ENDOMETRIOSIS: PAIN AND EMOTIONAL TURMOIL

The human body was created with pain receptors. Without them we could not survive. Pain receptors tell us, for example, when to pull our hand from a dangerously hot object. Should we come into contact with something and it pierces our skin, pain receptors tell us we are bleeding and need first aid. Pain receptors also alert us when internal organs misfunction – heads ache, kidneys throb, throats burn, a uterus cramps. Everyone knows what most of such pain is like, but it can be difficult for a person who has never experienced a wrenching, disabling pain to comprehend another’s misery. A knowledge of biology, a degree from a medical school, or even compassion for another human being cannot always guarantee either understanding or correct treatment.

Why is pain such a mystery? An individual’s response to bodily pain is always unique because pain is supremely subjective. Two people may be able to agree with each other about what a headache feels like and that childbirth usually causes more physical distress than a routine internal examination. They may not, however, agree about exactly which sensations and what degree of intensity constitute acute pain or an odd and persistent ache.

Each of us has a different pain threshold, which is a combination of psychological and neurological factors. At one extreme, stoics and mind-control practitioners may choose to feel no pain—some can even staunch the flow of blood from a wound by use of willpower alone. At the other extreme, hypochondriacs fervently believe in their suffering, and encourage it or create new illness. Most people fall somewhere between these two extremes. Whatever the pain—acute, throbbing, stabbing, burning, dull, aching—they can describe it accurately enough in all us varying degrees and severity so that others can understand.

This ability to communicate a private sense of pain to another gives us a chance to obtain medical help in a manner that is most effective. But what happens when communication is thwarted by a physician who invalidates a patient’s report of pain, thereby invalidating the cause?

For women who have been told by doctors again and again that the pain they feel does not exist, emotional turmoil may become as much a symptom of endometriosis as the actual physical disability. As a palliative, unsympathetic doctors may prescribe Valium or other tranquilizers. Generally, when the pain persists, another doctor is consulted. Should he concur with the first, he may simply prescribe stronger tranquilizers, and a woman’s illness becomes doubly wearing. Her self-doubt begins to grow as her pain increases in severity. The questions such a victim asks herself, however, remain unanswered: “How can I be creating such horrible pain? Since doctors tell me that I am to blame, bow can I stop doing this to myself?’ Clearly, this situation is emotionally wrenching. Rather than follow their own inner voices, which know chat this pain means something, these women are made to feel defeated, somehow responsible—and guilty—until the disease becomes so advanced and so serious that even a minimally experienced physician is finally able to diagnose it.

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COPING WITH ENDOMETRIOSIS: VITAMIN AND MINERAL THERAPY

Many women with endometriosis have heard of the benefits of treating the disease with vitamins and minerals and certainly members of the Endometriosis Association (Victoria) have talked about success with vitamin B6 and evening primrose oil in eliminating pain and treating lethargy and depression.

Most vitamins and minerals discussed in this section below can be bought off the shelf at your local health food shop.

Vitamin B

Vitamins can help in alleviating pain; in particular, vitamin B6 has been reported as being beneficial in the treatment of premenstrual syndrome and associated problems.

Although it is not certain why vitamin B6 helps, many PMS sufferers vow it has been instrumental in alleviating their symptoms of depression, lethargy, mood swings, irritability and pain.

Vitamin C

The merits of vitamin C have long been acknowledged. Alternative therapists say it helps not only with heavy bleeding (because it strengthens the blood vessel walls and helps the body to absorb iron) but also helps promote healing.

Vitamin E

Another healing vitamin, it is often recommended for the prevention of thick scar tissue and to promote healthy skin; this would explain why it helps alleviate pain as it acts on adhesions and scar tissue left by endometriosis implants.

Zinc

Many practitioners believe zinc helps with PMS symptoms and also improves fertility.

Evening primrose oil

Many PMS sufferers cannot do without their evening primrose oil (EPO) as they say it helps alleviate symptoms and keeps the condition under control.

Endometriosis sufferers on hormonal drug therapy also report that it has helped them cope with the side effects often associated with these drug treatments.

