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Hi, my name is Robin Johnston. Welcome to your Endeavor Medical Course. I'm gonna talk to you today about woman's specific issues in the wilderness and woman's health in the wilderness. I work in anesthetics in intensive care and also uh in expedition medicine in the field as often as possible. I have always enjoyed being in the outdoors and spent a lot of my childhood and growing up outside hiking, um, climbing paddling. And then when I studied medicine, um, I found the opportunity to work in expedition medicine and one of the things that I've noticed both in my personal sporting and outdoors activities, but also going along as an expedition medicine medic with big groups, um, is that you're often the only female on the trip. So while it might seem slightly unfair to have a whole lecture on women's health issues and not on men's health issues, I think that it is something that needs to be talked about because you are often, um, as a female, you're often in the minority in the group. And if you are a male in the group, you have a huge ability to advocate or be aware of some of the issues that might come up and make uh the wilderness more accessible for females. Um but also make sure that their trip is safer and more comfortable. Um And some of the things that I talk about will be applicable to any gender and some of them are more specific to people who um are biologically female or identify as female. What I want to talk about today are um the following topics. So a little bit about female specific physiology and then the peas, which I think are some of the more important topics when it comes to women's health in the wilderness and a little bit about altitude and pregnancy is an extra bit because it's something that I've found you often get asked about. Um I won't spend a lot of time on anatomy and physiology, but I think it is worth saying that things are different between male and females and the cold and heat sensitivity are different. Um Often women do tend to feel the cold more than men do and might need to pack extra layers and have warmer gloves and think about things like hand warmers. Um We have differences in exercise tolerance and we have differences in body composition. In general. We have less lean muscle mass, um lower basal metabolic rates. Um and so produce less heat than men might. Um The other thing is that clothing and equipment and packs are often designed for men and there are more and more female specific designs coming out. But it is worth thinking about um, that when finding comfortable equipment and packs that often um fitting them slightly differently or finding female specific equipment does make the difference between a comfortable and less comfortable trip. The peas, I have to fully admit that I've stolen from a really, really fantastic talk by the Wilderness Medicine Society in the States in their 2021 conference, they did a lecture which is worth watching on woman specific issues in the wilderness. And, um, there have been a few other really good, um, female specific wilderness medicine talks through them as well. And they talk about the peas and a friend of mine is the president of the Canadian Wilderness Medicine Society. She brought them to my attention and I think I had covered a lot of them in, in previous talks that I had done, but hadn't named them the same way. So I hope that they don't mind me copying their idea. Um, but the peas are basically peeing pooing periods, pregnancy, passion and pumping. So the first one is often how I start speaking to people about women's health on trips. It's really worth talking about how to pee in the wilderness. A lot of people haven't been in the wilderness a lot haven't been in nature settings. Um, haven't had to deal with either no toilets or pit toilets. And I think it's something that if you've grown up spending time out in the wilderness and you're very comfortable. You can actually forget how intimidating this is and how uncomfortable and how scary it can be for people. The great thing about this is you really don't have to be a female to demonstrate this. So I would encourage everyone to demonstrate this to their group at the beginning. And for men, I think it's usually very easy to go for a wee when you're in the wilderness, even if you're surrounded by other people and you just turn your back. And we, and for a woman, I think the thing that's really important to be aware of if you're a man in the group with woman in it is that it's very difficult to do the same thing as a female. It's not quite so subtle if you just drop your trousers and bear your bum to the world. And I've been on trips where we've had groups, film trips where we've had groups of 100 and 50 guides, porters crew. It can be very, very difficult to find a private place to go for a week. Um And then when you do, it can be difficult to work out. What's the best way to do this without falling over or weighing on yourself or bearing your bum to the world. Showing this position actually can be a great icebreaker at the beginning of a trip. If you put on two pairs of pair of trousers and a pair of shorts over top so that you can demonstrate a lot of people who haven't spent a lot of time weeing outside without toilets will think that you need to drop your trousers or your pants right around your ankles. And that actually makes it much more difficult. So if you keep your clothing bunched up around your knees, it's much easier to squat and um stay stable and steady on your feet because you can keep a nice wide base with your feet. So this little diagram just shows how you keep your clothing around your knees and keep your feet nice and flat and spread apart. And then if you're using a squat toilet, which way to face. And the other thing that I found was holding on to a either a friend's hands or you can hold if you're very close friends, um or holding on to a tree or a pole