oestrogen' increase the risk of developing endometrial hyperplasia and endometrial cancer. For example:

• Coming into menopause late (>55 years), or being postmenopausal
• Previous ovarian tumours or polycystic ovary syndrome (PCOS)
• Infertility, when associated with a lack of ovulation
• Oestrogen-only hormone replacement therapy
• Taking tamoxifen for breast cancer (the benefits outweigh the risks, discuss any concerns with your doctor)
• Being overweight or obese
• Family history of ovarian, uterine, breast or bowel cancer

Diagnosing uterine cancer

Screening for uterine cancer is not feasible as there is no available simple method to detect early stage uterine cancer and only about 50% of women with uterine cancer will have malignant cells that can be detected by a Pap test.

If a woman presents with symptoms of uterine cancer, diagnostic tests may include:

Physical examination

• Checking abdomen for swelling, checking the uterus (possibly with use of a speculum)

Transvaginal ultrasound

• The most common diagnostic test for uterine cancer, a transvaginal ultrasound observes size of uterus, ovaries and thickness of endometrium. If anything unusual if seen a biopsy (tissue sample) may be recommended.

Hysteroscopy and biopsy

• Insertion of a hysteroscope through the vagina into the uterus allows a gynaecologist to see the inside of the uterus and allow a biopsy to be taken if required.

Blood and urine tests

• Assess general health

Other tests

• If uterine cancer is detected, other tests such as X-rays, CT scans MRI scans or PET scans may be used to determine whether the cancer has spread to other parts of the body.

Staging:

Uterine cancer is staged according to the International Federation of Gynecology and Obstetrics (FIGO):

• Stage I – the cancer is confined to the body of the uterus
• Stage II – the cancer has spread to the cervix
• Stage III – the cancer has spread to the vagina, tubes, ovaries or lymph nodes
• Stage IV – the cancer has spread to the bowel, bladder or to distant organs such as the lungs or liver

Treatment or uterine cancer

Surgery (hysterectomy and bilateral salpingo-oophorectomy)

As long as the cancer has not spread to other areas of the body, the majority of women can be treated solely with surgery. The most common surgical treatment is a total hysterectomy, where the uterus and cervix are removed. When the fallopian tubes and ovaries are also removed the process is called a bilateral salpingo-oophorectomy. Removing the ovaries reduces the risk of the cancer returning as the oestrogen they produce can cause cancer to grow. Pre-menopausal women who a have bilateral salpingo-oophorectomy will experience menopause following the removal of their ovaries.

Radiotherapy

Radiotherapy uses X-rays to kill or injure cancer cells to help prevent the cancer from returning. Radioactive material may be given internally via tubes placed near the cancer or else the radiation may be directed externally by a machine

Hormone treatment

If the cancer has spread or recurred, or if surgery is not a viable treatment option, hormone treatment where progesterone is given to the patient may help shrink the cancer and control symptoms.

Chemotherapy

Chemotherapy (given intravenously) may be used to control the cancer or to relieve symptoms for certain types of uterine cancer, when cancer has returned following surgery or radiotherapy, or if it hasn't responded to hormone treatment.

Useful resources

Australian gynaecological cancer foundation

https://www.agcf.org.au/about-gynae-cancer/cancers-of-the-body-of-the-uterus-womb/endometrial-cancer

Cancer Council Australia

http://www.cancer.org.au/about-cancer/types-of-cancer/uterine-cancer.html

Understanding cancer of the uterus

http://www.cancer.org.au/content/about_cancer/ebooks/cancertypes/Understanding_Cancer_uterus_booklet_April_2017.pdf#_ga=2.95019612.1525809396.1500789383-1142737512.1500789383

Screening for cervical cancer

The National Cervical Screening Program initiated in 1991 currently provides cervical screening tests via a Pap smear. Pap smears do not detect or diagnose cervical cancer, however they are important for identifying cellular changes or abnormalities which may be pre-cancerous. This allows the identification of people who need further tests and can improve the chances of successful treatment through early detection.

