ENDOMETRIOSIS PART 1
What is Endometriosis?
is a disease that affects females in their reproductive years. It is
a painful, chronic disease that affects more than 5 1/2 million
women and girls in the USA, and millions more worldwide. The
endometrium is the tissue that lines the inside of the uterus, which
builds up and sheds each month in the menstrual cycle. With
Endometriosis this tissue is found in locations outside of the
uterus, and develops into nodules, lesions, tumors, growths, or
This misplaced tissue develops into growths or lesions which respond to the menstrual cycle in the same way that the tissue of the uterine lining does: each month the tissue builds up, breaks down, and sheds. Menstrual blood flows from the uterus and out of the body through the vagina, but the blood and tissue shed from endometrial growths has no way of leaving the body. This results in internal bleeding, breakdown of the blood and tissue from the lesions, and inflammation - and can cause pain, infertility, scar tissue formation, adhesions, and bowel problems.
in the abdomen
on the ovaries,
uterine tubes (called fallopian tubes in the past),
and ligaments that support the uterus;
the area between the vagina and rectum;
the outer surface of the uterus;
and the lining of the pelvic cavity.
Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva, and in abdominal surgical scars.
Less commonly they are found in the lung, arm, thigh, and other locations.
Infertility affects more than 40% of endometriosis infected women, and is a common result with the progression of the disease.
What are the most common Symptoms of Endometriosis?
Pain before and during periods
Heavy or irregular bleeding
Pain during and after sex
Lower back pain
Painful urination during periods
Painful bowel movements during periods
Other Gastrointestinal upsets such as diarrhoea, constipation, nausea.
In addition, many women with endometriosis suffer from:
Frequent yeast infections
Some women also have the following problems:
speech or vision problems
numbness or tingling in their limbs
bone & joint pain
migraines and various other problems.
Conventionally, the diagnosis of endometriosis is considered uncertain until proven by laparoscopy, a minor surgical procedure done under anesthesia. A laparoscopy usually shows the location, size, and extent of the growths.
What Causes Endometriosis?
The cause of endometriosis is unknown.
The retrograde menstruation theory (transtubal migration theory) suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes, implants in the abdomen, and grows. Some experts believe that all women experience some menstrual tissue backup and that an immune system problem or a hormonal problem allows this tissue to grow in the women who develop endometriosis.
Another theory suggests that endometrial tissue is distributed from the uterus to other parts of the body through the lymph system or through the blood system.
A genetic theory suggests that it may be carried in the genes in certain families or that some families may have predisposing factors to endometriosis.
Surgical transplantation has also been cited in many cases where endometriosis is found in abdominal scars, although it has also been found in such scars when accidental implantation seems unlikely.
Another theory suggests that remnants of tissue from when the woman was an embryo may later develop into endometriosis, or that some adult tissues retain the ability they had in the embryo stage to transform reproductive tissue in certain circumstances.
Research by the Endometriosis Association revealed a startling link between dioxin (TCCD) exposure and the development of endometriosis. Dioxin is a toxic chemical byproduct of pesticide manufacturing, bleached pulp and paper products, and medical and municipal waste incineration. It is commonly found in Tampons. The EA discovered a colony of rhesus monkeys that had developed endometriosis after exposure to dioxin. 79% of the monkeys exposed to dioxin developed endometriosis, and, in addition, the more dioxin exposure, the more severe the endo.
Is My Pain Due To Endometriosis?
Some women have
pain all the time, while others may only have pain before or during
their period. Some women have no symptoms, and the amount of pain is
not necessarily related to the extent or size of the growths.
As good as laparoscopic electrosurgical excision of endometriosis is for temporary relief of pain, it will not treat pain caused by other things. Pain due to endometriosis is often described in very specific geographical or anatomical terms and is associated with specific points of tenderness on exam. These patients have the best results. If a patient cannot describe her pain accurately, or if pelvic examination does not reproduce the pain, excision of endometriosis may not provide any pain relief at all.
Other causes of pelvic pain can include non-endometriotic ovarian cysts, fibroid tumors, adhesions, adenomyosis, and other unknown factors. For this reason, there is no way to guarantee pain relief after endometriosis surgery.
word "cyst" means a fluid-filled cavity, usually with a
lining. Cysts can occur in the normal monthly functioning of the
ovary. Two common types of "normal" cysts are follicular
cysts, which prepare the egg, and the corpus luteum cyst, which
forms after ovulation each month. Although these two types of cysts
are usually temporary, each may persist longer than they should and
can cause pain.
