When cancer Cells find a host organ, the disease can consume the organ to which it has attached itself Endometriosis on the other hand, is most often symbiotic. It exists on its own terms while using the host organ as a nesting place. Endometriotic cells will not devour host organs. Rather, endometriosis recalls the properties of a high-density glue: organs can literally become stuck together. “Kissing ovaries” is a picturesque description of an extreme case of endometriosis. The ovaries adhere to each other and also fix themselves to the posterior cui-de-sac.

Endometriosis apparently depends on the process of menstruation and implicates prostaglandin levels and ovarian function. Estrogen, viruses, and numerous other variable factors have been identified in the onset of cancers of the female reproductive tract.

The growth pattern of each disease contributes the third key difference between them. Endometriosis, in most cases, spreads rapidly, and will lead to a buildup of cysts or masses in the pelvis. Because it grows rapidly, it is often associated with extreme pain. The size of an endometriotic lesion does not determine how much pain a woman will feel; as we observed, microscopic endometrial implants on or near nerve endings can cause greater pain than much larger growths. In contrast, most uterine cancers, or cancers of the female reproductive tract, will grow slowly and therefore cause little or no pain. This is often why cancer is difficult to diagnose. Cancer, obviously, can be life-threatening, but endometriosis, on the Other hand, is rarely fatal.

Sampson’s theory and the laboratory experiments with rhesus monkeys introduced a second important hypothesis on the cause of endometriosis: its link with immune system function, or dysfunction. More specifically, scientists asked, how different are the immune systems of women with endometriosis as compared with those of women who are tree of the disease?

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There is probably more than one cause of infertility in women with endometriosis. Many different theories have been proposed to try to explain the causes and it is likely that some of the theories will eventually be proven but much research still needs to be done. Some of the more widely known theories are outlined below.

Reduced intercourse

Painful intercourse — often a symptom of endometriosis — can contribute to infertility simply by reducing the frequency of sexual activity, thereby reducing the potential number of times that fertilisation can occur.

Failure to ovulate

A failure to ovulate, or anovulation, is not uncommon in women with endometriosis but whether it is due to their endometriosis is not known as many infertile women without endometriosis do not ovulate regularly either. A failure to ovulate will obviously cause infertility as there is no ovum to be fertilised.

Luteal phase defects

There are a range of abnormalities of the luteal phase of the menstrual cycle which may contribute to infertility. The most common abnormality is that the corpus luteum degenerates too quickly and the luteal phase becomes too short. Therefore, progesterone is not produced for a long enough time, or insufficient progesterone is produced, to enable the uterus to properly prepare its lining for implantation of the fertilised ovum.

The research into luteal phase defects in women with endometriosis has been contradictory. Some studies have shown that luteal phase defects are more common in women with endometriosis while others have not. In addition, at this stage it is not known whether or not luteal phase defects cause infertility in endometriosis.

Prolactin problems

Prolactin is a hormone that is secreted by the pituitary gland which helps to control ovulation. Research has shown that the levels of prolactin in women with endometriosis are higher than that found in women in general. The high levels of prolactin may contribute to infertility in women with endometriosis but the role that they play is unknown.

Macrophages

Macrophages, sometimes referred to as scavenger cells, are a special type of white blood cell which are found throughout the body. The function of these cells is to consume or ‘eat up’ and eliminate any unwanted debris or foreign material in the body, including sperm cells.

Women with endometriosis have an increased number of macrophages in their bodies, particularly in their pelvic cavity and fallopian tubes. Consequently, the macrophages are able to consume and destroy larger numbers of sperm than normally occurs, reducing the number of sperm available for fertilisation of the ovum.

Auto-immune response

Some women with endometriosis develop an abnormal immune response against their endometrial implants. It is thought that the immune system of these women for some, as yet unknown, reason thinks that the implants are foreign material and therefore begins to produce antibodies against them in an attempt to destroy them.

The immune system also perceives the normal endometrium in the uterus as being foreign material and therefore produces antibodies against it as well in an attempt to destroy it. If the immune reaction is strong enough the antibodies produced in the uterine endometrium may prevent implantation of the fertilised ovum.