or something like that allows you to balance more easily if you're not very good at squatting. And this is often what people do when they have young kids who are learning how to pee in the wilderness is they'll hold their hands and let them squat leaning back, holding their hands. Obviously, people have started to think about this, not only for wilderness settings, but places like festivals where it's very difficult to um find a portal loo that doesn't have a queue of 50 women waiting for it. And um you don't want to sort of squat and bear everything. So, some of the things that have come into existence more recently are um clothing that lets you we without exposing yourself or pulling your trousers the whole way down. So there are a couple of different brands. There are, the one on the left is I think it's called um Chick Fly or She Fly. Um one of those and it's basically overlapping fulls of material so that you can, um pull them apart and go to the toilet and then let them cover back up without actually taking your trousers down. And there are designs that have a zip that goes right under the bottom. Um, or there are actually trousers now that have a zip that goes all the way down to your ankle. So you can actually unzip the whole thing without taking your pants completely off. Um There are also, I think anyone who's been to a festival has probably seen shoes or funnels for weeing now. So you can, we standing up and there are disposable ones and there are silicone reusable ones that you can clean. And definitely, I think some people who do high altitude mountaineering and cold trips, um, might use something like this combined with the P and L Gene. And so they don't have to get out of the tent in the middle of the night. You just make sure to mark your pee bottle very well with something you can feel on the outside of the bottle so that you don't mix it up with your water bottle in the middle of the night. The other thing to think about is how you are going to clean yourself after you've gone to the toilet. And especially for females. This is important because um the consequences of poor hygiene um are urinary tract infections which are very unpleasant. So you can drip dry. Um, Some people will, you can buy bidets. Now, little hand bidets or you can make your own. Like this one from a water bottle, you just buy the little piece that screws onto the lid. In this picture, it's like a very cheap little silicone piece that you can screw onto any water bottle and make it into a little bidet to give yourself a quick wash. And there are also pee cloths now that are quite popular. Um It's like a little reusable cloth pad that's impregnated with. I think it's a little bit of a silver impregnated in there is an antimicrobial and can be reused and it can be washed and hung on the outside of your pack to dry. Like I mentioned, the reason that this is important is because um urinary tract infections are much more common in females because the urethra is much shorter. Um And so bacteria can translocate from the skin and the perineum up into the bladder and it's really unpleasant. Most women will have had a UTI at some point in their lives and it's really not something you want to be dealing with while you're in the wilderness. It could really spoil a trip. It's also worth thinking though, if you are a group leader or you're the medic on a trip that it's worth taking along antibiotics that will cover for UTI because it is quite common and especially when you get into warmer, more humid environments where it's difficult to keep things dry. The next topic that always comes up when you talk to people about trips, um And I think should really be mentioned openly on all trips because it's often the reason that women avoid going into the wilderness. Um And I know a lot of people even who are very experienced in the wilderness tend to avoid going on trips when they're menstruating because it's difficult to manage. But a lot of the, this can actually be um improved if you are open, open in communicating with the group about how they can manage um periods in the wild. So to me, two of the really important things to think about are how are you going to provide privacy for anyone in your group who needs more privacy than you would need just for doing a, we usually to change sanitary, your menstrual products. Um And the other thing I think is really important is to think about how you're going to carry out any menstrual products that you use, particularly if someone in the group or someone else in the group uses, particularly if, if people are using disposable products and I'll talk a little bit more about that. Um, a few slides on. So, what are your options for periods when you're in the wilderness? I think exactly the same as when you're back at home. And if you're male, this is a huge opportunity for you to be an advocate for females in the wilderness and in your group, I've encouraged all of my male friends, colleagues to always carry some pads and tampons on their first aid kits because almost everyone at some point has um needed sanitary products or menstrual products when they're not expecting to have a period. And it's something that can really spoil a trip and it's great when someone else can step in and save the day by providing some tampons or pads um in an emergency. And on top of that, they can be used for lots of other uses. So the trick with first aid kits is always having items in there that can be multipurpose and both pads and tampons can be used for dressings and covering wounds, nice absorbent dressings. So even if you never have to give them out to any of the females in your group, they might still come in useful somewhere else. I think if you are male, I would encourage you to talk to the females that you know about what issues they've found around menstruating in the wilderness and if they're comfortable talking about it, ask them what products they've used, what