HOW DOES STRESS AFFECT ENDOMETRIOSIS AND THE USE OF COMPLIMENTARY THERAPIES

We all know that stress affects our disease processes whatever it is cancer, infection or any other problem. Similarly it is understood that stress makes endometriosis worse by increasing pain, increasing nerve fibres in the uterus and inflammation of the peritoneum by affecting the immune and nervous system. It was thought that this stress may be helped by using complimentary therapies. Women suffering from endometriosis have plenty of stress due to pain, worry about daily routine, jobs, and probable inability to have a child. Some scientists decided to do an experiment using rats to see how stress affects endometriosis to prove this point. Endometriosis was surgically created in rats. Ten days later they were subjected to swim test. Following this the anxiety was assessed by the rats faecal dropping increased in frequency, this was linked to the anxiety in rats. After this it was found that Endometriosis was increased in size. Nerve growth factors and its receptors were increased in the uterus. This experiment is very basic, and rats may not be comparable to humans. Still this gives us an idea that stress management by complimentary treatments will help endometriosis. Why not try these? These can be diet, exercise, life style factors, herbal remedies, and procedures such as massage, meditation, chiropractic and acupuncture. Different treatments help in different ways, with pain, relaxation, too much bleeding and even having a baby.

SCREENING FOR CERVICAL CANCER

Cervical cancer is the second commonest cancer in women in the world. In 2012 528,000 new cases of cervical cancer occurred, out of which 266,000 died as compared to 26-37 women who died out of 100,000 in 1933. Now in 2008 7.5 women died. Thanks to the cervical cancer test invented by a Greek gynaecologist George Papanicolaou in 1928. This was a most important story in public health. The test in short is called a Pap test. 

He studied these cells on his wife and said these changes occur due to infection irritation and hormone changes which occur without any symptoms. These were called, CIN 1 (cervical intraepthelial neoplasia) mild dysplasia, or CIN 2 moderate dysplasia and CIN 3, which stood for severe dysplasia, high grade epithelial neoplasia or carcinoma in situ.

This further led to cervical cancer10 -20 years later. This led to the study of cervical cells called the “PAP” test prepared from the cervix. Cervix is the lowermost part of the Uterus. On examination the cervix is exposed and cells are collected from the cervix by a brush, spread on a glass slide fixed and sent to the laboratory then studied by a scientist called a cytologist. All this required a set up of laboratories, technicians and scientists. If indicated this is further followed up by another test called a colposcopy by a gynaecologist in which the cervix is examined by a microscope, biopsied, depending on the findings it is either followed up or treated. From 1960 onward random pap tests or opportunistic pap tests were performed. This gradually was bringing down the incidence of cervical cancer. In 1976 a German scientist suggested that a viral infection called Human Papilloma Virus (HPV) is involved in its causation. 

In 1980 Hausen identified HPV 16 and 18. He won a noble prize for these findings. In 1995 it was determined that HPV 16 and 18 are certainly Oncogenic, and are responsible for cervical cancer. In the next 1-3 years they started to test for these viruses in the cervical samples. 1996 -1999 the collection of the cervical sample was done in a liquid medium. In 2006 a DNA test was developed for HPV. At this time co-testing started; that is a PAP test as well as DNA for HPV. Things were progressing fast HPV vaccines also came on the market. Vaccination was introduced in 2007. Originally there were 2 vaccines, Gardiasil 4-valent (This worked against 4 viruses ,16, ;18 , 11,6)and Cervarix (2 valent). As of 2014, in some countries they have Gardiasil 9-valent, this means it prevents against 9 HPV viruses 6, 11, 16, 18, 31,33,45,55 58. It is suggested that the vaccine is given at the age of 11 to12 years, in the first year of secondary school both to boys and girls.

 3 injections are required; within 6 months, the first

Injection; the second 2 months later and the last within the initial 6months. The protection is not 100%, and there are some side effects, like in any other vaccine, but overall the benefit is tremendous.

There are several types of cervical cancers one of them is called neuroendocrine (tumour from a combination of nervous tissue and hormone tissues) this is very rare, only about 1.2 % of all cervical cancers. It is not preventable by any means.

In many countries around the world including Australia and, New Zealand, USA and Austria, national cervical screening programmes were introduced in the early 90’s. In this programme the cervical screening started at the age of 18 to 65 or even earlier if sexually active, this was done every 1-3 years depending on the country. If an abnormality was found these women had further tests and were treated. The treatments offered were, diathermy, cryotherapy, leep (loop electrosurgical excision) ,letz (loop excision of an area of the cervix called  transformation zone)  laser vaporisation, cone biopsy and even hysterectomy. This was not good for their reproductive future. National screening programmes

have  reduced the risk of cervical cancer in many countries by almost 50%.

Vaccination programmes started in 2006-2007. It is hoped this will reduce the risk of cervical cancer further.  Vaccination does not prevent every cervical cancer. It is effective against those which are caused by HPV16 and HPV18. Now with the use of Gardiasil 9-valent it will be effective against many more. It is found that there are 100 different types of HPV. 14 of these have been found to affect the genital tracks (causing cancer) both in men and women.

Recent research has found that the risk of cervical cancer has been markedly reduced in women over 25 years of age but not so in younger women, although the cervical cancer vaccination was started in 2007, it is already showing a reduction of cervical dysplasia abnormalities and it will reduce them further as time goes on as more and more individuals will be vaccinated. The risk of cervical cancer in the age group of 20 -24 is very small 1.3 cases out of a population of 100,000, may be one death per year as compared to  7 per 100,000 in the age group of 25 -39 ,or over. Cervical screening programs have not shown any further reduction in cervical cancer in the age group of 20 -24.  There is no doubt that HPV is the main culprit in the causation of cervical cancer. It takes 10 -20 years for the changes in the cervix to develop after the infection in naturally well immunised healthy women and 5-10 years in compromised women. The other factors which add to occurrence of cervical cancer are early sexual activity, multiple partners by a woman or even her partner, early and multi parity, tobacco, poor hygiene, and poor nutrition. 99% of HPV infection clears by itself, even the changes caused in the cervix

heal.  However if a woman takes birth control pills for a long time, hormones in the pill may change its ability to clear HPV hence taking oral contraceptives is a risk factor for cervical cancer(CC). HPV is the main offender. It has been estimated that HPV positive women showed cervical abnormalities in 1% of women tested as compared to women tested by cytology alone in 0.1%. HPV vaccination gives further protection but it is not effective if you are already infected.

