Endometriosis ~ Abdominal Pain ~ Endo ~ Scar Tissue ~ Adhesions ~ Infertility ~ Hysterectomy

Wednesday, November 29, 2006

Abbott backs away from IVF age cap

By Sandra O'Malley
November 29, 2006 08:16pm
Labor described it as a community victory against a cruel plan by the health minister.
HEALTH Minister Tony Abbott has backed away from any plans to restrict women's access to taxpayer-funded IVF on the basis of their age
Labor described it as a community victory against a cruel plan by the health minister.
A year and a half after commissioning an IVF review and nine months after receiving the report, Mr Abbott today signalled the Government would not restrict the procedure based on a woman's age or number of treatments.
Concerned about the growing cost of IVF, also known as assisted reproductive technology (ART), the Government – ahead of last year's Budget – had been considering caps on procedures.
Mr Abbott indicated at the time that he believed there was a limit on the amount of money that should be spent on such non-essential procedures.
The Government was thought to be considering reducing the number of Medicare-funded treatments to three a year for women aged under 42 and capping the number of treatments for women aged over 42 to three cycles in total.
Doctors condemned any moves to change the status quo, which also attracted criticism from elements within the Coalition backbench.
Read More

Doctors inject botox into womb to treat cramps

7.20am Wednesday November 29, 2006

SYDNEY - A drug famed for smoothing women's wrinkles may soon be soothing their period pain too.

In a world-first trial at Sydney's Royal Hospital for Women, doctors have begun injecting Botox into the womb of women with severe and prolonged monthly cramps.

Up to 10 per cent of fertile women suffer from period pain, when the uterus contracts erratically and "fights" against itself.

Professor Thierry Vancaillie from the department of endo-gynaecology said anecdotal evidence seems to show the toxic bacteria botulinum toxin can paralyse the region and bring relief.

"Like it works on the face, we believe if you inject Botox into the uterus it relaxes the muscles by stopping the nerves from working," Prof Vancaillie.

"It's really logical but it hasn't been tried yet which is amazing."

Botox is most widely used for cosmetic purposes but has also been shown to be effective in treating cerebral palsy, neck and facial spasms, chronic migraine, incontinence and chronic sweating.
Read more

Tuesday, November 28, 2006

Quality of life after laparoscopic colorectal resection for endometriosis.

Hum Reprod. 2006 May;21(5):1243-7. Epub 2006 Jan 26
Dubernard G,
Piketty M,
Rouzier R,
Houry S,
Bazot M,
Darai E.
Service de Gynecologie, Obstetrique et Medecine de la Reproduction, Hopital Tenon, Universite Saint-Antoine Paris VI, Assistance Publique des Hopitaux de Paris, France.
BACKGROUND: Indications of colorectal resection for endometriosis remain controversial because of the risk of major complications. Therefore, the aims of the current study were to evaluate the efficacy of laparoscopic segmental colorectal resection for endometriosis on quality of life and gynaecologic and digestive symptoms, and its complications. METHODS: After magnetic resonance imaging and rectal endoscopic sonographic evaluation of symptomatic colorectal endometriosis, 58 consecutive women requiring colorectal resection were included in this study. Symptom questionnaires and the short-form (SF)-36 Health Status and the quality of life score were completed. Linear intensity scores for several gynaecologic and digestive symptoms and perioperative complications were also recorded. RESULTS: Fifty-one women (88%) underwent laparoscopic segmental colorectal resection and seven required laparoconversion. Major complications occurred in nine cases (15.5%), including six rectovaginal fistulae (10.3%), and the three remaining complications corresponded to a haemoperitoneum, a uroperitoneum and a pelvic abscess. Median follow-up after colorectal resection was 22.5 months (2-55 months). A significant improvement in dysmenorrhoea (P < 0.0001), dysparaeunia (P < 0.0001), bowel movement pain or cramping (P < 0.0001), pain on defecation (P < 0.0001), diarrhoea (P < 0.016), lower back pain (P < 0.0001) and asthaenia (P < 0.0002) was observed. Tenesmus, rectorrhagia and constipation were not improved. All the items of the SF-36 Health Status and the quality of life score were improved after colorectal resection for endometriosis. CONCLUSION: Laparoscopic segmental colorectal resection for endometriosis significantly improves quality of life and gynaecologic and digestive symptoms. However, women have to be informed on the risk of complications including rectovaginal fistula. PMID: 16439504 [PubMed - indexed for MEDLINE]

Talking about endometriosis

by Marc Laufer, MD, Endozone Advisory Board member, Chief of Gynecology; Children's Hospital Boston; Associate Professor of Obstetrics, Gynecology and Reproductive Biology
What is endometriosis? Endometriosis is a condition that occurs when tissue similar to the lining of the uterus is found outside its normal location. Common locations of these endometrial implants, or lesions, include the ovaries, fallopian tubes, ligaments that support the uterus, and tissue covering the bladder and rectum. The location of the endometrial implants, and the way in which the lesions affect the pelvic organs, contributes to the symptoms adolescent and adult women may have. Some teens with a lot of lesions have very little pain, while others with a small amount have severe pain.
What causes endometriosis? Although we know that some young women may be slightly more likely to develop endometriosis because female relatives have it, the truth is, we don't know the cause of this disease. Any woman, anywhere, can get endometriosis.
What symptoms are associated with endometriosis? The most common symptoms include occasional or constant pelvic pain and/or severe period cramps—often referred to as chronic pelvic pain. Pain can occur before, during or after a period and may be cyclic or acyclic. Teens may experience pain at rest, with exercise, sex or after a pelvic exam. Painful or frequent urination, diarrhea or constipation may accompany the pelvic pain, confusing the diagnosis of endometriosis with inflammatory bowel disease, recurrent urinary tract infection, appendicitis, or pelvic inflammatory disease.
How is endometriosis diagnosed? The only way to be completely sure that the problem is endometriosis is to have a laparoscopy—a minimally invasive, outpatient surgery to examine the pelvic organs. Blood tests, cultures to check for infection, an ultrasound or an MRI may help rule out other diagnoses prior to laparoscopy. It is important to refer young women to gynecologists who specialize in treating teens with endometriosis as it can be more challenging to recognize endometriosis in teens than adult women.
How is endometriosis treated? Although we can't cure endometriosis, there are many options for treating symptoms. The goals are to relieve pain, control the progression of the endometriosis and preserve fertility. Treatment can make a big difference in improving the quality of a young woman's life, and early treatment may preserve a woman's fertility. We recommend continuous treatment through child bearing years or until desired family size is reached.
Some common treatment methods include:
Over-the-counter pain relievers, such as aspirin, acetaminophen, ibuprofen and naproxen sodium can offer relief for some. Others require prescription drugs.
Oral contraceptives taken continuously relieve symptoms in eight out of 10 patients. GnRH agonists (gonadotropin releasing hormone drugs), such as Lupron, temporarily stop periods by lowering estrogen levels.
During laparoscopy, doctors can use special instruments to laser or cauterize the endometriosis. Many teens find relief from symptoms after going through this procedure, although over time, some may experience pain again.
Acupuncture, herbal remedies, homeopathy and healing touch are a few alternatives we've seen grow in popularity. We've also found many of these therapies to be effective. We encourage patients to speak with their primary care doctor or gynecologist before pursuing alternative treatments, as research studies are limited and not every alternative approach has been proven to be safe and effective.
Eating well and getting enough rest helps the body to manage pain. Exercise often helps to relieve or lessen pelvic pain and menstrual cramps. Practicing relaxation techniques, such as yoga and meditation, help ease pain too.
Many centers work closely with other health care providers in programs that provide treatment and support for acute and chronic pain. Following an evaluation, services such as biofeedback, physical therapy, TENS (transcutaneous electrical stimulation) and exercise programs, may be offered.
Is endometriosis being researched? Yes. A variety of research is underway around the world. At Children's, we've just finished collecting data on a blood test for endometriosis that may one day provide a less invasive way to diagnose it. We are also studying the way complementary and alternative therapies, such as acupuncture, may help manage symptoms alone or in conjunction with other forms of treatment.
Where can young women or parents find more information?The Center for Young Women's Health is a great resource for young women, parents and health professionals. Their Web site (www.youngwomenshealth.org) includes pages on basic health, nutrition and fitness, emotional health, sexuality and reproductive health. Common questions about endometriosis are answered in sections specific to teens, parents and health professionals. The Endometriosis Association (www.endometriosisassn.org) is another good resource for more information on endometriosis.
Each month the CYWH hosts an online chat about endometriosis, inviting women anywhere in the world to participate. Additional chats are held each month on a variety of topics. To learn more, visit www.youngwomenshealth.org.


