It doesn’t seem possible to have a progressive, chronic condition and not be aware of it, but with endometriosis this can happen. A sufferer may consult an unsympathetic doctor or a practitioner inexperienced in diagnosing or treating the disease. For her pain, she may be dismissed—told that her symptoms are all in her head or that they are blown out of proportion. The chief complaint—pelvic pain—is however, not psychosomatic at all, but a very reef characteristic sign of the disease.
Victims of endometriosis experience an unnatural biological phenomenon: the misplacement of endometrial cells that normally line the uterine cavity. These cells are pushed backward from the uterus during menstruation and run wild, implanting themselves on pelvic organs, where they not only grow but proliferate. Eventually, clumps of endometrial1 masses spread more and more with each menstrual cycle, contorting organs and making normal functioning difficult or impossible. This invasive process results in severe cramps, pain, and, if the ovaries and fallopian tubes are gravely involved, sterility.
Along the way, women who suffer from endometriosis often are subjected repeatedly to unnecessary surgery, endure years of drug therapy that may not be of much benefit or can even worsen the disorder, develop other stress-related problems from unrelenting abdominal discomfort, and relinquish chances for fulfilling personal and professional goals because of ill health.
Dr. Donald Chatman, an obstetrician and gynecologist at the Michael Reese Hospital and Medical Center in Chicago, specializes m treating women with pelvic pain. He, too, is concerned that a problem exists in medical circles when it comes to understanding this disease. “There is no question that endometriosis is often misdiagnosed or underdiagnosed,” he told. “Primarily, I think physicians are not aware of the potential presence of the disease. For example, a mother calls her doctor and says, ‘My teenage daughter has recurrent menstrual pain.’ He might well say, ‘That’s a woman’s curse,’ and prescribe a drug like ibuprofen or Motrin and assume the girl’s pain is of no consequence. Similarly, a woman in her thirties with severe menstrual pain can race the same kind of put-off response when she sees her gynecologist.
Misdiagnosis is predictable when physicians don’t have the heightened awareness needed to make the correct diagnosis. In fact, a study was done on pelvic inflammatory disease (PID), a sexually transmitted disorder, in which it was found chat the error rate of diagnosis was 35 to 50 percent! Many of those women actually had endometriosis, not PID.
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Many endometriosis sufferers feel that they cannot exercise because of chronic pain or constant tiredness and lethargy. However, exercise is important in that it increases your muscle tone, improves your fitness and gives you a feeling of well-being. Exercise also increases the production of endorphins.
Before starting on an exercise programme it might be sensible to visit your doctor for a physical examination.
One of the most important aspects of exercise is that you must find it enjoyable. Try to find a form of exercise that causes you little or no pain. Start exercising slowly for a short time each day. As your muscles strengthen you will gradually be able to increase the rate and length of the time that you exercise.
If necessary avoid jarring exercises, such as jogging, which may cause more pain by pulling on adhesions and scar tissue.
An excellent non-jarring exercise is swimming. Your exercise regime should also include some weight-bearing exercises such as walking, to help protect against the development of osteoporosis.
During the last few years many women in Australia have found that they have benefited by attending water aerobics classes.
Water aerobics has the benefit of being a weight-bearing, low impact exercise and is suitable even for those who can not swim. Because the water is supportive it does not have the same jarring effect on the body as floor aerobics.
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There is a huge range of possible symptoms of endometriosis and it is important to remember that the symptoms women experience can vary widely. Some women will have few symptoms. Others, unfortunately, suffer many. A few women experience no symptoms and their endometriosis is only discovered during surgery for an unrelated condition. Other women experience no symptoms other than infertility.
The symptoms experienced depend on a number of factors including the severity and extent of the endometriosis and the location of the implants.
The severity of the symptoms varies from mild to severe and does not necessarily have any relationship to the extent of the disease but it usually bears a closer relationship to the location of the implants.
Thus, a few tiny spots of endometriosis may cause excruciating pain especially if they are located in an area where there are many nerve endings, such as in the Pouch of Douglas or on the utero-sacral ligaments. In contrast, severe endometriosis may cause little pain because the implants are located in an area where there are few nerve endings, such as on the ovary.
The range and severity of symptoms often increases as the disease progresses. In addition, the number of days in the month during which the symptoms are felt often increases as the condition worsens.