In practice we have found a dramatic rise in incidence of ovarian cysts over the past few years. Almost three out of every five woman that consult me today suffer from some measure of ovarian cysts. This could be ascribed to the massive exposure to hormones from our food, especially meat (especially beef and chicken), from our drinking water in the form of pseudo-estrogens, the same with beverages in plastic bottles and also from the pseudo-estrogens contained in the packings of cosmetics. Homoeopathy is one of the very few disciplines that can successfully treat cysts by medicinal means.
Cysts don't always have to be large to cause pain. Several small cysts can occur within an ovary and cause pain by stretching the ovary slightly. If scar tissue is on the ovary, a cyst can expand and pull on the scar tissue and cause pain. A medium-sized cyst can twist on its pedicle, and this can cause pain. Other types of abnormal cysts include endometriotic and dermoid cysts. Some patients can have very large cysts and no pain at all.
When they cause pain, ovarian cysts usually cause pain off on one side or the other, and the pain can radiate slightly around the flank. A cyst which is bleeding or leaking some irritative fluid can cause generalized pelvic and lower abdominal pain which may seem to spread from the affected side. Some women can have recurrent ovarian cysts after spontaneous resolution of, or surgical removal of a cyst, since each of some 200,000 oocytes (eggs) in each ovary at birth is surrounded by a small follicle or potential cyst.
Fibroids (also called "leiomyoma")
are accumulations of smooth muscle which arise within the uterine
muscular wall. They expand in size somewhat concentrically, like a
pearl growing in an oyster. A large fibroid would be the size of a
grapefruit or larger. A small fibroid would be smaller than a
marble. They can cause uterine cramping between menstrual flows and
severe cramping and heavy bleeding with the flow, unless they are
hanging off the outside surface of the uterus, in which case
symptoms may be absent.
Fibroids sometimes cause difficulties with bowel or bladder function since they can press against the bladder or bowel if they get big enough. Low back pain can sometimes occur, since the fibroid can press against the tailbone (sacrum) and since the uterosacral ligaments can transmit uterine pain to the sacrum as well. GnRh agonists can produce a dramatic, but temporary reduction in the size of fibroids. Although fibroids can be removed surgically, some fibroids that might be too small to be seen or felt at surgery can remain in the uterus to grow and cause problems later. Accounts of successful treatment of fibroids with homoeopathy is too numerous to mention here.
Adhesions (also called scar
tissue) stick things together. They can be thin and wispy like wet
tissue paper or dense and thick like hardened glue. An adhesion goes
from one point in the pelvis to another point, although this
distance may be functionally non-existent, as when an ovary becomes
plastered to the side of the pelvis. Adhesions form after injury to
the peritoneum, whether by infection, surgery, or chronic
inflammation. The peritoneum is the Saran wrap-like lining of the
pelvic and abdominal cavities.
Occasionally, adhesions can form without apparent reason. The tendency to form adhesions varies among patients, which is not surprising since people are different. Why some people form fewer adhesions than others with the same type of surgery is not known. Some adhesions cause pain, others do not. Some patients with extensive adhesions have no pain, whereas one small, well-placed adhesion can kink a loop of bowel and cause bowel obstruction.
When adhesions hurt, they hurt in the place they occur. Patients sometimes use terms such as "pulling" or "stretching" to describe adhesion pain. Adhesion pain would not be expected to vary with the menstrual cycle unless adhesions around an ovary get stretched by the slight growth of a cyst. Many patients with endometriosis have adhesions as well, and it is often not possible to determine whether their pain is due to adhesions or endometriosis.
After laparoscopic excision of endometriosis at St. Charles Medical Center, 2/3 of reoperated patients have the same or a reduced adhesion score. There is no evidence that dissection with scissors produces more adhesions than laser or electrocoagulation. In fact, a study comparing the tissue damage of laser and scissors concluded "The significant increase in tissue necrosis and the subsequent foreign body reaction that follows laser incision compared with microscissor incision lead us to conclude that sharp mechanical incision is the modality of choice."