products they know about. Um, it's really valuable, I think for all the group members to know about what everyone else in the group might be going through because that way you can actually support each other much better. And while I'm on the topic, I think I probably should have acknowledged at the beginning that I am very aware that gender is not binary and that there will be people who identify as male, who are menstruating and people who identify as female, who don't menstruate. And for the sake of this talk, I'm using male and female to keep things simple. But I would like to acknowledge that I really want this talk to be helpful in supporting people of any biological sex and any gender when it comes to period products. These are some of the common things that people might choose to use. So they're reusable and they are disposable options. Um The disposable options tend to be um things people have heard of like tampons and pads which you'll see in the middle of that picture. And then there are a lot more reasonable products that have come into popularity in the last um the last number of years, especially so things like period pants, panties that are lined and have an absorbent zone and can be washed and reused, things like um Menstrual Cups, which you'll see there by the Moon Cup. There are lots of different brands. There are menstrual discs. Um, and all of these are usually silicone products that can be emptied, um, rinsed out and reused again. Some of the things that, uh, can be challenging in the wilderness are if you're using disposable products, what do you do with them when they're used? And I think this is something that as a group needs to be acknowledged by the group leaders because otherwise disposable products like pads and tampons end up abandoned or buried or discarded in wilderness areas. And they don't degrade, they last for a huge amount of time because they have plastics in them. So I don't know if any of you have been up Kilimanjaro. It's one of the overwhelming memories of my first trip up Kilimanjaro in 2008 was seeing sanitary pads and tampons disposed behind almost every boulder that you would stand behind to go and do a week. And they've done an amazing job on Kilimanjaro and they've really cleaned up the mountain and it's not nearly as bad. But, um, you do still see tampons and pads discarded on the mountain. And I think this is not a failure of the clients who have left them there. I think this is a failure of their guides and trip leaders who haven't actually provided them with a good option for disposing of them and haven't talked with them about this ahead of the trip. So if you're going on a trip and anyone on that trip, I think it should be set on every trip. But especially if you have anyone on the trip who might be menstruating ahead of the trip before you even pack for departure, encourage people on the trip to bring along personal Ziploc bags to carry out any disposable products and various companies and trips will have different ways that they handle waste. What I've found useful with large groups where people aren't carrying out all of their own garbage and waste is that beside any sort of short term pit toilets, you put a, a piece of PC piping or I think people have used NG bottles before. Um, so that everyone can dispose of tampons and use pads into that piece of piping that screws has screw on caps or into a bottle that then gets screwed closed and carried out. Ideally, everyone carries out their own waste. I think in often Ziploc bags works quite well for that, keeping it um sealed so that it's not smelly and it doesn't make a mess of anyone's bag, but they can carry out their own disposable products that way. But I do think if you've got bigger groups where the expectation isn't to carry out all of your own waste and garbage, then you do need to provide an option for how people dispose of their sanitary products. Otherwise they'll get put into the ground or left lying around somewhere with, um, reusable products like menstrual cups and discs. And, um, even with the reasonable cloth pads and underpants, the tricky part can sometimes be, how do you keep them clean? How do you wash them? And in theory, the menstrual cups are meant to be, um, washed and cleaned every time they're emptied and then they should be boiled at the end of every, um, menstrual cycle on expedition. This isn't always possible. So it's going to just depend on what you have available on your trip. And if you have access to soap and water, that's great. Um You can get special cleansers for them that people can bring for themselves. Um And there are actually sanitizing wipes that are specifically made for menstrual cups um that are non irritant to the vagina. The other thing to think about with all of this is hand hygiene. Um because while you might have hand washing stations set up um at camp for lunch time and for supper time and meal times and things like that, you often are going to need, people will need to change sanitary products or empty menstrual cups along the trail during the day and making sure that there are, is hand sanitizer gel and ideally also some water for hand washing. Um after this and similarly to with hygiene after wing is that um perineal hygiene is also important to prevent UTI S and fungal infections, especially in warm and humid climates. The other thing I think is worth thinking about and, and this really comes in if you have the opportunity to talk to the rest of your group before your trip is, can you avoid menstruating on your trip if you're going on a, a wilderness trip for a number of days or weeks? And there are definitely options and I think we know a lot more about this now than, than was known 20 years ago. And some of the things um that people can talk to their GPS about are, you know, whether they take, if they are on the contraceptive pill, normally, whether they just take the pill continuously and skip, skip a