Thus, in the early stages of the disease the symptoms may be mild and only apparent for the first one or two days of a period but, as the condition worsens, the symptoms may be felt with increasing severity for most of the month. However, for some women the range and severity of their symptoms remains constant for many years.
The most common symptoms include dysmenorrhoea, dyspareunia, pelvic pain, bleeding problems, ovulation pain, bowel problems and infertility.
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Certain kinds of work may be linked with reduced fertility for both partners. This is backed up by substantial research.
For example, professional drivers spend long hours sitting which can result in a lower sperm count and higher numbers of abnormal sperm.
Likewise, welders exposed to intense heat may have reduced quantity and quality of sperm. In the same way, firefighters face intense heat, and they are also exposed to a large variety of chemicals which affect their fertility. Indeed, any man who works in a hot environment (such as a foundry or bakery) could find that his sperm production decreases.
Agricultural workers exposed to pesticides and other chemicals have low sperm counts. Research also shows that their partners have a high rate of miscarriages. In 1991, 1,500 men in Costa Rica became sterile after being exposed to a pesticide used to treat bananas. Other pesticides, such as DBCP (dibromochloropropane), have caused changes in sperm counts, of which were reversible after exposure had stopped. Women exposed to pesticides can have problems conceiving and an increase in miscarriages.
Healthcare workers can be exposed to waste anaesthetic gases, ethylene oxide, cytostatic drugs, mercury and X-rays. And, as we have already seen, s and their assistants experience fertility problems due to the mercury in amalgam fillings.
Painters and printers are exposed to solvents and pigments which can affect male fertility.
Women who are exposed to chemicals and heavy metals often have problems with their menstrual cycle, experiencing hormone imbalances and miscarriages, while taking longer to get pregnant.
Problems with fertility can occur if you or your partner works with lead (used to make storage batteries), radiation, pesticides and/or solvents. For example, workers in drycleaners and hairdressers come into contact with a wide range of chemicals.
In 1997 the Lancet, the leading medical journal, published a whole range of occupations and their implications for fertility. Agents toxic to sperm included inorganic mercury, dibromochloropropane, ethylene dibromide, ethylene glycol ethers, chloropropene and carbon disulfide. Certain other occupational risks were found, including heat, strenuous work, ionising radiation, exposure to lead, antineoplastic agents, waste anaesthetic gases, ethylene oxide, methyl mercury, polychlorinated biphenyls and carbon monoxide.
Visual Display Units
Like televisions, VDUs produce a range of electromagnetic radiation frequencies, including ultraviolet, infrared, microwave, radio frequency and extra low frequency (ELF). Even though so many workers, male and female, now sit in front of a screen all day, surprisingly little is known about the impact of VDUs on health and fertility.
The Health and Safety Executive, the UK’s main workers’ watchdog, found no evidence of an increased miscarriage risk among VDU operatives in a 1992 survey. But other studies point to dangers.
The length of time spent at the computer may be the key. One study found that women who spent more than 20 hours a week in front of the screen had twice as many miscarriages as non-VDU workers. But under 20 hours there was no increased risk. Researchers have also found that not only are miscarriages correlated to the amount of time spent on a VDU but also the same for premature births and stillbirths. Out of those spending up to 6 hours a day at a computer 66 per cent had a problem relating to either a miscarriage, premature birth or stillbirth compared to only 25 per cent for those women spending one hour a day on a VDU.
A number of studies on women VDU workers have also considered stress as a contributing factor to fertility problems. Working at a screen means that women can be sitting in the same position for long hours, doing repetitive work, and often under time pressure.
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How to prevent HIV infection
HIV is difficult to catch. Body fluids containing the virus must go directly into your blood or tissues through a break in the skin or body lining membranes such as the lining of the vagina or rectum. These fluids are:
• blood (including menstrual blood)
• semen
• fluid from the vagina and cervix
• breast milk.
The virus has been found in very small amounts in saliva, but there is little evidence that it has been passed on through saliva. Similarly, there have not been any reports of transmission associated with vomit, urine or faeces.
HIV is transmitted through:
• unprotected vaginal or anal sexual intercourse with an infected person
• injection with a needle or syringe contaminated with infected blood
• pregnancy, in the womb or during delivery, though less than one in five infants born to infected mothers are infected at birth
• breast-feeding, which doubles the risk of a baby becoming infected. The risk is less if the baby doesn’t have its mother’s milk for two weeks after delivery. This is because colostrum contains much more HIV than milk produced later.