Who needs a Pap smear?
All women who have ever had sex or skin-to-skin genital contact are recommended to have Pap smears. Even HPV-vaccinated women need to have regular cervical screenings as the vaccine does not protect against all HPV strains which may cause cancer.
Women aged 18-69 are eligible to take part in the National Cervical Screening Program which provides Pap smears for cervical screening every 2 years. Pap tests are not recommended before the age of 18, and from the age of 70 your health care professional may advise that it is safe for you to stop having Pap tests providing that you have had 2 normal screens within the last 5 years.

From the 1st December 2017 changes are being made to the National Cervical Screening Program. These changes include increasing the age of first screening from 18 to 25 years, increasing the time between tests from 2 years to 5 years and replacing the Pap smear with a more accurate Cervical Screening Test which will also detect HPV infection. 

What happens during a Pap smear?
During a Pap smear, the doctor inserts a speculum to open the vaginal canal and view the cervix. A swab is used to collect cells from the transformation zone (where the outer squamous cervical cells meet the inner glandular cervical cells) at the surface of the cervix. These cells are then sent to the laboratory for testing.

I'm scared it will hurt
Pap tests are very quick and are not painful, although there may be a little discomfort. Many women avoid Pap smears due to embarrassment, however they are an essential defence against cervical cancer. It is estimated that regular cervical screening saves over 1200 Australian women from cervical cancer each year, whereas approximately three out of four women who develop cervical cancer have either never had a cervical screening test or else have not had one within the last 5 years. 

What do the results mean?
Although the majority of Pap smear results are normal, approximately 10% show changes in the cells of the cervix. 

There are 3 main types of abnormalities:

1) Low-grade abnormalities

• Cervical cell changes are present due to minor inflammation caused by an acute infection with HPV. 
• Most women with low-grade abnormalities are usually asked to return for a repeat Pap smear in 12 months to ensure that HPV has been cleared by the body, or to be referred for further tests.

2) High-grade abnormalities

• Cervical cells appear abnormal and have undergone greater changes, likely due to a persistent HPV infection. These cells are rarely cancer but need to be investigated further to prevent progression. 
• Women with high-grade abnormalities are referred to a specialist for a colposcopy.

3) Glandular abnormalities

• There abnormalities are located in the cells at the top part of the cervix leading to the uterus/womb. These changes are difficult to monitor by Pap smear alone, therefore all women with glandular abnormalities are referred to a specialist for a colposcopy.
• These changes are usually not cancer, however finding these abnormalities allows them to be treated earlier and more easily before the possible progression to cervical cancer. 

What happens next?
Following a diagnosis of cervical cell changes, you may require further tests, and be referred to a specialist who will discuss your treatment options with you.

Colposcopy
If you have been diagnosed with high-grade or glandular abnormalities it is likely that you will be referred for a colposcopy. A colposcopy helps identify where abnormal cells are and what they look like. During a colposcopy the doctor will insert a speculum to open the vaginal canal, and then use a colposcope (similar to a pair of binoculars on a stand) to see a magnified picture of your cervix, vagina and vulva. If the colposcope is fitted with a camera you may be able to view the procedure yourself on a screen. The doctor may also coat your vagina and cervix with a fluid to highlight any abnormal areas. A colposcopy is not painful, but you may experience 10-15 minutes of mild discomfort during the procedure.

Biopsy
During a colposcopy it is likely that the doctor will also take a small tissue biopsy (sample) to be examined under a microscope in the laboratory. This may feel like a sharp pinch and you may feel some discomfort or pain similar to menstrual cramping for a short time after the biopsy. It is possible that there will be some bleeding or vaginal discharge for a few hours following the procedure, and the doctor will advise you to avoid sexual intercourse or using tampons for 2-3 days to allow healing and reduce the chance of infection.

Cervical cancer – Cause, prevention and treatment

Cervical cancer is the growth of abnormal cells in the cervix (the lower part of the uterus/womb). There are two main types of cell that cover the cervix: squamous cells (making up the outer cervix) and glandular cells (making up the inner cervix). Most cervical cancers begin in the 'transformation zone', which is where these two cell types meet.

Statistics from the Australian Institute of Health and Welfare (AIHW) estimate that cervical cancer will remain the 14^th most common cancer affecting Australian women, with approximately 912 new cases to be diagnosed (1.5% of all female cancer cases) and 254 deaths resulting from cervical cancer expected in 2017.