period. Um There are implanted devices and intrauterine devices like the Mirena that a lot of people will actually stop having periods. Um But with all of these things, what um the important thing to advise people is not to try this for the first time ever while they're on their expedition or while they're in the wilderness because it doesn't always go to plan. So some people will have a lot of spotting will have really irregular bleeding that then lasts longer than a period and can make things really difficult. So these are all things that if you have time before a trip to plan and talk as a group, um are worth bringing up and people can have discussions with their, with their doctors um, come up with a plan and try it while they're still at home to see if it's going to work when they're in the wilderness. But there are definitely options to avoid having a period while you're in the wild. And for some people, that's what they find the best option. A few other things just to tie up menstruation that I think are worth considering are that irregular bleeding is regular in the wilderness. So I think there are some studies that have showed up to. I think it was 87% of women in wilderness back country trips have irregular periods or unexpected periods. I know anecdotally at altitude. Almost everyone I know has had a period which is up to two weeks early um or has missed periods. So, um another reason why I think it's really important that other people carry some menstrual products in their first aid kits, especially if you're a triplea or a guide. Um Again, if you can talk about this with your group ahead of time, it means that people don't get caught by surprise and come prepared with the products that they need on that topic. The other thing that I really encourage people to do on trips is to bring their own simple pain relief, usually paracetamol and ibuprofen. And I think this especially becomes important with menstruation because a lot of people get quite bad period, pain and cramps and you can go through what you would have thought was a reasonable group supply of Paracet and Ibuprofen very quickly if someone's needing three or four days of um pain relief for cramps. So I would always encourage every member of the group, male, female to bring along a personal supply of paracetamol and ibuprofen and um plan that they may need this for small injuries, but also for menstruation, I think we've mentioned most of the other topics on this slide. Um It is worth mentioning on the note of pain relief that some people do get very bad. Um period cramps. Um A lot of pain, um nausea, vomiting can be very uncomfortable. My very first high altitude mountaineering trip when I was 19 or 20 was with our, our sort of group leaders were two dads of friends of mine. And the thing that made my trip so much better was that when I got really bad period cramps, the dad was not phased at all and he had pain relief. He was completely happy to talk about it openly um with his daughters, with myself um and adapt the trip around what we were able to do based on how we were feeling. And that really made a big difference as a teenager who was still quite awkward talking about those topics at the time, I think uh the other points on the slide, um wildlife sometimes comes up, people ask about bears being attracted to period products. And I think there's not good evidence that bears are necessarily attracted to menstruating females. I know this has been a concern that people have raised. Um, but I think it's always sensible to, if you're in bear country to realize that bears are attracted to smells and they're curious and it's better to keep anything scented or fragranced or smelly away from your sleeping area. And so that means when you're emptying menstrual cups to go far from camp, the same as you would with toilet and to keep, um, any scented wipes, any used disposable products, um, double bagged in Ziploc and into a dry bag and raised up into a tree or into a bare cache. The same as you would with food or with toothpaste or with deodorant. The last thing I would say is just the, the point on privacy that it's difficult to change, uh, period products in the wilderness. And, uh, you do need a bit more privacy than you might need just to do a week. And so providing that for people in your group who might need it. Um, making sure they have opportunities. Um, and in some situations that's gonna mean that they get very comfortable with a friend holding a towel up in front of them or a jacket up in front of them to provide a bit of privacy, but making sure that there is a time and that there are open conversations that people can ask when they need that the next topic is so the next p is passion, um, which might seem like a topic that you don't need to consider in wilderness trips. But actually, uh, something that can be quite a common topic or a common thing that can cause problems. Um, often on wilderness trips, people are out of their usual environment. They're with a group of friends or new friends, new acquaintances and you're in a situation which is adventurous and encourages new friendships, new relationships, bonding is out of your ordinary. And it's amazing how often romances start in these situations. Some of the things to consider are hygiene again. So how will you clean yourself up afterwards to make sure that you're not at higher risk for getting urinary tract infections, particularly for females in the group where intercourse is one of the common causes of UTI S. Again, thinking about urinary tract infections as a risk and having antibiotic cover available for that. If it happens within your group, if you are the medic on a trip, whether or not you're gonna carry antibiotic cover for common sexually transmitted infections. And considering whether you're going to have any contraception or um condoms, particularly available in the med kit um for group use or encouraging your group to bring