What is Endometriosis?

When probed about ‘what is endometriosis?’ it is a perplexing hormonal, immune condition afflicting females in ages from 8 onwards till post-menopausal phase. It is a widespread gynaecological problem which is acute, agonizing and mostly advancing condition among females.

Usually the tissue lining the uterus called as endometrium is present solely inside it and is discarded from the body during the monthly period cycle. But due to endometriosis, infinitesimal parts of this tissue manages to break away from the uterus backward into the abdominal area, adhering and growing on the organs located in the abdomen or pelvis. Implantation of such endometrial cells generally occurs all through the pelvis and mostly involves other reproductive organs like outer uterine wall, ovaries, ligament forms supporting the uterus and the gap in-between the rectum and uterus. Rarely, these might reach past the abdominal region and affecting other organ types like lung.

Similar to the endometrium, the tissue after transplantation would respond to progesterone, estrogen hormones and thickens and bleeds monthly. However as the relocated tissue embeds on to other tissues thus blood production fails to break away thereby causing irritation to the adjoining tissues that would cause cyst, scar and the fusing in together of body tissues. It could finally cause binding together of reproductive organ forms and resemble a single mass formation when medically examined. It could cause acute distortion to the usual pelvic structure and as a result cause an enormously unfavourable effect on fertility.

Endometriosis which is a non-malignant condition has been categorized as: mild, minimal, moderate or severe based on lesion extent and the depth of penetration within other organs in the body. These are additionally referred to as stage I to IV.

Endometriosis Causes:

Scientists have not yet been able to identify precisely the manner in which the endometrial tissue manages to reach other body areas or why it occurs. One possible explanation would involve a disorder known as backward/retrograde menstruation wherein instead of the normal process of parts of discarded uterine lining exiting via the cervical and vaginal region it would travel backward via the fallopian tubes and might then be carted into the abdominal cavity thus causing endometriosis. Physicians have observed that females having physical disorders like vaginal or cervical obstructions are more likely to develop retrograde menstruation.

Atypically, endometriosis could affect the lungs or other tissues distantly placed from the uterus. Scientists conjecture that the wandering endometrial pieces chart their course via the blood or lymphatic system, though the reason for this occurring is still unclear.

When they grow to a large extent or become symptomatic, the fibroids need to be removed by surgical intervention. HIFU or High Intensity Focused Ultrasound is the only top-of-the-line, non-invasive treatment for fibroids. Ultrasound waves comprising of high frequency sound waves inaudible to the human ear are focused on the offending tissue that heats it up, much alike the operation of a magnifying glass. Employing this principle, well-focused ultrasound waves are concentrated into the body and at the central point the ultrasound waves heave the temperature of the fibroid tissue causing its annihilation. Continual imaging of the targeted aberrant tissue during treatment aids in ascertaining a favourable therapy result. This is a non-invasive outpatient method.

Advantages of HIFU

• Effectual adjunct to surgical intervention and hormonal treatment.
• Totally non-invasive – without the need for surgery, anaesthesia or loss of blood.
• No hospitalisation required.
• Aids in preservation of the uterus and cervix.
• Majorly enhances the quality of life and swifter return to normal functioning.

Type of Fibroids being treated using HIFU

HIFU could be employed on all fibroid forms namely, submucosal, subserosal and intramural. These terminologies depict the site of the fibroids within the uterus. Fibroids located in unreachable locations by the concentrated ultrasound, might not be treated.

The Treatment Procedure

The complete procedure is conducted on a task-specific treatment table wherein the doctor captures images to spot the uterus and the presence of one or more fibroids. These images are then employed for development of a treatment plan-of-action.

When the treatment commences, a small ray of concentrated ultrasound is aimed at the target for a short duration of time and aids in raising the temperature leading to heating up of the tissue. The images of the offending tissue are taken during the phase.