What is HPV? It is a cancer causing virus, which is sexually transmitted by skin to skin contact; hence it cannot be protected by condoms. WHO recommends it causes 5.2 % of cervical cancers world wide. AS already pointed out there are only 1.3 cases of CC in per 100,000 women may be one death in the age group of 20 -24, as compared to 6.7 in the age group of 25 -49. So far scientists have identified more than 100 types of HPV, about 14 of these effect our genital tract, cervix, vagina, and vulva. It also causes cancer of the rectum, throat and penis cancer in men. HPV is also known to cause some cancers in the brain.

In view of great success of immunisation programmes, and understanding of HPV being the main culprit for causation of cervical cancer, many countries are changing the cervical cancer screening programmes, in Australia which is one of the first countries this will start on first of Dec 2017.It has been confirmed that starting cervical cancer screening at 25 is safe. The best protection for women under 25 is vaccination; worldwide in developed nations almost all girls and boys are being (Vaccinated) protected.

From now on (1 of Dec 2017) the government in Australia will send women an invitation on their 25th birthday vaccinated or not .The sample from the cervix will be collected without much trauma by a clinician. In fact many women will be allowed to do their own vaginal swab, this is sent in a liquid medium to the laboratory. This will have a great cultural and social benefits so that a lot of women will be tested, who so far are reluctant to have this done. Sample is generally equally good they do not have to face a clinician, and spend money. This sample will be tested for HPV, if negative; the women only have to return after 5 years up to the age of 70 then they are offered an exit test at 75. The risk of CC is almost nil, as long as they are HPV negative. It is such a relief for women also in time and cost savings. In Australia this will be very good for women living in Torres Strait islands and aborigines who normally never have the test done, although they are 4 times more likely to get CC. If you are already on the old 2 yearly test, you will have this new test within 3 months of the time when your test is due. If you have never had a test done for CC screening, join the new programme. If the test was positive, they test the geno type, to test for virus 16 and 18, if so cervical cytology is also performed on the same sample and if required the woman is referred to a gynaecologist for colposcopy (examination of the cervix by a microscope by a specially trained Gynaecologist) and treatment if required. So almost all tests are done on one sample, and treated the same day. In severe cases 6 months later a pap test and colposcopy is repeated. One year later a PAP test and HVP test is done. 24 months after treatment HPV and PAP test is done again if both are negative, twice in sequence a woman can have 2 yearly check ups. This makes the screening very simple and inexpensive both for women and their countries they live in. In fact many countries like Canada and Austria are hoping that cervical cancer can be totally eliminated by using Vaccination and HPV testing. CC will become a thing of the past. If the HPV test was not convincingly negative it is repeated after one year. If a woman is symptomatic e.g. having discharge, blood staining, pain, bleeding on intercourse, irregular bleeding, weight loss, she should be investigated urgently for CC and STD’s, irrespective of her age. There are some cases reported where some women are dying of cervical cancer under the age of 25.

In USA cervical screening programmes are slightly different. Under 21 years of age they are no longer screened whether they were vaccinated or not. 21 -29 PAP every 3 years.  Many members ACOG prefer a co test meaning HPV test and cervical smear as well. 30 -39 PAP test every 3 years or a co test every 5 years. Over 65 there is no need to test if they have never had a CIN or the last co test was negative performed with 5 years.

In many western countries the cervical cancer deaths are as low as 1.8 per 100,000 women per year. Where as in developing countries they can be as high 75 per 100,000 (Melanesia, Southern and Middle Africa). Main burden of cervical cancer deaths falls on low and middle income countries (LMIC), in 2012 when 266,000 women died in the world, 230,158 died in developing countries. In LMIC, countries the work on prevention of cervical cancer is still in progress. In some LMIC countries they are trying to use vaccination. Some countries are using one vaccine instead of three, further tests have shown that they provide adequate protection and you can vaccinate three times as many girls. PAP tests are not feasible in these counties due to social economic and technical reasons. These women are subjected to a visual test.

The diseased parts of the cervix do not take the iodine stain.

Application with 3-5% accetic acid or lugols iodine. Visual inspection of the cervix and vagina is fairly informative. These have sensitivity of 80% and with logols iodine specificity of 92%. 

This can be difficult in older women and also depends on the training of the test performer. If these tests are positive these women are treated with cold coagulation (cryo-therapy),if it is found to be more significant, they are referred for proper assessment and treatment.  They are also referred for molecular testing (these are newer types of tests that are under research) depending on the health resources. WHO recommends targeting women at age 30 for HPV testing. I personally somehow feel, it could be earlier, as life in these countries begins early. These measures in LMIC are being helpful little by little. It is estimated that when a vaccine is introduced in the western world, it usually takes 10-30 years before it can be used in low and middle income countries and the reasons for this are many and varied but the principle one is the cost factor.

The current change in screening for cervical cancer, which is a totally preventable disease, is due to our discovery of HPV as a causative factor.

Thanks to Hausen for this discovery. It was confirmed that HPV infection causes cervical cancer 10- 15years after the infection. So if we test for HPV we can totally exclude CC. Hence these changes in screening for cervical cancer will start at the age of 25 and will be required every 5 years. Women can collect their own samples and triage can be done on the same day with the same sample. This will save 20% more lives. Some countries hope, like many other diseases, cervical cancer will be a thing of the past.

95% of HPV and changes in the cervix clear by themselves, this will change so much in convenience and cost for women and countries. All the changes introduced in LMIC are also improving their mortality. There are now 71 countries in the world who are offering free HPV vaccination to school girls like any other vaccines and hopefully this in time will be global.

POST MENOPAUSAL BLEEDING (PMB)

Post menopausal bleeding is defined as bleeding after 12 months of amenorrhoea in women at the age of menopause. It will also include women who had early or premature menopause but not women who had amenorrhoea due to psychiatric reasons or while breast feeding. PMB should always be taken seriously and investigated although more than 80% of times will not be serious. 10 -13 % of women over the age of 60 get endometrial cancer. The risk factors for endometrial cancer are , older age,obesity, high blood pressure, diabetes, fibroids, never being pregnant, history of polycystic ovarian syndrome, being on hormones for breast cancer,  early start of periods and late menopause and inherited colon cancer syndrome .

The other common causes of PME are thinning of the vagina due to lack of oestrogens, thinning of the lining of the uterus, thickening of the uterine lining called the endometrial hyperplasia, collection of blood in the uterine cavity, polyps ( growth of the local tissues as these are generally are not cancerous)of the uterine cavity, cervical canal, and the cervix ,fibroids bulging in the uterine cavity, cancer of the cervix and vagina.

Pelvic inflammatory disease due to sexually transmitted infections; such as Chlamydia,  and gonorrhoea. Drugs such as HRT and hormone therapy, to prevent recurrence of breast cancer.  Some drugs used for blood thinning such as aspirin can also cause PMB. Sometimes bleeding from the bladder and rectum can be confused as PMB, or when a woman is suffering from PMB, do not ignore the bladder and the rectum.

