Dr. George Redmon
For may women suffering from the pain and devastation of endometriosis, life can become a daily challenge. Current data estimates that about 20 percent of reproductive-age females in the United States suffer from this malady.
The following article was originally published in the March/April 2006 issue of American Fitness Magazine. All rights reserved. For more about American Fitness magazine, click on the magazine at right.
For may women suffering from the pain and devastation of endometriosis, life can become a daily challenge. Current data estimates that about 20 percent of reproductive-age females in the United States suffer from this malady. Peter Kovacs, MD, clinical instructor at the Department of Obstetrics and Gynecology, Albert Einstein College of Medicine in Bronx, N.Y., maintains that 50 percent of all infertile women may suffer from endometriosis. Many of these five million women live in agony for decades before a definitive diagnosis is made and treatment is administered.
Endometriosis is defined as a condition in which endometrial tissue - the tissue that lines the inside of the uterus - grows outside the uterus and attaches to other organs within the abdominal cavity, such as the fallopian tubes, colon, small intestines, spleen and lymph nodes. Endometrial tissue growing outside the uterus has been found, in many cases, on the bladder, uterus, rectum and ovaries. Endometrial tissue found attached to the ovaries, in many cases, causes a blood-filled cyst to develop, which is known as an endometrioma or a chocolate cyst.
L. Russell Malinak, MD, professor of Obstetrics and Gynecology at Baylor College of Medicine in Houston, Texas, says the term “chocolate cyst” describes the formation of old blood on the ovaries, which appears similar to chocolate. Laura E. Corio, MD, board-certified OB/GYN at The Mount Sinai Hospital in New York, N.Y., and co-author of The Change Before the Change (Bantam Books, 2000), states that these stray pieces of endometrial tissue sit still acting like uterine tissue, swelling and bleeding on a monthly cycle and causing excruciating pain. (Note: Some female patients have described the pain as being similar in nature to contractions that occur during the birthing process - only continuous.)
The Monthly Cycle
To fully understand the long-term complications associated with this disorder, let’s briefly review the physiological aspects of the menstrual cycle. During a woman’s reproductive years, one of the ovaries releases an egg into the fallopian tubes once a month. It is the ovaries that increase estrogen and progesterone production, which signals the endometrium to grow. This growth prepares the endometrium to support the implantation of a fertilized egg via its rich network of blood vessels and glands. When a egg is not fertilized, it, along with endometrium, passes out through the vagina. This passage of endometrial tissue is the monthly menstrual flow.
During menstruation, via some unknown mechanism, endometrial tissue finds its way to other sites and organs in the body, reacting as if they were part of the normal growth pattern. This abnormal growth of tissue can cause severe pain and disrupt normal functioning of vital organs.
Signs and Symptoms
C. Everett Koop, MD, medical director for Time Life Medical and former United States Surgeon General, says that many women with this disorder experience pain during sexual intercourse and bowel movements, and tenderness during pelvic examinations. Other possible signs and symptoms are infertility, improper immune functioning, bladder dysfunction, coughing of blood during menstruation, pneumonia-like symptoms with fever, rectal bleeding, severe menstrual cramping and binding together of various organs such as the uterus, ovaries, fallopian tubes and intestines.
A Difficult Diagnosis
One of the most insidious facts surrounding endometriosis is that it can go undetected for decades. This unfortunate error, according to Edmond Confino, MD, of the Department of Obstetrics and Gynecology at Northwestern University Medical School in Chicago, Ill., occurs because endometriosis is an enigmatic disease with an unclear etiology (the cause of a disease or abnormal condition), an unpredictable clinical course, and has varied effects on different patient’s reproductive potential and quality of life. Because of the factors cited above, many women move from one doctor to the next, and from one test to another, for as many as 10 to 15 years without reaching a definitive conclusion as to what their problem is. This is due, in part, to the fact that in many cases, the pain emanating from a particular site or organ can mask signs and symptoms of many varied conditions such as pelvic inflammatory disease (PID), appendicitis, ectopic pregnancy, hernia, cancer, ovarian cysts and gonorrhea.
This unfortunate trend, however, is changing, as cited by Deborah A. Metzger, PhD, MD, FACOG, a reproductive endocrinologist based in San Jose, Calif., who specializes in endometriosis and infertility. Metzger states that today many gynecologists are becoming more aware of this disorder - especially among teenage women. This is of vital importance due to the fact that mounting evidence shows a genetic connection to this disease’s onset, as well as symptoms that are present early in a woman’s reproductive years - which can also cause infertility.
Causes of Endometriosis
While doctors are not quite sure how or why endometriosis occurs, there have been many theories postulated to explain its occurrence.
The Immunologic Theory
This theory proposes that immune cells, through some unknown mechanism, allow normally shed endometrial cells to attach and grow instead of destroying them. Dr. George T. Schneider, professor of Obstetrics and Gynecology at the Louisiana State University of Medicine in New Orleans, La., also maintains that there is some correlation between immune system dysfunction, infertility and endometriosis. It is believed that immune cells, known as macrophages, in their normal job of seek and destroy, try to dismantle implanted endometrial tissue in the fallopian tube and end up annihilating egg and sperm cells, thus interrupting the fertilization process.
The Genetic Connection Theory
Based on current genetic studies, researchers believe that this condition has a genetic connection. Health officials affiliated with the Georgia Reproductive Specialists facility in Atlanta, Ga., which specializes in infertility and reproductive endocrinology, have found that patients with an affected mother or sibling are 61 percent more likely to have severe endometriosis than those without affected relatives (23 percent).