Monday, November 27, 2006

Environmental influences on women's health: how to avoid endocrine disrupting compounds

Townsend Letter for Doctors and Patients, July, 2004 by Marianne Marchese

Over the years there has been a steady rise in women's health conditions such as breast cancer, fibroids, endometriosis, miscarriage, and infertility. There also has been a rise in conditions such as fibromyalgia, chronic fatigue syndrome and hypothyroidism, which mostly affect women. Studies show that human exposure to chemicals in our environment such as pesticides, herbicides, insecticides, and manufacturing byproducts, can cause these endocrine disrupting conditions.

An endocrine disruptor is any substance that alters normal hormone levels or activity in the body. Synthetic chemicals can disturb the normal activity of estrogens, androgens, thyroid and other hormones. (1) They do so by binding directly to hormone receptors, activating it and causing the chain of events as if the hormone itself were binding to the receptor. (1-3) The toxic chemical may also bind and occupy the receptor, blocking normal hormonal activity, or it may interfere with proteins that regulate the activity of hormones. (1-5) These effects may be associated with the development of illness and disease.
We are exposed to endocrine-disrupting compounds in our everyday life, often without knowing we are being exposed. Pesticide residues can be found on fruits and vegetables sitting in the store to be sold. (9) Animal products are tainted with dioxins and dioxin-like compounds and often have hormones and antibiotics added to them. (9) Certain fish have high levels of mercury and pesticides. (9,14) Chemicals used as plasticizers in flexible polyvinyl chloride products can harm the female reproductive system. Polyvinyl chloride products include tablecloths, shower curtains, soft-squeeze children's toys, plastic medical equipment and plastic food wrappings. The plastic containers that food and condiments are stored in can leach out harmful chemicals. (10,26) Hormone disrupting compounds can be found in both well water and city water providing yet another means of exposure. (9) Toxic compounds are also inhaled or absorbed through the skin by contact with most household cleaning products, cosmetics, perfumes, dry cleaning, carpet, vinyl floors, copy machines, furniture glues, air fresheners, mattresses, shampoos, and the list goes on. (11,12)
Find More Results for: "endocrine-disrupting compounds endometriosis "
Xenoestrogens at...Lessons from...Drugging our water: we...DDT and its...

Pain, mast cells, and nerves in peritoneal, ovarian, and deep infiltrating endometriosis.

Anaf V,
Chapron C,
El Nakadi I,
De Moor V,
Simonart T,
Noel JC.
Department of Gynaecology, Academic Hospital Erasme, Free University of Brussels, Brussels, Belgium. vincent.anaf@ulb.ac.be
OBJECTIVE: To detect and quantify mast cells in peritoneal, ovarian, and deep infiltrating endometriosis and to study the relationship between mast cells and nerves in endometriosis. DESIGN: Prospective histological and immunohistochemical study. SETTING: University of Brussels, Belgium. PATIENT(S): Sixty-nine women undergoing laparoscopic excision of endometriosis for pain. Thirty-seven biopsies of normal tissue were obtained from women without endometriosis. INTERVENTION(S): Excision of endometriosis from different anatomical locations. MAIN OUTCOME MEASURE(S): Immunohistochemistry with chymase and tryptase to confirm the presence of mast cells and activated mast cells, respectively, in endometriotic lesions. Quantification of mast cells, activated mast cells, and degranulating mast cells in the different locations of endometriosis. Study of the relationship between mast cells and nerves by quantifying mast cells located less than 25 mum from nerves immunohistochemically stained with S-100 protein. Preoperative pain score evaluation by visual analogue scales. RESULT(S): Patients with deeply infiltrating lesions had significantly higher preoperative pain scores than patients with peritoneal or ovarian endometriosis. Mast cells and degranulating mast cells are significantly more abundant in endometriotic lesions than in nonaffected tissues. Deep infiltrating lesions show a significantly higher number of mast cells, activated mast cells, and mast cells located <25 microm from nerves than peritoneal and ovarian lesions. We found significantly more degranulating mast cells in deep infiltrating lesions than in peritoneal lesions. CONCLUSION(S): The presence of increased activated and degranulating mast cells in deeply infiltrating endometriosis, which are the most painful lesions, and the close histological relationship between mast cells and nerves strongly suggest that mast cells could contribute to the development of pain and hyperalgesia in endometriosis, possibly by a direct effect on nerve structures.
PMID: 17007852 [PubMed - in process]
Fertil Steril. 2006 Nov;86(5):1336-43. Epub 2006 Sep 27

Tuesday, November 21, 2006

Happy Thanksgiving


ARDvark Blog: Nerve Pain ? ~ Look at Lyrica

ARDvark Blog: Nerve Pain ? ~ Look at Lyrica

Levonorgestrel-releasing intrauterine device (LNG-IUD) for recurrence of symptoms in women who have had surgery for endometriosis

Abou-Setta AM, Al-Inany HG, Farquhar CM
This is a Cochrane review
abstract and plain language summary, prepared and maintained by The Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

Endometriosis is the presence of endometrial tissue outside the uterus, usually in the pelvis, that can lead to infertility and pelvic pain. It is managed with hormonal medications, surgery or a combination of both. The aim of this review was to assess if the use of a hormone-releasing IUD was beneficial for managing associated painful symptoms and for preventing recurrence of endometriosis. At this stage, although preliminary findings are encouraging there is only limited evidence of a beneficial role in reducing recurrence of painful periods with the use of the LNG-IUS following surgery for endometriosis.
Read More

Monday, November 20, 2006


Menopause happens most dramatically as the result of surgical intervention, namely a hysterectomy and bilateral oophorectomy where both ovaries are removed. Sometimes this is called TAH/BSO, or total abdominal hysterectomy with bilateral salpingo-oophorectomy. Salpingo refers to the fallopian tubes which connect the ovaries to the uterus. In the case of a hysterectomy, where only the uterus is removed and the ovaries maintained, there will be some confusion about when menopause occurs because of the absence of a period.
When the uterus is removed (hysterectomy) and the ovaries remain, menstrual periods stop but other menopausal symptoms (if any) usually occur at the same age that they would naturally. However, some women who have a hysterectomy may experience menopausal symptoms at a younger age.
There are many decisions to make when faced with surgical menopause. You can never have enough information about the process. You can't just take your doctor's word! Become proactive…this is your body. Listed below are a few points of information that should help your transition into this process:
The younger the woman going through surgical menopause, the more problems she will likely encounter.
It is crucial that every young woman scheduled for a hysterectomy have a complete hormonal blood work-up. That way there is a baseline to go by when determining hormonal needs. You can look back at those tests and see what the levels were when you felt normal and try to achieve those levels again with the right hormones.
Plan on your care after the hysterectomy. As a young woman it is important to find a "specialist " in hormonal therapy; someone who is up to date and keeps up to date with the newest medicine and side effects from surgical menopause. This doctor has to be someone you can trust, who provides good information and is open minded and will see you as a partner in your healthcare.
Research, research, and more research! The long-term affects of surgical menopause at a younger age has not really been determined. We are just now finding out how it relates to heart disease, osteoporosis and general health.
Not every woman will experience these symptoms, but it is a proven fact that if you are in surgical menopause, then you will experience most of these symptoms in a more severe fashion than women going through menopause naturally.
Hot Flashes
Thyroid dysfunction
Night sweats
Bladder infections
Increased appetite
Weight gain
Hair Loss
Vaginal dryness
Painful intercourse
Suicidal thoughts
Decreased sexual desire

HERS FOUNDATION (Hysterectomy Educational Resources & Services)422 Bryn Mawr Avenue Bala Cynwyd, PA 19004 Email: info@hersfoundation.com
To request a free information packet: Tel (610) 667-7757To arrange a telephone appointment with a counselor: FAX (610) 667-8096

Sans Uteri Hysterectomy Forum, communication between hysterectomized women and women considering surgery. This site has many segments including a private mailing list of women who have had hysterectomies. Other features of the site are described in their FAQ.

Alternatives to Hysterectomy is designed for women who have been told they need a hysterectomy and are searching for alternative treatment. This site is under the direction of Michael E. Toaff, M.D.

Alternatives in Gynecology is the site of Paul D. Indman, M.D., FACOG. Topics explored at this site are common gynecological problems and procedures that should be considered when contemplating hysterectomy.

A Woman's Guide to Overcoming Endometriosis from IVF.com - complete and thorough resource about endometriosis

EarlyMenopause.com offers information and support for women who are experiencing early menopause—whether it's happened naturally or due to premature ovarian failure; surgery (hysterectomy and oophorectomy), cancer treatments (such as chemotherapy or radiation), autoimmune disorders, and more.

Hystersisters, a woman-to-woman support website for hysterectomy recovery. This group offers resources and kindness so that visitors can discover options and make decisions for themselves.


