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How did I get endometriosis?” women want to know. “Why me?” “Why is one woman susceptible to the disease and not another?” doctors ask.

Endometriosis is not a disease with a single cause. Clinicians have long been attempting to find the key to the onset of endometriosis. Is it associated with a virus, a weakness in the immune system, a hereditary predisposition, or is it related to personality—especially in regard to coping with stress or numerous other environmental variables?

Further probing brings up other questions of why one woman will fall victim to endometriosis and not another: Is the susceptibility traceable to a balance, or imbalance, of some combination of factors? Can you accidentally give yourself endometriosis as the result of a fall or any other accident? How implicated are birth control pills or even intrauterine influences from before you were born?

Ingenious laboratory experiments and dedicated scientific observations over the last decade have added to a vast body of knowledge about the disease. We have solved a few intriguing riddles about this condition, although we are still puzzling through the many possible theories. Of them, a number have been scientifically validated; others are myths—or misinformation—but they tend to hold a certain power for believers.

There could be no better time than now to find the Cause and cure of endometriosis. Women understand their bodies and arc more informed partners in their health care. This is an extraordinary time in women’s lives. Contemporary pressures and biological nuances—such as high-pressure life-styles and the problems of delaying childbirth, in combination with abnormal menstrual bleeding—have significantly added to the number of victims of endometriosis. Overwork, worry, fatigue, and stress-related illnesses common to working women also contribute to the onset of the disease.

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Eczema frequently becomes infected, and in such cases oral antibiotics may be very useful. In general it is better to treat infection with oral antibiotics than with antibiotic creams. More potent cortisone-based creams are of course sometimes necessary, but they should be reserved for sparing and infrequent use on the more severely affected areas of the skin. This is because of

their well-known local and internal side-effects, which will be discussed elsewhere.

It is still unknown what the place of diet is in the management of these children. Some workers have found that breastfeeding for as long as possible may delay the onset of atopic eczema in some so predisposed children. This work has as yet not been confirmed. Some children improve when goats’ milk or soya-based milk is substituted for cows milk. This is usually only of benefit to children that show other evidence of milk-protein allergy, and rarely has any prolonged benefit for children with eczema alone. Occasionally the parents will notice that the ingestion of one or two specific foods is followed by severe itching, and it seems sensible for them then to avoid these foods. However the withdrawal of potentially essential nutrients, in the hope that a cure for eczema might be found, it ill advised.

The hospitalization of those cases of severe generalized eczema which do not respond to normal treatment is often extremely beneficial. This enables one to remove the child from a potential area of stress, and allows more adequate reassessment and the introduction of a controlled, supervised treatment programme. In particular it is very useful to be able to bandage the child adequately, so that the skin which has been scratched has an opportunity to heal and regain its normal function. This can only be done by skilled nursing staff, who can then train the parents to follow this regimen at home if necessary. In hospital surroundings ‘messy’ creams and potions (which are often very useful) may be used without the parents becoming too upset about the appearance of their child’s bed linen. In hospital surroundings it is also much easier to reintroduce a normal diet for children who have been unnecessarily restricted in this regard. It is common experience for parents who may never have seen their child’s skin normal and clear to be astounded, after one week’s hospitalization, at the sight of their child with normal skin, astounded at how the skin ‘really looks’. Of course once the skin is back to normal it is much easier to keep it that way, and the parents should now have the confidence and skills required to do so.

What future or prognosis do these children have? It is often stated, quite correctly I believe, that children usually ‘grow out of eczema. This is because their oil and sweat glands mature and begin to function normally. Consequently their skin becomes less dry, less easily overheated and irritable; consequently the attacks of eczema become less and less frequent. More specifically however, the prognosis is related to whether the genetic pie-disposition is present in one or both parents. Statistically, many children have cleared by the age of 2 years, and at least 50 per cent are clear by the age of 6. Of the remaining 60 per cent, 30 per cent will clear by the age of 12, and a further 10 per cent by the age of 15.