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The symptoms of endometriosis vary widely and the results of a physical examination are not usually conclusive. Therefore, it is not possible to accurately diagnose endometriosis simply from symptoms and a physical examination. In fact, many studies have shown that there is an error rate of up to 50% when the diagnosis has been made on this basis. Even though symptoms may strongly suggest endometriosis, the diagnosis must always be regarded as uncertain until it has been confirmed by a laparoscopy.

History

Taking a history for endometriosis involves building up a detailed picture of the nature and history of symptoms.

The nature and variety of symptoms associated with endometriosis means that it is often difficult for a doctor, especially a general practitioner, to readily recognise your symptoms as being attributable to endometriosis. Nevertheless, in most cases the nature, timing and progression of your symptoms should eventually alert your general practitioner to the possibility of a diagnosis of endometriosis and therefore the need to refer you to a gynaecologist.

In general, the medical profession believes that the classical symptoms of endometriosis are progressively worsening period pain, pelvic pain, pain with intercourse and infertility. Therefore, many doctors tend to look for that pattern of symptoms when considering the possibility of endometriosis. Their suspicions will often be increased if the symptoms, particularly pain, are reported to be cyclical, especially if they are more severe around the time of your period.

In order to maximise the chances of being diagnosed it is important that a doctor be given as comprehensive a history as possible of all symptoms. The nature, onset, timing, severity and progression of each of the symptoms should be discussed, even if a particular symptom, such as pain with intercourse, is embarrassing to talk about.

Obviously, it should be easier to alert your doctor to the possibility of endometriosis if you have some or all of the typical symptoms. If you do not have typical symptoms, it is important that you make sure that you continue to report your symptoms to your doctor until she or he investigates them properly or refers you to another doctor for further investigation.

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Meat

Beef, pork, lamb and game should, in my opinion, be omitted completely.

Apart from the hormones pumped into the animals, red meat has been linked to illnesses such as bowel cancer and diverticulitis (a condition in which parts of the colon protrude and get inflamed).

In 1997 the Government’s Department of Health Committee on Medical Aspects of Food and Nutrition Policy (COMA) took the rare step of publishing a report entitled Nutritional Aspects of the Development of Cancer, which suggested a possible link between the consumption of red meat and bowel cancer. It suggested that intakes at or above the current average of around 90g (3.2oz) per day should be reduced. When you consider that an average portion of bacon is 45g (1.6oz), while just two pork sausages weigh approximately l00 g (3.5oz), it makes you realize how easy it is to eat far too much reel meat.

The saturated fats in red meat and poultry produce a hormone called prostaglandin PGE2 which is highly inflammatory. It can cause swelling and pain, including period pains, and may worsen the symptoms of endometriosis. It has also been linked to the spread of endometrial tissue which can be a major cause of infertility.

Chicken can also be a source of salmonella infection. Buy organic chicken if you can, and cook it thoroughly to kill off any harmful bacteria.

Eggs

Choose organic free-range eggs which have been produced without the use of growth promoters, antibiotics or hormones. That way you are reducing your intake of chemicals which can have a direct effect on fertility.

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Screening has its limitations. It can’t anticipate all health risks or pick up every disease before symptoms appear (for example tumours deep inside the body that are too small to be felt or that don’t show up on the usual screening tests). However, screening can discover the most common health problems of older people. Routine health screening includes the following.

General physical examination

A thorough physical entails:

a inspection of the skin to look for precancerous changes that can be removed

b counting the pulse and listening to the heart sounds

с examining the pulses in and condition of the legs and feet to detect any problems with circulation to the lower limbs

d listening to the breath sounds

e feeling for enlarged lymph glands in the neck, armpits and groin, and feeling the thyroid gland in the neck

f inspection of the mouth and throat

g feeling the abdomen for any enlarged organs or other swellings

h breast and pelvic examination for women, and Pap smear every two years until the age of 70

j examining the retina (the lining of the back of the eye).

Blood-pressure measurement

If raised blood pressure – which rarely causes any symptoms – is reduced by treatment (often simply weight reduction and exercise, sometimes medication) the risk of later stroke is greatly reduced or prevented.

Urine testing

Testing for sugar is very important. About half of all cases of late onset diabetes remain undetected, because this disease may cause no symptoms until complications have developed. If diabetes is suspected on urine testing and confirmed by blood tests, early treatment can prevent or reduce serious complications and there is a greater possibility that blood sugar can then be controlled by diet alone.