If adhesions are present at the time of surgery, there is a good possibility they will reform in the exact location after their removal. Scar tissue develops more commonly when operating in and around the ovary and intestines. Significant adhesions rarely develop after operating strictly on the peritoneum of the pelvic floor.
Interceed, a cellulose fabric material, was thought to help prevent the formation of adhesions, but is no longer used in surgeries. This is because it has not actually been studied for use in endometriosis patients and 5 of 6 reoperated patients in whom Interceed was used had dense, vascular adhesions wherever it had been used. Also, an abstract presented at the 1991 American Fertility Society Annual Meeting showed that Interceed caused de novo adhesions in animals, even though no surgery was done. Homoeopathy is fortunate in that we are blessed with a wide range of medicines capable of, not only reducing, but actually eradicating adhesions. Homoeopathically one can also treat the tendency towards adhesions and thus prevent future occurrences thereof.
Adenomyosis is a structural change within the muscular wall of the uterus which occurs when tissue resembling the uterine lining invades the muscle. The uterus can look and feel normal, yet still have adenomyosis. Neither laparoscopy nor hysteroscopy can diagnose adenomyosis, and there is no conventional / allopathic medical treatment known to eradicate it. The only medical solution to date is removal of the uterus, although a very rare patient can have an isolated area found in the uterine musculature. Homoeopathically of course this is completely different as it is highly successful in the treatment of this unfortunate condition.
For an explanation of terms relating to matters infertility please visit our Glossary pages
of the uterus:
In rare situations, patients actually have endometriosis of the uterus. This is very difficult to see at surgery unless there is some visible sign on the outside of the uterus such as discoloration or scarring. If no signs are there, meaning the endometriosis is within the muscles of the uterus, it can not be diagnosed and therefore treated, except by hysterectomy, as with most cases of adenomyosis. Sometimes, but less commonly, endometriosis is hidden within the ovary, with no visible signs on the outside of the ovary to detect its presence. In both, endometriosis of the uterus and endometriosis of the ovary, the only means of treatment available is that offered by Homoeopathy.
prolapse, uterine retroversion:
to the uterus dropping down (and sometimes out of) the vagina. It is
seen more commonly in women who have had children, since the
childbearing process can loosen up the pelvic support structures. It
is also seen more commonly in post-menopausal women, since estrogen
helps supply some tone to the pelvic support structures.
Since this is a defect of ligaments, tendons and connective tissue, it frequently does not respond well to exercise of the pelvic muscles. The pain of uterine prolapse is caused by the dropping and pulling down of the pelvic tissue, and patients frequently use terms such as "bearing down," "falling out," or "like I'm about to have a baby." Low backache and an aching sensation are sometimes mentioned. Loss of urine with sneezing, coughing, exercise or lifting may also occur.
Retroversion is the same thing as a "tipped" uterus. The uterus lays against the rectum instead of being suspended in front by the bladder. This can lead to low backache, painful intercourse and painful bowel movements. The painful intercourse can occur because the body of the retroverted uterus lies just beyond the end of the vagina and can get hit during intercourse like a punching bag, particularly if it is involved by adenomyosis. Painful bowel movements can occur if a retroverted uterus with adenomyosis or some other uterine problem lies against the rectum and gets scraped by stool coming through the rectum.
Pelvic calcifications or chronic inflammation are occasionally found instead of or accompanying endometriosis. The general distribution of these findings is identical to that of endometriosis. Although their origin is unknown, these can occasionally cause pain, since some patients with no other findings achieve pain relief when these areas are removed. Chronic inflammation is not an infection, and it does not respond to antibiotic therapy. Some patients have pain for reasons that remain unknown, even after pain relief is achieved by removal of the normal uterus, tubes and ovaries. This serves to remind us that we still don't know all we need to about the causes of pelvic pain.
Symptoms of Endometriosis
Endometriosis is the most common finding associated with pain in
women of reproductive age. It is arguably the most common cause of
pain, and it deserves most of the bad press it receives.
Endometriosis pain is frequently localized by the patient to the
pelvic area that is involved by the disease. Some patients can
describe exactly where their disease is by the nature and location
of their pain.
Since the cul-de-sac, uterosacral ligaments and posterior broad ligaments are the most commonly involved pelvic areas, many patients experience pain related to irritation of disease in these areas by common bodily functions. Therefore, cul-de-sac and uterosacral ligament endometriosis can be irritated by deep penetration with sexual intercourse, whereas more superficial pain with intercourse is usually not due to the disease.