HOW TO LOOK AFTER THESE WOMEN?

A detailed history about the pattern of bleeding should be compiled and how long it has been going on for also any history of post coital bleeding.  Any HRT or any other drugs, age of menarche and menopause, any children, bleeding disorders or any cancers, personally or in the family.

After the initial history taking, the clinician should discuss with the patient the causes of these problems, the route that they will take to come to a diagnosis. After the initial weight, blood pressure and general examination, a pelvic examination is then done. An explanation should then be given to the woman about what this examination covers i.e. looking at the condition of the vaginal and cervical tissues. Cervical smear can be done. The sizes of the uterus are assessed and look for any pelvic masses.  

Common tests we need for this group of women, are normal full blood examination, bleeding and clotting test, a vaginal ultrasound as described in the previous posts, on AUB, saline infusion vaginal ultrasound, this will show us any polyps, intrauterine fibroids, and thinned  endometrium (Less than4 mm)  4 mm is the cut off point) Or thickened endometrium(more than 4mm).  These tests give us the correct reason for the bleeding then we can offer the precise treatment. 

Atrophic vaginitis can occur in 20 to 25% PMB women. It causes pain or bleeding with or without intercourse, it gets infected, urinary tract infections happen frequently, even without UTI, it causes pain and burning on urination. On examination this vagina seems shortened, loses its elasticity and shows minute haemorrhages. Moisturising  creams and normal domestic oils are helpful. In some cases a gentle douche with vinegar is useful. Women can use one table spoonful of vinegar in a litre of water, wash it with a pippett or can buy a proper douche can. In more severe cases oestrogen creams and tablets are used.  These are made from a very mild form of oestrogens called oestriol, it is not absorbed in the body hence no progesterone is required. However another form of local oestrogen is supplied by a string and it is placed in the upper part of the vagina , it has some risk of endometrial cancer, in this case discuss with your care giver if you need progesterone. If you are on oral HRT you may not need local treatment. Sometimes the cervix gets stenosed, and an atrophic uterus gets filled with old blood and even pus, you have to dilate the cervix, maybe do an endometrial biopsy and follow this with a short term course HRT. I have come across many cases of Haematometra and Pyometra (Blood or Pus in the uterine cavity).  When the ultrasound suggests an endometrial hyperplasia, an endometrial biopsy is performed, depending on the degree of hyperplasia and any other risk factors for endometrial cancer, in consultation with the woman either a hysterectomy with removal of both ovaries is advised or progesterone therapy is tried. If it confirms a diagnosis of endometrial cancer, it is referred to an oncologist (specialists who treat cancer patients). Endometrial polyps, some sub mucous fibroids can be treated by hysteroscopic procedures.

The important conclusion is that postmenopausal bleeding is an unexpected cause of bleeding 12 months after menopause, there is 90 % likely hood that this will be due to a benign cause but this should always be investigated urgently, as in 10% of cases it is due to endometrial cancer.  The commonest cause is vaginal atrophy, than endometrial and other polyps, others are HRT and endometrial hyperplasia which often leads to endometrial cancer, so always take it seriously. 

LATEST ON HORMONE REPLACEMENT THERAPY(HRT or MHT)

After the publication of the women’s health initiative study and its publication in 2002, most women went off HRT which was detrimental to them. The truth is that HRT is very beneficial to women, the risk factors are small and can be minimised when given with due care and individualised. It should be given in adequate dosage (lowest dosage that helps) for adequate length of time as long as it is required. There is one prerequisite that is best for woman under the age of 60. After 60 they probably have already got the changes that we are trying to prevent. There are four conditions that are recommended for the use of HRT. 

1) Severe hot flashes, night sweating, mood swings

Forgetfulness, poor sleep, lack of concentration and fatigue. These put together make the quality of life very poor.

2) To prevent bone loss especially in delicate thin women with family history of osteoporosis. Recent researches suggested that woman of any age should be watched for and given treatment for osteoporosis when required.

3) Removal of ovaries or premature ovarian insufficiency (POI)

4) Genitourinary syndrome means sexual and urinary problems.

The fear that HRT causes cancer is over expressed. Recent studies suggest that HRT causes cancer in 1700 women per year, obesity will cause 1800 cancers per year, smoking causes 68000 cancers per year. You can see for yourself that the risk for cancer is small from HRT compared to many other life style factors. If 1000 Women start taking HRT at age 50 for 5 years 2 extra women will get breast cancer and 1 extra woman will get ovarian cancer. Although some: now generation, (Meaning studies over generations) studies suggest that the risk was underestimated. This research is still going on.

On the other hand HRT decreases the risk of bowel and stomach cancer.

Taking HRT is a very personal decision, and we clinicians have to be very careful in individualizing

a woman’s needs and involve her wholly in the decision making. The HRT is not given to women who have had breast cancer, or heart disease. In women with history of deep venous thrombosis,positive BRCA gene mutation, family history of breast cancer family history of deep venous thrombosis, we have to have detailed consultation and extra care when prescribing HRT to this group.

There are many types of HRT and given by many different routes and many different forms, we have come a long way since the WHI study was done using only conjugated combined oestrogens and synthetic progesterone which was called medroxyprogesteron acetate. This is a synthetically produced hormone. In the WHI, study there was no classification of age group, or symptomatology , all women between the ages of 50 – 79 were  included.

There are many such synthetic hormones, they are called progestin, and the progesterone obtained from plant sources is similar to human hormone and is called bioidentical. These progestins had upset the whole WHI study. These progestins had some different actions as well. They could potentiate the proliferative activity of oestrogens. Many research papers have been published since, in which natural progesterone and micronized progesterone are used, and they are given in a cyclic manner, as well as continuously. These studies do not show any effect on breast cancer risk.

Beside the breast cancer risk the other risks are: deep venous thrombosis (DVT), pulmonary embolism (PE), stroke, and endometrial cancer. It has no effect on primary or secondary prevention of heart disease. Any increased incidence in heart disease cannot be excluded at this stage. Some research papers have concluded that women on HRT have a longer life expectancy. This could be due to cardiac benefits. Many methods are being used to cut the risk of DVT. One such method is to use Tran’s dermal patches (On the skin). This sends the oestrogens directly into the blood stream without going to the liver; it is in the liver that coagulation factors are altered increasing the risk of DVT and PE.

There is another new group of drugs called SERMS. They are selective oestrogen receptor modulators meaning that at one organ they will act as oestrogens and at another organ they will protect it from oestrogens. We will talk about these as we go along.  They are very useful in full filling a woman’s need for HRT.

