About Health & Medicine

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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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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Essential fatty acid supplements

Most of us don’t eat enough essential fats, so when you are trying to maximize your fertility it’s a good idea to add them to your diet in supplement form. Research has shown the benefits of supplementing with essential fatty acids during pregnancy to avoid low birth weight and also the advantages to the growing baby in terms of brain development’.

Choosing and using oils

Oils can easily get damaged so you need to take care when choosing, storing and using them. If oils are over-heated, left in sunlight or re-used after cooking, they are open to attack by free radicals (which have been linked to cancer, coronary heart disease, rheumatoid arthritis and premature ageing).

To avoid the formation of free radicals, always choose cold-pressed unrefined nut or seed oils or extra-virgin olive oil. A number of supermarkets now have organic oils. Unfortunately, non-organic standard supermarket oils are manufactured and extracted using chemicals and heat. This destroys the quality of the oil and its nutritional content. Store your oil away from sunlight and do not be tempted to re-use it after cooking.

Do not fry polyunsaturated fats, as they can become oxidized when heated. Use olive oil or butter for frying. Monounsaturated olive oil is less likely to create free radicals and butter will not because it is a saturated fat. Reduce the cooking temperature to minimize oxidation. Keep all fats to a minimum when frying. Try to bake or grill instead.

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This very itchy skin infection is caused by a tiny (0.4 mm) mite called Sarcoptes
scabiti. The mite burrows into the surface layer of your skin. Its burrow is seen through the skin as a fine, red, wavy line. The adult female lives in the burrow for four to eight weeks, laying a couple of eggs along the tunnel each day. The eggs hatch onto the skin surface within 10 days and live there for another two weeks until they’re mature enough to burrow in, and so the infection goes on.

The most common places to find scabies tunnels are the wrists, between the fingers, armpits, breasts, penis, scrotum, thighs and buttocks. The itching is caused by an allergic reaction to faeces left by the mite along the tunnel. The itch is worse when your skin is warm after a hot bath or shower, and in bed. If you scratch too much you can tear the skin, which can then become infected by bacteria.

Scabies is caught from any sort of skin contact (including sex), and can also be picked up from clothes and bedclothes. It often spreads to all members of a household and among children who play together.

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Men at risk

Women may be at risk of catching a serious STD from husbands or steady partners who are bisexual, many of whom are very secretive about their homosexual activities. Some men deny their bisexuality, thinking that an occasional homosexual episode doesn’t count. Such encounters are potentially at high risk for STD.

If you suspect that your partner may be bisexual you must protect yourself by asking him about it, hoping that he’ll answer your questions truthfully. The same applies if you think your partner could be having sex with other women, and to partners who inject drugs and share injecting equipment.

Safer sex

These days we are plied with information about safer sex and how to avoid STD. Can sex ever be safe? I hope so! If you and your partner believe that you both carry minimal risk, the way should be reasonably clear.

On a recent plane trip I read an article called ‘Travel Safe’ in the airline magazine. It was about avoiding STD, and advised that everybody should use condoms for all sex when away from home. I thought this statement was rather ambiguous. Did it really mean all sex or only casual sex or sex with a new partner? What if you were travelling with your steady partner?

In Sydney I asked some AIDS educators what they thought it meant. They answered: ‘We now recommend condoms for all sex, even between steady partners’. I asked: ‘Should couples who’ve loved, trusted and been faithful to each other for years start using condoms?’. Yes,’ they replied, ‘you can’t trust anyone about matters of life and death such as AIDS.’

This advice seemed absurd to me. How would babies be conceived? And I don’t like to think that you can’t trust anyone, even your nearest and dearest. Perhaps I’m being unrealistic. I admit that you can’t be absolutely sure, but there must be times when a long-term trusting relationship counts for something. Here are the rules for safer sex.

• Ask new partners these questions.

a How many partners have they had? How often were condoms used? Have they had sex overseas, with other men, or injected drugs? If so, have they been tested for STDs, and when?

b Have they ever had any STD? If so, what, when, how did they get it, how was it treated?