These lower pelvic areas can also be irritated by stool passing by during bowel movements, so painful bowel movements can occur when these pelvic areas are involved, although usually this pain is primarily related to the menstrual flow. When the rectal wall is involved by endometriosis, the patient may complain of pain with every episode of bowel movement regardless of menses.
Dr. Dean Sharpe and others have found that pain with each bowel movement regardless of menses - not constipation or diarrhoea - is the cardinal sign of rectal endometriosis. The bladder, however, can be involved by extensive endometriosis and the patient will rarely complain of bladder symptoms.
The pain of endometriosis is often described as sharp, burning, or knifelike. It may occur all month long, although exacerbated by the menstrual flow. The notions that endometriosis primarily hurts only during the menstrual flow or that the cardinal symptom is uterine cramps are incorrect.
The cardinal symptoms of pelvic (non-intestinal) endometriosis include a sharp, stinging, burning knifelike pelvic pain which occurs away from the menstrual flow but which may be aggravated by the flow, pain at the top of the vagina with deep penetration during intercourse, and painful bowel movements during menses.
Not Typical of Endometriosis
Heavy menstrual bleeding is not a primary symptom of endometriosis and most likely will not be changed with conservative surgery for endometriosis. Other symptoms which are not necessarily suggestive of endometriosis are clitoral pain, leg and groin pain, nausea, fatigue, constipation, diarrhoea and bladder discomfort.
Word About Cramps
If dysmenorrhoea (menstrual
cramps) is the main symptom, then conservative surgery for
endometriosis alone may not improve this symptom, since this is the
symptom least likely to respond to conservative surgery for
endometriosis. Other conditions can cause painful periods. If
endometriosis is the cause, your periods will improve and become
less painful. If the cramping is coming from the uterus itself,
however, removing endometriosis from areas outside of the uterus
will not help this situation.
Two other treatments may help with menstrual cramping: transection of the uterosacral ligaments and presacral neurectomy. These procedures are designed to prevent the nerves from transmitting the cramping sensation and both can be performed through the laparoscope.
endometriosis "come back" after surgical
According to conventional medical publications, the facts about conservative surgical intervention dispute the theory that endometriosis "comes back" in all patients. One of their highest reliable reported recurrence rates after conservative surgery is only 27%. Most studies report half that rate.
The truth of the matter is that one finds, in most instances, that endometriosis certainly does return in the majority of cases. Some women have experienced a return after 7 or more surgical attempts to remove endometriosis. It is actually laughable to even contemplate such a high success rate. Only in cases where endometriosis is localised to very specific areas, would surgical removal be successful. Unfortunately endometriosis is seldom found to be localised to such extant and it is most commonly found to be spread through various sites in the body, where it would be practically impossible to even access the growths.
endometriosis spread with age?
Although it seems straightforward enough, until recently no one had conducted an actual study to find out whether endometriosis does or does not spread throughout the pelvis with advancing age (it doesn't). It was just assumed that it did. This is another example of therapy being guided by opinions rather than facts. Experimental endometriosis in animals has also been shown not to spread geographically, and a 1991 pelvic mapping study from Belgium found that the peritoneal surface area involved by endometriosis does not increase as older age groups of patients are examined. The notion that endometriosis spreads throughout the pelvis like dandelions in a field is wrong and has contributed to irrational medical care for women with endometriosis.
should the effectiveness of a specific treatment be measured?
conservative surgery has been attempted, it has frequently required
opening the abdomen and then burning, scraping, or cutting out the
disease, causing more damage and more adhesions (scar tissue).
Although there has been a glimmer of pain relief reported in the
literature following conservative surgery, success has still been
measured mainly by pregnancy rates. In as far as pain is concerned,
little genuine proof exists of its effectiveness.
Conservative surgery has been found to slightly improve pregnancy rates, particularly for patients with a lot of scar tissue in the pelvis. Breaking up the scar tissue allows the pelvic organs, for a brief period, to regain some of the natural mobility required for normal function.