Finding blood or protein in the urine may suggest other disorders of the urinary system.

If you are past the menopause and not using HRT, your doctor will suggest using oestrogen-containing pessaries in the vagina for a week before taking your smear. Results can be misleading if a Pap is taken when the epithelium covering the cervix is affected by lack of oestrogen. This sounds like a lot, but these routine screening procedures take only about 20 minutes.

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There may be no warning symptoms of chlamydia and gonorrhoea until the infection is advanced and the inflammation has caused some permanent damage. If there are symptoms, men usually notice them earlier than women, often between two days and two weeks of catching the infection. Silent infection is more common in women than men.

You will usually only know that you’re infected if your partner develops symptoms or if you have swab tests taken by a doctor. It’s important to understand that chlamydia can be present in a woman’s cervix for several years without causing symptoms.

The symptoms in men

In men the most common symptoms are discharge from the urethra or discomfort during or shortly after passing urine. The discharge is often worse first thing in the morning. Gonorrhoea generally causes the most discharge, which is often yellow.

Non-specific urethritis (NSU)

If men develop these symptoms without evidence of gonococci in the discharge, the condition is called non-specific urethritis (NSU)’ or ‘non-gonococcal urethritis’ (NGU). Now that it is easy to test for chlamydia, it can be shown to be the cause of about a third of the infections that would previously have been called NSU. Some of the remainder is caused by ureaplasma. For most others no infectious cause can be found which means that there may be other germs we don’t know about or the symptoms are the result of a previous infection or non-infectious inflammation. If a germ is found to be causing the symptoms, the specific name for the condition (such as ‘chlamydial urethritis’) could be used instead of NSU.

Other symptoms of these infections in males include pain and discharge from the rectum if they practice anal receptive intercourse with other men. If the infection has spread beyond the urethra to the epididymis, pain or swelling around the testes can occur.

The symptoms in women

In women there are often no symptoms until the infection is advanced. Some symptoms might be noticed earlier.

•     Infection of the cervix may cause increased vaginal discharge, which is often yellowish and smelly.

•     If the urethra is involved, there may be discomfort on passing urine and an urge to pass urine more often (frequency).

•     If the Bartholin’s glands become infected there may be a painful lump near the entrance to the vagina on one or both sides.

•     If the infection has spread to the uterus and tubes, there may be abdominal pain, pain on intercourse, lower back pain, bouts of fever or fatigue, heavier periods and perhaps bleeding between periods or after intercourse.

•     Occasionally the infection can spread from the tubes into the abdominal cavity to cause an inflammation on the surface of the liver. This is called the Fitz-Hugh-Curtis syndrome, which causes upper abdominal pain, usually on the right side and often made worse on deep breathing or coughing, and sometimes pain in the right shoulder.

Symptoms in both women and men

• If the rectum is infected with gonorrhoea, there may be pain and discharge from the back passage and pain when passing a bowel movement. Chlamydia in the rectum rarely causes symptoms.

• Gonorrhoea can spread into the blood stream to cause fever, skin rash and multiple joint infection with redness pain and swelling, particularly of the
fingers, wrists, elbows, ankles and knees.

• Oral receptive sex can lead to throat infection, which usually causes no symptoms but can be transmitted to a partner during fellatio or cunnilingus.

• Infection transferred to the eye can cause conjunctivitis – severe with gonorrhoea, milder with chlamydia.

• Reiter’s syndrome is a rare, inherited, hypersensitive reaction to chlamydial infection that can cause arthritis, eye problems and recurrent urethritis in both men and women.

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Premenstrual breast changes affect both breasts. Because there’s more gland tissue in the upper outer quarter including the tail that goes up towards the armpit, tenderness and swelling may be more noticeable in this part (which is also more likely to be bumped by arm movements).

The variation in premenstrual breast symptoms in different women and in the same woman from one cycle to the next are not clearly understood, though hormonal fluctuations must be the main explanation.

Many women find that vitamin B6 (25 mg four times a day) or evening primrose oil (3 g per day) relieves premenstrual breast tenderness. If these don’t help and premenstrual breast soreness regularly disrupts your life, see your doctor to discuss possibly using prescription medications that can influence the effect of ovarian hormones on breast tissue.