This, however, does leave some 10 per cent of individuals who still get eczema over the age of 15. The older child or adult with persistent eczema may have it localized to just the hands, the creases, or some other less important area. This group must avoid contact with sufferers of active cold sores, and should not receive smallpox vaccinations as complications of a severe kind may result. They would be best advised to avoid those occupations which involve contact with irritant chemicals, including; oils, degreasing agents, and various hairdressing solutions. Other than this, it is important that affected children lead a normal life.

It must be stressed that children with eczema require continuing support and careful explanation of how they can learn to live within their skin’s capabilities; they need reassurance that their life can be made more comfortable, and that no permanent disfigurement will result. Worrying, especially about such things as these, will lower the individual’s threshold to skin irritation, and lead to more scratching and aggravation of the eczema.

Although the family must give a child with eczema special attention, it is important that the child not be allowed to ‘rule the roost’; rather firmness, with love, should be employed by the parents. When the child is older he must become an active participant in life rather than a passive recipient of treatment.

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The methods by which individuals select low-fat diets have been placed into four categories. A comprehensive approach to reducing dietary fat will consider ingredients, cooking methods, different foods and reduced-fat foods.

Another method often promoted for fat loss is the fill, trim, pick, nick and skip technique, i.e.:

Fill: Fill your diet with low-fat foods (fill your plate with vegetables, fill out your meatloaf with bread crumbs, fill up on bread and fruit).

Trim: Trim the high-fat bits (trim fat from meat, remove chicken skin, scrape the butter off the cafeteria muffin and the cream off the sponge).

Pick: Pick the low-fat foods (low-fat milk, yogurt instead of sour cream, fruit instead of cake, low-fat salad dressings).

Nick : Just nick those high-fat foods. Be a gourmet (who takes a little, treasuring the taste) not a gourmand (who takes a lot and treasures the volume).

Skip: Skip the high-fat foods more often. Have takeaways once in a while, not every week. Eat chocolate and desserts only on special occasions.

Any combination of fat-related dietary changes can lead to a target level of fat intake. Research has shown that substitution of low-fat foods such as reduced-fat dairy products is more easily adopted and maintained than the avoidance of high-fat items like meats and savoury snacks. It appears that people are willing to avoid some ‘fatty foods and limit consumption of others. Distinguishing between food items a client is willing to exclude, and those they are willing to limit intake of will be important when assessing individual eating behaviour.

Some research has been carried out to examine the individual perceptions of fat content in foods. In one study, men and women were asked to estimate the fat content of various foods. The results showed that for some foods the fat content was dramatically under-estimated, whilst for other foods it was over-estimated. Foods commonly mis-classified as being higher in fat included potato, spaghetti, baked beans and beer. Those foods incorrectly perceived to be lower in fat included chicken with the skin, sardines, cheese and peanuts. Almost 70 per cent of subjects thought that margarine was lower in fat than butter.

Even doctors and nutritionists studied in this survey had widely varying perceptions of fat in foods. These findings underpin the inability of consumers to recognise the fat content of their own diets and the need to educate clients about the fat content of foods.

From all of the above, it appears obvious that fat is the key nutrient for reducing body fat because (a) it is higher in energy density than other nutrients, (b) it is stored more efficiently as fat in the body and (c) it is less likely to result in ‘fullness’ after a meal and therefore to encourage a greater food intake. However, caution needs to be taken with some people who are restrained eaters and who see food labels in black and white terms. This was demonstrated in one study where non-dieting women were given yoghurt to eat 30 minutes before a meal, and were told it was either high-fat or low-fat. When they were told it was low-fat they tended to eat more at the following meal, hence perhaps negating the effect of the reduced-fat product. Hence, although prime attention needs to be given to fat in the diet, attention should not be distracted from total energy input and compensations which may occur.

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In severe endometriosis the ovaries and fallopian tubes are often tightly bound to the nearby organs and enveloped in a dense network of adhesions. Occasionally, adhesions may even be found on the inside of the fallopian tubes.