Friday, November 17, 2006

Procedures To Help You Become Pregnant









A health forum for teenagers goes beyond phys ed

A Pinecrest student is organizing a health forum for teens and their moms Sunday at South Miami Hospital.
At the age of 12 -- before she was even officially a teenager -- Valerie Berrin had to learn about the inner workings of her reproductive system.
The Pinecrest resident had been diagnosed with endometriosis, a condition where the uterine lining tissue is found in other pelvic organs, and had to undergo surgery. She quickly became familiar with terms she had not yet been taught in school or at home.
''I realized that if I wasn't sick, I wouldn't know much about my body,'' the 18-year-old Gulliver Preparatory senior said.
Now Berrin wants to make sure other teens get educated about their bodies, and has organized a mother-daughter health forum Sunday at South Miami Hospital.
Read More


Elizabeth A Stewart, MD
UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.3 is current through August 2006; this topic was last changed on August 9, 2006. The next version of UpToDate (15.1) will be released in February 2007.
INTRODUCTION — Adenomyosis refers to the presence of endometrial glands and stroma within the uterine musculature. Adenomyosis can be present as diffuse disease only apparent by microscopy or it can form nodules clinically resembling leiomyomas (termed adenomyomas). The ectopic endometrial tissue appears to induce hypertrophy and hyperplasia of the surrounding myometrium, producing a diffusely enlarged uterus. This more closely resembles the concentric enlargement of a pregnant uterus than the irregular enlargement of a leiomyomatous uterus and is often termed "globular" enlargement.
The three major types of benign tumors of the uterus are adenomyosis, leiomyomas (fibroids), and endometrial polyps. Adenomyosis will be reviewed here while leiomyomas and endometrial polyps are discussed separately. (See "Epidemiology, pathogenesis, diagnosis, and natural history of uterine leiomyomas", see "Treatment of uterine leiomyomas", and see "Endometrial polyps").
EPIDEMIOLOGY AND RISK FACTORS — The incidence of adenomyosis has not been accurately determined since the diagnosis can only be made by microscopic examination of the uterus. Although generally estimated to affect 20 percent of women, the incidence was approximately 65 percent in one study in which meticulous histopathological analysis of multiple myometrial sections was performed [1].
Adenomyosis appears to be more common among women with a history of childbearing than in nulliparous women [1]. However, since diagnosis has typically been made only at the time of hysterectomy, this may be a confounder. A greater number of pregnancies is not associated with a higher risk of the disease [2]. Prior uterine surgery may also be a risk factor [3]. Symptoms typically occur in women between 40 and 50 years of age ().
Most women with this disorder have another pathologic


[Printer-friendly version -- PDF file, 235 Kb]
What is endometriosis?
What are the symptoms of endometriosis?
Who usually gets endometriosis?
What can raise my chances of getting endometriosis?
How can I reduce my chances of getting endometriosis?
Why do patches of endometriosis cause pain and health problems?
Why is it important to find out if I have endometriosis?
How would I know if I have endometriosis?
What causes endometriosis?
How is endometriosis treated?
How do I cope with a disease that has no cure?
See also:
What is endometriosis?
Endometriosis is a common health problem in women. It gets its name from the word endometrium, the tissue that lines the uterus (womb). In women with this problem, tissue that looks and acts like the lining of the uterus grows outside of the uterus in other areas. These areas can be called growths, tumors, implants, lesions, or nodules.
Most endometriosis is found:
on or under the ovaries
behind the uterus
on the tissues that hold the uterus in place
on the bowels or bladder
Endometriosis rarely grows in the lungs or other parts of the body. This "misplaced" tissue can cause pain, infertility (not being able to get pregnant), and very heavy periods.
What are the symptoms of endometriosis?
Pain is one of the most common symptoms of endometriosis. Usually the pain is in the abdomen, lower back, and pelvis. The amount of pain a woman feels does not depend on how much endometriosis she has. Some women have no pain, even though their disease affects large areas. Other women with endometriosis have severe pain even though they have only a few small growths. Symptoms of endometriosis include:
Very painful menstrual cramps
Pain with periods that gets worse over time
Chronic pain in the lower back and pelvis
Pain during or after sex
Intestinal pain
Painful bowel movements or painful urination during menstrual periods
Heavy and/or long menstrual periods
Spotting or bleeding between periods
Infertility (not being able to get pregnant)
Women with endometriosis may also have gastrointestinal problems such as diarrhea, constipation, or bloating, especially during their periods.
Who usually gets endometriosis?
About five million women in the United States have endometriosis. This makes it one of the most common health problems for women.
In general, women with endometriosis:
get their monthly period
are 27-years-old on average
have symptoms for two to five years before finding out they have the disease
Women who have gone through menopause (when a woman stops having her period) rarely still have symptoms.
What can raise my chances of getting endometriosis?
You are more likely to develop endometriosis if you:
began getting your period at an early age
have heavy periods
have periods that last more than seven days
have a short monthly cycle (27 days or less)
have a close relative (mother, aunt, sister) with endometriosis
How can I reduce my chances of getting endometriosis?
Some studies suggest that you may lower your chances of developing endometriosis if you:
exercise regularly
avoid alcohol and caffeine
Why do patches of endometriosis cause pain and health problems?
Growths of endometriosis are almost always benign or not cancerous, but still can cause many problems. To see why, it helps to understand a woman's monthly cycle. Every month, hormones cause the lining of a woman's uterus to build up with tissue and blood vessels. If a woman does not get pregnant, the uterus sheds this tissue and blood. It comes out of the body through the vagina as her menstrual period.
Patches of endometriosis also respond to a woman's monthly cycle. Each month the growths add extra tissue and blood, but there is no place for the built-up tissue and blood to exit the body. For this reason, growths tend to get bigger and the symptoms of endometriosis often get worse over time.
Tissue and blood that is shed into the body can cause inflammation, scar tissue, and pain. As the misplaced tissue grows, it can cover or grow into the ovaries and block the fallopian tubes. This can make it hard for women with endometriosis to get pregnant. The growths can also cause problems in the intestines and bladder.
Why is it important to find out if I have endometriosis?
The pain of endometriosis can interfere with your life. Studies show that women with endometriosis often skip school, work, and social events. This health problem can also get in the way of relationships with your partner, friends, children, and co-workers. Plus, endometriosis can make it hard for you to get pregnant.
Finding out that you have endometriosis is the first step in taking back your life. Many treatments can control the symptoms. Medicine can relieve your pain. And when endometriosis causes fertility problems, surgery can boost your chances of getting pregnant.
How would I know if I have endometriosis?
If you think you have this disease, talk with your obstetrician/gynecologist (OB/GYN). Your OB/GYN has special training to diagnose and treat this condition. The doctor will talk to you about your symptoms and health history. Then she or he will do a pelvic exam. Sometimes during the exam, the doctor can find signs of endometriosis.
Usually doctors need to run tests to find out if a woman has endometriosis. Sometimes doctors use imaging tests to "see" large growths of endometriosis inside the body. The two most common imaging tests are:
ultrasound, which uses sound waves to see inside the body
magnetic resonance imaging (MRI), which uses magnets and radio waves to make a "picture" of the inside of the body
The only way to know for sure if you have endometriosis is to have a surgery called laparoscopy. In this procedure, a tiny cut is made in your abdomen. A thin tube with a light is placed inside to see growths from endometriosis. Sometimes doctors can diagnose endometriosis just by seeing the growths. Other times, they need to take a small sample of tissue, or a biopsy, and study it under a microscope.
What causes endometriosis?
No one knows for sure what causes this disease, but scientists have a number of theories.
They know that endometriosis runs in families. If your mother or sister has endometriosis, you are six times more likely to get the disease than other women. So, one theory suggests that endometriosis is caused by genes.
Another theory is that during a woman's monthly periods, some endometrial tissue backs up into the abdomen through the fallopian tubes. This transplanted tissue then grows outside the uterus. Many researchers think a faulty immune system plays a part in endometriosis. In women with the disease, the immune system fails to find and destroy endometrial tissue growing outside of the uterus. Plus, a recent study shows that immune system disorders (health problems in which the body attacks itself) are more common in women with endometriosis. More research in this area may help doctors better understand and treat endometriosis.
How is endometriosis treated?
There is no cure for endometriosis, but there are many treatments for the pain and infertility that it causes. Talk with your doctor about what option is best for you. The treatment you choose will depend on your symptoms, age, and plans for getting pregnant.
Pain Medication. For some women with mild symptoms, doctors may suggest taking over-the-counter medicines for pain. These include: ibuprofen (Advil and Motrin) or naproxen (Aleve). When these medicines don't help, doctors may advise using stronger pain relievers available by prescription.
Hormone Treatment. When pain medicine is not enough, doctors often recommend hormone medicines to treat endometriosis. Only women who do not wish to become pregnant can use these drugs. Hormone treatment is best for women with small growths who don't have bad pain.
Hormones come in many forms including pills, shots, and nasal sprays. Many hormones are used for endometriosis including:
Birth control pills block the effects of natural hormones on endometrial growths. So, they prevent the monthly build-up and breakdown of growths. This can make endometriosis less painful. Birth control pills also can make a woman's periods lighter and less uncomfortable. Most birth control pills contain two hormones, estrogen and progestin. This type of birth control pill is called a "combination pill." Once a woman stops taking them, the ability to get pregnant returns, but so may the symptoms of endometriosis.
Progestins or progesterone medicines work much like birth control pills and can be taken by women who can't take estrogen. When a woman stops taking progestins, she can get pregnant again. But, the symptoms of endometriosis return too.
Gonadotropin releasing hormone agonists or GnRH agonists slow the growth of endometriosis and relieve symptoms. They work by greatly reducing the amount of estrogen in a woman's body, which stops the monthly cycle. Leuprolide (Lupron®) is a GnRH agonist often used to treat endometriosis. GnRH agonists should not be used alone for more than six months. This is because they can lead to osteoporosis. But if a woman takes estrogen along with GnRH agonists, she can use them for a longer time. When a woman stops taking this medicine, monthly periods and the ability to get pregnant return. But, usually the problems of endometriosis also return.
Danazol is a weak male hormone. Nowadays, doctors rarely recommend this hormone for endometriosis. Danazol lowers the levels of estrogen and progesterone in a woman's body. This stops a woman's period or makes it come less often. Danazol also gives pain relief. But it often causes side effects like oily skin, weight gain, tiredness, smaller breasts, and hot flashes. Danazol does not prevent pregnancy and can harm a baby growing in the uterus. Since it can't be used with other hormones, like birth control pills, doctors recommend using condoms, diaphragms, or other "barrier" methods to prevent pregnancy.
Surgery. Surgery is usually the best choice for women with endometriosis who have a severe amount of growths, a great deal of pain, or fertility problems. There are both minor and more complex surgeries that can help. Your doctor might suggest one of the following:
Laparoscopy can be used to diagnose and treat endometriosis. During this surgery, doctors remove growths and scar tissue or destroy them with intense heat. The goal is to treat the endometriosis without harming the healthy tissue around it. Women recover from laparoscopy much faster than from major abdominal surgery.
Laparotomy or major abdominal surgery is a last resort treatment for severe endometriosis. In this surgery, the doctor makes a much bigger cut in the abdomen than with laparoscopy. This allows the doctor to reach and remove growths of endometriosis in the pelvis or abdomen. Recovery from this surgery can take up to two months.
Hysterectomy should only be considered by women who do not want to become pregnant in the future. During this surgery, the doctor removes the uterus. She or he may also take out the ovaries and fallopian tubes at the same time. This is done when the endometriosis has severely damaged them.
How do I cope with a disease that has no cure?
You may feel many emotions—sadness, fright, anger, confusion, and loneliness. It is important to get support to cope with endometriosis. Consider joining a support group to talk with other women who have endometriosis. There are support groups on the Internet and in many communities.
It is also important to learn as much as you can about the disease. Talking with friends, family, and your doctor can help.
For More Information...
You can find out more about endometriosis by contacting the National Women's Health Information Center (NWHIC) at 1-800-994-9662 or the following organizations:
Endometriosis Association Phone Number(s): (414) 355-2200Internet Address: http://www.endometriosisassn.org/
The American College of Obstetricians and Gynecologists Phone Number(s): (800) 762-2264 x 192 (for publication requests only)Internet Address: http://www.acog.org/
Endometriosis Research Center Phone Number(s): (800) 239-7280Internet Address: http://www.endocenter.org/
All material contained in the FAQs is free of copyright restrictions and may be copied, reproduced, or duplicated without permission of the Office on Women's Health within the Department of Health and Human Services. Citation of the source is appreciated.
This FAQ was reviewed by:
Kerri Parks, MDAssistant ProfessorLos Angeles County Women's and Children's HospitalUSC-Keck School of MedicineLos Angeles, CA
Mory Nouriani, MDSher Institute of Reproductive MedicineGlendale, CA