What causes cervical cancer?

Certain strains of human papillomavirus (HPV) have been identified as a major risk factor for cervical cancer development. HPV infection is common, affecting approximately 80% of people during their lifetime, and can be transmitted through sexual activity and genital contact. Anyone can develop cervical cancer after they become sexually active, however the risk increases after the age of 30. Usually an HPV infection is cleared naturally by the body within two years, however a persistent (long-term) HPV infection can lead to the development of cervical cancer.

Symptoms

Symptoms are rarely seen during early changes in cervical cells, however if they are left undetected and develop into cervical cancer common symptoms include:

• Unusual vaginal bleeding – between periods, after menopause, after intercourse, longer or heavier menstrual bleeding etc
• Pain during intercourse
• Lower back pain
• Pain or swelling in the legs
• Unusual vaginal discharge
• Excessive tiredness

Preventing cervical cancer

Cervical cancer is highly preventable through vaccination and early detection. Through the National Immunisation Program most girls (and since 2013, also boys) are offered the vaccination free of charge at around the age of 12-13 years at school. You can speak to your doctor about being vaccinated against HPV later in life if you missed out in school, however the cost is not covered by the National Immunisation Program.

Other than vaccination, early detection is a critical defence against cervical cancer. Women aged 18-69 are eligible to take part in the National Cervical Screening Program which provides PAP smears for cervical screening every 2 years. Having regular cervical screenings help identify abnormal cells and begin treatment before they become cancerous. Even HPV-vaccinated women need to have regular cervical screenings as the vaccine does not protect against all strains of HPV which may cause cancer. Approximately three out of four women who develop cervical cancer have either never had a cervical screening test or else have not had one within the last 5 years. It is estimated that regular cervical screening saves over 1200 Australian women from cervical cancer each year.

Other lifestyle changes such as quitting smoking, eating healthily, exercising regularly, maintaining a healthy weight and avoiding/limiting alcohol consumption all help prevent the development of cancer.

Treating cervical cancer

Cervical screening can detect cell abnormalities and early signs of cervical cancer, however further tests (colposcopy, biopsy) are required to confirm a diagnosis. If cervical cancer is confirmed, your doctor will refer you to a specialist to discuss your treatment options.

Treatment options and survival outcomes (prognosis) differs depending on the stage of the cervical cancer (how far it has spread). In Australia the cervical cancer stages are described as:

• Stage 0 – Abnormal cells are found only in the first layer of cells lining the cervix.
• Stage 1 – The cancer is found only in the tissues of the cervix
• Stage 2 – The tumour has spread to the vagina and the tissues next to the cervix
• Stage 3 – The cancer has spread throughout the pelvic area
• Stage 4 – The cancer has spread beyond the pelvic area to nearby organs such as the bladder or rectum, or possibly others.
• Recurrent – If the cancer returns after initial treatment (either in the cervix or another part of the body), this is known as recurrent cancer.

The earlier that pre-cancerous cell changes or cervical cancer is diagnosed, the better the prognosis. If your biopsy has confirmed pre-cancerous cervical cell changes treatments (i.e. laser, wire loop excision, cone biopsy) will focus on preventing the progression to cervical cancer. Treatment for cervical cancer may include a combination of: surgery, chemotherapy and radiation therapy.

Resources

http://www.cancer.org.au/about-cancer/types-of-cancer/cervical-cancer.html

https://cervical-cancer.canceraustralia.gov.au/statistics

https://www.cancerwa.asn.au/resources/specific-cancers/gynaecological-cancers/cervical-cancer/

Contraception use in Australia

According to one national survey, approximately 50% of Australian women experience an unplanned pregnancy during their reproductive lifetime. This is despite the fact that approximately 70% of Australian women are currently using contraception and up to 85% of women have ever used contraception. The majority of these unintended pregnancies result from either not using contraception or using it incorrectly during sex,with only a small proportion resulting from contraceptive failure.
Despite advances in contraception, including an increased variety of high efficacy methods, surveys show that Australia is still lagging behind in its use of contraception compared to the rest of the developed world.