The Retrograde Menstruation Theory
Normally, endometrial cells can be seen in the peritoneal fluid (the smooth, transparent membrane that lines the abdominal cavity) of all women at the time of menstruation. However, it is presumed that fragments of endometrium tissue shed during menses back up or find a way into the fallopian tubes. These pieces make their way from here to other sites in the body.
The Metaplastic or Induction Theory
According to Lyle J. Breitkopf, MD, director of the Endometriosis Clinic of the New York Infirmary-Beekman Downtown Hospital in New York, N.Y., these two theories focus on changes at the cellular level leading to endometriosis. These theories suggest that repeated irritation of the cells, in the lining of the abdominal cavity, such as a reoccurring infection, could cause cell changes that precipitate endometriosis.
Diagnosis and Classification
As previously discussed, endometriosis can go undetected for years because of the varying degree of symptoms. Some women may experience severe discomfort, while others exhibit little evidence of the disease. Due to these factors and the wide variations of individual signs and symptoms, a healthcare provider may categorize the individual’s level of endometriosis based on the four stages: Stage I (Minimal), Stage II (Mild), Stage III (Moderate), Stage IV (Severe). Based on where one is categorized, the healthcare provider will suggest certain levels of treatment. While many physicians use questionnaires to asses one’s condition - family history, pelvic examinations and ultrasound - the most definitive diagnostic procedure is using a laparoscope. A laparoscope is a lighted tube with a miniature camera that is inserted through a tiny incision by the navel. This instrument allows the doctor to view the organs and any endometrial implants.
Treatment for endometriosis often depends on whether the patient’s goal is to relieve pain, improve fertility, or both, says Koop. Surgically removing implants and/or performing a hysterectomy are sometimes employed. These options are often used in Stages III and IV. It is advisable to seek a second opinion before proceeding with this treatment option. Julia Older, author of A Woman’s Guide to Endometriosis (Charles Scribner’s Sons, 1984), reminds us that in teaching hospitals, interns must perform a certain quota of surgical procedures. Women might be advised that a hysterectomy is the best option without being told what the alternatives are, explains Older. Other Medical treatments using various drugs are aimed at reducing the stimulating effect that estrogen has on transplanted endometrial tissue by altering or stopping the menstrual cycle. Drugs used in this category include oral contraceptives, Gn-RH agonist (used to lower estrogen levels to stop menstruation) and danazol (a synthetic male hormone that stops menstruation).
2. Natural Alternatives
You may not be given the opportunity to explore other treatment alternatives. The protocols listed below can offer you other options or serve as adjuncts to your current medical treatment modalities. Susan M. Lark, MD, director of the Menopause and PMS Self-Help Center in Los Altos, Calif., recommends:
1 Eliminating dairy, meat products and saturated fats from your diet, avoiding caffeine, sugar and excessive salt, and consuming fresh fruits, vegetables and other high fiber foods. (Note: Women who suffer from endometriosis should avoid soy products due to the presence of mild estrogens.)
2 Supplementing the diet with B-complex vitamins (50 to 100 milligrams). B-vitamins assist the liver in converting excess estrogen into weaker forms.
3 Using supplemental vitamin C and bioflavonoids to strengthen blood capillaries and reduce bleeding and cramps (1,000 to 4,000 milligrams of vitamin C daily).
4 Using herbs such as white willow bark and meadowsweet to reduce pain, fever, cramps and inflammation of endometrial tissue. Other herbs like false unicorn, black cohosh, anise, fennel and blessed thistle may offer help due to their ability to balance the hormonal system. Lark recommends 100 milligrams of any of the above individual supplements.
5 Increasing the consumption of essential fatty acids (EFAs), which contain hormone-like substances called prostaglandins. Prostaglandins may help relax muscles and blood vessels, thus preventing cramping. EFAs are found in nuts, seeds, salmon and trout and various dietary supplements such as flaxseed oil and evening primrose oil.
Other alternatives used to manage endometrial symptoms and pain include acupuncture, acupressure, transcutaneous electrical nerve stimulation (TENS), meditation, biofeedback, massage therapy, meditative exercises such as yoga and tai chi, and sex therapy via a qualified practitioner.
Based on current knowledge, it would be safe to conclude that endometriosis could pose serious negative consequences to one’s quality of life. It is also safe to assume that this disorder has a beginning point with an unknown origin, which interferes with the body’s natural metabolic machinery. It is also safe to assume that this disorder is not associated with middle age, but has a possible genetic connection and/or association with the reproductive cycles and may have an initiation point during the early teenage years. It is highly advisable that any female who suffers from any of the signs and symptoms outlined here - especially severe pelvic pain - take the necessary precautions and further investigate the situation to rule out the possibility of endometriosis. Decades should not pass before appropriate treatment is administered.
While attitudes in the medical community are changing, there still exists much resistance to women’s descriptions associated with the pain and discomfort of endometriosis. In fact, Mary Lou Ballweg, President and Executive Director of the Endometriosis Association, cited a recent survey presented at the 58th Annual Meeting of the American Society for Reproductive Medicine which found that 52 percent of women ages 15 to 59 were told by their OB/GYN that they were exaggerating their pain.
Judith Sachs, author of What Women Can Do About Chronic Endometriosis (Dell, 1991), states that, “If you are currently under the care of a physician who appears to be confused about your symptoms, is impatient with your questions or provides you with treatment that is not giving you relief, it is time for you to think about changing doctors.” Herbert Jaffin, MD, senior attending physician of Obstetrics and Gynecology at The Mount Sinai Hospital believes that a cure for endometriosis may be a long way off. Jaffin, however, reminds each patient that endometriosis can be managed and treated, and that there are remissions.
Ending this vicious cycle of events begins with you. Knowledge and early treatment are key to managing endometriosis. Don’t let this disorder manage you.
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