Thursday, November 16, 2006

Endometriosis and Depression

For reasons both physiological and psychological, depression can be a very real part of coping with Endometriosis. Those of you who feel alone in this, don't! You are among a great many who suffer silently as I did for years and years. Whether you are embarrassed or angry with yourself for not being able to 'snap out of it," don't despair. Depression can have it's hold on you so tightly and it's not your fault!
The definition of depression is, "a state of despondency characterized by feelings of inadequacy, lowered activity and pessimism about the future, and extreme state of unresponsiveness to stimuli, together with self-deprecation, delusions of inadequacy and hopelessness". Sadly, this definition implies a defect of character or weakness because you are suffering. Nothing is further from the truth.
Read More on the Jennifer Lewis Endometriosis website
Her site is one of the very best endo clearinghouses on the web....

Wednesday, November 15, 2006

Ovarian remnant syndrome.

Magtibay PM,
Magrina JF.
Division of Gynecologic Oncology, Mayo Clinic, Scottsdale, Arizona 85259, USA. magtibay.paul@mayo.edu
Ovarian remnant syndrome (ORS) refers to a condition occurring in women who have had a bilateral salpingo-oophorectomy (BSO), with or without a hysterectomy, that leaves behind ovarian tissue. This residual ovarian tissue then results in pelvic pain or a pelvic mass. Risk factors associated with incomplete removal of an ovary and subsequent development of ORS include a history of endometriosis, pelvic inflammatory disease, multiple previous surgeries, and pelvic adhesive disease. Patients most frequently present with chronic pelvic pain, pelvic pain associated with a pelvic mass, or an asymptomatic pelvic mass. Definitive criteria for diagnosis of ORS include a history of BSO with histologic documentation of ovarian tissue obtained during subsequent surgical excision. The recommended treatment for ORS is surgical excision by laparotomy or, more recently, laparoscopy. We present the presentation and management of patients with ORS and a review of the published literature.
PMID: 16885659 [PubMed - indexed for MEDLINE]
Clin Obstet Gynecol. 2006 Sep;49

Tuesday, November 14, 2006

The Stage or Severity of Endometriosis

Surgery also helps determine the severity of endometriosis in a patient. Doctors commonly diagnose endometriosis in stages. Here are the common stages of endometriosis:

Stage 1: Endometriosis in stage one is classified as minimal. Most patients will get a score of 1 to 5 points, meaning there are isolated incidents of endometrial tissue growth outside the uterus.

Stage 2: Endometriosis in stage two is considered mild. A patient having a score of 6 to 15 points has mild endometriosis. A doctor makes this diagnosis when there are several small implants and a few small areas of scar tissue or adhesions.

Stage 3: Stage the endometriosis is moderate. Patients with 16 to 40 points have moderate endometriosis. The implants in stage three must be superficial and deep. There must also be several prominent areas of scar tissue or adhesions. Typically the symptoms of endometriosis are common in patients with moderate Stage III endometriosis.

Stage 4: This is the most severe stage of endometriosis, with over 40 points needed for diagnosis. Patients with stage IV endometriosis will have many superficial and deep implants as well as large adhesions. Endometriosis symptoms including infertility are common in patients with stage IV endometriosis.

Some women with endometriosis will have no symptoms at all. The symptoms of endometriosis experienced by women do not necessarily correlate with the severity of the disease or the stage of endometriosis. Some women with mild endometriosis will experience severe symptoms, while women with severe endometriosis may not have any symptoms at all. Pelvic pain however is most common in women with severe endometriosis.
If you suspect that you are experiencing any of the symptoms of endometriosis it is important that you consult with your healthcare provider. Your doctor can provide you with several different treatment alternatives for relieving the pain and discomfort of endometriosis.