Conservative surgery through the laparoscope has been accomplished by electrocautery, laser vaporization, sharp dissection, and electro-excision. The most meaningful follow-up to indicate successful treatment of endometriosis is the rate of discovery of biopsy-confirmed endometriosis at reoperation. In many cases infertility may not be caused by endometriosis at all, particularly in lower stages without a lot of adhesions, so studying fertility parameters after treatment of endometriosis is misleading. Pain is a more specific symptom of endometriosis than is infertility and if a symptom must be measured in order to gauge the effectiveness of a therapy, it should be pain relief, not infertility. Homoeopathy is still the most effectve means of treating endometriosis, which leads to much reduced or removal of pain, with pregnancy as an added bonus in cases where the endometriosis was the cause of the infertility.
pregnancy protect against or cure endometriosis?
has never been shown by any biopsy-controlled study that pregnancy
eradicates or cures endometriosis. In fact, there are several
studies which have shown a predominance of previously fertile women
among patients diagnosed with endometriosis.
Haydon found that 58% of his endometriosis patients had previously delivered babies. Counsellor found a 61.3% crude previous birthrate among 737 married patients with endometriosis. Bennet found a previous crude birthrate of 88% in his married patients with endometriosis as their only gynecologic pathology. Dougherty found that 87% of his endometriosis patients were parous, leading the author to wonder whether pregnancy caused endometriosis. Andrews and Larsen found a crude previous pregnancy rate of 72% among their married patients with endometriosis. Redwine found that 65% of his newly-diagnosed patients with endometriosis had been pregnant, and 51% had delivered babies. These rates would be even higher if corrected for patients not attempting pregnancy. It should also be remembered that so many women give birth by caesarion section these days, which causes scar tissue, which causes its own sets of problems, one of which may be the spread and cause of post-natal endometriosis.
Certainly if pregnancy were a cure for endometriosis, none of these fertile patients would have had the disease. Instead, it is obvious from the reported literature that there have been hundreds of patients with endometriosis who have previously been pregnant. The problem arose because the studies mentioned above were not the first studies commenting on previous fertility and endometriosis. The earlier studies by Sampson and Meigs had found a crude previous fertility rate of around 40% in married endometriosis patients. (No mention was made of other fertility factors, or whether the couples were even trying to conceive.) It has to be mentioned though that the data on the endometriosis staus of these women prior to their pregnacies are not clear and one doesn't know if they had had endometriosis before and other factors involved that could have had an influence.
The conclusion was made from these early studies that pregnancy seemed to be protective against endometriosis, and, the corollary followed that infertility was due to endometriosis. This all occurred as a result of Berkson's fallacy - the observation in hospitalized patients of a possibly spurious relationship between disease states or symptoms, followed by the conclusion that this relationship was cause and effect. The notion was proposed, seemed logical, and was accepted as an accomplished fact which has gone unquestioned to this day. This is now recognized as a classic case of the misdirection which can be introduced by selection bias.
Since so many studies have been published which show a predominance of fertility among endometriosis patients, one might reasonably ask, as did Dougherty, whether pregnancy causes endometriosis, or whether endometriosis causes fertility. While these types of proposals may seem outrageous, consider that their opposites (that infertility causes endometriosis or that endometriosis causes infertility) have not only been proposed, but have been accepted as scientific fact and offered as a viable treatment for generations of women with endometriosis. Ascribing causality solely on the basis of an observed relationship is a truly outrageous abuse of the scientific process which would not be allowed in an introductory course on epidemiology.
Birth control pills (BCPs) seemed a logical therapy which might duplicate the imagined protective effect of pregnancy. Pseudopregnancy therapy of endometriosis with BCPs had its impetus from a patient without proven endometriosis who was thought to have been cured of her "disease" by pregnancy. Ironically, subsequent studies which found surgical treatment slightly more effective than BCPs or which studied response of the uterine lining, not endometriosis, were used to support the use of BCPs for endometriosis, just another abuse of science.
The notion of an "assumed fact" used in the scientific process was first mentioned in the early development of BCP therapy. It is now recognized that in order to study a specific therapy, it is incorrect to combine it with another therapy and ignore the added therapy. Also, the inaccuracy invited by studying any disease process by studying something else other than the disease should be obvious.
This may seem confusing, which it is, but the bottom line is that research has and always will be manipulated to influence the outcome in favour of the treatment option being studied.
For an explanation of terms relating to matters infertility please visit our Glossary pages