First reason why women need HRT is vasomotor symptoms (VMS). This includes hot flashes, sweating at night, poor sleep, forgetfulness, emotional changes, headaches, memory loss and fatigue. There are many more and; the more women you see, the more problems you will hear. If a woman is younger and not fully menopausal, meaning that she has not had a full 12 months without a period (which is what is considered Menopause), we call it peri menopause or menopause transition. During this period, many women have irregular and/or heavy periods.

Keep your investigation to a minimum. You may do a full blood examination, Thyroid function test, an ultrasound to exclude uterine and ovarian pathology. Thyroid disorders often occur at the time of menopause. Do a general examination including blood pressure; take a detailed personal and family history of breast cancer, DVT, heart disease or any other significant illness. Also make sure if she still has a uterus. HRT without a uterus becomes very easy. We need two hormones, Oestrogen and progesterone if the uterus is present, progesterone is to protect the uterine lining the endometrium, against endometrial cancer. In 1960 when HRT was started it was only oestrogens. Then there was a flurry of endometrial cancer, and then progesterone was created and added to HRT. In fact when endometrium is well protected the incidence of endometrial cancer is less in women on HRT as compared to the normal population. If a woman is peri menopausal and is having bleeding episodes in my view an intrauterine device called Mirena is very useful. You can read about this on my previous post on contraceptive and AUB. It is a small T shaped plastic device which contains a hormone called Levonorgestrel, it is placed inside the uterine cavity. It lasts up to 5 years, stops bleeding and periods after the initial hitch, it is a contraceptive and has no side effects in most women. There is no increased risk of DVT, stroke, heart attack and, breast cancer. Its use is tremendous when women are allergic to progesterone, and have risks from the above mentioned conditions, history of abortions and ectopic pregnancy, bone metabolic disease and high blood pressure. Imagine the cost saving instead of buying progesterone month after month. Only oestrogens can be used if you have no uterus except if you have suffered endometriosis. Oestrogen alone can restart the activity of a small endometrial patch lying in the abdominal cavity .This may have been inadvertently left while trying to remove deep infiltrating Endo. In fact endometrial cancer has been reported in these instances.

The other alternative can be oestrogen with a drug called Bazedoxifene, this is a SERM as explained, and it prevents endometrial cancer. The combination of Oestrogen with Bazedoxifene is also called Tissue Selective Oestrogen Complex (TSEC) this is a very useful drug in the management of HRT.

Micronized progesterone is another very useful hormone. It is identical to the hormone produced in a woman’s body by the corpus Luteum (develops in the ovary after ovulation).  Micronized progesterone can be used alone as a 300mgm tablet taken daily without estrogens, for hot flashes; It helps with sleep, forgetfulness and other vasomotor symptoms of menopause. It is best to take it at night, as it can make you drowsy. It can be taken as long as required. It is also given with oestrogens in a cyclic manner, 200mgm tablets daily for first 15 days of the cycle, 100mgm tablets daily for 25 days.

In spite of all these new drugs such as, Serms and micronized progesterone, HRT should be used for specific symptoms not in asymptomatic women of an older age group above 60. The age group between 45 -60 is expressed as window of opportunity and HRT should be started in this age group. If started after 60 it can do more harm than good as they may already have the changes we are trying to prevent. It cannot help to prevent secondary heart disease, if started at time of window of opportunity; it can still show improvement in cardiac, and brain function activity.

Most women require oestrogens and progesterone for protection of endomertrial lining. This can be given in a cyclical manner or continuously (cyclical progesterone will cause regular bleeding). It will depend on the woman’s wish, her age and how long she has been menopausal. If she is peri menopausal some forms of oral contraceptive pills are better. If she is well into menopause, a synthetic preparation called Tibolone, which acts both as oestrogen progesterone and even testosterone is good. It is   also useful after a hysterectomy with removal of the ovaries, or premature ovarian failure (POI, premature ovarian insufficiency). Women often require testosterone. Often in these women we put an oestrogen implant in (a little pellet under the skin it comes in 25, 50 75, 100 micrograms, we used a testosterone implant as well at the same time) It worked well. Start with lower dosage so that they do not get the side effects of a very high oestrogen dose, tender breast, nausea vomiting. In some countries Androgen preparations are available, which are useful for poor libido and energy level.

It is best to use Trans dermal oestrogens when you are using testosterone cream, as oral oestrogens interfere with testosterone activity.

Besides vasomotor symptoms and depression and osteoporosis, genitourinary problems which start happening with menopause to women are very nerve wrecking. On one hand you lose bladder control, on the other your sexual function goes all hey wire. You lose your libido, you have pain when you make love, and your vagina is constantly pain full. Systemic HRT oral or Trans dermal helps to some extant but still problems remain. Pelvic floor exercises are helpful for stress incontinence but psychosexual problems like dyspareunia remain. For this you can use moisturisers, they help to some extent. Local oestrogen creams and tablets are useful. They are made from the mildest form of oestrogens called oestriol, their absorption in the body is negligible hence you do not need any progesterone. The latest drugs for dyspareunia, is a SERM. This SERM is an oral tablet called Ospemifene. You require 60 mg dose orally daily with food. It is the latest non hormonal selective oestrogen receptor (SERM). We can only imagine how a woman with breast cancer treatment; suffers after all the treatment for her cancer. Her quality of life is totally destroyed. Ospemifene is a great drug for dyspareunia, along with moistures. So far it has not been found to have any endometrial or breast related concerns. Recent animal studies suggest that it may be as effective as Tamoxifan against breast cancer, further research is ongoing. The things that you can do, is look at your life style factors.  You have to have a good diet, exercise, yoga, aerobics, swimming, no cigarettes, very limited alcohol, less caffeine and try and cut down stress. Masturbation helps, try and dilate the vagina with a lubricated finger or dilator. You can use olive or coconut oil, this will break down adhesions. Try and have frequent intercourse whenever possible after foreplay. The relief of other symptoms such as VVS after breast cancer at this stage is very limited.  May be, as we discover more SERMS, treatment will improve. Complementary therapies are not recommended as we do not have significant results on their benefits and the way they are tested in the saliva is also not satisfactory.  You can try Acupuncture. There are some pharmacological preparations which are sometimes used. One of these is called Clonidine. Normally it is used for high blood pressure however if a woman has high blood pressure along with the other symptoms you can try this drug. It is not so popular any more.