Iron Therapy Shows Promise Against Endometriosis

A treatment that eases iron overload could help women fight painful endometriosis , researchers report.
Endometriosis is a disorder in which endometrial tissue develops outside the uterus, and attaches to ligaments and organs in the abdomen. The disease can cause bleeding, pain, inflammation, adhesions and infertility. Experts say up to 10 percent of women may be affected.
In their study with mice, Belgian researchers concluded that an overload of iron in the pelvic cavity may help make these lesions grow by promoting the proliferation of their epithelial (lining) cells. This iron overload does not actually cause endometriosis, the study said.
Read More

Monday, November 13, 2006

Endometriosis Profile

endometriosis externa
General description
Endometriosis is the growth of skin tissue that lines the uterus (called endometrium), at a site outside of the uterus, usually on the lining of the abdominopelvic cavity called the peritoneum. The growing tissue includes both glands and supporting tissue recognizable under the microscope as endometrium but not in the usual location inside the uterus.
The tissue growths are like seeds that implant outside of the uterus and undergo hormonal stimulation just like the tissue inside the uterus and grow and slough monthly. These areas range mostly from the size of a pin head to the size of a pencil eraser although sometimes the lesions can can become quite large like an egg, apple or even grapefruit in size. The endometriosis growths can cause chronic or acute pelvic pain from leakage of their contents (mostly blood and tissue) or from just swelling up with nowhere for the blood and sloughed tissue to go. Also, monthly swelling of extrauterine endometrial tissue may cause inflammation of the nearby tissue and discomfort secondary to the release of irritant chemicals such as prostaglandins, interleukins, or tumor necrosis factor that come from the endometrial tissue (1). This irritation produces symptoms of pelvic pressure or bowel bloating.
While one might expect that a larger area of disease would cause more pain, studies to date show no relationship between the extent of endometriosis, known as stage, and the amount of pain a woman experiences. Women can have severe pain from small areas of endometriosis and very little discomfort even with involvement of large areas in the pelvic cavity. The American Fertility Society developed a staging system for endometriosis based on weighted points. It was revised in 1996 and is supported now by the American Society of Reproductive Medicine. An example of the staging system explains it best.
With respect to infertility, however, data does support a relationship between the amount of disease and the decreased ability to conceive a pregnancy. More advanced endometriosis disease produces more difficulty conceiving (1).
Is it common?
Endometriosis is estimated to be present in anywhere from 2-22% of asymptomatic, reproductive age women, in 40-60% of women who have developed the new onset of severe menstrual cramps, and in 20-30% of women with subfertility. The peak incidence appears to be at age 40. (5) In one group of subfertility patients, a higher incidence of endometriosis was found at laparoscopy, 43%, with about half of those having stage 1-2 disease and half having stage 3 and 4 disease (7).
It is not a new or recent disease of modern living. Endometriosis was described in European documents over 300 years ago. In 1690, a German Physician named Daniel Shroen in a book entitled Dusputatio Inaguralis Medica de Ulceribus Ulceri recorded the first description. Later, in 1860 another German, Carl von Rokitansky, wrote a detailed description of what we now term endometriosis. (3)
Differentiating features
The predominant clinical features of endometriosis are cyclical (mostly monthly), pelvic pain, non-cyclical pelvic pain, backache, pain during intercourse, painful urination, painful bowel movements and infertility. (1, 5)
The definitive diagnosis is made from microscopic examination of tissue biopsies taken at time of laparoscopy or other surgical exploration. Visualization by the surgeon of what looks to be endometriosis is only confirmed about 77% of the time by pathologic examination of the biopsies (8). Histologic confirmation of endometriosis in a biopsy specimen is therefore the gold standard for diagnosis.
Other features
Endometriosis has been reported in almost all tissues such as the bowel, liver, lung, brain and skin. Symptoms would depend upon which tissue is involved and often occur or worsen monthly with the menstrual cycle.
Endometriosis is the result of one or a combination of processes including the following (1):
retrograde menstruation-at the time of menses - blood and endometrial tissue flows backwards out the tubal opening into the pelvis and implants on other pelvic or abdominal structures;
lymphatic and/or vascular spread - microscopic tissue gets into the lymph channels or vascular channels and spread throughout the pelvis and/or body;
reactivation of arrested embryonic cells - small foci of totipotential stem cells from the developmental process become reactivated and differentiate into endometrial tissue;
other unknown mechanisms.
The precise way in which these elements are formed is unknown, but several theories exist. Risk factors known to be associated with endometriosis include the following:
Genetics - an affected mother or sister doubles your risk;
Hormonal status - increased circulating estrogen and prolonged or heavy menses increases your risk, but to an unknown degree;
Lifestyle - obesity and smoking increase your risk, also to an unknown degree. (1)
Unnecessary studies
The tumor marker CA-125 can be positive with endometriosis but is not useful in diagnosing endometriosis, even with ovarian involvement (1). CAT scan, MRI imaging studies, and even ultrasound are not indicated to diagnose endometriosis. They are only helpful if ovarian endometriomas (blood filled cysts of the ovary) are seen, but then the differential diagnosis expands to include all other ovarian tumors both benign and malignant.
Natural historyuntreated
It is thought that endometriosis results in subfertility because the extrauterine implants undergo cyclical bleeding like intrauterine endometrial tissue. This cyclical bleeding causes not only pain but it can result in inflammation, adhesions, fibrosis, distorted pelvic anatomy, endocrine abnormalities, abnormal immune function, altered pelvic chemical environment, and possibly interferes with embryo implantation. (1)
In one study in which laparoscopy was performed 12 months after diagnosis with no treatment in between, it was found that the endometrial implants resolved spontaneously in a quarter, deteriorated in nearly half, and were unchanged in the remainder.
Goals of therapy (Rx)
The goals of treatment should be to reduce pain, increase fertility (if desired), and decrease the amount of surgical intervention needed.
1st choice therapy
The choice of therapy that is best, or first line, should be individualized based on the patient. For example, the treatments for a patient wanting to have children may differ greatly from the treatment for a patient who has completed their childbearing.
For pain as the main symptom
If endometriosis is strongly suspected on the basis of symptoms or if it has been diagnosed as minimal or mild (Stage 1 or 2) by laparoscopy or other surgical exploration, then treatment is primarily suppression of the normal, cyclical ovarian function induced by ovulation. For the patient desiring pain relief and who may or may not have completed childbearing, continuous oral contraceptive pills (OCPs) or DepoProvera® injections (9) and non steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are generally used for 3-6 months (1). If the goal of this therapy is not being met in 3-6 months and endometriosis is just suspected, definitive diagnosis with laparoscopy is indicated before any further treatment.
If endometriosis cysts inside the ovary are found (endometriomas), removal of the cyst results in a lower pain recurrence rate and higher pregnancy rate than just drainage of the cyst (10).
For subfertility - failure to conceive over 12 months of trying - as the main symptom
Surgery should be performed to diagnose the presence and extent of any endometriosis lesions. Tubal patency should be established. Any endometriosis of Stage 3 or 4 (moderate or severe) that restricts normal movement of the Faloppian tubes and/or ovaries, or any endometriosis or scarring involving the small bowel or large intestine should be surgically removed if possible. Scar tissue (adhesions) should be freed up to allow the tubes and ovaries to move as freely in the pelvis. Visible endometriotic implants should be surgically excised or ablated using laser or electrical or thermal cautery. With minimal or mild endometriosis (stage 1 or 2) laser ablation or surgical resection, does not appear to improve fertility rates at all (11). Therefore other causes of infertility have to be ruled out but most treatments end up with the same 45-50% pregnancy rate (12). After a certain amount of time attempting unsuccessfully to conceive, in vitro fertilization may be the best option for patients with endometriosis (13).
Asymptomatic endometriosis
Sometimes endometriosis is diagnosed during surgery for problems unrelated to pain or infertility. Because this disease will progress and become more extensive in a certain percentage of cases, hormonal treatment is recommended to alter the natural course.
Other therapies used
For pain as the main symptom
For a patient who is sure that her childbearing has been completed, hysterectomy and removal of the ovaries may provide symptomatic relief from the pain. Studies have shown that women experience up to 92% relief of symptoms after undergoing a hysterectomy and oophorectomy for endometriosis. If child bearing is not completed or hysterectomy is not an option, gonadotrophin releasing hormone stimulator (GnRH), like leuprolide (Lupron®), may be used in place of OCPs or DepoProvera®. It is very effective in lessening the pain of endometriosis, but there are more side effects than progestin or estrogen and progestin ovulation suppression. Lupron® produces severe hot flashes and depression (14). GnRH treatment should probably be given with "add-back" therapy (menopausal estrogen and progestin) because it lessens the hot flashes but it is just as effective at reducing endometriosis implants as when given alone without the add-back (15).
Laparoscopic presacral neurectomy does not seem to reduce pain with sex, back pain or pain on the right of left sides any more than just laparoscopic resection of the endometriosis alone; midline menstrual cramps may be helped however (16, 17).
For subfertility as the main symptom
For any documented stage of endometriosis, assisted reproductive technology procedures such as in vitro fertilization, or oocyte donation may be options. (1) Adoption is also an alternative after a certain amount of time has been spent with trying to conceive unsuccessfully.
Treatments toavoid
Ovulation suppression to enhance fertility after discontinuing it does not seem to improve conception (18).
Patients should avoid chronic use of narcotic medications.
Reason for Rx choices
A patient’s need for symptomatic pain relief, or subfertility should dictate how treatments should be individualized. Also, it should be pointed out that the treatments that help control pain best, OCP’s and GnRH agonists, work by suppressing ovulation and themselves keep patients from conceiving. It is very important that a woman and her physician communicate and agree upon the goals of treatment for endometriosis, so that there is the best possible outcome with the treatments available.
Birth control pills alone seem to be as effective at reducing pain from endometriosis as GnRH medications (19). Since they are less expensive and have less side effects, they are the first choice therapy over GnRH agonists.
1. Adamson, G. D.: A 36-year-old woman with endometriosis, pelvic pain, and Infertility. JAMA 1999; 282:2347-54
2. Redwine DB: Ovarian endometriosis: a marker for more extensive pelvic and intestinal disease. Fertil Steril 1999; 72(2):310-5
3. Knapp VJ: How old is endometriosis? Late 17th-and 18th-century European descriptions of the disease. Fertil Steril 1999; 72(1):10-4
4. Olive DL, Pritts EA: Drug therapy: Treatment of endometriosis. N Engl J Med 2001. 26;345(4):266-75
5. Farquhar, CM: Endometriosis. BMJ 2000 27;320(7247):1449-52
6. Prentice A: Regular review: Endometriosis. BMJ 2001 14;323(7304):93-5
Other resources
Images of endometriosis
Endometriosis Association

