Archive | October, 2011

Compare and Dispair!

25 Oct

I was having a very deep conversation the other day with a good friend about FACEBOOK and it’s potential to bring out the not-so-great co-dependent aspects of one’s personality (should you have any,  of course 🙂 ie., ‘OMG they’re doing this and going there and my life’s so dull etc., etc., etc.,   Essentially comparing other peoples’ ‘outside’ with your’ insides’ with the result that you will always get it wrong – EVERYTIME!

What I know for sure (after a couple of years of ill-health from which I’m now gratefully emerging) is that life is about BEING and not DOING and it’s in the moments when we just BE OUR FUNNY/RANDOM old selves that we experience the most deep joy.  Have you noticed how doing whatever we do in those moments (smelling a baby’s head, petting the dog, stretching, meditating, listening to music, arranging flowers, napping, smelling fresh laundry, watching a sunset or an awesome sky) costs us either nothing or very little.  So (and I say this to myself too…..) Let’s all spend a whole lot less time ‘comparing and dispairing’ and start living our AUTHENTIC lives on OUR OWN TERMS.  Possibly one of the greatest gifts we can give to ourselves EVER!

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Obesity Starts in the Womb Article – From Midwives Online

25 Oct

Obesity ‘starts in the womb’

Posted: 26 September 2011 by Rob Dabrowski 
Childhood obesity starts in the womb, according to the findings of a new study. 
Weighing scales
Using state-of-the-art magnetic resonance scanning technology, researchers monitored fat levels in unborn babies.The study of 105 babies at Chelsea and Westminster Hospital found that just under a third had more fat around their abdomen than expected.The amount of fat increased proportionately in relation to the body mass index (BMI) of the mother-to-be.

Newborn babies normally have about 700g of adipose tissue, but for each unit increase in maternal BMI, this increased by about 7g, with a large build-up of fat in the liver.

The researchers say this is the first direct link that shows a relationship between the weight of a mother-to-be and her child.

The study was led by Professor Neena Modi, professor of neonatal medicine at Imperial College London.

She said the findings are ‘very important’ and open new doors in understanding the impact a mother’s metabolism can have on her baby.

‘This shows how sensitive the baby is to the environment experienced within the womb and how lifelong effects may be initiated before birth,’ she said.
 
Previous studies have shown obese youngsters are more likely to develop an array of health problems as they grow up.

These include heart disease, brittle bones, diabetes and asthma, among others.

The study is published in the September volume of Pediatric Research journal.

It comes after recent financial figures show obesity cost the NHS £4.2 billion last year and is expected to rise to £6.3 billion by 2015.

NI Set to Charge for C-Sections – Article From Midwives Online

25 Oct

Northern Ireland is set to charge for caesarean sections

Posted: 29 September 2011 by Rob Dabrowski 
Women in Northern Ireland may have to pay for caesarean sections, under plans to revamp the maternity service.
Caesarean section
Health minister Edwin Poots said he believes those who have the procedure for non-medical reasons should be charged.The minister made the announcement on Wednesday (28 September) as he launched a consultation on a review of maternity services in Northern Ireland.   ‘If people choose to have a caesarean section they should pay for it,’ he said

‘Caesarean sections are not about choice, they are about necessity.

‘So if people want to move away from necessity and use it for choice then the public should not have to pay for that.’

In 2010, 30% of births in Northern Ireland were by caesarian, compared to 24% in England, 26% in Wales and Scotland, and 25% in Ireland.

The minister’s wife had the procedure for the birth of one of their children for medical reasons.

He said he fully supports the operation when it is ‘absolutely necessary’ but that, when possible, a natural birth has ‘better outcomes for mother and baby’. 

He added that women who have no medical need to undergo the surgery should be encouraged to choose to give birth naturally.

At present, women who elect to go private to have a caesarean on non-medical grounds pay for their pre and post-natal care.

But the cost of the delivery is met by the health service.

Breedagh Hughes, RCM UK Board for Northern Ireland board director, said the caesarean section rate is ‘very high’ and the focus is on trying to ‘normalise’ childbirth.

She continued: ‘One of the things we hope will come out in the review will be asking trusts to look at the numbers of deliveries that they have, to look at the reasons for the caesarean sections and to focus on trying to prevent women from having that first caesarean section, which very often leads to the old adage – ‘once a section always a section’.