Evening primrose oil is expensive (currently about $20 for a month’s supply) so you have to weigh up the benefits with the cost. EPO is a good source of gammalinolenic acid (GLA) — one of the essential fatty acids which produce prostaglandin.

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IS ENDOMETRIOSIS BECOMING MORE COMMON

There is much debate as to whether or not endometriosis is becoming more common.

Some gynaecologists believe that there has been an increase in the actual number of women who have endometriosis. These gynaecologists believe that the condition has become more common because women are having fewer children and having them later in life — two factors which they believe predispose women to developing endometriosis.

Other gynaecologists believe that there has only been an increase in the number of women being diagnosed. The rate at which endometriosis has been diagnosed has certainly increased over the last 30 years, particularly since the introduction of laparoscopy in the early 1970s. This does not mean that the condition is more common than it was 30 or 40 years ago. It is more likely to mean that the condition is being diagnosed more frequently because the introduction of laparoscopy has made it much easier to diagnose and because there is a greater awareness and recognition of the condition by the medical profession.

The increased rate of diagnosis could also be a reflection of the fact that nowadays women are less likely to accept that some of the symptoms of endometriosis such as period pain and heavy bleeding are a normal part of a woman’s life. Consequently they are more persistent in seeking a diagnosis — and treatment — for their symptoms.

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ENDOMETRIOSIS: MORE ABOUT LAPAROSCOPY

What is a laparoscopy?

A laparoscopy is a relatively safe and simple minor operation, performed under a general anaesthetic, in which a telescope-like instrument known as a laparoscope is inserted into a small cut near the navel.

Nowadays, laparoscopy is a fairly common operation which is used to diagnose a range of gynecological conditions, including endometriosis and pelvic inflammatory disease. It is also used to treat a variety of gynecological conditions, including drainage of simple ovarian cysts, and to perform sterilization operations.

A laparoscope is a long thin telescope-like instrument approximately 30 centimeters long. It has a lens at the end which magnifies and lights up the pelvic organs and allows a gynecologist to look for the presence of endometrial implants and cysts in the pelvic cavity. It can also be used to remove samples of tissues for testing, to perform minor surgery, to perform laser surgery and to take photographs.

What do I need to discuss before I have my laparoscopy?

Your laparoscopy should be performed by a gynecologist who is skilled and experienced in performing laparoscopics and diagnosing endometriosis – very few general practitioners have either the skills or the experience to perform laparoscopics.

Some gynecologists believe that a diagnostic laparoscopy for endometriosis is best done just before or during a period when the disease is most active and easier to see. It may be worthwhile discussing this aspect of the timing of your laparoscopy with your gynecologist.

It is also extremely important that you discuss with your gynecologist before the operation precisely what she or he intends to do during your laparoscopy if endometriosis is found.

In particular, if endometriosis is found, you need to discuss whether your gynecologist intends only to diagnose the condition at the time and defer any further surgery until you have considered all the available options or whether it is intended to proceed immediately onto laparoscopic surgery. You should indicate clearly which of the alternatives you want.

Even more importantly, you should discuss what you want your gynecologist to do if extensive surgery is needed. For example, if organs or large cysts need to be removed do you want a laparotomy performed immediately or do you want it delayed so that you can discuss the operation and consider all your options?

If surgery is performed at the time of your diagnostic laparoscopy it avoids having to undergo the inconvenience and costs of a second period of hospitalization, a second general anaesthetic and a second recuperation period. But it also means that you will not be able to participate in making any of the decisions regarding your surgery nor will you have the time to make the emotional and psychological adjustments associated with being diagnosed as having a chronic condition such as endometriosis.

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WOMEN’S BODIES: MORE ABOUT SYPHILIS

How is syphilis diagnosed?

If syphilis is suspected in the primary and secondary stages, fluid from the base of an ulcer can be examined under the microscope to see if it contains spirochaetes. It takes a special microscope attachment and a lot of practice to be able to see them, so this test is usually only done in sexual health clinics.

Blood tests are also taken, but because it can take up to three months after infection for the tests to become positive, if your first test is negative another test should be done a few months later. If syphilis is suspected or proved, your doctor will usually advise tests for other STDs in case you picked up something else at the same time.