Patients with deep infiltrating endometriosis represent a challenge to surgical procedures

Langebrekke A,
Istre O,
Busund B,
Johannessen HO,
Qvigstad E.
Department of Gynaecology, Ulleval University Hospital, Oslo, Norway. anton.langebrekke@ulleval.no
BACKGROUND: To study the feasibility, complications and symptom relief of laparoscopic treatment in patients with deep infiltrating endometriosis. METHODS: From January 2004 to March 2005, 24 patients with deep infiltrating endometriosis were treated with laparoscopic techniques. Preoperative symptoms, staging, involvement of the disease, and surgical procedures were recorded. Operating time and perioperative complications were also registered, as well as follow-up of the patients. RESULTS: The surgical treatment was individualized with removal of deep infiltrating endometriosis in all 24 patients, additional bladder resection in five patients and colorectal resection in eight patients. In two cases laparoconversion was performed, and one patient had a temporary loop ileostomy. We observed no major peri- or postoperative complications. Median operating time was 3.4 h (range 1.4-8.0 h). All patients with bladder involvement were relieved of their urinary dysfunction, while all except three patients were successfully treated for their pain problems, and also these three patients had symptom relief. CONCLUSIONS: Patients with deep infiltrating endometriosis represent a challenge to surgical procedures. Our results show that radical laparoscopic surgery including colorectal and bladder resection is feasible, safe, and effective in almost all patients.
PMID: 16752264 [PubMed - indexed for MEDLINE]
Acta Obstet Gynecol Scand. 2006;85(6):712-5.

Saturday, November 11, 2006

A rare case of precoccygeal endometriosis

Titre du document / Document title
A rare case of precoccygeal endometriosis
Auteur(s) / Author(s)
MICHA John P. (1) ; GOLDSTEIN Bram H. (1) ; RETTENMAIER Mark A. (1) ; BROWN John V. (1) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Gynecologic Oncology Associates, Hoag Memorial Hospital Cancer Center, Newport Beach, California, ETATS-UNIS

Résumé / Abstract
BACKGROUND: Endometriosis is commonly identified in the abdomen, specifically the ovaries, adnexa, and fallopian tubes, and sometimes in more distant areas; precoccygeal endometriosis is an extremely rare phenomenon. CASE: We present a case involving a 44-year-old woman diagnosed and treated for precoccygeal endometriosis. She underwent laparotomy, extensive lysis of pelvic adhesions, and resection of a 2.5-cm midline precoccygeal mass. After surgical excision of the precoccygeal endometriosis, the patient recovered without incident. CONCLUSION: Precoccygeal endometriosis is a very rare diagnosis.
Revue / Journal Title
Obstetrics & gynecology (Obstet. gynecol.) ISSN 0029-7844 CODEN OBGNAS

Pain Management: Neuropathic Pain

Neuropathic pain is a complex, chronic pain state that usually is accompanied by tissue injury. With neuropathic pain, the nerve fibers themselves may be damaged, dysfunctional or injured. These damaged nerve fibers send incorrect signals to other pain centers. The impact of nerve fiber injury includes a change in nerve function both at the site of injury and areas around the injury.
One example of neuropathic pain is called phantom limb syndrome. This occurs when an arm or a leg has been removed because of illness or injury, but the brain still gets pain messages from the nerves that originally carried impulses from the missing limb. These nerves now misfire and cause pain.
What Causes Neuropathic Pain?
Neuropathic pain often seems to have no obvious cause; but, some common causes of neuropathic pain include:
Back, leg, and hip problems
Facial nerve problems
HIV infection or AIDS
Multiple sclerosis
Spine surgery
What Are the Symptoms of Neuropathic Pain?
Symptoms may include:
Shooting and burning pain
Tingling and numbness
How Is Neuropathic Pain Diagnosed?
A doctor will conduct an interview and physical exam. He or she may ask questions about how you would describe your pain, when the pain occurs, or whether anything specific triggers the pain.
How Is Neuropathic Pain Treated?
Some neuropathic pain studies suggest the use of non-steroidal anti-inflammatory drugs, such as Aleve or Motrin, may ease pain. Some people may require a stronger painkiller, such as those containing morphine. Anticonvulsant and antidepressant drugs seem to work in some cases.
If another condition, such as diabetes, is involved, better management of that disorder may alleviate the pain.
In cases that are difficult to treat, a pain specialist may use invasive or implantable device therapies to effectively manage the pain. Electrical stimulation of the nerves involved in neuropathic pain generation may significantly control the pain symptoms.
Unfortunately, neuropathic pain often responds poorly to standard pain treatments and occasionally may get worse instead of better over time. For some people, it can lead to serious disability.
Reviewed by the doctors at The Cleveland Clinic Pain Management Department. Edited by Charlotte E. Grayson, MD, WebMD, June 2004.

Friday, November 10, 2006

Ahead of the Bell: Neurocrine Biosciences

NEW YORK — Shares of Neurocrine Biosciences Inc. edged higher in Tuesday premarket electronic trading after a Baird analyst upgraded the biopharmaceutical company and said any disappointing news related to insomnia drug Indiplon would likely be offset by gains from other products.
Neurocrine's stock plunged on Friday after the company said it planned to conduct more studies on Indiplon. The Food and Drug Administration rejected a high-dose version of the drug and also requested more information on two lower dose versions.
But analyst Lawrence H. Neibor upgraded his rating on the stock to "Neutral" from "Underperform," expecting the company to see gains from other products, including its Gonadotropin-Releasing Hormone, or GnRH, antagonist in endometriosis a condition where endometrial tissue grows outside the uterus and forms painful cysts on the ovaries, fallopian tubes and abdominal cavity.
"With investor expectations currently running at a seven-year low, we believe the potential for future Indiplon disappointment is balanced by the potential for positive updates on earlier-stage products in the pipeline such as the GnRH antagonist in endometriosis," Neibor said.
In a Phase 1 dosing trial, data showed that its endometriosis treatment lowered levels of a female hormone, estradiol, associated with the disease.
Neibor also said his upgrade was based on a stock price that is approaching his $7 price target, as well as Indiplon gains once the drug is finally launched.
"The launch of Indiplon would quickly transition the company from the development stage to an operating entity and could make the company profitable shortly thereafter," Neibor wrote in a client note.
The stock rose 12 cents to $7.96 in the premarket electronic session, after closing at $7.73 on the Nasdaq.