The system then transcends into the subsequent treatment plan and the process is continued till the total volume has been treated. HIFU is conducted on an outpatient basis in the absence of any anaesthetic procedure and takes close to half an hour following which the patient can be discharged. The number of sittings needed would vary in accordance to the type of each fibroid.

Due to any particular reason the patient does not experience respite from her niggling symptoms, then laparoscopic fibroid removal is conducted as the penultimate line of treatment.

The ovaries produce human eggs or ovules on a monthly basis. A mature ova is passed via a follicle into the uterus by the ovaries. However, in the case of PCOS there is an abnormal development of at least twelve or more follicles in the ovaries. These follicles are also known as cysts, hence disease has been named Poly(many) Cystic(follicles) Ovary Syndrome. In women with PCOS, the cysts in the ovary are fluid-inundated sacs and wholly benign, however grave complications could arise if it is left untreated.

In PCOS, there are several under-developed follicles in the ovaries. The eggs present in these follicles do not attain maturity hence their release from the ovaries is inhibited, instead forming cysts in the ovary thus contributing to sterility.

The under-developed follicles and the incapability in releasing an egg are possibly caused due to depleted follicle stimulating hormone (FSH) and more than normal male hormone levels (androgens) that the ovary produces.

The alarming rise in the number of PCOS cases, as frequent as, one in fifteen women have been observed to majorly affect adolescent women than the middle or elderly aged bracket women. PCOS might additionally cause undesirable alterations in one’s appearance. Often the symptoms start during the teen years. Treatment could aid in curbing the symptoms and avert long-lasting problems.

Polycystic Ovary Syndrome Causes:

All causes that lead to the development of POCS are interrelated, leading to a vicious circle of events.

• Changes in hormone levels that could be caused by more than one reason.
• Hereditary in certain cases and could be passed down from either the maternal or paternal side.
• Inactive and unhealthy lifestyle.
• Faulty dietary intake.
• Irregular meal times.
• Smoking, stress and alcohol intake.

Polycystic Ovary Syndrome Symptoms:

• Erratic menstrual cycles and at times lesser flow. Many women with PCOS often experience less than nine menstrual cycles during a year while others having no periods or conversely some having quite heavy menstrual flow.
• Stoppage of periods, though not often, after going through a single or more, normal menstrual cycle during teenage years – a condition known as secondary amenorrhea.
• Abdominal pain.
• Unexplained, sudden weight gain that is difficult to lose and if prolonged might additionally lead to depression.
• Inexplicable and excessive hair growth on the face and other parts of the body known as hirsutism. Mostly women with PCOS develop thicker texture and comparatively darker facial hair growths. There is more hair growth on the chest, abdominal and back area.
• Virilisation like excessive body and facial hair, voice getting deeper, clitoral enlargement, scalp hair starts thinning out resembling male-pattern balding.
• A decrease in breast size.
• Problems with conception or infertility.
• Skin darkening or pigmentation on the neck and arms.
• Excessive skin eruptions or acne.
• Diabetes.
• Improper insulin response that leads to the accumulation of insulin in the blood.

Diagnosis & Tests:

• The doctor after delving into the patient’s health history, symptoms and menstrual cycles would then carry out a physical examination to lookout for signs like excessive hair growths, high blood pressure and check for the BMI or Body Mass Index count after noting the height and weight.
• During the course of the pelvic exam, the doctor might note for an enlargement in the ovaries and the clitoris (a very atypical finding).
• A blood test is carried out that helps in determining levels of insulin, female hormones – oestrogen and progesterone and male hormones like testosterone. The blood tests done would be inclusive of the serum HCG or Pregnancy test, Prolactin levels and Thyroid function tests.
• If there is a surge in testosterone levels then the doctor would further recommend a sonography to corroborate the findings in the blood test. A sonography would help in detection of cyst formations on the ovary and aid in determining the extent of the problem.
• Tests would also include a MRI scan and ultrasound of the abdomen, ovary biopsy, levels of estrogen, LH and FSH, urine 17-ketosteroids, fasting blood glucose and insulin levels, laparoscopy. Hormone tests could aid in ruling out thyroid and other associated gland problems that might cause analogous symptoms.

