Directory of health resources for healthcare professionals.

Estrogen supplements (taken either in pill form or vaginally) lessen many unpleasant postmenopausal symptoms, including painful intercourse. Taken long term beginning at menopause, they are also the most effective treatment for preventing osteoporosis – the postmenopausal bone loss that makes women prone to fractures in later life.
But taking estrogen involves problems. It increases a woman’s risk of endometrial cancer (cancer of the lining of the uterus) from about one in one thousand per year to about four in one thousand. It is associated with high blood pressure, blood clots, abnormal vaginal bleeding, and a slightly higher risk of gallbladder disease.
On the other hand, estrogen does not have the frightening side effects that had previously been feared. The latest studies show that estrogen supplements do not increase the risk of breast cancer; they may even help protect against the disease. Taken long term, they may also decrease the chances of a heart attack.
When its link with endometrial cancer was found about a decade ago, many women stopped taking estrogen. Today estrogen supplements are coming back into favor. Not only are the studies of their effectiveness in preventing osteoporosis encouraging this trend, but new research suggests that the risk of endometrial cancer is reduced (or virtually eliminated) when estrogen is given in cycles of three weeks on and one week off and is combined with the hormone progesterone toward the end of a woman’s cycle. Also, endometrial cancer is relatively rare in any case, even among women who take estrogen. It is also a slow-growing type of cancer, almost always diagnosed while it can still be cured.
Many experts advise not taking estrogen if you have a family history of endometrial or breast cancer, blood clots, strokes, coronary artery disease, severe migraine headaches, liver disease, or unexplained vaginal bleeding. Before starting, they advocate a thorough medical checkup, including a pelvic examination and Pap smear, breast examination and mammogram, tests for blood sugar, liver and thyroid function, and cholesterol levels. Many also recommend an endometrial biopsy (test for endometrial cancer) as an additional precaution.
For you, do estrogen’s benefits outweigh its risks? The Consumers Union consultants recommend, in making a final decision, asking yourself these questions: ‘ ‘Do I need estrogen?” (Am I at high risk for osteoporosis: of small build, a smoker and heavy drinker, sedentary? Are my “change of life” symptoms very upsetting? Is my sex life suffering greatly?) “Do I want to take estrogen despite the risks?”
If your answer is yes, proceed, taking estrogen with progesterone. Get semiannual breast and pelvic exams. Consult your doctor promptly if you have abnormal bleeding. Periodically review new information about estrogen-replacement therapy with your physician.

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The monthly cycle of ovulation and menstruation is regulated by hormones secreted by the pituitary and the ovaries. Menopause technically refers to the total cessation of menstrual periods, the end of a woman’s capacity to have children. This change is the culmination of an ongoing phase called the climacteric. About fifteen years before menopause, during a woman’s late thirties and forties, her reproductive system gradually functions less well. Ovulation and menstruation become increasingly irregular; the chances of miscarrying or bearing a child with a birth defect increase; the ability to get pregnant lessens. This falling off of reproductive capacity and its finale, menopause, is orchestrated largely by a decrease in the female hormone estrogen.
Estrogen depletion has no direct effect on sexual desire; the male hormone testosterone, present in the female body too, regulates the intensity of the sex drive in both women and men. However, it indirectly affects a woman’s enjoyment of sex because it dramatically alters the vagina and surrounding tissues, ultimately causing many women discomfort during intercourse. During a woman’s childbearing years, the walls of the vagina have thick, cushiony folds that expand easily to admit a penis or accommodate childbirth. After menopause, the vaginal walls thin out and become smoother and more fragile. The vagina also shortens, and its opening narrows. The size of the clitoris and labia decreases. There also is a diminution in the amount of sexual lubrication. It tends to take longer after arousal for a woman to begin lubricating, and fluid is never produced as copiously as before.
Unfortunately, these changes tend to happen at the same time as a woman’s partner may be having difficulties with erection. The combination of a drier and less penetrable vagina and a penis less able to penetrate causes some older couples real trouble with intercourse. One method of easing the problem was suggested earlier, using a lubricant – either lovemaking oil, K-Y jelly, or any substance that makes the vagina less dry. The Kegal exercises recommended stimulating vaginal tone after childbirth may also help strengthen the vagina. Or relief may be found by a somewhat more controversial route, taking replacement estrogen.

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Herbs are not simple spice* and should be treated with exceptional wisdom and respect. Medicinal herbal cures and treatments are as old as the first amateur botanist who most likely discovered the effects of plants quite by accident. A respectable percentage of modem drugs are made from plants, or were made from plants, before they were artificially reproduced. Penicillin and belladonna are two such drugs; Valium, the tranquilizer, may have had its roots in valerian, an herb known for its identical effect. How safe, then, arc herbs for the woman with endometriosis?