Recently a group of drugs called selective serotonin and adrenaline reuptake inhibitors are being used. Normally these drugs are used for depression. Another drug called Gabapentin (Initially used for epilepsy) is also found to have meaningful help with VMS in women after breast cancer. The other drugs are Paroxetine and Desvenlafaxine. These drugs are still being worked out and for example, if a woman suffers from migraine, Gabapantin would be good, if a mood change is there, an antidepressant would be good. Do not use Paraoxitine if a woman is on Tamoxifan for breast cancer.  These drugs are still being worked out in relation to their risk benefit ratio. They have side effects such as dizziness, suppression of libido. Your clinician will be able to discuss these drugs with you in consultation with your oncologist. A few new treatments such as, called Stellate Ganglion Block, Surgical Improvements, and Laser Treatments are being tried for VMS and GSM. It is not recommended to try herbal treatments or progesterone cream as this is made with many steroids in the laboratory and can be harmful to women after breast cancer treatment.

These women should be supervised for osteoporosis and treated when ever required.

Prevention of bone loss also needs attention. Indication for prevention of bone loss particularly in women at high risk, and these are women with fair hair, low BMI, those who have used cortisone treatment for long term conditions, such as asthma, who have a family history of osteoporosis, sports women and premature menopause. The test required to assess the bone health is called Dexascan. Menopause hormone treatment (MHT) can be used as a primary treatment for bone specific medications, depending on who is treating the woman. The scenario of window of opportunity should be followed. Life style factors are important to follow.

The other very important group of women is women who have very low natural oestrogens.  This can be genetic ovarian failure, premature ovarian insufficiency, and premature surgical menopause. This group of women need MHT like any others if there are no contraindications of MHT until the normal age of menopause. They require much higher doses of MHT as they are younger. Please do not be hesitant to take higher doses as required and recommended by your clinician, if you had your own ovaries you would have been exposed too much higher dosages of oestrogens from your ovaries.  These women often require testosterone as well.

Let us now talk about the risk factors for HRT which is now often called MHT.

Current research shows that MHT should be started during the window of opportunity; that is between the ages of 50-60, within 10 years of menopause.  If started later, women have already undergone the changes we are trying to prevent. It is not helpful for secondary prevention of heart disease. Other safety issues are history of liver and gall bladder disease, previous breast cancer, endometrial cancer, coronary heart disease, unexplained vaginal bleeding, personal and family history of VTE, in this situation it is worth while investigating for any bleeding disorders. The other conditions are; Porphyria Cutanea Tarda( this is an enzyme disorder), high triglycerides, endometriosis , stroke, dementia, migraines and fibroids.

MHT can cause many side effects. They can be improved by adjusting the dose, and route of administration. It is now considered that the best route is patches, jelly, cream, implants and even vaginal. When used percutaneous or ( non orally) the drugs go directly into the blood stream without going through the liver ( which is called the first pass), thus protecting bleeding  clotting factors minimizing the risks of VTE, STROKE, and CVS problems. The common side effects of MHT are nausea, bloating, fluid retention, mood swings and tender breasts. In spite of the popular belief MHT causses weight gain it does not do so. Serious side effects are breast cancer, stroke, and endometrial cancer if oestrogen is not properly covered by progesterone, VTE, issues of bile production, in spite of the protective effect of oestrogens on heart, it can cause a Myocardial Infarction (Heart Attack). It depends on the age of the woman, obesity, smoking, her previous health and when MHT was started.

How long can women take MHT? There is no strict rule. 71/2 years is generally recommended as the symptoms generally last for 8 years and the risk of breast cancer sets in about this time. If a woman is happy and healthy they can continue to take it. Have a regular check up once a year. And if they have osteoporosis they need to have a biannual bone density test. I have had many women who have had MHT for 30-40 years. If they have no uterus, it is very easy to give them low dose transdermal patches once or twice a week, as oestrogen alone decreases the risk of breast cancer. Even if they have a uterus they can combine it with micronized progesterone as this does not increase the risk of breast cancer. Tibolone is another MHT (It is a synthetic drug) which exerts different actions on different tissues, it has oestrogenic effects on bone and vaginal tissues, progesterone like action on the endometrium, it has inhibitory activity on enzymes in the breast tissue. It provides relief from VMS and prevention of bone loss. It does not show any stimulation of the endometrium and breast tissue. It has some androgenic activity as well. It improves libido, improves vaginal dryness and decreases dyspareunia. Works all round. Most of menopausal women remain very happy with this. You need one table daily, which is a bit expensive, but what is cost for improved quality of life. Some of the side effects of Tibolone are thrush, increased hair, minor bleeding, talk to your clinician if they continue. If you are going to have an operation tell your doctor that you are on Tibolone.

  

BENEFITS of MHT (HRT)

18 of October 2016 was declared World Menopause Day, when it was found that around the world only 3% of women were aware of menopause and it’s problems. The purpose is to inform the world what can be done for effects of menopause. In 1998 there were 477 million, post menopausal women in the world, it is estimated that by 2025 there will be 1.1 billion postmenopausal women, who may suffer from different ailments of menopause, a poor quality of life. Surely it is our moral duty to come to the aid of these women. Let us see how we can help them. What are the benefits of HRT? First of all let us make them aware that they have to get in touch with a clinician, when they are still young and energetic, this is between the ages of 50 -60 years and when the symptoms of menopause start. Let us make them aware of these symptoms, the short term and long term health issues, benefits of MHT which can control a women’s irregular bleeding, hot flashes, sweating, lack of proper sleep and forgetfulness. This improves the quality of life .With increasing equality in men and women, many of these women may be CEO’s, school principals, senior doctors, lawyers and in many important positions and will greatly improve their life by these changes. Benefits of MHT (HRT) far outweigh the risk of MHT in symptomatic woman, if started during the window of opportunity i.e. within 10 years of menopause under the age of 60. It is beneficial if the MHT is individualised depending on a woman’s need and personal history. MHT with oestrogens alone is more favourable, than with both oestrogen and progesterone. So if she does not need progesterone do not give it to her,(Post Hysterectomy) or even if she needs progesterone she can use micronized progesterone which is very safe; both as regards breast cancer and DVT. If this particular woman suffers from irregular bleeding, without any uterine pathology, and also desires contraception, Mirena and an intrauterine device would be an excellent choice.

If the clinician chooses, an appropriate preparation and dose, adjustments as required and correct route of administration of MHT is very beneficial without any significant side effects.