Polycystic Ovary Syndrome Treatment:

• A women with PCOS needs to shed excess weight by altering the diet to ideally  be low in carbohydrates and high in proteins, eating healthy and light meals and engaging in some form of physical exercise. Even a mere loss of ten pounds would aid in getting the hormonal balance and menstrual cycle back on track.
• Cessation of smoking is advisable as it has been observed to lead to higher levels of androgen that could be a contributor to both PCOS and heart ailments.
• Reducing the intake of foods that have high levels of saturated fats. Those with blood insulin issues would benefit if they had similar levels of carbohydrates during every meal time. Seeking advice from a qualified dietician would aid in crafting an idyllic dietary plan to suit one’s lifestyle and health conditions.
• The doctor could recommend contraceptive pills that are quite safe, hassle-free and could decrease the appearance of excessive facial hair and skin eruptions or acne. An androgen-decreasing medication, spironolactone might be employed alongside birth control pills to aid in further reduction of symptoms, however not used when one is trying to conceive. In those women trying to conceive, the doctor would suggest other fertility pills that aid in synchronisation of the hormone levels and stalling cystic growths.
• Glucophage (Metformin), a diabetes medicine could aid in controlling insulin and blood glucose levels and reducing androgen levels. This lowers the chance of getting diabetes and heart ailments and aids in restoring normal menstrual cycles and fertility.
• Treatment with medicines like clomiphene citrate stimulates the pituitary gland to produce more levels of FSH that helps the egg is maturation and release. Other medications like flutamide and spironolactone are also used to treat PCOS.
• As these treatments could take some periods of time to aid with the symptoms like facial hair or acne, one could in the meanwhile take certain prescription or other over-the-counter medications to help lower skin ailments. For excessive, undesirable hair growths there are an array of options like one could wax, tweeze or shave them. Electrolysis and laser treatments though pricey can help in permanent hair removal. A topical skin cream could also be advised to slow down hair growth for as much of time as one could apply it on a regular basis.

Possible Complications:

• The conditions of hirsutism and obesity continue unabated.
• Possible heightened chances of breast cancer.
• Abrupt halt in menses way prior to menopause.
• Sterility.
• Early diabetes.
• Heart ailments or hypertension.
• Hypothyroidism.
• Increased likelihood of cancer of the womb or endometrial cancer.

Prevention:

There are no evident means of preventing PCOS, though preliminary diagnosis and treatment of PCOS aids in averting long lasting escalations like sterility, metabolism syndrome, heart ailments, diabetes and obesity.

During a news broadcast, the FDA stated that this test would be beneficial for both patients and their doctors in choosing who would perform and what would be the form of surgery that needs to be undertaken. However, the OVA1 test is not meant for screening of ovarian cancer and should not be employed for specific ovarian cancer detection.

The FDA stated that the OVA1 test recognizes those set of women that would gain from referral to a gynaecological oncologist for their surgery to be performed in spite of scientific and radiological tests giving negative outcome for ovarian cancer. Despite other test results indicating cancer; being referred to an oncologist is apposite regardless of negative OVA1 test outcome.

The FDA said that the OVA1 test ought to be employed by primary care GP’s or gynaecologists as a complementary testing method that should not be a substitute for other analytical and clinical methods.

During the OVA1 testing, the blood sample is utilised for testing it for levels of five proteins that show variation due to the presence of ovarian cancer. The comprehensive test merges the five separate outcomes into one numerical scoring that lies in the range between 0-10 to signify the probability of whether the pelvic mass is benign or malevolent in nature.

OVA1 is solely designed for 18 years and over women that have already been chosen for surgery due to the presence of the pelvic mass. The information about whether the woman concerned has been menopausal is required to interpret the outcome of the test.