their own. The other thing on this topic is that I think it's really important to carry pregnancy tests in your medical kit, whatever capacity as a medic um that you're working with a group and even potentially in your own personal medical kit um for personal trips with friends because the differential for diagnosis, for someone with abdominal pain who could be pregnant is much more um time critical and, and worrying if you don't, you know, if you can rule out them being pregnant, then at least, you know that you don't have the potential for a ruptured ectopic pregnancy which would require immediate evacuation. Um, often it's not something that companies will think to put into their medical kits if you're working for a company that provides a medical kit. So it's something that I always include in my own and places like boots sell the generic ones for, I think you can get a five pack for 2 lbs or something very cheap on that topic. What you'll often get asked about or what people might wonder about and not feel comfortable asking about is what about their contraception and timing of contraception? Especially when you start traveling over time zones. Um, if people are on the combined or contraceptive pill, generally, um, a lot of people will just keep taking it at the same time that they would take it at home. So they'll set an alarm on their clock for whatever time they usually take it at home and they just keep taking it every 24 hours at that time. And that works well for short trips, for longer trips, people might not want to keep doing that and they might want to change it to a more convenient time and then it depends what kind of pill they're taking. So, if they're on a combined oral contraceptive pill, there's varying advice. But in general, the advice seems to be that you can vary the time by shift, the time by about three hours per day until you're on to a more convenient time. Or if it's a longer trip, you could wait until your week of pill free week. Um, and then when you start the new pack, start it at a more convenient time for the progesterone only pill or the mini pill, it's much more important. The timing of the pill and the advice varies from shifting it, not more than one hour per day. Um, or on some websites, they'll say not more than two hours, but for safety sake, definitely no more than two hours different every day. Or it risks making it ineffective. The other things to think about are absorption of pills. So, if someone gets really bad gastroenteritis, which is common when you're traveling, um, so if they're having bad diarrhea and vomiting, they might not absorb their pills and they need to think about using backup contraception for seven days. Um, people used to worry a lot about antibiotics, interfering with pills and they used to offer me advice to use backup contraception when you're taking antibiotics, but generally that's not what's advised anymore. The only antibiotic that really seems to cause problems is rifampicin, which isn't a very common one to be using. So most people can take antibiotics without worrying about their pill being ineffective. What about risks? Um, of being on contraception in the wilderness? And I think this is something worth thinking about. Um, you have a higher risk of blood clots. And so with long haul travels means you have a risk of clots in your legs and clots in your lungs, which is higher if you're on a contraceptive pill than if you're not. Um, and I think the same probably applies to altitude, although there's not a lot of evidence on it. So any situation where you're going to be potentially lying still, um, at altitude where you're potentially dehydrated long trips and planes, long trips and buses, you are at higher risk of blood clots when you're on the pill. The other thing, I think a lot of people don't plan for when they go on a trip is what's your backup plan? If you have a failure of contraception while you're traveling while you're home, potentially in the UK or wherever home is, it's quite easy to walk to a pharmacy and get the morning after pill or plan B and contraception. Um, it might not be that easy to get it um, in other countries and whether that's worth having along with you, um, as a backup plan. If, um, all of that fails, then the next topic is pregnancy. So a lot of, uh, times as a trip medic you will get asked by people what they can do and can't do and what trips they could potentially go on. Um, when they're pregnant, what things they need to think about, what places it's acceptable to go to or not acceptable to go to. If you start looking up some of the guidelines, I think a lot of them are quite old fashioned and conservative. Um And in general, the best advice that I've found is that what you can do during pregnancy is going to depend on what you did before you got pregnant. So if you were an Olympic sprinter before you got pregnant, it's probably reasonable to keep sprinting and running and training even while you are pregnant. Um Whereas if you've never run a day in your life after you're pregnant, it's probably not the time to take up ultramarathon running. Um And that extends to most activities. The other thing to say is that it's going to be a very individual thing. People will feel different um when they're pregnant, very different experiences of being pregnant and very different risk tolerances. Um And they will also have different experiences from one pregnancy to the next. So it is a very, I think any advice has to be very individualized and taken with a grain of salt in general. The things to think about are um the severity of the exercise. So a lot of guidelines will say keep heart rate below 140. But again, there are Olympic athletes who've trained for the Olympics and competed at, um, world national level, international level while pregnant and I'm sure they didn't keep their heart rate that low and their babies were fine. So I don't think it's something that's research