Osteoporosis is a very big global problem. 30 -50 % of post menopausal women suffer from osteoporosis, which literally means bones with holes. This obviously makes them break easily; it causes fractures of the spine, hip and radius bone in the forearm with the slightest trauma. Besides the financial burden, the health professionals’ have to cope with woman with disability and pain and depression. You may not die of HRT but your chances of dying after an osteoporotic hip fracture are very high. There are 200 million women, worldwide suffering from osteoporosis which is increasing every day. It can be easily prevented by many different MHT’s without too many risks. Why not do it? In my view this would be the biggest benefit of MHT. In young women without a uterus we can give the oestrogens only or Tibolone. This is also very useful in women who had their last period 12 months ago. It is a synthetic preparation which has a selective oestrogen regulatory activity. It acts like an oestrogen and helps with VMS; it is protective on the endometrium and colon cancer. It has no risk of VTE many recent studies have shown no risk of stroke, as long as the women are under 60 years of age. It cannot be given to women who have had breast cancer. It has been shown than half the normal dose of Tibolone (1.25 mgmdaily), showed antifracture activity, improved BMD and bone turnover effects. We now have very good Dexascan to study BMD. The other MHT that can be used for Osteoperosis , is a combination of oestrogens( an another new SERM  Bazedoxifene . The combination of these two drugs is called tissue selective oestrogen complex (TSEC).

Incidentally this also helps with, management of menopause, VMS and genitourinary syndrome of menopause, improves libido, and improves vaginal tissues. This can be further helped by oestriol cream which is a very low dose cream, it is not absorbed in the body. This is further helped by testosterone preparations and the latest SERM Ospemifene. When a woman is not so depressed, sexually satisfied, not moody, no aches and pain, healthy skin with 25 % increase in collagen, less or no wrinkles, she is a much better woman to live with.

This has been used for management of menopause in women who still have a uterus and cannot use progesterone. This should not we used for women who have unexplained vaginal bleeding ,endometrial hyperplasia, DVT Thromboembolic disease, myocardial infarction, ischemic stroke, breast cancer,  oestrogen dependent cancers ,liver and kidney problems.

So we can see there are many types of MHT which are very useful for different problems in different women.

Provided it is stared soon after menopause (or within 10 years) between the ages of 50-60. The newer drugs and equipment helps a lot. Use purified oestrogens, micronized progesterone, SERMS (Bazedoxifene, Tsec, Ospemifene) SSRI,

Tibolone, Non oral hormone drugs.

All these drugs help our QOL, prevent heart attacks if started early, urogenital problems, reduced risk of colorectal cancer, Alzheimer’s, some help for a woman after breast cancer treatment, reduced risk of breast cancer ,and DVT.

Not useful for primary or secondary heart disease or prevention of diseases of old age.

Conclusion: HRT was initiated in 1936 when Robert Wilson published a book called "Feminine forever".  His concept was rubbished as he said all women need oestrogens and sexuality and sex were confused. When in the 80’s and 90’s I practiced as gynaecologist and suffering myself after an early surgical menopause, I realised how important it was to understand menopause.   I researched the subject and published a book in 1994 ( Menopause and Beyond), this was very well received by thousands of woman and now in 2017 I find that many women still suffer in silence, use unauthorised preparations because of fear. I am very glad that international menopause society has declared an international menopause day. This is doing a great job of publicity, information on life style factors to make the life of a woman after menopause to be healthy and happy. Life style factors are very important such as exercise, diet, maintain correct weight and help with the prevention of diseases such as osteoporosis, heart disease and genitourinary problems. This all has to start even before menopause (peri menopause or menopause transition). It is too late if you leave it for years, when it starts to show its ugly side. To help yourself if you need MHT OR HRT so be it, do not be frightened. Please talk to clinicians who are well informed about Menopause. In this day and age, they have very safe MHTs and there are very individualised treatment options with very little risk of DVTS and cancers. 

Please ask for help, do not suffer in silence make your life happy and healthy.

ENDOMETRIOSIS-A CHRONIC PAINFUL CONDITION

Endometriosis is a chronic inflammatory condition, due to the presence of endometrium (normal lining of the uterus) outside the uterus; commonly behind the uterus, ovaries, tubes, pelvic peritoneum and also far off from the pelvis. Endometriosis of the lungs, kidneys and other far off places is also seen.  This endometrium undergoes menstruation with each menstrual cycle. Blood has nowhere to escape. It remains there and causes inflammation, and adhesions.  This blood clots quickly but still within normal time. It happens in 1 in 10 women, it is estimated that there are one and a half million women in the world suffering from this terrible condition, yet most governments give very little money for research on ENDO (Endometriosis). It can begin at any age after the start of the menstrual cycle. I have come across many young girls, as young as 12 years, and teenagers. They are often told you have to put up with it.  They miss school and are unable to participate in a normal life. ENDO causes very painful periods, painful sexual activity, painful bowel action, pain on passing urine, if bowel and bladder is involved which is often the case. It causes infertility in about 50% of women and excessive bleeding. Besides all this it also causes fatigue, depression, diarrhoea, constipation, nausea and often pain all the time. It is estimated that it often takes 8-10 Years before diagnosis of endometriosis is confirmed.  I feel that this may be due to a woman’s reluctance to undergo the diagnostic test, which a surgical procedure is called Laparoscopy. The diagnosis can be confused with irritable bowel syndrome, pelvic inflammatory disease, ovarian cysts; none of these conditions cause as much pain as Endo unless the ovarian cyst is twisted.

WHY DOES ENDO HAPPEN

1) It is believed that during the period, there is a backward flow (Retrograde flow) of blood in the abdominal cavity through the fallopian tubes, and if the blood is too much or for some reason the body is unable to clean it, it remains there with the endometrial cells. There is some genetic role if two close family members of the family have ENDO, you are more likely to have it.

There are many women who do not have a uterus, or how does ENDO go to the lungs, eyes or very distant organs.

2) There is another theory called, Transformation Syndrome or Induction Theory, which has a view that under the influence of hormones or immune factors the peritoneal cells transform into endometrial cells. 3) Embryonic cell theory, hormones may transform the remaining cells into endometrial cells.

4) Blood vessels, tissue fluids and Lymphatics, transplant the endometrial cells to other parts of the body.

5) Immune system disorders do not recognise the endometrial cells at funny places and therefore do not destroy them.

  6) Last but not the least there is the human factor,

  after an operation we inadvertently implant the

  endometrium on the scar. I have seen a few cases of

  Caesarean section scar endometriosis.

I feel in some cases more than one factor is at work. For argument sake in retrograde menstruation, the immune system is unable to clean all the blood.

SYMPTOMS OF ENDOMETRIOSIS

Endomertriosis is a nasty lifelong disease. There is really no cure for it; however we can relieve its symptoms and may be improve the quality of life to some extent. There are two main symptoms, pain and more pain and infertility in 30-50% women.