Prevention seems straightforward. Never have any sort of injection with a needle or syringe that has been used by anyone else, and never have unprotected sex (that is without use of a condom) unless you are certain that your partner is not infected. These are the main risks. Also, we should all follow the habits of general hygiene that protect against the spread of all infectious diseases.
If you do accidentally come in contact with, say, the blood of an accident victim, don’t panic. It’s extremely unlikely that infection could occur under these circumstances, but if you’re worried, talk to your doctor about whether treatment or a test is advisable, even if only to reassure you that all is well.
Any woman known to carry HIV will have been well advised on how to prevent its spread to others and how best to look after her health.
The statisticians of the epidemic would be pleased if we were all tested so that the real prevalence of HIV infection could be known. I believe that such an enormously expensive exercise is at present unnecessary. Most women will know whether they have ever been at risk of infection.
Who should be tested?
If you have the slightest fear that you may have been infected, I would recommend a test so that you’ll know where you stand and not be wracked by uncertainly. Remember that over 99 of every 100 women at ‘high risk’ tested so far have been negative. Reasons for having the test include:
• if you had a blood transfusion between 1980 and 1985 in Australia. If you’ve ever had a transfusion overseas, ask your doctor whether you should be tested
• if you have ever shared needles or syringes
• if you have ever had a sexual partner whom you suspect may have had sex overseas, multiple female partners, any male partners or has ever injected drugs. Blood for the test can be collected by your doctor, any public hospital or at any sexual health or family planning clinic. Before taking the test, read the pamphlets (available wherever tests are done), which explain what the test and its results mean, and how you can avoid HIV. If you have any concerns about the test or whether you should have it, speak to a doctor, nurse or counsellor. You can be sure that any information you give when taking the test is confidential.
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Acute cystitis
In every case of suspected cystitis the diagnosis should be confirmed by laboratory examination of the urine to identify any bacteria and see what antibiotics will get rid of them. A mid-stream urine specimen should be collected before any treatment is started. However, you will usually be given antibiotics at the first visit, especially if your doctor has looked at your urine under the microscope and seen that it contains pus and blood.
It’s important to check with your doctor when the laboratory report returns to make sure that you’re taking the right antibiotic, which should start to relieve symptoms within 24 hours. Most doctors also like to confirm that the infection has cleared completely by a follow-up urine test after you’ve finished the treatment course; this is particularly important if you’ve had recurrent infections.
It’s also very important to complete the full course of antibiotics. If you have a tendency to develop thrush when you take antibiotics, tell your doctor so that you can have some antifungal treatment on hand.
Here are some other ways to relieve the symptoms of an acute attack while waiting for specific treatment to work.
• Drink as much water as you can to dilute your urine and help flush out the infection.
• Empty your bladder whenever you feel the urge: never try to hold on if you have a urinary infection. Be sure to completely empty the bladder each time.
• Avoid coffee, strong tea, cola drinks (caffeine irritates the bladder) and alcohol.
• Take something to make your urine alkaline, such as a teaspoonful of bicarbonate of soda in a glass of water, or one of the proprietary urinary alkalinisers your pharmacist will recommend.
• Avoid intercourse until all symptoms have gone.
Chronic and recurrent cystitis
If you have chronic or recurrent bladder symptoms it’s very important to have a thorough urinary tract examination so that the cause can be found and treated. Recurrent cystitis can be a symptom of mm serious conditions. Tests usually include X-rays of the kidneys and bladder and perhaps cystoscopy and biopsy of the
bladder lining. It’s also important to check that you’re not diabetic.
If you get repeated infections after sex (proved by bacteria being found in your urine), you should see a specialist urology to discover the cause of the problem. It may be that you have a chronic infection of the mucus-secreting glands near the urethral outlet, or some other bladder or urethral condition that can be corrected. Your doctor may advise you to take low-dose antibiotics daily to prevent further infections until the cause can be treated. However, bladder symptoms after sex aren’t always due to infection. It takes about eight hours for an infection to get established in the bladder, so if symptoms come on very soon after sex, they’re likely to be due to the urethral syndrome.
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Endometritis
Endometritis is infection of the lining of the uterus. It can occur after childbirth or after spontaneous or induced abortion, especially if the uterus is not completely empty of all fragments of the placenta. It is treated by antibiotics and, if necessary, removal of any retained placental tissue.
Endometritis is also part of PID.