Abigail Rist, a registered nurse and registered acupuncturist with a specialty of herbalism, who has worked with midwives and treated many women with menstrual disorders, believes that sufferers of endometriosis may gain some benefits from a number of herbal remedies. She follows the Chinese school of thought, viewing disease as imbalances of female (yin) and male (yang) energies, heat and cold, expansion and contraction. The herbal teas or tinctures she recommends arc based on these evaluations.

Since this system of medicine does not specify the disease precisely, “endometriosis is diagnosed and treated by its more irritating symptoms,” Ms. Rist told me. “In this sense, endometriosis is a tightening and over cooling of what is called ‘the lower burner,’ or urogenital area. For this area, we prepare an herbal remedy to replenish heat (or yang) and reestablish a balance, in another example, it’s as if you have a fever or sore throat, accompanied by thirst. The remedy prescribed will bring down body heat, soothe the rawness of the throat, and help quench thirst. Dandelion tea, for example, induces these qualities. The same will be done for endometriosis.”

Using this reasoning, the overcooling effects of endometriosis would need to be treated or counteracted with warmth. The herbs used would tonify the blood, stimulate and warm the organs. “In traditional Chinese medicine,” Ms. Rise continued, “doctors attribute the function and regulation of some aspects of the blood to the liver and spleen. If a woman has dark clots during menstruation, it is attributed to an imbalance of the liver. If a woman has lighter red blood but profuse bleeding, this would be related to an imbalance of the spleen. The herbs prescribed would be “tissue specific,’ that is. herbs with some affinity to each organ which can, if possible, influence and regulate its function.”

There are teas and tinctures that Ms. Rist recommends. The white peony has specific liver action, so it will actually decrease abdominal tightness and pain. The peony, which may be either dry-roasted or cured, depending on what the herbalist decides for each case, is often one of four other herbs blended in a concoction and prepared to be taken as tea. “Its nature is to be cooling,” says Ms. Rist, “so when it enters the spleen and liver channels, it can tonify the blood. The herbs can also help stop pain by relaxing the tendons and tissues.”

Another popularly used herb is dong quai, considered a “female” root plant, the way that ginseng it assigned male properties. Dong quai is found in many “female trouble” herb blends that are commercially made and distributed to hearth food stores. It is a cured root that, says Ms. Rist, “is thought to help establish an endocrine balance, increasing tissue sensitivity to estrogen and helps with ending menstrual cramps and pelvic congestion.”

Another tea suggested by this herbalist is raspberry tea, handed down as a remedy from grandmother’s rime to its use by present-day midwives. It is reputed to help relax muscles and dilate the cervix. Other teas that are toning or can help reduce inflammation or relieve pain arc rosemary tea, licorice tea, chamomile, and witch hazel tea.

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Endometriosis is the growth of tissue resembling the endometrium in parts of the pelvis where it is not usually seen. This ‘stray’ tissue grows in an estimated 1-6% of women. It occurs on the ovaries, Fallopian tubes, the outside of the uterus or its supporting ligaments, the bowel, bladder or vagina.6 It occurs in about one in five women with fertility problems, suggesting a significant role in infertility. The tissue behaves like the endometrium in some respects, bleeding at the same time as the usual menstrual period. If the blood cannot easily escape from the body, it may cause irritation or pain and may develop into blood-filled cysts.

Sometimes endometriosis only lasts for a few cycles, but it may also continue throughout reproductive life, getting worse as women enter their thirties and forties. The behaviour of endometriosis in pregnancy is highly variable and it rarely disappears permanently after pregnancy. Published reports indicate that some women continue to have problems due to endometriosis after menopause. It can limit bending, stretching, standing and taking exercise, especially on days of menstrual bleeding. Although it is also associated with infertility, many women with endometriosis become pregnant without difficulty.

Endometriosis is regarded as the most common cause of chronic pain in women aged from fifteen to fifty-five years. This pain is nearly always cyclical, that is, it tends to occur at about the same time in most menstrual cycles. It may be experienced by a woman when she ovulates, menstruates or is about to menstruate. It may also occur when she has sexual intercourse, urinates or passes a bowel motion. It sometimes causes spotting between periods. Although it has much in common with period pain it does not respond to medications, such as anti-prostaglandins, found helpful in that disorder. When Laura sought advice from her doctor about chronic pelvic pain, a number of factors in her history suggested a diagnosis of endometriosis. These included a history of painful periods which had worsened with age, short menstrual cycles with a relatively large number of days of bleeding, and a family history of pelvic pain among her female relatives. Despite this suggestive evidence, Laura’s doctor advised her that the diagnosis required a laparoscope entailing a visual inspection of her abdominal organs. He said a number of other procedures might assist in arriving at a diagnosis but he preferred not to perform a biopsy of suspected lesions, a vaginal ultrasound and blood tests until he did the laparoscopy. In fact, the laparoscopy was sufficient to reveal the endometriosis and he and Laura discussed a number of possible treatments, including drug treatment and surgical removal.