Blood tests are also used to diagnose latent and tertiary syphilis. In these stages, tests on the cerebrospinal fluid (that surrounds the brain and spinal cord) are occasionally advised to see whether the nervous system has been affected. Tests for syphilis are very complex and it takes an expert to interpret the results to work out what stage the disease has reached and whether the infection has been cured. Some tests for syphilis remain positive for life, even after the infection has been treated and cured.

How common is syphilis?

After penicillin began to be used for treatment in the early 1940s, the number of cases diagnosed diminished rapidly until the 1970s. Since then, syphilis has been on the increase.

In developed countries syphilis is much less common than it used to be. However, there are many parts of the world (including remote parts of Australia) where syphilis is rife. It should always be considered a possibility, especially if there is a persistent or slow-healing ulcer on or near the genitals.

Syphilis and pregnancy

Worldwide, the number of babies born with syphilis is increasing. In some countries many babies are born severely deformed and ill or are stillborn because of being infected in the womb.

Doctors and midwives usually advise all pregnant women to be tested for syphilis. No matter how unlikely it seems that you may have been infected, it is wise to accept this test to protect you and your baby. If you’re particularly at risk, the test for syphilis should be repeated towards the end of pregnancy. Treatment during pregnancy will cure both mother and foetus.

Treatment

Syphilis can be cured. The organisms that cause it are very sensitive to antibiotics. Penicillin is still the best treatment, usually by daily injection for 10-21 days. If you’re allergic to penicillin, certain other antibiotics can be used. After treatment you’ll be advised to have checks to be sure that the treatment has worked. Some of the blood tests become negative after all the spirochaetes in the body have been killed.

How can syphilis be prevented?

The most certain way is to stay in a monogamous relationship with someone you know won’t infect you. Never have sex with anyone who has any sort of genital ulcer. Condoms can give some protection against infection to and from the penis, but they’re no good if the ulcer is elsewhere.

If you’ve had sex with anyone you’re not sure about, do have a test: it’s never worth taking a chance about syphilis. Early diagnosis and treatment break the chain of infection.

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WOMEN’S BODIES: URINARY PROBLEMS. URGE INCONTINENCE

This term describes loss of bladder control almost as soon as the urge to urinate is felt. In other words, when you suddenly feel the urge, you have trouble hanging on until you get to the toilet, ranging from dribbling all the way to uncontrollable flooding.

Just about everyone has experienced the occasional episode of urgency. For example, when you arrive home after being out for some time and are vaguely aware of a full bladder, have you noticed that the minute you turn the key in the door (and your mind semi-consciously registers that bladder relief is close at hand) you’re overwhelmed by a powerful desire to pass urine and are lucky to make it to the bathroom? If this happens frequently and when your bladder contains a meagre 50 ml or so, you could have an unstable bladder and urge incontinence.

We women are especially liable to urgency and unstable bladders from years of going to the toilet whenever one is handy rather than when our bladders are full. By doing this, our bladders learn to send ‘full’ messages at the slightest stretch, and our pelvic-floor muscles never get enough practice at holding on.

Little girls are sent to empty their bladders at every opportunity so they won’t want to go at some inconvenient time (in the car or bus, in shops, during movies and suchlike). The habit of emptying our bladders frequently ‘just in case’ continues into adult life.

WOMEN’S BODIES: MORE ABOUT ENDOMETRIOSIS

What causes endometriosis?

We don’t know. There are four theories. Each explains how some but not all endometriosis could develop. It is likely that there are a number of causes.

• The retrograde menstruation theory proposes that if menstrual fluid flows backwards through the fallopian tubes into the pelvic cavity, fragments of endometrium could implant and grow wherever they come to rest. Retrograde menstruation has been shown to happen in many women, but only a small number develop endometriosis. It is suspected that slight differences in hormonal balance may make it more likely that endometrial fragments will implant.

• The blood and lymph transport theory suggests that fragments of endometrium can enter the blood or lymph vessels and be carried away from the uterus. This could explain occasional spots of endometriosis far away from the uterus, such as in the lungs.