Prolapse
When the structures that hold the uterus in place become weakened or abnormally stretched (usually during pregnancy or delivery), the uterus may drop down from its normal position. This is called uterine prolapse. The cervix may move further down in the vagina, and may even protrude through the entrance to the vagina.
As the uterus moves downwards, it pulls the vaginal walls and often the bladder and rectum with it. When the front wall of the vagina and part of the bladder sag downwards, it is called a cystocoele. When the back wall of the vagina and part of the rectum sag downwards, a rectocoele has formed. Either or both may bulge outside the vagina. If the perineum has been torn during delivery and not repaired, cystocoele and/or rectocoele can occur without uterine prolapse.
Not all women who develop prolapse of the pelvic organs have had children. Anything that increases pressure in the abdomen, such as chronic cough, chronic constipation and obesity, puts excessive strain on the pelvic supports and can lead to prolapse. Also, the pelvic supports weaken with age and with reduced production of oestrogen. Many women with prolapse find that symptoms will begin or are aggravated after the menopause.
Symptoms of prolapse
Symptoms depend on which organs are prolapsed and how much. A mild prolapse may not cause any problems.
Prolapse of the uterus can cause a dragging feeling in the lower abdomen and back, increased vaginal discharge and perhaps the feeling that something is coming out of the vagina. Symptoms are usually relieved by lying down.
If cystocoele is present, symptoms include difficulty in starting and stopping urination, urinary frequency, feeling that
the bladder needs emptying again soon after you’ve been to the toilet, and problems controlling the bladder. Recurrent urinary infections can result if the blade never empties properly.
Rectocoele can cause difficulty emptying the bowel, in spite of a constant feeling that the rectum is full and needs to
be emptied. Constipation can become a problem.
Treatment of prolapse
This depends on how severe the symptoms are and the extent of the prolapse Slight prolapse of the uterus without symptoms needs no treatment. Moderate uterine prolapse can often be helped by wearing a strong ring pessary in the vagina to hold up the uterus and to help lift associated cystocoele and rectocoele. If the supports of the uterus are so stretched that the uterus protrudes from the vagina, surgical repair is usually needed.
Mild and moderate degrees of cystocoele and rectocoele are often greatly helped by exercises and other physiotherapy to strengthen the muscles of the pelvic floor and improve emptying and control of the bladder and bowel. However, if these muscles are not only weak but also badly torn or otherwise damaged, surgery may be the only answer.
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Absence or underdevelopment of the ovaries is rare, and is due to abnormal combinations of sex genes. The most common is failure of the sex gene from the sperm to be transferred at fertilisation, resulting in a single X sex chromosome. This is called Turner’s syndrome. Because XX is needed for ovaries to develop and Y for testis development, people with Turner’s syndrome have no gonads, but have tubes, uterus, vagina and female external genitals. There may be associated congenital problems such as heart and bone defects, webbing of the neck and growth retardation resulting in short stature.
Without ovaries to produce oestrogen, none of the characteristic female developments of puberty can take place. If Turner’s syndrome is diagnosed (by tests showing abnormal genes and absence of ovarian hormones, and if the ovaries can’t be found by laparotomy), hormone replacement treatment must be given to complete development and so that health can be maintained during adult life. If a woman without ovaries has a normal uterus and vagina, menstruation will follow hormone treatment.
It is always very hard to explain to a young woman that she was born without ovaries or without a uterus, because it means that she will never be able to have children of her own. If the vagina is also absent, the prospect of needing surgery or the use of dilators to be able to have intercourse is an additional distress. Very sensitive counselling is needed to help overcome grief and to try to prevent sexual maladjustment.
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Most testing can be completed within few months. At the first visit your doctor will take a thorough medical history and will usually carry out on both you and your partner a general physical examination that will also include examining the reproductive system. This may indicate which tests you need. The reason for doing any test, what the test involves, its cost and the results will be fully explained to you: if not, ask.
Some of the following tests may be advised.
Starting a basal body temperature chart This is cheap, easy and no risk. If it shows that you’re ovulating, it’s reassuring and tells you when intercourse is most likely to result in conception.
Sperm count (semen analysis) This is the simplest test, needing only a sample of semen to be sent for examination. You’ll be given instructions on how to collect the specimen. Semen analysis is usually done early and may be repeated two weeks later if the first count is low. Sperm counts that are temporarily reduced, for example by a bout of high fever, will have returned to normal after about three months.