According to the FDA, the suggestions and the subsequent reports published by the American College of Obstetricians and Gynaecologists and the Society of Gynaecologic Oncologists show that ovarian cancer patients had better survival and lowered surgical complications if their surgery is carried out by gynaecologic oncologists rather than by gynaecologists or surgeons.

The FDA approved the OVA1 test on the basis of a study carried out on 516 patients that included 269 patients assessed by non-gynaecological oncologists that put side by side the outcome from OVA1 and biopsy. When gelled with pre-surgical data like radiography and other lab analysis, the outcome from the OVA1 tests recognized further more patients that could reap benefits from oncology referral that weren’t detected by pre-surgical data.

The American Cancer Society has stated that regular blood screening using the CA-125 and the trans-vaginal ultrasound scanning is normally not undertaken in the common populace. These screening procedures for ovarian cancer detection were not advised even by the American Cancer Society or several other medical establishments. However, these screening procedures are mostly recommended to those women that were in the high risk bracket, like those women that had an overbearing family past of ovarian cancer.

Dr. Andrew Li who is gynaecologic oncologist from the Cedars Sinai Medical Centre, LA has said that the outcome of the study adds credibility to numerous other studies undertaken in the past that found analogous discoveries that point to the fact that ovarian cancer is in no way a silent killer as was normally believed by the experts. Dr. Li elaborated that this outcome only underlines what most of the past studies have revealed, that ovarian cancer does give out loud signals and that both the women and the doctors concerned must be vigilant about.

Despite the fact that Hamilton and his associates had unravelled the trio indicators of abdominal pain and distension and increased urination to become evident earlier than six months prior to the ovarian cancer detection, the clinical scenario his panel encountered with those patients was classically diverse. Dr. Li states that women are in good health till abruptly in a time span of close to a month, they mainly started developing the trio symptoms.

Scientist Joan Austoker from the University of Oxford has pointed out in the editorial that came along with the study that largely the rate of surviving ovarian cancer is a mere 30-40%  that augments to greater than 70%  on prompt early detection. However, presently a meagre one-fifth of the women are detected in their stages. She has cautioned regarding the presence of distension that must be promptly diagnosed.

Although the ultrasound scan is quite precise in giving results, the CA-125 however is not that exact as it gives certain cancers a miss.

A senior lecturer at the University of Bristol, Mr. William Hamilton, M.D. whose research is available online in BMJ.com has stated that contrary to the saying, ovarian cancer is in no way a silent disease, rather it is quite strident. The problem is that many are not adept enough to interpret that sound. Hamilton states that ovarian cancer has accounted for four percent of the entire cancers found in women, but regrettably has the worst possible diagnosis in comparison to all gynaecologic cancer forms.

The study carried out by Hamilton and his associates assessed 212 women in the age bracket of forty years and over, with an analysis of primary ovarian cancer. A comparison was then drawn against 1,060 women that were in good physical shape. The women visited nearly forty diverse GP doctor’s clinics located in Devon, England. The scientists examined the annual medical documentation prior to the diagnosis of cancer, similarly following up with the healthy women. The researchers made a note of the signs the women carped about and during what period of time they occurred.

The study revealed the following key signs and symptoms that were observed to be correlated to ovarian cancer that comprised of the following:

• Distension noticed in the abdominal region.
• An increase in the regularity of urination.
• Stomach pain.
• Bleeding experienced subsequent to menopause.
• Decreased craving for food.
• Blood loss from the rectum.
• Bloated feeling in the abdominal region.

Hamilton and his associated discovered that the trio symptoms of ovarian cancer like stomach pain and distension and increased rate of urination were cited nearly six months prior to it being detected and were crucially linked to ovarian cancer.

Many women employ terminology ‘bloating’ for describing distension. However, medical researchers widely deem distension to be a steadily continuing enlargement in size of the abdomen while bloating is believed to be a sporadic enlargement and reduction.