Hysterectomy in the United States, 1980–1993

Frequency of Hysterectomy
Approximately 600,000 hysterectomies are performed each year in the United States at an estimated annual cost of more than $5 billion. More than one-fourth of U.S. women will have this procedure by the time they are 60 years of age. Hysterectomy is the second most frequent major surgical procedure among reproductive-aged women.
From 1980 through 1993, an estimated 8.6 million U.S. women had a hysterectomy.
The rates of hysterectomy per 1,000 women aged 15 years and older declined slightly from 1980 (7.1) to 1987 (6.6). From 1988 to 1993, the average annual rate was stable at 5.5. The decline observed from 1987 to 1988 is a result of changes in the survey used to collect the data.
Women at High Risk for Hysterectomy
From 1980 through 1993, rates of hysterectomy differed by age.
Each year, rates were highest among women aged 40–44 years and lowest among women aged 15–24 years.
Of all hysterectomies, 55% were among women aged 35–49 years.
Hysterectomy rates also differed by geographic region.
From 1988 through 1993, almost twice as many women received hysterectomies in the South (6.8 per 1,000 women) as in the Northeast (3.9). The average annual rates were 5.5 in the Midwest and 4.9 in the West.
During 1980–1993, the average age of women who had a hysterectomy was 47.7 years in the Northeast, 44.5 in the Midwest, 44.0 in the West, and 41.6 in the South.
Annual rates did not differ significantly by race.
Conditions Associated with Hysterectomy
During 1988–1993, the three conditions most often associated with hysterectomy were uterine leiomyoma ("fibroid tumors"), endometriosis, and uterine prolapse.
Among women less than 30 years of age, the conditions most frequently associated with hysterectomy were menstrual disturbances and cervical dysplasia. Among women aged 30–34 years, endometriosis was the most frequently associated diagnosis; among those 35–54 years, fibroid tumors; and among women 55 years and older, uterine prolapse or cancer.
Hysterectomy Surveillance
CDC compiles information on hysterectomies by using data from CDC’s National Hospital Discharge Survey. This survey, which collects data on discharges from U.S. hospitals, provides the only population-based estimates of U.S. hysterectomy rates.
Data from national hysterectomy surveillance can be used to increase understanding of the relative public health importance of the conditions that lead to hysterectomy, identify changes in clinical practice, and assist in setting biomedical research priorities.
The complete report may be printed by downloading the 15-page August 8, 1997, Special Focus: Surveillance for Reproductive Health surveillance summary, Hysterectomy Surveillance--United States, 1980–1993 (796KB PDF) Source: MMWR, August 8, 1997, Vol 46, No SS04;1.
Back to Hysterectomy

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Date last reviewed: 04/17/2006

Wednesday, November 08, 2006

ENDOMETRIOSIS Is surgery the best treatment?…Teenagers get endometriosis, too… Aromatase inhibitors

April 2006 · Vol. 18, No. 4

ENDOMETRIOSIS Is surgery the best treatment?…Teenagers get endometriosis, too… Aromatase inhibitors

Anthony R. Scialli, MD
Principal Scientist, Sciences International, Inc.,Alexandria, Va, and Adjunct Professor,Department of Obstetrics and Gynecology,Georgetown University School of Medicine,Washington, DC
Surgery may not be the best option for diagnosis and treatment of endometriosis, one of the most common causes of chronic pelvic pain. Although laparoscopy has been the traditional approach, new findings show surgery may cause more adhesions than it removes.
Recent research has also focused on endometriosis in adolescents—and the lack of consensus on what treatment is best. Finally, aromatase inhibitors, a new class of hormone-based therapy, look promising for treatment of pain due to endometriosis.

Even adhesion-reducing surgery causes (and may worsen) adhesions

Surgery avoidance may be the best strategy for evading adhesions
Fast Track
Adhesions after surgery are inevitable, even with meticulous technique
Parker JD, Sinaii N, Segars JH, Godoy H, Winkel C, Stratton P. Adhesion formation after laparoscopic excision of endometriosis and lysis of adhesions. Fertil Steril. 2005;84:1457–1461.
We have known for decades that surgery causes adhesions. The importance of this study is that it demonstrated that careful and thorough surgery designed to remove adhesions and endometriotic implants appears to make no difference in the presence of adhesions 2 years later, and might even worsen adhesions.
This NIH study evaluated 38 women with chronic pelvic pain attributed to endometriosis. At the time of an initial laparoscopy, the locations of endometriosis lesions and adhesions were recorded. All lesions and adhesions were excised using a neodymium-YAG laser, with meticulous hemostasis and careful tissue handling. Ovaries were wrapped in an adhesion barrier (Interceed) after removal of endometriomas; adhesion barriers were otherwise not used. Second-look laparoscopy was performed 2 years later to assess the presence of adhesions.
At the initial surgery, 74% of the 38 patients had adhesions, and at the second-look operation, 82% of the patients had adhesions. Most of the adhesions found at the second operation were not at the original adhesion sites—they were at sites where endometriosis had been excised.
Eighteen endometriomas were excised at the first operation. Although ovaries had been wrapped in an adhesion barrier after excision of the endometriomas, operative site adhesions occurred at 15 of the 18 excision sites. Despite this apparent failure of a barrier to prevent ovarian adhesions, the authors speculated that use of an adhesion barrier after adhesiolysis and after resection of superficial lesions might have prevented some of the adhesions they saw at second-look surgery.

Do adhesions cause pain?
A question not addressed is the role of adhesions in pain; this study did not report pain results. Although the researchers stated that they assumed that adhesions can cause pain, randomized trials have not confirmed this belief.1,2 Even if adhesions do cause pelvic pain, surgery does not appear to be an effective way to reduce adhesions in the long run.REFERENCES
1. Peters AAW, Trimbos-Kemper GCM, Admiral C, Trimbos JB. A randomized clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol. 1992;99:59–62.
2. Swank DJ, Swank-Bordewijk SC, Hop WC, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomized controlled multi-centre trial. Lancet. 2003;361:1247–1251.

Adolescents get endometriosis, too Should they have laparoscopy?

Given the propensity of surgery to cause adhesive disease, the fertility of young women may be at risk
Fast Track
There is no evidence that progestins and GnRH analogs are less safe than OCs for endometriosis therapy in teens
The ACOG Committee Opinion does a disservice in promoting laparoscopy as superior to drug therapy for endometriosis in young women
Song AH, Advicula AP. Adolescent chronic pelvic pain. J Pediatr Adolesc Gynecol. 2005;18:371–377.
Stavroulis AI, Saridogan E, Creighton SM, Cutner AS. Laparoscopic treatment of endometriosis in teenagers. Eur J Obstet Gynecol Reprod Biol. 2006; in press.
ACOG Committee on Adolescent Health Care. Endometriosis in adolescents. ACOG Committee Opinion No. 310. Obstet Gynecol 2005;105:921–927.
Evaluation and treatment of adolescents with chronic pelvic pain can be more challenging than the care of adults with this complaint. Song and Advicula encourage clinicians to consider endometriosis even in the very young adolescent, and they stress attention to the privacy of the adolescent and the importance of letting her decide whether an accompanying parent should be present during an examination.
It is unfortunate that laparoscopy early in the work-up is encouraged, without evidence of the effectiveness of surgery. Oral contraceptives and nonsteroidal anti-inflammatory drugs are recommended as empiric therapy, but progestins and gonadotropin-releasing hormone (GnRH) analogs are discouraged, although there is no evidence that progestins and GnRH analogs are less safe than oral contraceptives in this age group.
A number of conditions that cause chronic pelvic pain in adolescents are described, but missing are discussions of psychiatric disorders and fibromyalgia, which are important causes of chronic pain.
Stavroulis et al is the latest of anecdotal reports claiming that laparoscopic treatment of endometriosis in teenagers is safe and effective. In this retrospective review of case records of 31 girls younger than 21 years who underwent laparoscopy for chronic pelvic pain, no abnormalities were found in 36% and endometriosis was found in another 36%. The remainder had other findings, including some (ovarian cysts) that are not generally associated with chronic pain, and others (obstructed uterine horn) suggesting that endometriosis may have been missed. Six girls with severe endometriosis had surgical excision, and 5 of the 6 were described as improved after 19 to 112 months of follow-up.
As in most of the literature advocating surgical management of endometriosis, this study had no control group treated with placebo surgery or other therapies. In addition, all the young women who underwent surgery were treated postoperatively with hormonal therapy for an unspecified length of time, making it unclear how much of the pain relief was due to surgery.