The consultation will run until 23 December 2011.

Pre-eclampsia – RCOG Patient Info

24 Oct

What is pre-eclampsia?

Pre-eclampsia means ‘before eclampsia’. It is a condition that only occurs in pregnancy. In some cases, pre-eclampsia may progress to a serious condition known as eclampsia.

Pre-eclampsia is a combination of:

  • raised blood pressure (hypertension)
  • protein in your urine on testing (proteinuria).

Swelling of the ankles is common in pregnancy and is usually nothing to worry about, but it can be a feature of pre-eclampsia.

Mild pre-eclampsia does not have any symptoms. It is usually picked up at your routine antenatal appointments.

The exact cause of pre-eclampsia is not understood.

More serious symptoms may develop as pre-eclampsia progresses. Around one in 200 (0.5%) women develops severe pre-eclampsia. The symptoms tend to occur later on in pregnancy but can occur for the first time after birth.

The symptoms of severe pre-eclampsia include:

  • headaches
  • blurred or altered vision
  • feeling very unwell
  • abdominal pain
  • nausea or vomiting
  • confusion
  • shortness of breath.

These symptoms are serious and you should seek medical help immediately. If in doubt, contact the delivery unit at your local hospital.

How does pre-eclampsia affect my baby?

Pre-eclampsia affects the development of the placenta and can affect the baby’s growth in the womb. There may also be a reduced amount of water (amniotic fluid) around the baby in the womb.

If the placenta is severely affected, the baby can become distressed or even die. Monitoring aims to pick up those babies who are most at risk.

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Who is at risk of getting pre-eclampsia?

It is hard to predict who will develop pre-eclampsia in pregnancy. You are at greater risk if:

  • this is your first pregnancy
  • this is your first pregnancy with a new partner
  • you are aged 40 or over
  • your mother or sister had pre-eclampsia during pregnancy
  • you had pre-eclampsia in a previous pregnancy
  • you have a body mass index (BMI) of 35 or more (you weigh 90 kg or more)
  • you are expecting more than one baby
  • you have a medical problem such as high blood pressure, kidney problems and/or diabetes.
  • you are pregnant from egg (oocyte) donation.

How is pre-eclampsia monitored?

With mild pre-eclampsia you will have more regular antenatal checks.

If the pre-eclampsia is getting worse or is severe, you may be monitored in the hospital. This is in case you need treatment and/or the baby needs to be delivered.

Tests include:

  • Regular blood pressure checks. If the pre-eclampsia is severe, this may be as often as every 15 minutes but more commonly is every 4 hours.
  • Urine test. If the pre-eclampsia is severe, you will have a catheter in your bladder to measure how much urine your kidneys are making.
  • Blood tests to check your blood count, clotting, liver and kidney function.
  • Ultrasound scans to measure the baby’s growth and wellbeing.
  • When you are in labour the baby’s heart rate will be monitored continuously.

What is the treatment for severe pre-eclampsia?

If you develop severe pre-eclampsia, you will be cared for by an experienced midwife, senior obstetrician and anaesthetist.

Treatment includes bed rest and medicines (either tablets or a drip) to lower and control your blood pressure and to prevent complications such as convulsions or fits. Convulsions are an unusual complication but, if they occur, the condition is termed eclampsia. These medicines will not harm the baby.

The only way to prevent severe pre-eclampsia from developing into eclampsia (convulsions) is to deliver the baby in a planned and prompt way. Each pregnancy is unique and the exact timing will depend upon your own particular situation. This should be discussed with you.

There may be enough time to start (induce) labour. In some cases, delivery will need to be by caesarean section.

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What is eclampsia?

Eclampsia is a life-threatening condition. The main problem is fits (seizures/ convulsions). These are like epileptic fits.

Eclampsia occurs in one in 2000 pregnancies (0.05%).

Other complications include:

  • kidney failure
  • liver failure
  • lung failure
  • a combination of the above (this is known as HELLP syndrome). This is a combined liver and blood clotting disorder.
    • [H] stands for ‘haemolysis’ (breaking down of the red blood cells)
    • [EL] stands for ‘elevated liver enzymes’ in the blood (meaning damage to the liver)
    • [LP] stands for ‘low blood levels of platelets’ (platelets are specialised cells which are necessary for blood clotting).