According to the United Kingdom existing parameters Hamilton has mentioned in the document that stomach distension is an indicator that does not need imperative analysis. The American Cancer Society has pointed out that bloating is amongst the indicators that probably endure in women plagued with ovarian cancer than in comparison to healthy women in the populace.

The cervix retaining or sparing approach is beyond doubt, deemed technically uncomplicated and safer surgery in comparison to the total abdominal hysterectomy (TAH). The reason being this approach averts the requirement to dissect through the vastly vascular para-vaginal cuff in close quarters to the ureter. The procedure is entirely an intra-peritoneal one and evades contact between the potentially contaminated vagina and abdominal cavity. There have been persistent suggestions that there direct outcomes of the approach are related with the clinical advantages.

A latest review has suggested that has been a greater inclination towards a cutback in surgical time, blood loss and post-operative febrile morbidity found in those women who underwent STH procedure. On the other hand, there were no marked disparities in grave morbidity rates or re-admissions subsequent to undergoing either STH or TAH procedures.

The other suggested reasoning towards retaining the cervix is better sexual, bowel and bladder function. Hysterectomy is known to disturb nerve plexuses and anatomical relations in the pelvic region. This has the likelihood to have an effect on the functioning of the pelvic organs comprising of the urinary bladder, bowel and the pelvic floor.

An assessment suggestive of the fact that the STH procedure improves sexual function garnered significant media awareness in the West. But, this assertion failed to brace the intransigence of larger and superior-conducted randomised tests. Also, noted was that there was no variation in bowel or bladder function following either STH or TAH procedure.

Finally, the conclusions drawn were that the benefits of the STH approach to hysterectomy are restricted to the peri-operative phase. Possible advantages like a swifter post-operative recuperation and enhanced short term quality of life, particularly with the laparoscopic STH, must be verified by adeptly sized randomised tests.

On the other hand, there are no long-term benefits of retaining the cervix and post hysterectomy cervical cancer examination on regular intervals is compulsory. The perils of vaginal blood loss and recurrent symptoms are not counteracted by enhancements in pelvic organ or pelvic floor function. In such scenarios, there seems to be the strong bearing for TAH remaining the default hysterectomy in certain third world or underdeveloped countries where opportunities for cervical screening are inadequate.

The subtotal or supracervical hysterectomy approach has adeptly garnered phases of recognition with varying benefits and downsides being regularly brought to light by both supporters and challengers. Even the highly eminent gynaecological laparoscopists have staunchly vouched for STH in an effort to relieve the hitches of cervical removal at laparoscopy.

There are legible reasons for opting for cervix removal like the presence of cancer in the left over cervical base. There are grave perils of morbidity and deaths associated with cervical cancer developing in the retained cervix. This is the highly dreaded of most impediments of a retained cervix. Gynaecologists for a major part of the 20th century have been plagued by this major fear to remove the cervix. It was noted in a Brazil based series that close to 4% of a set of 363 cases amassed during the period of fifteen years had shown cancer developing in the cervical stump. It must be known that such rates mirrored the broad population rates in countries that fail to have adept cervical screening programs. No data is available regarding the risk of contracting cervical stump cancer in those women that were correctly diagnosed, but it is assumed to be negligibly low. Hence, the justification for cervical removal to avert cancer does not hold true in a populace wherein there are appropriate scanning procedures.

Following a STH, many women may still continue to experience cyclical or erratic vaginal blood loss. This was noticed in nearly 11.4% of such women who underwent the procedure, of whom 7% needed further surgery to reduce the symptoms.

When surgery was performed to treat endometriosis or pelvic pain, nearly one in four women would have enduring symptoms if STH is performed. This finding could reflect the early on experience with laparoscopic surgery with a prospect of improper removal of corpus.