с Have they ever had a transfusion of blood or blood products? Not all people who had transfusions in Australia during the risky years (1980-85) have been tested.

• Use condoms. Condoms used properly give good protection against the transfer of infections from semen and vaginal fluids as well as to and from skin of the penis and vagina (and against unwanted pregnancy). They don’t prevent transfer of infections from other parts of the genitals, which may be important for some STDs. But because of this don’t think they’re not worth using. Condoms are good for preventing most of the serious STDs: HIV, hepatitis, gonorrhoea and chlamydia, as well as many others.

Many people use condoms for the first three months of a new relationship. A round of negative STD tests by both partners after this period offers confidence that neither of you carry an infection if you both remain faithful.

• Sexual activities with a high risk of STD that should be avoided include:

a vaginal sex without a condom

b anal sex without a condom between men or between women and men. When the penis penetrates the anus there is a high chance of breaking skin and lining membranes, opening the way in for infection. Anal sex is thought to be about twice as risky as vaginal sex for transmitting HIV

с sex with casual ‘pick-ups’

d changing partners – the more you have, the greater the risk

e sexual intercourse with anyone who has a genital discharge or sore. The latter may not be due to STD (for example, it could be due to injury or some sort of dermatitis) but it’s wise to make sure before taking a chance.

• Avoid contact with anyone else’s genital secretions until you know they’re safe.

You have every right to refuse sex or insist on condoms and other safe sexual practices. Remember that there are many ways that you can both be sexually satisfied (by ‘heavy petting’ and mutual masturbation) without penis-in-vagina intercourse. But though the women’s movement has given many women the confidence to make their own decisions and take initiatives in many matters, there are lots who still find it hard to say ‘No’ to men about sex, suggest alternatives to intercourse, or stand up for their right to protect themselves against STDs. But it’s your responsibility to guard your health.

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If you have endometriosis, there is always a choice whether or not to have treatment and, if so, what type. You will decide with your doctor what to do, and your choice will be guided by your symptoms and whether you want to become pregnant.

The aim of treatment is to relieve symptoms and preserve or restore fertility. Medical treatments include pain relievers, hormonal treatment and surgery. There is no treatment suitable for every case, and no guaranteed cure.

In mild cases with few or no symptoms it may be appropriate to wait and see if the disease gets better or progresses. You’ll need regular checks, and if there’s no improvement you’ll probably accept more active treatment.

Another option is to relieve pain without treating the disease by taking pain relievers and/or anti-inflammatory drugs. This may be suitable if the pain is mild or if you’re near the menopause, after which symptoms usually subside. Other measures that help with any chronic pain, such as heat pads or a hot-water bottle, massage, yoga, meditation and acupuncture have brought relief to some sufferers.

The hormones used to treat endometriosis either prevent the production of oestrogen or counteract its effect. Without oestrogen, endometrial tissue doesn’t grow and the endometrial deposits outside the uterus become inactive and shrink.

Hormonal treatments used in Australia include danazol (Danocrine, Azol) and progestogens (Duphaston, Primolut N, Provera, Depo-Provera). Danazol is a weak male hormone that reduces the amount of oestrogen produced by the оvaries to postmenopausal amounts. Progestogens also reduce oestrogen production (though not as much as danazol does) and if taken continuously prevent breakdown of endometrial tissue. Sometimes the combined oral contraceptive Pill, taken continuously, is used to stop endometrial breakdown.

All hormonal treatments take six weeks to relieve symptoms used in courses of 3-12 months have side-effects: if hormonal treatment is suggested, you should be told what side-effects to expect. The condition can relapse after hormonal treatment is stopped.

Surgery may be needed to remove tissues affected by endometriosis: not only the deposits and cysts, but also adhesions within the pelvis and abdomen. It is often combined with hormonal treatment.