Adhesions can hinder the process of conception in several ways. Adhesions around the ovary, especially if there are also large endometriomas present, can make it difficult for the ovum to be expelled from the ovary. If the fallopian tube is bound down by adhesions, the ends of the fallopian tube cannot move around to pick up the ovum when it is released from the ovary thus preventing the ovum entering the tube to be fertilised by the sperm. Adhesions within the fallopian tube may obstruct the tube and therefore block the passage of the ovum through it. Similarly, if there are adhesions on the outside of the fallopian tube they may bend the tube into a tight U-shape which may also block the passage of the ovum.

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Studies to investigate the possible factors that may increase or decrease a woman’s risk of developing endometriosis have only been conducted in the last few years. The results obtained so far are still tentative and many of them are contradictory.

Genetics

Some women may have an inherited or genetic predisposition to developing endometriosis. Several studies suggest that a woman is seven times more likely to develop endometriosis if her mother or sister had the condition.

Altered immune system

Most women have some retrograde menstruation but not every woman develops endometriosis. Therefore, there must be some unknown factor or factors that determine whether or not a particular woman develops endometriosis.

One of the more promising areas of research revolves around the possible role of the immune system. Recent research suggests that women who develop endometriosis may have an abnormal immune system.

It appears that if a woman has a healthy immune system she is able to dispose of any misplaced endometrial fragments deposited in the pelvic cavity because her immune system is able to destroy and remove the fragments before they implant.

It is possible that endometriosis develops in women whose immune system is defective, thereby allowing the endometrial fragments to implant.

It is also possible that endometriosis develops in women who have a large amount of retrograde flow because their immune system is overwhelmed by the large amount of flow and is unable to dispose of it before it implants.

Menstrual cycle characteristics

One study found that women who had menstrual cycles of less than 28 days and had periods which lasted for more than seven days were twice as likely to develop endometriosis. The increased likelihood of developing endometriosis is probably due to the fact that the women menstruated for more days per year and presumably had a greater amount of retrograde menstruation than other women.

The study also found that three-quarters of the women with endometriosis had a history of heavy bleeding.

Oral contraceptives

It has long been assumed that the use of the oral contraceptive pill should prevent or reduce the likelihood of developing endometriosis because it reduces the amount of menstrual blood flow and thereby presumably reduces the amount of retrograde menstruation. The results of the studies conducted to-date have been contradictory and they have not shown that the use of oral contraceptives reduces the likelihood of developing endometriosis.

IUDs

It has often been assumed that use of an IUD (intrauterine device) would be associated with an increased risk of developing endometriosis because IUDs increase the menstrual blood flow by 50% to 100%. This presumes that the amount of retrograde menstruation is also greater. The studies so far have produced no clear evidence of the role of IUDs in the development of endometriosis.

Ta m p o n s

Opinions differ widely as to whether or not the use of tampons affects a woman’s likelihood of developing endometriosis. Some believe that tampons act as a barrier to the vaginal menstrual flow which thereby promotes retrograde menstruation. Others believe that tampons act as a wick which promotes the vaginal menstrual flow and thereby reduces the amount of retrograde menstruation. There is also the belief that tampons have no effect on the vaginal menstrual flow.

The only two studies published to-date have found no evidence to suggest that the use of tampons leads to an increased risk of developing endometriosis.

Exercise

One study has found that women who exercised regularly were less likely to develop endometriosis. This effect was limited to women who had begun regular exercise before the age of 26 and who exercised for more than two hours per week; the effect was most marked in women who engaged in vigorous exercise such as jogging or aerobics.

It is thought that this protective effect is due to the fact that regular vigorous exercise usually lowers the oestrogen levels in the body which in turn reduces the amount of oestrogen available for the growth of the endometrial implants.

Association with other diseases

For many years there has been some speculation by doctors that women with endometriosis have a higher incidence of other chronic health problems, particularly allergic conditions, such as hay fever and eczema, and auto-immune diseases, such as rheumatoid arthritis and systemic lupus erythematosus (SLE).

Unfortunately, only a couple of small studies investigating this topic have been published to-date: they found that women with endometriosis had a higher incidence of yeast infections and allergic conditions, particularly food sensitivities and hay fever, but were unable to show an association of endometriosis with any auto-immune diseases — probably due to the limited number of women involved.

Interestingly, these studies also found that more women with endometriosis reported that they had suffered from glandular fever.

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