When is the best time for the baby to be born?

Your baby may need to be delivered early (prematurely) if the symptoms are getting worse and affecting you and/or your baby. A course of two steroid injections can help mature the baby’s lungs and reduce the chance of breathing difficulties if the baby is premature.

If the pre-eclampsia is less severe, you may be monitored to check that you can safely continue the pregnancy until labour starts naturally or is induced.

What happens after the birth?

You will continue to be monitored closely. Up to half of the women who develop eclampsia do so after the delivery. You may need to stay in hospital for several days. You may need to continue taking medicine to lower your blood pressure.

If your blood pressure is still high six weeks after the birth, or there is still protein in your urine on testing, you may be referred to a specialist.

If you have had severe pre-eclampsia or eclampsia, you may have a postnatal appointment with your obstetrician to discuss the condition and what happened. Your obstetrician will assess if there are any risk factors and preventative treatment before another pregnancy.

It is important to attend for routine antenatal appointments in all future pregnancies, where these checks are done.

A useful organisation

Action on Pre-Eclampsia (APEC)
84–88 Pinner Road Harrow
Middlesex HA1 4HZ
Helpline: 0208 427 4217 (Mon–Fri: 10am to 1pm)
Email: enquiries@apec.org.uk [4]
Website: www.apec.org.uk [5]

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline on The Management of Severe Pre-eclampsia/Eclampsia(which was published in March 2006 and is due to reviewed in January 2009). You can find it online here [2] (Page 3 paragraph 3 line 6 ‘A level of 30 mg/nmol appears to be equivalent to 0.3 g/24 hours.’ has been amended to ‘A level of 0.03 g/mmol appears to be equivalent to 0.3 g/24 hours.’)

Clinical guidelines are intended to improve care for patients. They are drawn up by teams of medical professionals and consumer representatives who look at the best research evidence available and make recommendations based on this evidence.

This information has been developed by the Patient Information Subgroup of the RCOG Guidelines and Audit Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It was reviewed before publication by women attending clinics in Bradford, Truro and Taunton. The final version is the responsibility of the RCOG Guidelines and Audit Committee

The RCOG consents to the reproduction of this document providing full acknowledgement is made.

A final note

The Royal College of Obstetricians and Gynaecologists produces patient information for the public. This is based on guidelines which present recognised methods and techniques of clinical practice, based on published evidence.The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor or other attendant in the light of the clinical data presented and the diagnostic and treatment options available.

A Health Questionnaire Template for Pregnancy Massage Therapists

24 Oct

 

Pregnancy Pre-Therapy Health & Lifestyle Questionnaire

Client Name:

DOB:

Client Address:

Client Phone No:

Client Email:

Due Date/No. Of Weeks Pregnant:

 

Health Care Provider Details:

 

First Impressions/Visual Assessment

 

 

 

 

 

 

Reason for seeking therapy today? Where do you have pain/discomfort?  (Use Body Map Diagram).

 

Any excessive or sudden swelling and water retention?

History of miscarriages?

Any history or blood clots or Thrombosis? Any extreme calf pain, swelling or redness?

Last visit to Primary Health Provider and outcome?  Scan results?

 

Any severe and chronic itching (globally) ?

Extreme high blood pressure – current and previous history?

 

Any excessive thirst and urination? Gestational or Controlled Type 1 or 2 Diabetes?

Any rapid or large weight gain while Pregnant?

 

 

Any varicose veins or haemorrhoids?

Any Varicose Veins?

Current multiple pregnancy?

 

Any Bleeding During Pregnancy?

Any skin rashes, open or unhealed cuts or bruises?

 

Any Headaches, Blurred Vision, Vomiting today or recently?

 

Any previous/recent illnesses or injuries or hospitalization?

Any Symphysis Pubis Dysfunction or other Pelvic Pain?

 

Any strange/worrying physical symptoms during your pregnancy recently or previously?

Notes/Treatment Plan & Session Outcome/Follow-Up

 

 

 

 

 

 

 

 

 

 

www.burrelleducation.com – Passionate About Pregnancy & Post Natal Health & Fitness Education FOREVER! 