Pain is pelvic pain, dysparunia, dysmenorrhea, and chronic pelvic pain. Pain is not always cyclic pain; it is also not proportional to the severity of this disease. A small number of women are pain free. Unusual symptoms are bowel problems, and when the bowel is involved e.g. spasms, diarrhoea, constipation and rectal bleeding, it is very often confused with IBS. If the urinary bladder is involved the women get urgency, frequency, and haematuria (Blood in the Urine). Rarely if there is chest involvement women can get chest pains, air or fluid in the pleura (lining of the 
lungs).

DIAGNOSIS OF ENDOMETRIOSIS

One can suspect  ENDO from the history of pain , infertility and a family history, however the gold standard  for diagnosis is laparoscopy which is a surgical  procedure many women and mothers are reluctant to have this performed; hence the diagnosis of ENDO is often delayed. However many of us often start the treatment after fair clinical certainty. After taking the history a clinical pelvic examination is performed in females who are sexually active. Very young girls and teen agers often require a laparoscopy to conform the diagnosis. It is not disastrous to start them on oral contraceptives if their mothers agree, as they help with the pain of ENDO and keep the disease under control.

On clinical pelvic examination we may find a uterus with restricted mobility, stuck to the bladder or the rectum depending on the pathology of the ENDO. You may also find cysts on one or both ovaries which result from the ENDO of the ovaries. They are called endomeriomas or chocolate cysts. Further diagnosis is confirmed by ultrasound, this has to be a transvaginal or rectal ultrasound. In very young girls it can be vulval, often it is not required as the disease in very early stages, and you may not see much on ultrasound.  Ultrasound is good at detecting endometriomas they are low level echoes with a thick cyst wall, they have hyperchoic nodules and many other findings differentiate these from other cysts and, ovarian cancer. 

Doppler studies are also done. MRI further adds to elaborate the diagnosis of ENDO. MRI is very useful to make the diagnosis of extra pelvic endometriosis such as cervix, vagina, round ligament of the uterus, abdominal wall lesions, rectus muscles, deep infiltrating lesions. Any lesions on the abdominal wall bigger than 5 mm are considered deep infiltrating lesions. They are often very painful.

Adhesions Causing Pain

Deep infiltrating lesions are fibrous solid and thickened. It is difficult to diagnose the lesion on the nerves e.g.  Presacral nerves. If the rectum is cleansed before ultrasound we get a lot more information.      

Since laparascopy is a surgical procedure newer non invasive diagnostic tests are being investigated for the diagnosis of ENDO, these include CA125 (Blood Test for inflammation) and genetic data from endometrial tissue obtained from endometrial biopsy. With CA125 one has to be careful as a high value of CA125 is also used for screening of ovarian cancer. Cut off reference for ovarian cancer is 35 international units per ml. CA125 is tested in two phases of menstrual during menstruation and midcycle. If it is low during menstrual phase the probability of ENDO is low as normally it is high due to inflammation, desquamation of tissues and breakdown of haematological barrier. If high in both the phases it suggests a more severe type of ENDO. This is expressed as deep infiltrating endometriosis. It is very painful and more difficult to deal with as compared to endomeriomas. About 6% of cases of deep infiltrating endometriosis involve the appendix as well, this further contributes to infertility. This test CA125 can be useful if negative, it can help to exclude the diagnosis of ENDO.

The other non invasive test that is being tried is Gene expression. The investigators found different gene expressions, in the endometrium of the women suffering from endometriosis. Gene expression in different conditions showed different immune activation. The researchers are trying to further define these tests. It will be very simple then. A simple endometrial biopsy can give us the diagnosis of endometriosis.

STAGES OF ENDOMETRIOSIS

Stage 1 

Minimal superficial spots

Stage2

Appearance of more spots which appear within the deeper layers of the tissues

Stage 3

Moderate. It is present on one or both ovaries. It may also show thin adhesions. It may also have adhesions behind the uterus in the normal empty space (cul de sac)

Stage 4

Deep implants, Endometriomas, adhesions, bowel and bladder involvement, distortion in the shape of the uterus. Involvement of the peritoneum ; nodules bigger than 5 mm,on the peritoneum

Most severe pathology is deep infiltrating lesions and Endometriomas 

TREATMENT OF ENDOMETRIOSIS

At the present stage of our knowledge, there is no real treatment of endometriosis (ENDO) we try to control its progression, pain and help with infertility that it causes.

A fair bit of research is going on with several drugs, which interfere with oestrogen production without causing the total inhibition of ovarian function. Drugs that decrease the size of ENDO, immunological drugs that decrease the inflammatory reactions, thus helping with pain. It will be many years before these drugs will be available for human consumption. Let us see how we are helping them now. In milder types of ENDO, particularly in young girls we use combined oral contraceptives. This suppresses the ovarian function, thus the activity of ENDO, they can go to school or uni, and improve the quality of life. a pain killer such as nurofen can be added. The pill can be taken continuously for many months so that the period happens 3-4 months a year instead of every month.

Danazol is another drug that is useful. It is a derivative of testosterone, it helps by causing anovulation. Dose of Danazol is 600 -800mgm daily, at this dose it can cause masculising effects such as deepening of the voice and increased hair growth. Long term it can increase cholesterol and can cause liver damage. It is only a short term answer. It does not help in dosage lower than these. If by chance you get pregnant while on Danazol, the female foetus can become masculinised.

Progestational drugs are useful long term. They    have their own side effects. Medroxyprogesteron injection is effective. It is given as an injection of 150mgm every 3months. It causes complete absence of periods with very little pain. However the other side effects are breast tenderness, fluid retention, constipation, depression and above all loss of bone density. The other progesterone preparation which is commonly used is Dienogest (Visanne). It works by decreasing oestrogen production, decreases pain and also ENDO. This is about the best oral treatment available at this stage; it is shown to be very useful to prevent recurrence after operative treatment.This can cause asthma and allergic reactions. Do not take these drugs if you have risk factors for heart attack, stroke or DVT. The two other drugs that are being studied in animals are, letrozole and retinoic acid which decreases the size of ENDO and inflammation respectively. May prove to be very useful in human’s, in the future. They act by preventing cell proliferation apoptosis (Cell Death) and neovasculizition. They are anti oestrogen and are used in breast cancer treatment.  The other medical treatment which is very useful is GnRH agonists and GnRH antagonists.These can be used in different forms such as subcutaneous injections (1.8mgm once a month or 3.75mgm once every 3months or nasal spray, implants. These cause two main side effects; loss of bone density and menopausal symptoms; such as loss of sleep and hot flashes, and almost runs the whole gamete of menopausal symptoms. Add back HRT is used which is very helpful for both symptoms of menopause and loss of bone density. (These have been discussed in management of AUB). The other drug which has been found useful is GnRH antagonists. 3mgm of Centrirelix( is injected once a week for eight weeks.