Contraceptive methods used
The oral contraceptive pill has been available in Australia for over 50 years and remains the most popular form of contraception used by Australian women (27-34%), followed by condom use (20-23%). Despite the fact that long-acting reversible contraception (LARC) options including the implant, IUDs and injection all have higher efficacy rates, they are used by very few women in Australia. For example, in the BEACH study of female patients aged 12-54 years who consulted a GP for contraception, 69% of those prescribed were for oral contraception, compared to 15% prescribed for any type of LARC. In addition, in comparison with other developed countries Australia is lagging behind on its use of LARC, with IUD use in Australia at approximately 0.8% compared to 9.8% on average in other developed countries.

Figure 1: Estimates of contraceptive methods used throughout Australia

Interestingly, when the data is broken down by Australian territory, the use of oral contraceptives and condoms are less common in the Northern Territory compared to the other states (Figure 2). In addition, the Northern Territory shows a higher frequency of LARC and sterilisation being used to prevent pregnancy, and has the highest prevalence of current use of contraception at 79%.

Figure 2: Type of contraceptive method by Australian state and territory, 2011

Additionally, the proportion of women who have ever used emergency contraception ranged from 19-27%, with only 0.4% of women reporting that emergency contraception was one of the methods they used to prevent pregnancy. Nonetheless, over-the-counter access to emergency contraception has not decreased the number of unintended pregnancy or abortion rates in Australia. This is likely attributed to lack of knowledge regarding availability without a doctors visit and efficacy beyond 24 hours after unprotected sex.

Contraception use by age
Oral contraception and condoms are the most commonly reported methods of contraception for all age groups except those over 40 years of age, and the proportion of women reporting using these methods declined with increasing age. On the other hand, partner sterilisation increased from the age of 35 years. This is likely due to the changes in family dynamics as older women have finished their families and look to a longer-acting contraceptive method.

Figure 3: Choice of contraceptive methods by age group, 2011

Resources
The data presented in this article represents some of the main findings of the resource from the family planning alliance of NSW which summarises data collated from various surveys on contraception use. For more information and the full report please click here. 

Why more women should switch to long-acting reversible contraception (LARC) methods

Although over two-thirds of Australian women of reproductive age use contraception, it is estimated that over half of Australian women experience an unplanned pregnancy. Currently the most commonly used methods of contraception in Australia are the contraceptive pill (27-34%) and condoms (20-23%), the efficacy of which can be easily affected by human error. Experts suggest that the number of unplanned pregnancies could be reduced if more women used long-acting reversible contraception (LARC) methods, however currently they have one of the lowest uptakes.

Family Planning NSW's 'Reproductive and sexual health in Australia' resource states:

"Very few women used long acting reversible contraception (LARCs) with injectable contraception accounting for 0.9 to 2.1% of contraceptive use with similar proportions of use for the implant (1.1 to 3.6%) and intrauterine contraceptive methods (IUDs) (1.2 to 3.2%).”

Improving the public's understanding of LARCs will not only allow women to have more choices of contraception, but also decrease the risk and rate of unplanned pregnancies.

What are LARCs?
LARCs are the most effective forms of contraception after abstinence and are considered to be on par with sterilisation. Unlike other methods of contraception, human error generally has very little impact on LARCs as they do not require action to prevent pregnancy on a daily basis or prior to each incidence of sexual intercourse. The long-acting nature of LARCs often gives them the tag line 'fit and forget' as once they've been inserted they will be effective for a number of years. LARCs need to be inserted and removed by a doctor, and are fully reversible allowing a quick return to full fertility after removal.

There are three main types of LARC:

Implant

What is it?
The implant is a 4cm plastic rod that is inserted under the skin in your upper arm by your doctor. It continuously releases a synthetic hormone similar to progesterone into the bloodstream and lasts up to three years. Fertility returns very quickly upon removal of the implant by your doctor.

Efficacy
The implant is one of the most effective contraception options available with a rate of 99.95% protection with typical use (how most people use it).

Side effects
Some women may experience dramatic changes to their menstrual cycle, or other hormone-related side effects, and are recommended to trial the implant for three months and discuss issues with a doctor before considering removal.

Intrauterine devices/systems (IUD/IUS)

Early forms of IUD/IUS had a bad reputation, but modern types of IUD/IUS have greatly improved and are an excellent choice for women who have completed their families or younger, childless women. There are two types currently available – hormonal (IUS) and copper (IUD).