• Accidental transplantation describes fragments of endometrium that implant in the path of a surgical incision. This would explain how endometriosis occurs in the scars of uterine surgery, caesarean delivery and episiotomy.

• According to the metaplastic theory, women have cells scattered in the pelvis, and perhaps elsewhere, that can turn into endometrial cells. Why this happens is obscure; hormonal stimulation is the most likely explanation. Women with endometriosis often wonder if something they have done in the past may have caused the problem. Three things have been cleared: use of the Pill, IUDs and tampons are not connected with any increased risk.

How common is endometriosis?

Because many women with endometriosis have no symptoms, it’s hard to answer this question. Many textbooks say about 5 per cent, but now that diagnosis is more accurate many gynaecologists believe that 10-15 per cent of women may be affected at some time during their reproductive years. Endometriosis is the second most common gynaecological condition affecting women during their menstruating years, and it is the reason for a quarter of all abdominal gynaecological surgery.

There has been a lot of debate about whether endometriosis is becoming more common. Some gynaecologists believe that because women these days have fewer children and have them later in life, more cases of endometriosis are developing. Others believe that there are no more cases today than there were 20 or 50 years ago, but greater numbers are recognized and counted now because of more accurate diagnosis.

Who gets endometriosis?

Endometriosis occurs in women who are menstruating regularly; it doesn’t occur before puberty or after the menopause. It is less common among women who start child-bearing early and have many pregnancies, and among women who have long spells without periods. It seems that frequent interruptions to menstruation protect some but not all women against endometriosis.

In the past, endometriosis was believed to be a disease of women in their thirties and forties. It’s now clear that it is more common than was thought in women in their twenties, and is even found in some teenagers. Previously, because it wasn’t expected or suspected in younger women, the diagnosis was often missed.

There is a traditional belief, still held by some doctors, that endometriosis is a disease of white, middle-class, intelligent, nervous, ambitious women. This belief is not borne out by the facts, which show that it can affect women of all races and from all walks of life. It is inaccurate and unfair to refer to endometriosis as ‘the career
woman’s disease’.

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WOMEN’S BODIES: EXTERNAL GENITAL PROBLEMS.VULVAL ITCH

Itching of the external genitals (and perianal area) is particularly miserable and trying, because you just can’t scratch except in total privacy. And scratching is even more likely to be harmful than on less delicate skin elsewhere on the body: the more you scratch, the worse things become. So finding and getting rid of the cause of genital itch is an urgent priority.

Itching is a symptom of skin inflammation due to infection, allergy, physical or chemical trauma and thinning (atrophy) of the skin due to a lack of hormones or a disturbed supply of blood. Common causes of vulval itch include infections such as candidiasis, trichomoniasis, pubic lice, and the early and healing stages of herpes simplex recurrences. Genital warts sometimes cause itch.

After the menopause, itching may be due to atrophic vulvitis, a non-infectious inflammation that can develop in genital skin that has become excessively thin and vulnerable due to lack of oestrogen. It can usually be remedied by applying oestrogen cream.

Itching from allergic dermatitis should always be suspected when there’s no evidence of infectious inflammation. Things that may cause such a reaction include

feminine hygiene products (including douches), soap ingredients, bubble baths, bath salts and oils, laundry detergents, spermicides, condom rubber or lubricants, even the dye from coloured toilet paper -just about anything can irritate the vulva if you’re sensitive to it. Foods and drugs that bring you out in allergic rashes can also affect genital skin.

Chafing from pantihose, pantigirdles, tight trousers and sanitary pads may cause the itch. Synthetic garments that trap moisture around the genitals are often to blame: always wear cotton next to your genital skin.

One of the most distressing itches comes from chronic dermatitis of the genitals. The irritation is maddening, and its cause is often a mystery, which makes it harder to get rid of.

What to do about genital itch

Find and eliminate the cause. You will usually need the help of your doctor with this unless there’s an obvious culprit such as a new brand of laundry detergent.

WOMEN: COMMON QUESTIONS ABOUT THE MENOPAUSE

Will my body become dependent on the hormones?

HRT is not addictive in the manner of, say, narcotics, but your body will on the hormones to prevent symptoms, which may return if you stop treatment. Symptoms show that the body isn’t doing very well without oestrogen.