Visit the SITE and FACEBOOK PAGE for lots of FREE STUFF, COURSES & ‘THE CRUNCHLESS CORE DVD’.

 

Why Alcohol Makes You Fat :-(

24 Oct

By Jenny Burrell BSc (Hons), Founder of Burrell Education, Specialist For Pregnancy and Post Natal Fitness & Therapy, London, UK.

I know some clients don’t want to hear this…..but I think a little clarity on the science-bit will help us all make better choices……especially hormonally-compromised post natal women seeking fat loss who habitually polish off a couple of glasses of wine after they have put the baby down for the night.  Absolutely no judgement here, just presenting information ;-).

 

Alcohol has a two-fold effect negative effect on your ability to lose fat:

  1.  It’s highly calorific (second only to fat itself at 7kcal/g – fat is 9 kcal/g, both Protein and Carbohydrate roughly 4kcal/g)  and easily over-consumed and as always, any excess calories consumed are stored as fat!
  2. The simple presence of alcohol in your system have a hugely negative impact on your ability to metabolise that stored fat!

This was illustrated by a study where 8 men were given two drinks of vodka and lemonade separated by 30 minutes.  Each drink contained just under 90 calories.  Fat metabolism was measured before and after consumption of the drink.

FOR SEVERAL HOURS AFTER DRINKING THE VODKA, WHOLE BODY LIPID OXIDATION (A MEASURE OF HOW MUCH FAT YOUR BODY IS BURNING) DROPPED BY 73%!!!!!

The reason why alcohol has this dramatic effect on fat metabolism has to do with the way alcohol is handled in the body.  Rather than getting stored as fat, the main fate of alcohol is conversion into acetate and the presence of acetate in the system puts the brakes on fat loss – SIMPLE! The greater the quantity of alchohol, the greater the quantity of acetate created, the less likely fat is metabolised.

The type of fuel your body uses is dictated to some extent by availability therefore by limiting your carbohydrate intake, your body is forced to rev up its fat-burning machinery, so you become fat adapted.

In other words, your body tends to use whatever you feed it, and after a time becomes adapted to the macro nutrient intake. Unfortunately when acetate levels rise, your body burns the acetate preferentially.

So the body simply burns the acetate first, and with the rapid rise seen with alcohol intake, this basically pushes fat oxidation out of the metabolic equation.

www.burrelleducation.com – Passionate About Pregnancy & Post Natal Health & Fitness Education FOREVER! 

Visit the SITE and FACEBOOK PAGE for lots of FREE STUFF, COURSES & ‘THE CRUNCHLESS CORE DVD’.

Long Term Pelvic Pain – RCOG Patient Info

24 Oct

Contents

Key points

  • Pelvic pain is any pain in the lower abdomen or pelvis. Long-term pelvic pain is pain that persists for at least six months.
  • Long-term pelvic pain is common. It affects around one in six women.
  • Long-term pelvic pain is a symptom, not a diagnosis.
  • It is often due to a combination of physical, psychological and/or social factors and should be managed or treated ‘as a whole’, rather than as a single underlying condition.
  • If a cause for long-term pelvic pain cannot be found, women may have fears that people will say it is ‘all in the mind’.
  • Whether or not a cause for long-term pelvic pain is found, doctors work in partnership with women to discuss a treatment and management plan.

About this information

This information is intended to help you if you have long-term pelvic pain. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The Initial Management of Chronic Pelvic Pain [2](published by the RCOG in April 2005).

This information tells you about:

  • the main factors that may contribute to long-term pelvic pain
  • what your doctors can do to investigate and identify the cause of your pain
  • the most effective methods recommended in the UK for managing long-term pelvic pain .

This information tells you about the recommendations the RCOG guideline makes and aims to help you and your healthcare team make the best decisions about your care. It is not meant to replace advice from a doctor or nurse about your own situation. This information does not tell you about what can be done for women whose initial treatment has not been successful. It does not tell you in detail about conditions that may be the cause of long-term pelvic pain, or about treatments for those conditions. For further information about these conditions see the section on ‘Other organisations’.

Some of the recommendations here may not apply to you. This could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor, nurse or another member of your healthcare team.