This does not cause any menopausal symptoms, oestrogen level is maintained at the lower limit of normal and it does not cause any serious side effects. One study showed that 60% of cases showed a decrease in the degree of endometriosis.

There are three things in endometriosis which need treatment, the disease itself, intractable pain caused by the disease, and infertility. None of these problems are totally curable but we try and help them. The medical treatment which we have discussed is to help many women if the diagnosis is made early; they are treated and followed up forever.
SURGICAL PROCEEDURES DONE IN ENDOMETRIOSIS

The first procedure required in endometriosis, is a laparoscopic examination of the abdomen. At present this is the gold standard for confirming the diagnosis and extent of ENDO. This being an operative procedure is the reason why there is delay in the diagnosis of ENDO. As already mentioned there is fair bit of research going on to make the diagnosis of ENDO without laparoscopy. A simple laparoscopy if performed for diagnosis alone is a simple procedure. However we obtain consent from the women, that if we find ENDO, we will deal with it at the same time. All the possible complications are explained. It is a day procedure, performed under general anaesthetic. You are prepared for the theatre like any other operation.

To start with a tiny cut is made at the belly button. A small needle is inserted into the abdomen making sure it is moving freely. The abdomen is filled with a certain amount of carbon dioxide. A surgical telescope is passed inside the abdomen so that we can see all the organs. The ovaries, tubes, and the area behind the uterus, between it and the bowel called the cul de sac, along with the uterus itself. This is common place where ENDO starts. It can then involve the bowel, and also cause what we call deep infiltrating endometriosis (DIE). We also look at the

appendix, the bowel ,peritoneum(the covering of the abdominal cavity). Extra one or two small incisions are made to pass other instruments into the abdomen which we will use to operate. Scattered ENDO, is excised (sent for biopsy), or ablated by high energy heat source very carefully, so that the adjoining tissues are safe. In early stage disease both pain and infertility improve. Main problems with ENDO are:

1) Endometriomas , this is a collection of blood around the ovarian ENDO. This can be easily diagnosed by transvaginal ultrasound. If a woman is a virgin, vulval (just from outside) an ultra sound can be done or you have to do a Trans abdominal ultrasound. Endometriomas are unilocular cysts with a ground glass appearance. These when found on Ultrasound or laparoscopy should be removed. It is not good enough to drain them as infertility results are better when the endometriomas are removed completely; it will also not reoccur. Removing the cyst wall completely is the best treatment. One of the latest alternative suggestions or options is that cyst wall should be partially removed and the rest vaporised and sealed. This gives the best results for infertile women.

2) The second difficult problem is deep infiltrating endometriosis, when the nodes on the peritoneum are more than 5 mm it is considered deep. When the bowel is involved it can be upto10mm. For lesions deeper than 5 mm heat coagulation and laser ablation should not be done. For deep infiltrating ENDO, very experienced laparoscopic surgeons are necessary, often you have to have multiple speciality surgeons e.g. bowel surgeons, urologist, if urinary bladder or ureter is involved.  The complication rate for deep ENDO  treatment is high. It is often better to transfer them to a standalone ENDO centre . These cases can be studied in detail including using an MRI which can also identify ENDO outside the pelvic organs, and different specialists are on the spot. It is still debated whether it is best to dissect out the nodules on the bowel or do segmental resection (remove the involved bowel). The decision depends on individual cases and women’s involvement and the surgeon’s expertise. If it can be done it should be done, as it reduces pain, improves quality of life and improves chances of fertility. If not we try to help with hormone therapy to help pain and quality of life. The question often arises what is better laparoscopy or laparatomy (opening the abdomen). In my opinion laparoscopy is always better, but you have to have very good facilities, equipment and experienced laparoscopic surgeons. After laparoscopy you can recover sooner and invest less time in the hospital stay.

The other operations that are done with ENDO are:

1) Appendectomy, it is believed that if appendix is involved with ENDO, the chances of infertility are higher.

2) During laparoscopy it was frequent that the surgeons ablated the uterosacral ligaments (ligaments behind the uterus) hoping that the nerve supply of the area will be cut and this will help with the pain. However this did not help. This is being given up.

3) The group of nerve fibres that are cut are called presacral nurectomy. This helps with central abdomenal pain. You need an expert to do this.

4) Removal of adhesions that are formed in ENDO can often be an operation in itself.

Luckily the adhesion formation is less after laparoscopic surgery and when we finish the operation leave the cavity clean, rinse it and place a piece of protective material now available over the operated area. This material will prevent tissues rubbing against each other and prevent adhesions. This material will get absorbed by itself in due course.

The final operation for endometriosis is hysterectomy with removal of both tube and ovaries, as it is the ovaries which propagate ENDO.This can be vaginal, abdominal, normal or laparoscopic depending on the different situations. Most women will require hormone replacement treatment. They should we given both oestrogen and progesterone. Oestrogen alone can reactivate any residual ENDO. It can even run the risk of endometrial cancer. Endometriosis increases the risk of ovarian cancer by 1% compared to the population in general.

Currently many studies are being done and investigated to see if post operative treatment is useful, but it appears there is no benefit from hormone therapy within 6 months of operation.  However it is being tried for contraception, prevention of pain and reoccurrence. In women operated on for endometriosis and are not keen to have a baby LNG-IUS (Mirena) a long acting intrauterine device or a combined oral contraceptive is useful for secondary prevention of ENDO. Mirena can also be used as an initial treatment of ENDO.

Women who suffer from infertility due to ENDO do benefit from surgery. It is best to do laser ablation of ENDO at the time of laparoscopy; endometriomas should be removed not drained for better results for infertility. Hormonal treatment after surgery should be avoided if trying to help with infertility. Often it is useful to refer them to IVF for help from assisted reproductive technology. At our current stage of knowledge many woman still suffer from ENDO, with lifelong pain infertility and poor quality of life.

A lot of work is being done for early diagnosis by gene testing from simple endometrial biopsy. A lot of 

studying is required to know the role of the immune system on ENDO, and how to prevent  the

Inflammation, adhesion formation, pain and reoccurrence. We need to know what the best treatment for pain and infertility is to prevent recurrence of endometriomas and deep endometriosis. There is great need to make people aware of ENDO and its social impact so that early diagnosis is made while we are making every attempt to find easier ways to diagnose, than by laparoscopy. Public has to give up the dictum that you are a women so you have to suffer this period pain. How many teen agers suffer in silence from ENDO?

How many women remain infertile?
Recently in New Zealand, they have decided to discuss Endometriosis with teenagers so that they can discuss their menstrual problems with their health providers and it can be prevented from progressing. Then it does not become difficult to manage. This is very forward thinking in the management and education of Endometriosis. 

I hope that we can resolve and defeat some of these problems.