What’s wrong with these recommendations?
The ACOG Committee Opinion calls attention to the importance of considering endometriosis as a cause of pain in adolescents. The Opinion offers empiric therapy as an option for the management of young women with chronic pain believed to be due to endometriosis, but does a disservice in promoting laparoscopy as a superior method of diagnosis and treatment. The empiric therapy recommendation is marred by the statement that GnRH analogs should not be used in patients younger than 18 years, with surgery as the only option in this age group. The Committee goes on to recommend that if endometriosis is not visualized at surgery, the patient should be referred for gastrointestinal or urologic evaluation and for pain management services.
Withholding GnRH analogs in women under age 18 is arbitrary and without scientific foundation. The Committee expresses the concern that these agents might interfere with mineralization during this time of maximal bone accretion, and points to the lack of studies of GnRH analog therapy in this age group; however, it is acknowledged that add-back hormone therapy prevents bone mineral loss in the general population of women treated with GnRH analogs.1,2
Although the Committee is reluctant to recommend therapy because data from this age group are inadequate, it recommends laparoscopy despite the lack of data in this age group on either safety or effectiveness of surgery. The one study cited in support of the effectiveness of surgery3 was performed in adults, and compared laparoscopic excision to diagnostic laparoscopy, not to medical therapy. Finally, the Committee ignores danazol, a medication that continues to be useful for some patients.
Does surgery have more adverse consequences in adolescents than in adults? We don’t know. Given the propensity of surgery to cause adhesive disease, however, the fertility of these young women may be at risk. It is particularly disappointing to see the Committee recommending evaluation for gastrointestinal and urologic disease after failed surgery.
The correct approach is the evaluation and treatment of the patient before, and preferably instead of surgery.4REFERENCES
1. Hornstein MD, Surrey ES, Weisberg GW, Casino LA. Leuprolide acetate depot and hormonal add-back in endometriosis: a 12-month study. Obstet Gynecol. 1998;91:16–24.
2. Surrey ES, Hornstein MD. Prolonged GnRH agonist and add-back therapy for symptomatic endometriosis: long-term follow-up. Obstet Gynecol. 2002;99:709–719.
3. Abbott J, Hawe J, Hunter D, Holmes M, Finn P, Garry R. Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004;82:878–884.
4. Peters AAW, van Dorst E, Jellis B, van Zuuren E, Hermans J, Trimbos JB. A randomized trial to compare 2 different approaches to women with chronic pelvic pain. Obstet Gynecol. 1991;77:740–744.

Medical treatment: Aromatase inhibitors for endometriosis

It is time for a controlled trial on the question of whether aromatase inhibitors are superior to placebo or other medical treatments for endometriosis
Hefler LA, Grimm C, van Trotsenburg M, Nagele F. Role of the vaginally administered aromatase inhibitor anastrozole in women with rectovaginal endometriosis: a pilot study. Fertil Steril. 2005;84:1033–1036.
Amsterdam LL, Gentry W, Jobanputra S, Wolf M, Rubin SD, Bulun SE. Anastrozole and oral contraceptives: a novel treatment for endometriosis. Fertil Steril. 2005;84:300–304.
It has been widely accepted for decades that endometriosis is estrogen-dependent. More recently, it has been suspected that ectopic endometrium contains aromatase enzyme, which can produce estrogens locally from circulating androgens. This possibility has led to the use of aromatase inhibitors for the treatment of endometriosis.
Two new studies report on the use of the aromatase inhibitor anastrozole, which is marketed for the treatment of breast cancer:

Dose too low? Hefler and colleagues treated 10 patients with rectovaginal endometriosis, using a low dose (0.25 mg/day) of vaginal anastrozole, without much improvement in symptoms. They suggested that the dose may have been too low.

Higher dose improved pain. Amsterdam and colleagues reported that pain improved in 15 of 18 patients who used anastrozole at a dosage of 1 mg/day by mouth. An oral contraceptive was given for hot flash control and prevention of bone mineral loss.
These results, along with other reports in the literature, are encouraging. It is now time for a controlled trial to investigate whether aromatase inhibitors are superior to placebo or other medical treatments for endometriosis.
The author has been a consultant for TAP Pharmaceuticals.


Tuesday, November 07, 2006


1.) Chronic pelvic pain in women... (patients.uptodate.com) 2.) Chronic Pelvic Pain: A Tricky Diagnosis... (www.womenshealthmatters.ca ) 3.) Pelvic Pain... (healthywomen.org ) 4.) Chronic pelvic pain... (mayoclinic.com) 5.) All About Pelvic Pain... (isge.org) 6.) Chronic Pelvic Pain: A Patient Educational Booklet... (pelvicpain.org) 7.) Chronic Pelvic Pain is not " all in your head."... (Url is not found)

1.) Patient information: Chronic pelvic pain in women... Current through August 2005 http://www.patients.uptodate.com/topic.asp?file=wom_issu/4999&title=Pelvic+pain&session=GTgjmFHas36mp1GsgKoGKWs0O4
WHAT CAN CAUSE CHRONIC PELVIC PAIN? • Gynecologic causes • Other causes
HOW IS GYNECOLOGIC PELVIC PAIN TREATED? • Medical treatment • Surgical treatment

2.) Chronic Pelvic Pain: A Tricky Diagnosis... A Canada-based web site... http://www.womenshealthmatters.ca/facts/quick_show_d.cfm?number=567&session=GTgjmFHas36mp1GsgKoGKWs0O4
"The difficulty of obtaining a proper diagnosis and adequate treatment is due in part to the fact that many doctors are not well informed about the causes of pelvic pain."

3.) Pelvic Pain... http://www.healthywomen.org/content.cfm?L1=3&L2=124
- Overview - Diagnosis - Treatment - Prevention - Facts to Know - Questions to Ask
Key Q&A - Lifestyle Tips - Test Your Knowledge

4.) Chronic pelvic pain...
- Overview - Signs and symptoms - Causes - When to seek medical advice
Screening and diagnosis - Treatment - Self-care

5.) All About Pelvic Pain... http://isge.org/pshowp.php?pid=80
- What Defines Pelvic Pain? - What Are the Causes of Pelvic Pain? - Diagnosing Pelvic Pain - Some Potential Causes of Pelvic Pain - Treatment Options - Additional Treatment Options - Conclusion

6.) Chronic Pelvic Pain: A Patient Educational Booklet...
Understanding the Principles of Chronic Pelvic Pain
- Chronic Pelvic Pain: An Introduction - What is Chronic Pelvic Pain? -
Can CPP Start One Place and End Up Somewhere Else? - How Is Pain Perceived? -
What Are the Basic Elements of CPP? - How Do They Apply to Pain Therapy? -
How Do I Find Out If I Have CPP?
Appendix A - Sample Drug Contract

7.) Chronic Pelvic Pain is not " all in your head." (Url is not found)
"Many women are held captive by a recurring or constant pain in the abdomen. The pain can be intense and sometimes debilitating. It may last for months or even years, leading some women to jump from physician to physician in search of a cure.
"Chronic pelvic pain is defined as a pain in the pelvic or lower abdomen area, not related to the menstrual cycle, which persists for six months or more. Because of its vague and inconsistent symptoms, chronic pelvic pain is difficult to diagnose. But it is real, and in most cases it can be treated.
"There may be one factor causing the pain or there may be many. If the pain is gynecological, it could be caused by such conditions as pelvic adhesions, endometriosis, or pelvic inflammatory disease. Other common causes of pelvic pain are not gynecological, including irritable bowel syndrome, appendicitis or inflammation in the urinary tract.
"Because pelvic pain can be caused by a myriad of disorders, it is important to find a doctor who is sensitive to your needs and willing to take the time to solve the problem. Don't let anyone dismiss it as being " all in your head.". The solution may require time and energy, but most causes of pelvic pain can be treated successfully."

Monday, November 06, 2006

Retroversion of the uterus Tipped uterus


Alternative names Uterus retroversion; Malposition of the uterus; Tipped uterus

Retroversion of the uterus is a normal variation of female pelvic anatomy in which the body of the uterus is tipped toward the back rather than forward.

Causes, incidence, and risk factors
Retroversion of the uterus is common and is found to be the normal uterine position in about 20% of all women. Laxness of the supporting pelvic ligaments associated with menopause may cause retroversion in women who previously did not have a retroverted uterus.
Enlargement of the uterus, either as the result of a pregnancy or a tumor, may also change the relative position of the uterus within the pelvis. Pelvic adhesions (scar tissue that forms in the pelvis) resulting from salpingitis, pelvic inflammatory disease, or endometriosis have also been associated with holding the uterus in a retroflexed position.

Uterine retroversion by itself almost never causes any symptoms.
Rarely, retroversion of the uterus caused by an enlarging pregnancy or tumor may cause pelvic pain or discomfort.
Retroversion of the uterus resulting from other causes such as endometriosis may be associated with the symptoms of the underlying disorder.

Signs and tests
A pelvic examination reveals the position of the uterus. However, a tipped uterus can sometimes be mistaken for a pelvic mass or an enlarging fibroid. A rectovaginal exam may be used to distinguish between a mass and a retroverted uterus.
An ultrasound examination can be used to determine the exact position of the uterus, if necessary.

Treatment is usually not necessary. Any underlying disorders (such as endometriosis or adhesions) may be treated as needed.

Expectations (prognosis)
Usually this condition does not cause problems.

Atypical positioning of the uterus may be caused by endometriosis, salpingitis, or pressure from a growing tumor. These conditions should be ruled out in a patient with pain or other symptoms.

Calling your health care provider
Call your health care provider if you develop persistent pelvic pain or discomfort.

There is no known prevention. However, early treatment of PID or endometriosis may reduce the chances of a change in the position of the uterus.

Update Date: 10/25/2004
Updated by: Peter Chen, M.D., Department of Obstetrics & Gynecology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.