Hormonal IUS

What is it?
A small, T-shaped piece of plastic is inserted into the uterus by your doctor, and the attached fine threads protrude through the cervix to assist with removal. The hormonal IUS slowly releases the hormone levonorgestrel (similar to progesterone) for up to 5 years and fertility returns to normal very quickly following removal.

Efficacy
The hormonal IUD has a protection rate of 99.8% for typical use.

Side effects
A small number of women (~5%) may experience an unexpected expulsion of the hormonal IUS. Women can check whether their device is still in place by feeling for the fine threads that protrude through the cervix. The hormonal IUS can also alter a women's menstrual cycle, usually by causing periods to become lighter and less frequent so are particularly useful in women with heavy menstrual bleeding.

Copper IUD

What is it?
A small, T-shaped or U-shaped plastic device wrapped with copper wire is inserted into the uterus by your doctor, and the attached fine threads protrude through the cervix to assist with removal. The copper IUD inhibits the movement of sperm (sperm motility) and also creates an unsuitable environment for implantation. Different types of copper IUD last for up to 5 or 10 years and fertility returns to normal very quickly following removal.

Efficacy
The copper IUD has a protection rate of 99.2% with typical use.

Side effects
A small number of women (~2-3%) may experience an unexpected expulsion of the copper IUD. Women can check whether their device is still in place by feeling for the fine threads that protrude through the cervix. The copper IUD can also alter a women's menstrual cycle, usually by causing periods to become heavier, with up to 50% more bleeding. The copper IUD is a suitable choice for women who cannot, or prefer not to use a hormonal form of contraception.


The 'in-between'

Contraceptive injections

The contraceptive injection falls somewhere between short-term contraceptive methods and LARCs. Contraceptive injections last between 8-13 weeks so require more human input than other LARCs and therefore have a lower efficacy rate. Unlike the implant or IUD/IUS, the injection does not offer an immediate return to fertility.

What is it?
A synthetic hormone similar to progesterone is injected into the buttock or upper arm by a doctor or nurse every 8-13 weeks depending on the type. It takes 7 days to become effective and is not immediately reversible, with women taking up to two years to return to full fertility.

Efficacy
The injection has a protection rate of 94% with typical use.

Side effects
The contraceptive injection effects bone density and is not recommended as a first choice for women under 18 or over 45 years of age. However, this reduction in bone density is reversible after injections are ceased for women in their mid-reproductive years. The injection can also effect a woman's menstrual cycle, with ~50% of women having no bleeding after one year.

What can mothers do to keep away from alcohol during pregnancy?

It can be difficult to change your habits, and if you are used to drinking alcohol it may be challenging to stay away from it once you are pregnant. But you're now responsible for the health and safety of two people, not just yourself, and the only way to remain safe from the risk of your child having FASD is to not touch alcohol at all.

So what can you do instead to distract you from the urge to drink? Below are a few ideas to get you started:

Get creative!

Why don't you start decorating your baby' new room? If you're feeling really creative you could paint a mural design or alternatively create some artwork you think your baby might like and keep it near their crib or hang it on the wall. If painting isn't for you why not take up a new hobby like knitting and get to work making all sorts of new clothes and toys for your little one to enjoy when they arrive?

Go green fingered

Gardening is something you can keep up all year round here in Australia and keeps you healthy. Get outside and plant some flowers, pull up the weeds and mow the lawn and be rewarded with a beautiful backyard. Haven't got a garden of your own? Why not get some pots that you can plant up for in the house? You could even create your own herb garden to use in cooking.

Get some exercise

Playing a sport is a great way to have fun, make friends and get some exercise all at the same time. Go for a walk, whether it's just into town or out in the countryside, there's nothing like a bit of fresh air to clear the mind and it's a great free way to exercise and keep both your body and mind healthy. As well as health benefits exercise also produces endorphins which make you happy! If you aren't up for something quite so active, instead go swimming or do some stretching – your pregnant body will thank you for it!