Blood tests for hormones If a woman’s blood contains the hormone progesterone during the second half of her menstrual cycle, that’s strong evidence that she has ovulated.
Hysterosalpingogram (HSG) This is an X-ray of the uterus and tubes, to see whether the shape of the uterine cavity is abnormal or there is tubal blockage.
Laparoscopy This is a surgical procedure in which the uterus, tubes and ovaries are inspected.
Hysteroscopy This is to check the shape and lining of the uterine cavity.
Falloposcopy This is to inspect the interior of the tubes.
Post-coital test (Sims-Huhner test) Within a few hours of having sex during the fertile phase of your cycle, some mucus is taken from the cervix and examined under the microscope immediately to see whether sperm are present and surviving.
Sperm migration test This is also called the mucus penetration test. Mucus from your cervix is collected during the fertile phase. The rate of progress of your partner’s and donor’s sperm through your mucus are compared with their rate of progress through a donor’s mucus.
Not all these tests may be necessary. The result of one test may suggest certain other tests such as looking for sperm antibodies, genetic tests, and biopsy of the testis, ovary or lining of the uterus. If no abnormality is found, it means that the subfertility is due to something we don’t know about reproduction.
Many people are distressed by the intrusiveness of the tests, and by a sense of being judged on their results. One woman expressed her anguish:
There is no inner recess of me left unexplored, unprobed, unmolested. Now when we haw sex I think that what used to be beautiful and very private is now degraded and very public. I take my charts to the doctor like a child bringing home a school report. Did I
do well? Did I ovulate? Did I have sex at the right times?
If you can air these feelings with your partner, doctor, counsellor or others in the same boat, you may feel better about them.
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Conception
A new life begins when an ovum is fertilised by a sperm. Of the 200-400 million sperm in an ejaculation, only around a hundred make the 10-12 cm journey (which is believed to take about an hour) through the cervix and uterus to the outer part of the tube, and only one of these penetrates the ovum.
There’s more to conception than fertilisation. The fertilised egg, a single cell, must then travel down the tube to the uterus, dividing into many cells on the way to form a fluid-filled ball called the blastocyst. About three to four days are spent on the journey from fertilization to implantation site. Here the blastocyst buries in the lining of the uterus (endometrium). Within hours the placenta begins to form and conception is complete.
It’s believed that not every fertilised ovum implants. During if through the tube, the cells formed by its division release a protein called Early Pregnancy Factor (EPF) that changes mother’s immune response so that embryo won’t be rejected. EPF can be detected after ovulation in the bi women who don’t conceive.
For convenience, how far pregnant you are is stated in weeks from the beginning of the last normal menstrual period (LMP), which for most women is a certain date. It also marks the date when the egg began to mature. However, the LMP date is two weeks before the time of fertilisation, and about three weeks before the time of implantation.
The average time from LMP date to delivery is 40 weeks – about 10 days more than 9 calendar months. Pregnancy is divided into three stages, called trimesters, of roughly three months: the first trimester is from the LMP date to 12 weeks; the second or middle trimester is from 13-27 weeks; the third or last trimester is from 28-40 weeks.
A simple way to work out your expected date of delivery (EDD) is to add 10 days and 9 calendar months to the first day of your LMP date. For example, if your LMP date is 15 July, your EDD will be 25 April. In fact, only 5 per cent of women deliver on the EDD, but 80 per cent deliver within 10 days either side of it.
Confirming pregnancy
Gone are the days when we had to rely ; on an examination three to four weeks after a missed period to diagnose pregnancy. Pregnancy tests have become increasingly sensitive over the past decade. The developing placenta begins to produce pregnancy hormone within 24 hours of implantation. The newer blood tests can detect this hormone from the ninth day after ovulation, four to five days before your period is due. New urine tests (including some home tests) can confirm pregnancy from the eleventh day after ovulation. However, because it’s generally hard to be certain about the exact day of ovulation, results of these tests are not reliable until the date your period would have been due. And if for some reason you ovulated late (say, three weeks after the LMP date), a false negative result could come up for several days after the next period is due.
Apart from your burning curiosity, or if you’ve previously had problems very early, there’s generally little point in testing for pregnancy before or for a week or so after you miss a period, except for making changes in your lifestyle to safeguard the pregnancy: if you intend to give up smoking (you should!) and be careful with alcohol and other drugs (including medicines) when you’re pregnant, it’s best to do so as early as you can.
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