Some women try alternative therapies for endometriosis. These include a variety of diets, vitamin and supplements; naturopathy; homeopathy; osteopathy; herbal remedies. Many of
these therapies include counselling about self-esteem and lifestyle and can lead to new, beneficial attitudes to life and health, but I’ve heard no evidence that any alternative treatment (except some herbal extracts that contain hormones) сan influence the course of endometriosis.

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Can you catch thrash from sex or from other people?

It’s possible but not very likely. If your sexual partner has Candida in his penis or around his fingernails it could be transferred to your genitals or vagina, where it could grow and cause inflammation if the circumstances are right.

If you have had sex when Candida is building up in your vagina, your partner will be carrying an excessive amount of Candida on the skin of his penis, even if he has no symptoms. He should be treated at the same time as you; otherwise you’re likely to become reinfected.

It’s also possible to pick up someone else’s Candida from sharing towels, underwear or swimwear.

Symptoms of Candida vaginitis

Thrush causes redness and swelling of the vaginal lining and a white milky or lumpy discharge that can be maddeningly itchy. The discharge has no particular smell. The inflammation often extends to the genital skin, which becomes red, swollen and tender to touch. Small splits in the skin can develop, which sting badly when wet (by urine or washing). Sex and inserting tampons are usually painful.

How can Candida be diagnosed?

Very easily. The appearance of the discharge and the vaginal walls is usually enough to arouse suspicion, which can be confirmed by a simple on-the-spot examination of the discharge under a microscope. The budding threads of the fungus are unmistakable, but if any doubt remains, Candida can be cultured in the laboratory.

Is Candida ever misdiagnosed? Yes, if the diagnosis is made only on the symptoms and without identifying the fungus, mistakes may be made. Many women consult their doctors saying ‘I have thrush again’ and are given a prescription for antifungal medication without being examined, when their symptoms may be due to other causes. And women with candidiasis that affects mainly the genital skin may have little or no discharge; the main symptom will be burning on passing urine. If they are not examined, the problem may be diagnosed incorrectly as cystitis and treated with antibiotics, which makes the candidiasis worse.

For correct diagnosis, the fungus must be seen under the microscope.

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What are the symptoms?

Though some older women notice gradually
increasing joint and muscle aches and pains because their weakened bones are
less able to support the weight and movements of their bodies (and thus the onset of arthritis and tendon changes are hastened), it is a broken bone that most often gives the first clue that osteoporosis is advanced.

These fractures may happen as a result of a very slight injury or during normal daily activities such as bending, twisting, lifting a grandchild, being hugged and pen for no apparent reason. The bones of the spine, wrist, upper arm and hip are most likely to fracture.

The spinal vertebrae are at great risk because they contain a high proportion of the scaffold-like bone most weakened by osteoporosis. Fractures in the spine are often of the insidious ‘crush’ type where small areas of the vertebral cores collapse torn
time to time, resulting in curvature of the upper spinal – the dowager’s hump’ that used e considered inevitable in older women. Spinal fractures can also occur very suddenly causing severe pain radiating the trunk.

These spinal fractures can’t be straightened. The bone sets in the crashed position, leaving the spine permanently curved and resulting in loss of height, pain and disability due to distortion of posture.

Why is osteoporosis so much in the news today?

Osteoporosis is not new, but because there are many more older people (especially women) in the population now than there were 50 years ago, fractures due to osteoporosis have become an important problem of public health.

Let’s look at some statistics.

• In 1900 the average life expectancy for women was around 50 years of age: today it’s around 80 years. In women, most fractures due to osteoporosis occur after the age of 65; from then on the rate of these fractures doubles every five years.

• In the year 2000 there will be twice as many Australian women over the age of 80 as there were in 1985.

• In Australia, nine out of ten fractured hips occur in postmenopausal women.

• It is estimated that female hip fractures use around $400 million per year in health-care costs; other fractures due to osteoporosis cost a further $400 million.

• The number and cost of fractures from osteoporosis can be expected to double by the year 2020 due to the ageing of our population.