What is long-term pelvic pain?

Pelvic pain is any pain you feel in the lower abdomen or pelvis. Healthcare professionals consider pelvic pain to be long-term if:

  • you experience it either constantly or intermittently for at least six months
  • it happens at times other than when you have your period or sexual intercourse.

Long-term pelvic pain is common. It affects around one in six women. long-term pelvic pain is not a diagnosis in itself but a description of a symptom.

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What could long-term pelvic pain mean for me?

How we experience pain is an individual matter and may depend upon any number of factors. Long-term pain can be very difficult to live with. It may cause you emotional, social and even economic difficulties. You may experience depression, difficulties in sleeping and a disruption to your daily routine. Your may fear the worst about your pain, believing that it means you have cancer or you have a serious problem that may affect you having a baby. You may have fears that people will say your pain is ‘all in the mind’. The pain is not ‘all in your mind’.

The reasons for long-term pelvic pain are not always easy to diagnose. It is not always possible to treat. Women may need support in managing and coping with their pain.

Even if no reason can be found for the pain, many women find that the quality of their lives improves when they get a better understanding of what is involved.

What causes long-term pelvic pain?

In many cases, your healthcare professional will not be able to identify an underlying problem or give a clear diagnosis and he or she will only be able to assure you that there is no serious medical problem.

Long-term pelvic pain is often caused by a combination of physical, psychological and/or social factors, rather than a single underlying condition.

These factors may include:

  • endometriosis ( a condition where cells of the lining of the womb (the endometrium ) are found elsewhere in the body, usually in the pelvis)
  • adenomyosis (a condition where the endometrium is in pockets within the muscle wall of the womb)
  • pelvic inflammatory disease (PID) (a n infection of the womb, fallopian tubes and/or pelvis)
  • interstitial cystitis (bladder inflammation)
  • musculoskeletal pain (pain in your joints, muscles, ligaments and bones)
  • irritable bowel syndrome (IBS)
  • depression, including postnatal depression
  • previous or ongoing traumatic experiences such as sexual abuse in some women
  • adhesions (areas of scarred tissue that may be a result of a previous infection endometriosis or surgery); although these are common, they do not always cause pain
  • trapped or damaged nerves in the pelvic area.

For some women with long-term pelvic pain none of these factors may be found.

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What happens when I first see the doctor?

At your first appointment, you should have the chance to ‘tell your story’, describe the pain you have experienced and discuss your anxieties. Your doctor will take your concerns seriously and listen. By working in partnership with you, he or she will aim to identify the cause(s) of your pain. Although at times you may feel you are repeating yourself, your story is important. The way you describe your symptoms is crucial in making a diagnosis. Your doctor will probably ask you a number of questions about:

  • the pattern of your pain
  • what makes your pain better or worse (certain sorts of movement, for example)
  • whether you have noticed other problems that might be linked to the pain (intercourse, bladder, bowel or psychological symptoms, for instance).

You may be asked about aspects of your everyday life including your sleep patterns, appetite and general wellbeing. You may also be asked about how you are feeling and whether you are feeling depressed or tearful. This is because long-term pain is known to cause depression, which in turn may make your pain worse. If your healthcare professional knows how your pain is affecting you personally, this can be taken into account with your treatment.

Your doctor should explain the various factors that can lead to long-term pelvic pain (see section ‘What causes long-term pelvic pain? [7]’).

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What types of tests might I be offered?

Tests do not always involve getting a report from a laboratory. Your own history and the way you describe the pattern of your pain can provide much more valuable information or results. Because of this, you may be asked to keep a ‘pain diary’. This involves noting down when your pain occurs, how severe it is, how long it lasts and the things that seem to affect it. A pain diary will also help you to describe your pain and to become more aware of the ways in which it affects you.