Create something new in the kitchen

You might crave all kinds of foods whilst you're pregnant so now is the perfect time to try out some new recipes! Always wanted to go a bit more vegetarian or to cook more fish? Why not experiment in the kitchen, it's always fun and rewarding to come up with new dishes to share with friends and family

Start a memory book

Start a book full of photos, advice and life lessons that you want to share with your baby. You can add to it as the baby comes and they can keep it forever and add to it themselves before passing it on to their own children.

Do something for you

Love reading but never have the time? Used to sketch but haven't for years now? Always wanted to write a novel? Why not do something for yourself for a change and do that 'thing' that you've always wanted to do or get back in to an old hobby. Soon enough there will be another person requiring your attention so take the time now to do something for you.

These are just examples but whatever it is that you decide to do you'll not only have great fun but you'll also be keeping your child safe from the effects of FASD so nothing could be more worthwhile.

Why do women respond differently to alcohol and what are the consequences?

We all know that drinking too much alcohol can be damaging to our health, but evidence shows that women not only respond differently to alcohol compared to men but they are also more vulnerable to alcohol-related diseases.

According to a global study from the National Drug and Alcohol Research Centre, NSW Australia, women have now caught up with men in terms of the amount of alcohol they drink. The study, published in the journal BNJ Open, looked at the drinking habits of four million people over the last 100+ years and reveals that not only are women drinking much more but as a result are doing increasing amounts of damage to their health.

The researchers conclude that increased public health efforts need to be focused on young women.

“Alcohol use and alcohol-use disorders have historically been viewed as a male phenomenon. The present study calls this assumption into question and suggests that young women in particular should be the target of concerted efforts to reduce the impact of substance use and related harms,” they say.

Although women are drinking the same amount as men, we respond differently and are more vulnerable to the effects of alcohol than men.

Women's bodies process alcohol slower than men's do – in fact just 1 drink for a women can have twice the effect as it would do for a man.

Generally women weigh less than men, and their bodies are made up of more body fat and less water. Whereas water dilutes alcohol, fat actually retains it meaning that alcohol remains at a higher concentration and for longer in a women's body than it does in a man's.

Women also have lower levels of the enzymes which metabolise(break down) alcohol – alcohol dehydrogenase and aldehyde dehydrogenase. This means that women absorb more alcohol into their blood stream than men do.

Women are also more likely to be restricting their food intake than men. When food is present in the stomach, a valve closes and prevents the food (and alcohol) from entering the small intestine. Alcohol is less easily absorbed in the stomach. Drinking alcohol on an empty stomach however allows it to immediately pass through into the intestines where it is readily absorbed due to the large surface area.

There is also some debate as to whether differing hormone levels during the menstrual cycle, or the use of the oral contraceptive pill, may affect a women's response to alcohol consumption. However at present the evidence is inconclusive.

As well as responding differently to alcohol consumption, women are also more vulnerable to alcohol-related diseases than men. In particular, women are more likely to contract alcoholic liver disease including hepatitis (inflammation of liver) and are more likely to die from liver cirrhoisis (a chronic disease which progressively destroys the livers ability to help with digestion and detoxification).

Women are also more at risk of suffering from alcohol-induced brain damage including loss of mental function and reduced brain size.

Studies also suggest that excessive alcohol consumption increases the risk of breast cancer. The overall lifetime risk of breast cancer in female non drinkers is 9/100 (9%). For women who drink two standard alcoholic drinks a day this increases to just over 10/100 (10%). For women who six alcoholic drinks a day this increases to approximately 13/100 (13%).

As well as breast cancer female drinkers have an increased risk of osteoporosis, falls and hip fractures, premature menopause, infertility and miscarriages, high blood pressure and heart disease compared to non-drinking women.

Evidence also shows that women are more likely than men to abuse alcohol for self medicating conditions such as depression, anxiety, stress and emotional difficulties. Women can also become more easily addicted to alcohol than men, particularly later in life, and although they are more likely to seek help sooner, more barriers exist in preventing them get the treatment they require.

There are many factors that can affect your individual risk of damaging your health from drinking alcohol, as detailed in a special report published by Harvard Health Publications. As a woman it is important to be aware of the increased risks associated with alcohol consumption for our gender and ideally adapt our behaviour to reduce the incidences and consequences of alcohol abuse.