Can something be done to reduce the health problems resulting from osteoporosis? Yes! This is another reason for osteoporosis being so much in the news. It is now clear that fractures and other disabilities due to osteoporosis are mostly preventable.

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Tests to detect genetic abnormalities.

These may be advised if there is any family history of genetic disease or if the mother is over 35 years of age. The most common genetic disorder is Down’s syndrome. About half the children with Down’s syndrome are born to mothers over 35 years of age. Other genetic disorders that can be diagnosed before 20 weeks include cystic fibrosis, hereditary disorders of red blood cell formation such as thalassaemia, and many rare disorders of body chemistry resulting from congenital lack of particular enzymes. Hereditary disorders that are sex-linked (transmitted through the mother’s genes to all or half of all conceptions, but causing disease only in male offspring) can be predicted by detecting whether the foetus is male.

The chromosomes in the nuclei of foetal cells must be examined to detect genetic abnormalities. Chromosome tests will also discover the sex of your foetus, which you can be told if you wish. Foetal cells may be obtained in several ways.

Amniocentesis

This is a test to analyse the foetus’s chromosomes and genes. A sample of amniotic fluid can be obtained by inserting a hollow needle through the abdominal wall and the wall of the uterus into the amniotic sac. The procedure is done with local anaesthetic and the guidance of ultrasound. Amniocentesis takes about 10 minutes, though the needle is in the amniotic sac only for about 30 seconds. The miscarriage rate after amniocentesis is one in a hundred or less.

The fluid obtained is centrifuged to separate the cells from the liquid. The cells are placed in a nutrient broth and incubated until they have grown enough to be examined. This can take from a few days up to four weeks. When the specimen is ready, the chromosomes in the cells’ nuclei are examined. If certain genetic disorders are suspected, the genes concerned are identified by special techniques to see whether the foetus is affected by Down’s syndrome or other less common genetic problems.

Some foetal disorders that are not inherited may be discovered by amniocentesis. The amniotic liquid may be analysed
for alpha-fetoprotein and nine out of ten cases of spina bifida can be detected in this way. The degree of foetal anaeimia from Rh iso-immunisation and other disorders of red-cell formation can also be assessed from the amniotic fluid. In preterm labour, amniotic fluid can be examined to see whether the foetal lungs have produced surfactant.

Amniocentesis can’t be performed until
14-16 weeks, which means that the results of genetic tests may not be available until 18-20 weeks. If genetic abnormality is discovered and termination of pregnancy is chosen, it must usually be by induced labour.

Chorionic Villus Sampling (CVS)

This is a method of obtaining foetal cells by passing a slender tube through the cervical canal and using gentle suction to withdraw a fragment of the outer membrane (chorion) of the amniotic sac. CVS may also be performed through the abdominal wall. Both procedures are performed with ultrasound guidance.

More cells are obtained than by amniocentesis, so they can be examined immediately or after a short period of culture. Results are usually available within 10 days, often sooner. CVS can be performed from the eleventh week of pregnancy. The earlier diagnosis of genetic abnormalities allows termination of pregnancy, if necessary, by the safer method of suction aspiration. The test is not suitable for diagnosis of spina bifida. The risk of miscarriage after CVS through the cervix is about three per hundred, and a bit less if performed through the abdomen; less than 1 per cent higher than the risk of miscarriage at 10 weeks among women who haven’t had CVS.

Tests in the future

Researchers in Adelaide have developed a blood test to detect some foetal abnormalities from as early as eight weeks. The new test, which poses no risk for the pregnancy, is performed simply by taking a sample of the mother’s blood and isolating the foetal cells: some cells from the foetal placenta always enter the mother’s blood. The cells may then be cultured and examined for genetic defects. The test is not yet available outside the research centre, but in the future this Australian advance in antenatal diagnosis is expected to be used worldwide.

No doubt in future there will be more and better ways of diagnosing and monitoring foetal health. But it’s important to remember that there are no tests that can tell you for sure that you will have a normal baby.

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