or evidence based necessarily, it's, um, guidelines because it seems like it would be sensible and safe to keep your heart rate below 140. So as with all of this, I think it really depends what that person was doing before they got pregnant. Um core body temperature, this is probably one that is worth thinking about. Um the recommendation is to keep your core body temperature below 38 degrees. So very hard exercise and very um heat, intense environments might not be a great idea during pregnancy. Um And then this extends to things like advice against sitting in hot tubs and saunas while pregnant, the the type of exercise and the risks of that exercise. So generally, the advice is to um avoid things that have a high risk of falls and abdominal trauma. And again, this is gonna come down to a very individual risk tolerance and um personal experience and previous experience with that sport. So this is a picture of me when I was 32 weeks pregnant, I think climbing and I climbed before I was pregnant and I kept climbing when I was pregnant in my first pregnancy. But what I did find was I didn't want to lead climb. Um, and I actually decided after about 20 weeks that I didn't want to try to climb either. And so I stuck to bolted sport routes, um, with the top and for me that felt safe enough and reasonable. Um, I know other people who have kept leading and climbing tread. Um, and that's absolutely reasonable, I think, but it's an individual decision. Similarly, a lot of people feel that skiing is a really high risk for falls. Um I grew up skiing and I was comfortable skiing, but I know other people who have been very confident skiing and then had a fall and after that decided to stop skiing, um There are certain activities that are advised against in pregnancy. Diving is one of them. Um although there are case reports of people who have gone diving before they knew they were pregnant and their pregnancies went fine. Um But diving is particularly advised against in pregnancy as are like I mentioned earlier, hot tubs and saunas. The other thing to think about is whether any special equipment um is needed. So, um for example, in climbing, there are two companies that make climbing a pregnancy specific climbing harnesses, so full body harnesses for adults. And that's um I think pedal and I think this is the Mad Rock Mountain mama and they're both slightly different. They allow for a pivot point, belay point that sits about your chest rather than in your front of your pelvis. And the one thing I will say about them is that they have very limited gear loops, so it was almost impossible to fit, um, gear enough gear onto the gear loop. So I think there was one gear loop, possibly two. And the other thing is it's really not that comfortable. So it was absolutely fine for climbing, but trying to abseil down, um, more than one pitch was very uncomfortable and it's quite a strange feeling having your, um, pivot point be on your chest rather than down around your waist. The other thing to consider, and I think this is probably one of the biggest things is the accessibility of medical care if you were to need it. Um, or someone in your group was to need it. And that often is going to be the deciding factor on whether a trip is appropriate for someone during pregnancy or not. I'll talk about that a little bit more in my next slide very briefly. Um, some sport specific things. So climbing, I think, um, whether or not to wear a full body harness is again a personal choice. A lot of people will find that somewhere around the second trimester, they need to switch into a full body harness. Um, it is possible to keep climbing in a normal harness, um, and sling it below your tummy. Um, but it doesn't feel as secure. Um You know, and what you're comfortable with lead versus top group, et cetera, like we said, is very personal in terms of risk tolerance. Um, swimming and water sports are generally very well tolerated. Um You can often change the intensity to match what you feel is comfortable. Um And they tend to be low impact. Um A lot of people cycle, it's often very good because again, it's low impact. Um But at some point, it often does get uncomfortable trying to fit around a tummy. Um And then things like hiking um and carrying backpacks. Um Again, it is quite individual but will depend on how you're able to get your pack to fit and sometimes hard to buckle hip straps in a way that's comfortable. And there are also hormonal effects on joints that are worth thinking about. If you're starting to try and carry heavy loads, you might not be able to tolerate them as well. Um during pregnancy as you did before pregnancy. The other thing um that I hadn't thought about, but I know one of the speakers in the W MS lecture mentioned is that if you have a procedure like a cervical circlage, then you're absolutely not allowed to swim because of the risk of infection. So, on the next slide, um I think this is probably one of the most important considerations about pregnancy in the wilderness is um the remoteness and the availability of medical care and again, this is gonna be very different from person to person, depending on their individual risk tolerance. Um, and what they think is acceptable to them. I think in the end, what it comes down to is if you had a complication in this situation, um, and the same with the sports that you choose. If you had a bad outcome from the pregnancy, would you still be happy with your choice to have gone and put yourself into that situation? And that's not something you can decide for someone else. But I think they need to have all the information so they can weigh up the risks and um make that decision. People will often say that the second trimester is the safest because you've passed the first trimester where the risk of miscarriage is highest. Um and you're not quite into the third trimester where you start being more worried about preterm labor in remote