Then, depending upon your own situation, you may be offered any of the following types of tests:

  • You will probably be offered an ultrasound scan.
  • You may be offered screening tests for sexually transmitted infections.
  • If your pain is related to psychological, bladder or bowel symptoms, your consultant may refer you to a specialist or suggest you see your GP. If you have bowel symptoms, for example, you may be referred to a gastroenterologist who may offer you tests for irritable bowel syndrome (IBS).
  • If your pain occurs on a regular basis at a specific time in your menstrual cycle, then you may be offered drugs to suppress your periods for a few months. This may help your doctor in making a diagnosis.
  • You may be offered a diagnostic laparoscopy. This is a procedure carried out under general anaesthetic. It involves a small cut in the abdomen to examine your reproductive organs and look for any abnormality, problems or damage. The surgeon will insert a tiny telescope (called a laparoscope) so that your reproductive organs can be seen more clearly. A s with any surgical procedure, there are risks and benefits and these will be explained fully to you when you are offered the test.
  • If your health professional thinks that your pain is due to a particular cause, you may be offered treatment on a ‘try it and see’ basis. Such treatment could help you to avoid a diagnostic laparoscopy which carries small, but significant, risks.

What treatment may help?

Whatever your situation, you may be offered painkillers. If these do not help to control your pain, you may be referred to a pain management team or a specialist pelvic pain clinic. Depending on the type of your pain you may also be offered other treatment.

You should be offered treatment and advice if:

  • your pain is related to your menstrual cycle and you have heavy periods
  • your pain varies with movement
  • you have symptoms suggestive of irritable bowel syndrome
  • you may have symptoms suggestive of a sexually transmitted infection or PID.

Your doctor will provide you with full information about all treatment options

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Are there any risks?

Your doctor or specialist practitioner should give you full detailed information about the risks and benefits of any investigation, surgical procedure and treatment suggested. There are no risks associated with having an ultrasound scan.

Are there any alternatives?

Depending on your circumstances, you may have a range of possible options. You may be offered a combination of two or more types of treatment, such as medical treatments with tablets or injections (for example, pain relief or hormone treatment), surgery or pain management strategies. Some people find that complementary therapies can help to manage the pain.

What might happen if I don’t have treatment?

Your doctor may not be able to predict what might happen for you as an individual. For many women the pain gets better with time. Most women have no serious or life-threatening problem underlying the pain. Many women find that they can cope better with their pain after they have been given a thorough explanation of the nature of the pain, including previous test results and possible causes of the pain. They can also cope better when they feel reassured that there is no serious or life-threatening disease present.

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Is there anything else I should know?

  • You should visit your doctor if you experience any of the following:
    • bleeding from your rectum
    • a change in your bowel habits which has lasted for more than six weeks
    • new pain after you have passed the menopause
    • any unusual swelling in your abdomen
    • suicidal thoughts
    • excessive weight loss
    • irregular vaginal bleeding, such as bleeding between periods, or vaginal bleeding after the menopause or vaginal bleeding during or after sex.
  • No treatment can be guaranteed to work all the time for everyone.
  • You have the right to be fully informed about your health care and have the opportunity to share in making decisions about it. Your healthcare team should respect and take account of your wishes.
  • If you are not comfortable with the final diagnosis, you can ask for a second opinion.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The Initial Management of Chronic Pelvic Pai [2]n (published by the RCOG in April 2005). The guideline contains a full list of the sources of evidence we have used.

Clinical guidelines are intended to improve care for patients. They are drawn up by teams of medical professionals and consumers’ representatives, who look at the best research evidence there is about care for a particular condition or treatment. The guidelines make recommendations based on this evidence.

This information has been developed by the Patient Information Subgroup of the RCOG Guidelines and Audit Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It was reviewed before we published it by women attending clinics in London, Oxford and Southampton. The final version is the responsibility of the Guidelines and Audit Committee of the RCOG.

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Other organisations

These organisations offer support:

The Gut Trust
Unit 5
53 Mowbray Street
Sheffield S3 8EN
Helpline: 0114 272 3253 (Mon-Fri, 6-8pm; Sat 10am-noon)
Email: info@thegutrust.org [18]
Web: www.thegutrust.org [19]
[20]

National Endometriosis Society
50 Westminster Palace Gardens
Artillery Row
London SW1P 1RR
Helpline: 0808 808 2227
Email: nes@endo.org.uk
[21]Web: www.endo.org.uk [22]

The RCOG consents to the reproduction of this document providing full acknowledgement is made. The text of this publication may accordingly be used for printing with the addition of local information or as the basis for audiotapes or for translations into other languages. Information relating to clinical recommendations must not be changed.

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