The diagnosis of endometriosis usually relies on a laparoscopic examination, a procedure that enables a doctor to examine the contents of the abdomen without making a big opening in. Instead several small incisions are made and a long thin tube specially equipped with thin glass fibres is inserted through one of the incisions. Light travels along the fibres to ‘spotlight’ internal organs and a periscope-type attachment allows the doctor to see into the abdomen and pelvis. Other instruments used with the laparoscope (hence the need for the other incisions) enable the doctor to make photographic records of the inside of the abdomen, obtain samples (biopsies) of tissue for laboratory analysis and remove abnormal tissue. Using this technique, doctors have learned that the appearance of endometriosis varies markedly. Younger women tend to have clear growths or red lesions, whereas the lesions of older patients tend to be black or yellow-white.

Various theories have been advanced about why endometriosis occurs, but these are hotly disputed. Suffice it to say that no one yet knows if some women are born with a tendency to develop it or if endometrial-type tissue spreads in the body due to some unusual abdominal structure or function.

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Conservative laparotomy procedures vary and are changing all the time. The nature of your surgery will depend on a number of factors including the extent and location of your disease, your symptoms, your desire for future childbearing and your gynecologist’s training, experience and preferences.

The procedures, which will be performed as part of a laparotomy, may include any of the following:

• removal or destruction of implants and small cysts

• removal or destruction of large cysts and endometriomas

• removal of adhesions

• removal of an ovary or an ovary and fallopian tube

• removal of the appendix

• surgery on any other affected organs such as the bowel or bladder

• suspension of the uterus

• pre-sacral neurectomy or utero-sacral neurectomy

• any surgery necessary to correct other abnormalities found.

Implants and small cysts

Where possible any superficial implants and small cysts on the ovary and peritoneum will be removed or destroyed by cutting, cauterization or vaporization, provided that there is no danger to any underlying organs such as the bowel or bladder.

Large cysts and endometriomas

Any endometriomas will usually be removed by cutting them out. This often involves removing a small amount of the surrounding ovary as well to ensure that all the endometrial tissue is removed. Sometimes, endometriomas will be destroyed by puncturing them and then cauterizing or vaporizing their lining. Large cysts on the peritoneum will be removed by cutting them out.

Adhesions

Any adhesions will be cut, cauterized or vaporized and separated so that the normal positioning of the reproductive organs can be restored.

Ovaries

Sometimes an ovary will have to be removed because an endometrioma lying within it cannot be removed safely. Similarly, if one ovary and fallopian tube are severely diseased they may be removed, provided that the other ovary and tube are normal. The removal of an ovary and tube on one side does not seem to decrease the likelihood of pregnancy following surgery but does seem to reduce the risk of the disease recurring.

Appendix

Some surgeons routinely remove the appendix during a conservative laparotomy, especially if the endometriosis is extensive, but most will remove it only if endometrial implants are present.

Bowel and bladder

Most small implants on the bowel and bladder are superficial and can be removed or destroyed without any danger of damaging the underlying organs. If the implants have penetrated the wall of the bowel or bladder they must be carefully cut out and the affected area repaired. Occasionally a section of the bowel will have to be removed if the implants have surrounded and constricted it; if there is any possibility of this being done it is highly advisable that a bowel surgeon be on hand to assist.

Suspension of the uterus

Suspension of the uterus involves tightening or shortening the utero-sacral and/or the round ligaments in an attempt to hold the uterus in its normal position. This procedure is not commonly performed by gynecologists in Australia though it is quite common in America.

Presacral and utero-sacral neurectomy

A pre-sacral neurectomy and an utero-sacral neurectomy are two similar procedures which are only occasionally performed by gynecologists in this country, although they are performed much more commonly overseas. Both procedures involve cutting the nerves that transmit pain from the uterus to the brain. The same nerves are cut in both procedures but in the case of an utero-sacral neurectomy the nerves are cut closer to the uterus than is the case with a pre-sacral neurectomy. The two procedures are performed to relieve chronic pelvic pain but they are usually only effective for a maximum of about twelve months as by then the nerves have re-grown.

If you are contemplating a pre-sacral neurectomy or an utero-sacral neurectomy it is worth remembering that pain is one of the body’s warning mechanisms. If you cannot feel pain in the pelvic area you may not be aware that your endometriosis could be worsening or recurring. If you go into labour you may not be able to feel the contractions which signal the onset of labour. In addition, both procedures can occasionally interfere with normal bowel and bladder function.

Other

If your fallopian tubes are damaged or if you have any other disease or abnormality of the reproductive organs these will usually also be repaired.

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