• Increased bone loss of close to one percent every month that would to some extent is repealed by additionally consuming low-estrogen dosages. A majority of women reverted to the pre-therapy bone density subsequent to halting the GnRH-a treatment.
• Since the therapy is intended to arrest menses, if one still gets normal menses during the therapy period, then one’s doctor must be promptly informed about it.
• Some women suddenly experience feelings of quite high body heat accompanied by intense perspiration, with redness in the area above the waist, feelings of panic and angst, mild to increased heart palpitations.
• Moodiness, lack of lubrication or dryness in the vagina.
• Plummeting sex drive.
• A rise in levels of cholesterol.
• Lowered HDL or good cholesterol also known as high density lipoprotein.
• Sleeplessness, headache.

The above side effects caused due to decreased estrogen levels are wholly allayed by undertaking estrogen add-back treatment alongside GnRH-a treatment. When the treatment concludes, the bone density eventually picks up though not totally in some cases.

The widely established add-back therapy comprises of low dosage of estrogen and progestin that is believed to cause an adequate surge in the hormone levels so as to be beneficial to the bones, but stopping short of encouraging endometriosis proliferation.  The medications combo comprise of:

• GnRH-a therapy along with estrogen.
• GnRH-a therapy alongside progestin and low dosage estrogen.
• GnRH-a therapy with estrogen, progestin (optional) and etidronate disodium or Fosamax.

Some researchers beg to differ regarding the time and therapy intervals of the add-back treatment. Few doctors consider commencing therapy solely with GnRH-a, prior to employing the add-back treatment. Though latest studies have revealed that getting started with add-back treatment immediately will not impede the endometriosis respite achieved from GnRH-a treatment.

The GnRH-a treatment is quite costly mounting to some hundreds of dollars per month that does not take into account the outlay of add-back therapy. One must desist from GnRH-a, if one is pregnant. Though pregnancy is virtually impossible during the treatment course of GnRH-a as menses are halted, yet it is advisable to employ the barrier techniques of birth control, for instance condoms when undergoing the treatment course.

Read more at: GnRH-a Therapy: An Effectual Endometriosis Treatment – Part I

GnRH-a therapy is occasionally engaged prior to surgical intervention to assist in easier elimination of endometrial engrafts and also aids in decreasing the scar tissue formation caused due to surgery. Though, GnRH-a therapy is not employed for treatment of sterility, it could be employed prior to in-vitro fertilization or IVF.

Quite similar to other hormone treatments and surgery done for treating endometriosis, GnRH-a treatment doesn’t cure it. Though, nearly 90% of ladies cited complete or partial respite subsequent to six months of undergoing GnRH-a treatment with significant reduction of the endometrial engrafts.

Various researches undertaken on women with chronic endometriosis have uncovered that six months of Gn-RH-a therapy prior to IVF or in-vitro fertilization enhanced the probability of a successful and optimal pregnancy. If Gn-RH-a treatment was undertaken as a post-operative procedure, it was known to extend the span of pain reprieve by averting the recurrence or re-growth of new endometriosis engrafts.

The medicines used in the treatment include:

• The once a month, intramuscular injection of leuprolide acetate or Lupron Depot for a period of three months.
• The Nafarelin acetate or Synarel nasal spray taken two times a day.
• The 3.6mg strength Goserelin tablets inserted subcutaneously beneath the abdominal skin once during a 28 days interval that eventually gets taken up by the body.

GnRH-a treatment lowers the estrogen production to an extent found in menopausal women, thus leading to halting of menses or periods and impedes the proliferation and decreases the amount of endometrial engrafts. The comprehensive time span of the GnRH-a therapy lasts between three to six months. Subsequent to the treatment, some women found temporary respite enduring for number of months while for some other women the reprieve from endometriosis was long-term.

The chances of reappearance of endometriosis pain are as likely in GnRH-a therapy as it would be with several other hormone therapy treatments. Annually, close to 20% of those entire women who underwent treatment would experience a re-emergence of the pain following hormone treatment. Following a hormone therapy, nearly 37% women with mild endometriosis pain and close to 74% women with severe endometriosis pain would have a recurrence of the pain after five years.