If I had problems with the Pill, can I use HRT?

Because the hormones in HRT are slightly different and used in a different way from those in the Pill, many of t side-effects are avoided. Some women on HRT may notice unwanted side-effects
while taking the progestogen supplement. If you’ve had problems on the Pill, your doctor will take these into account when deciding how to advise you about HRT.

If I don’t have any symptoms, should I take hormones?

There may be no reason to take hormones if you have no symptoms. However, you may not have symptoms but still be at increased risk of either heart disease or osteoporosis. If your doctor recommends HRT to protect you against these disorders, the reasons will be explained to you.

Can I get rid of symptoms with diet, herbal remedies or vitamin supplements?

No.
If any herbal or other remedy for menopausal symptoms stops hot flushes, it may be made from a plant containing something that is converted to oestrogen in the body. It’s more likely, however, that the placebo effect of doing something positive about them has reduced your symptoms.

Can’t I prevent osteoporosis by taking calcium?

No, though you might think so after seeing the ads for calcium supplements and dairy foods. There is ample evidence that calcium alone won’t prevent osteoiporosis. However, everyone needs adequate calcium to maintain healthy bones, and women over the age of 50, pregnant and breast-feeding women, adolescents and children need more. If you think your diet lacks calcium, ask your doctor about supplements.

If I’m still having periods on the hormones, could I still become pregnant?

No, not once you’ve definitely reached menopause. Before that, when natural periods may be erratic, it’s important not to risk an unplanned pregnancy. Ask your doctor about suitable contraception at this time of life.

Must I have a hysterectomy if I want to take hormones?

Some doctors recommended this in the past, before progestogen supplements were added to HRT to prevent any increased risk of uterine cancer. It is no longer a valid reason for hysterectomy.

Must I have a curette every year?

No. When progestogen supplements were being studied, women attending research clinics for HRT were asked to have an endometrial sample taken each year (by curette or other means) to study the effect of progestogen on the lining of the uterus. This is not done any more, now that it has been shown that progestogen protects against the risk of cancer of the endometrium. Curettage is advised only if there is unexpected bleeding.

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WOMEN’S BODIES: COMMON QUESTIONS ABOUT PREGNANCY – I

Are all drugs risky in pregnancy?

No. In fact it’s important that women who need regular medication to maintain their health shouldn’t stop such medication without consulting their doctor, who will advise if any changes are needed to safeguard pregnancy. Otherwise it’s best to avoid drugs as far as possible, but this shouldn’t be taken to extreme. If you become ill, it’s usually safer to take treatment than not. For example, if you have a feverish illness, your foetus is at much greater risk from the fever than from taking paracetamol or aspirin to reduce it. Bacterial infections can safely be treated with oral antibiotics except tetracyclines, which disturb foetal bone and tooth development. If you intend to use over-the-counter medicines, always check with your doctor or pharmacist.

Should alcohol he totally avoided?

Alcohol should be limited, and this is generally easy because most pregnant women ‘go off it from the early weeks. But an occasional evening drink or a glass of wine with dinner has never been shown to do any harm. Health problems due to alcohol have so far only occurred in the infants of very heavy drinkers.

Other social drugs should be stopped. Heroin and methadone during pregnancy can cause serious problems for the baby, including withdrawal symptoms in the newborn due to addiction.

Is it safe to have your first baby after 35 years of age?

Studies during the past two decades have thrown doubt on the long-held belief that it is risky for both mother and baby if the first pregnancy occurs after 35 years of age. Results suggest that general health rather than age is the most important factor in predicting a good outcome for older mothers. This is good news, as first births to Australian women over the age of 35 increased by 37 per cent in the 1980s. Statistics show that older first-time mothers generally look after their health, don’t smoke, and are well prepared for childbirth. As might be expected, such women generally have healthy babies. However, the risk of genetic abnormalities, especially Down’s syndrome (mongolism), increases with age, regardless of whether it’s the first or a subsequent pregnancy. Pregnant women over 37 years of age are advised to have amniocentesis or chorionic villus sampling to check for genetic abnormalities.