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Inflammation of the vagina is not always due to infection. It may occasionally be caused by allergy or chemicals.

Antiseptics and deodorants used in douches can irritate and inflame the vagina. As already mentioned, douching is unnecessary (unless advised by your doctor) and can be harmful. I have seen severe chemical vaginitis in women who douched with undiluted antiseptics in an attempt to get rid of a discharge. Rarely, women have had allergic reactions to intravaginal treatments or spermicides, and even more rarely to the rubber of diaphragms or condoms (or their lubricants).

Allergic or chemical vaginitis causes redness and swelling of the vaginal lining and usually copious watery discharge that is not irritating. If the vulval skin is also inflamed by the allergy, it may be itchy or sore. Sex is usually painful.

The diagnosis may at first be difficult if allergy isn’t suspected. Often women don’t think to mention that they’ve been using something in the vagina or that their partner is using a new brand of condom, and doctors sometimes don’t think to ask about these things. If the vagina is inflamed but swabs show no evidence of infection, allergy or chemical irritations the most likely cause. The treatment is to find and eliminate the allergen or chemical irritant.

Atrophic vaginitis

The vaginal lining (and vulval skin) becomes thin and weak (atrophic) when oestrogen is deficient, such as after the menopause. The atrophic vagina and vulva are prone to infection and other inflammation. Itching, discharge and painful sex ate common symptoms. Atrophic vaginitis can be treated and its recurrence prevented by the use of pessaries or creams containing oestrogen, or by HRT.

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Gynaecological surgery

Gynaecological surgery generally has more emotional impact than surgery on other parts of the body, because our reproductive organs are so much a part of our sexuality and female identity. Most of us feel a greater loss after hysterectomy than if, say, our appendix or gall bladder is removed.

Much gynaecological surgery is either life-saving or can remove the cause of distressing symptoms and chronic ill health. However, some gynaecological surgeons have been accused of being too eager to remove women’s reproductive organs for unsound reasons or without giving non-surgical treatments a fair trial.

Some doctors (and some women) consider that after a woman has had as many children as she wants, her uterus is a useless organ that should be removed to prevent future possible disease. Some have the same belief about the ovaries after menopause. Prevention of possible future
disease is not a valid reason for the removal of healthy organs. It has never be suggested that healthy middle-aged ma should have their prostates removed although the prostate causes more ill health in more older men than the uterus or ovaries do in older women, and cancer of the
prostate causes more than twice as many deaths as cancer of the uterus and ovaries combined.

If you’re advised to have gynaecologal (or any other) surgery, there are some important points to consider.

• Has the cause of your symptoms been identified by appropriate investigations and have the results been satisfactorily explained to you?

• You should understand the reason for the surgery and believe that it is valid.

• Your surgeon should explain exactly what will be done and what the ореration aims to achieve. What is the access rate of such an operation?

• Are there non-surgical treatments that could be tried?

• Are there any risks to life or health from not having surgery?

• What is the emotional significance to you of the disease or symptoms, and the likely emotional effect of surgery, especially organ removal?

Other things to find out before surgery include all possible complications and other consequences, length of time required in hospital, costs, whether any special aftercare might be needed, and the likely length of convalescence.

Second opinions

Except in emergencies, you should get a second opinion if:

• you have any doubts about whether you really want or need the operation

• your surgeon is reluctant to give you full, clear information about reasons for surgery

• the surgeon seems overenthusiastic or tries to hurry you into a decision about surgery.

Your surgeon should be willing to refer you for a second opinion if you want one. If not, or if you don’t want to bring up the matter with the surgeon, ask your family doctor to refer you to another specialist. If you have any problems getting a referral, see another GP.

Day surgery

Many minor gynaecological procedures are now performed on a ‘day only’ basis. Most public hospitals encourage day patients; there are now private day hospitals for surgery and some medical investigations. The advantages of day surgery are that you don’t have to spend time away from home and the cost of overnight hospital care is avoided. You’ll need someone to help you when you get home, especially if you’ve had a general anaesthetic.

When day surgery is performed, backup services are arranged in case something unexpected happens when you get home. If there are complications during or soon after the procedure, you may need to stay in hospital overnight: in such cases, if your surgery has been done at a day hospital, you’ll be transferred to a general hospital for overnight care.

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