environments. But again, this is dependent on the situation because there's some suggestions that the second trimester might be a bad time, a particularly bad time to go to altitude because it's the time when um placental implantation happens. And we know that placentas are very um sensitive to hypoxia to low oxygen situations. And so we don't know, but there are concerns that being at altitude might affect how the placenta implants. The other thing to consider is if someone's in their first trimester, do they have a confirmed intrauterine pregnancy is it possible for them to get an ultrasound scan early to make sure that the pregnancy is intrauterine. So that if they did have any complications like bleeding, um and abdominal pain while they were in a remote environment, at least you know that it's not an ectopic pregnancy. And um I put this photo in because this is a very beautiful stretch of the Orange River between Namibia and South Africa. And I went paddling down the Orange River at about 31 weeks pregnant with a friend of mine. And this is the part of the world that I used to guide in. And so I was very comfortable with the risks and the environment, but it is still a good um probably at least a 12 hour evacuation to any average medical care and probably more than that to good medical care for me. In that situation. I decided that I'd had an uncomplicated pregnancy and I knew the area well and I knew how I would access medical care if I needed to. And I decided that it was worth it for a sort of once in a lifetime trip with a friend. But that said, um I had a very different experience um a year before where I found out that I was pregnant just as I was leaving for an expedition in quite a remote area. Um I spoke to a local obstetrician before I left who um told me that uh an ultrasound scan wasn't necessary and I was very unlikely to have any complications, which is generally true. But unfortunately, I had a miscarriage while I was in this remote environment. And because I didn't know whether the pregnancy was intrauterine or not, I ended up having to leave the trip so that I could get an ultrasound to confirm that I didn't have an ectopic pregnancy. And for me, that really changed my risk tolerance of what I was willing to do in the first trimester. And when I um was then pregnant again, the next time II was meant to be going to a space camp. And I decided that I wasn't willing to do that because I didn't want to be stuck in a remote environment where I couldn't access medical care if I had another miscarriage. So I think if you start talking to people, um A lot of people will have wondered about things like this. What I found valuable about having those experiences was that on my expedition work trips as a medic, I was actually able to have conversations with some of the other women in my groups about these topics. And it was interesting how often people brought it up. So I had people on my trips who weren't pregnant but were considering getting pregnant and were in film and TV work where they were often having to travel to very remote sites or to malaria areas. Um And they didn't really feel comfortable talking with the leaders of the trips who are often men about the fact that they were actively trying to get pregnant or would be actively trying to get pregnant in the next 6 to 12 months. Um, and they weren't able to always get great advice from their GP S. Often the advice was just to avoid remote areas or avoid malaria areas, which if your livelihood and career depends on you going into those areas is not always practical advice. So I think having a little bit of knowledge about what the risks are and what some of the sensible things you can do to mitigate risk. It is really useful. And I think you'll be surprised how often these kind of discussions do come up and people really appreciate being able to discuss these things openly. One of the topics I think is interesting and is, is getting discussed more and more is um altitude in pregnancy. We don't know a lot as with most things, we don't do studies on pregnant women because it's not really appropriate. Um So all of the evidence we have is generally anecdotal in case studies. Um There's probably a lot of individual variation on how people react to altitudes. So some people um have said that they, a lot of this comes from the states where there are ski resorts and um cities and towns that are at sort of 11,000 ft. And um there are a case of, you know, anecdotal evidence of people saying that they always got sick when they went up to 11 or 12,000. And then when they were pregnant, they didn't. And then there are other people who said that they never got up to do sickness, but when they were pregnant they did. So I think it is very individual. Again, generally, the advice is that anything under 2.5 1000 m is definitely safe. Um We don't really know higher than that. There are definitely people who have been higher than 6000 m while pregnant and have had healthy pregnancies with good outcomes. But um at this point, all all the evidence is sort of anecdotal and based on very limited case reports, one of the things that um a lot of people will notice is that their exercise tolerance goes down dramatically um during pregnancy even in the first trimester in the first four or five weeks. Um and they may not be able to push themselves as hard as they usually can. We do know from studying um populations that live at very high altitude permanently, that there are um risks in pregnancy associated with chronic altitude exposure. So, um things like higher risks of preeclampsia and intrauterine growth oration or small babies. Um So there definitely seems to be changes in the placenta and the blood supply of the placenta for people who live permanently at high altitude. But for people who are just going up to high altitude for a number of hours or days, we don't really know how safe or dangerous it is. Um, although there are probably now a reasonable number of case reports and anecdotal evidence of saying that it's probably not as risky as was previously thought. Again, I think this is one of those things that, um, people will have to make up their own mind on what their risk tolerance is. And again, consider uh what your options are for medical care if you needed it and what part of the pregnancy might be most appropriate to go to these places. So a lot of times people will ask about altitude for things like the Anna Perna circuit and never a space camp. And often with these situations, it may not be the attitude that the most risky thing. It may actually be the fact that you don't have access to um good medical care within a few hours. If something were to go wrong, then the last p and one that I think people tend not to know much about or think much about until they have to do it themselves is pumping. Um But it is something that is worth knowing about. And I think the more people, even people who will never have to pump themselves, the more people do know about it the better because again, it just removes barriers to people being in the wilderness. Um People might need to pump for a variety of reasons. So if you ask uh friends or family people, you know about breastfeeding, what you'll hear is that it's much harder than what most people expect. Um Some people have a lot of difficulty breastfeeding and they might have to pump for that reason. Some people might choose to pump because or have to pump because of work commitments or travel and it's hard, it takes a lot of effort and a lot of time and someone supporting you in this can make a huge difference in particularly in the first six months if you have a baby who is exclusively um drinking breast milk. Uh Any chance that you want to go into the wilderness without the baby attached to you, you're going to have to pump. Most women will find that out to pump. Um and it is possible and you'll see from this picture and this is, um I think she's actually a Canadian professional skier. Um It is possible but it's definitely not easy. Some of the challenges when you're traveling, even if you're just traveling, airline, travel countries, um travel for work or travel in the wilderness. Um Some of the challenges are how do you sterilize on pump parts and which are meant to be washed and sterilized after every use. A lot of people will keep them in the fridge between uses um when they're at home, but this is not usually possible when you're traveling. Um how are you going to store any breast milk that you pump? It needs to be kept cold and how we charge the breast pump. Some of them have um portable battery packs, some of them don't. Um And then the other thing worth knowing about is what the travel and airline restrictions and requirements are. Um generally you are actually allowed to travel with quite a lot of breast milk. Um but you will sometimes get difficulty from security agents um probably particularly in the States. So it's worth having those um guidelines printed out so that you can argue your case. And uh there are things that can make pumping easier for people. So there are pumps now that are hands free and wearable so you can keep walking or skiing or driving while pumping. Um And there I know in the States anyway, there are apps that actually map out all pumping locations. I think that probably exist in the UK. I haven't actually looked and I'm not sure how international they are but they'll um provide locations for private pumping facilities um where you can plug in a pump where there's um running water where there's a place to sit, that's private. The other thing worth knowing about if you have people on your trip who are breastfeeding at all or pumping are um resources for checking what drugs are safe during breastfeeding and there are a couple of different resources. So um if you Google it on, along with the NHS, you'll find some good guidelines. There are lamed or the breastfeeding network guidelines. Um The Leche League has some links on their page. Um and there's some good anesthesia guidelines if you're working in a hospital as well, which tell you which drugs are safe to give to someone who's breastfeeding and which ones aren't in general, things like simple analgesia, paracetamol, ibuprofen are all safe to be used um when breastfeeding. But often there's a lot of fear around taking medicines while breastfeeding. So it's good to have um thought about it ahead of time while you still have wifi and you can Google things. So I think that's our last pe. So as a quick recap, I think, just think about the difference in anatomy and physiology when you're considering your different trip members. Um Keep in mind the p when you're planning your trip, uh especially in pre trip preparation and the discussions that you're going to have with your group when you meet them. Um If you have any experience in o in pregnancy, there's some really interesting um information and data gathering at the moment going on, especially by some of the members of the Wilderness Medical Society. And I think there will be some changes to guidelines and interesting research coming out in the next few years. And the atropy that one of my friends uh mentioned who works in wilderness medicine was to think about prejudice and I think it's just worth mentioning. I'm not going to talk about it in this talk, but thinking about things we can due to remove barriers for anyone who's underrepresented in the wilderness. Um And women tend to be one of these groups, but there are lots of other minority groups as well. So thinking about ways that you can improve access to the wilderness for people who might not be as represented in the wilderness. Thank you very much. And I would love to hear if you think there are other topics um specific to women in the wilderness that we should be discussing. I hope you found it helpful and enjoy the rest of your endeavor. Course.