Thursday, September 29, 2011
Tuesday, September 27, 2011
Endometri-what? THE Female Trouble
By Jenn | Published: September 8, 2011
As I flipped through the 2011 Philly Fringe catalogue this summer, Cathy Quigley’s show Female Trouble almost didn’t catch my eye. To me, Female Trouble is a 1974 John Waters movie, a Charm City roller girls team or a reference that is bound to be offensive when it comes out of the mouth of a man (sorry, men). Ironically, this Female Trouble is the Fringe show I am most looking forward to seeing during the Festival this year because, as I found out, it’s the one I can relate to the most.
There are fifteen female performers, ranging in age from 18 to 50, in Cathy’s production, a multimedia performance about endometriosis. Endometri-what? (That, coincidently is the working title of my book about the disease.) This disease affects 10-15% of all women and is one of the top causes of infertility in women in this country. Normally, a women’s uterus will collect and grow tissue to prep itself for a baby and if said woman doesn’t become pregnant, it will release the endometrial lining that has formed. (This is her period.) When a woman has endometriosis, that endometrial tissue not only attaches itself to the uterus walls but also outside the uterus. Most commonly, it will create cysts on the ovaries but in more extreme cases, it can attach to other organs like the bowels, the intestines, even the lungs. The inflammation of the tissue not only affects the way the organ works but also creates a great deal of pain and fatigue in the woman suffering from endometriosis. Forty percent of all women who have endometriosis are infertile.
“This is a show about the patient,” Cathy told me when we spoke. “And while it focuses on endometriosis, it is about women’s health in general. My goal is to teach women to become their own activists when it comes to their health.”
After the jump: The challenges of diagnoses, and the intersection of drama, culture, and fertility.
Cathy doesn’t have to convince me. My endometriosis knowledge is not because of pre-interview research. I was diagnosed at age twenty one and since then, I’ve had two surgeries and even on days where I’m sure, to you, I look fine, I’m probably not. Endometriosis is not fatal but the pain is life altering. While learning how to decrease my own external symptoms of the disease, I saw nine doctors in six weeks. This is not uncommon, as Cathy confirmed.
“When I was in my twenties,” Cathy told me. “I suffered a lot of bizarre medical issues. My period was irregular and painful. I had a lot of stomach pain.” After two years of uncomfortable tests and probing by doctors, a nurse practitioner asked Cathy if she had ever heard of endometriosis.
“Ten to fifteen of women have this disease,” Cathy said. “And yet, it took two years for a medical professional to mention it [to me].”
Cathy became obsessed, something she and I have in common even though she doesn’t suffer from the disease. Laposcopic surgery showed she didn’t have the disease but she did have a ruptured cyst on her ovary. Once a surgeon cleaned that up and Cathy changed her diet, she felt much better. This is an illness that few doctors know about, and that has no cure. While wome speculate on the causes — and I find that those speculations come more from patients than from doctors -– there is no concrete explanation of where it comes from. 176,000,000 women suffer from this disease and yet, it has an average nine-year diagnosis rate: it takes nine years from the time a woman tells her doctor she has the symptoms of it to the time where a medical professional actually diagnoses her as having the disease.
Cathy and I talked about how endometriosis is a “silent” disease. It doesn’t have 5K races or marathons. It doesn’t have a designated ribbon. Mention it and women might have heard of it, or know someone who has it, but few can tell you exactly what it is or how it works.
While I believe that, among other things, that little is known because our society is so uncomfortable with talking about sex (one of the most common symptoms of endometriosis is painful sex for the woman with the disease), Cathy also thinks women’s relationship with fertility has a lot to do with it.
Cathy became interested in fertility while working on Female Troubles, the first version of which was her senior project at Montclair State University.
“In Western Culture,” Cathy says, “Women are obsessed with having a child. From a very young age, females are conditioned to have children. We are given dolls when we are kids and we are told to babysit when we are in high school. It is not always an easy thing to conceive a child and women don’t talk about that. It’s almost a taboo. But women are obsessed with it. You can see a Viagra commercial every time you turn on the television.” But no one is trying to sell you a drug to prevent your female parts from disintegrating during the next commercial break.
Her view on fertility is only one of Cathy’s sentiments that won me over. It is also something I can relate to. As an artist myself, I know that there are ways to create or give birth in today’s world that have nothing to do with giving birth to and raising a child however; as a victim of the disease (endometrial lesions were so heavy that they caused my fallopian tubes to fold over on themselves), infertility will always make me feel biologically broken.
“My hope is to be able to tour this piece to colleges and other spots where I can raise awareness about the disease,” Cathy said. “I’m not an ignorant person. I am educated and knowledgeable but until I dug deep into the research, I hadn’t even heard of the disease. With this piece, I want to raise awareness, explore why doctors know very little about women’s health and create an open dialogue to discuss these ideas.”
Female Trouble runs at 8:00 pm on Saturday, September 10 at 8:00 pm and at 2:00 pm on Sunday, September 11 at the Painted Art Bride Center, 230 Vine Street. $14.
–Jennifer Leah Peck
http://blog.livearts-fringe.org/2011/09/08/endometri-what-the-female-trouble
As I flipped through the 2011 Philly Fringe catalogue this summer, Cathy Quigley’s show Female Trouble almost didn’t catch my eye. To me, Female Trouble is a 1974 John Waters movie, a Charm City roller girls team or a reference that is bound to be offensive when it comes out of the mouth of a man (sorry, men). Ironically, this Female Trouble is the Fringe show I am most looking forward to seeing during the Festival this year because, as I found out, it’s the one I can relate to the most.
There are fifteen female performers, ranging in age from 18 to 50, in Cathy’s production, a multimedia performance about endometriosis. Endometri-what? (That, coincidently is the working title of my book about the disease.) This disease affects 10-15% of all women and is one of the top causes of infertility in women in this country. Normally, a women’s uterus will collect and grow tissue to prep itself for a baby and if said woman doesn’t become pregnant, it will release the endometrial lining that has formed. (This is her period.) When a woman has endometriosis, that endometrial tissue not only attaches itself to the uterus walls but also outside the uterus. Most commonly, it will create cysts on the ovaries but in more extreme cases, it can attach to other organs like the bowels, the intestines, even the lungs. The inflammation of the tissue not only affects the way the organ works but also creates a great deal of pain and fatigue in the woman suffering from endometriosis. Forty percent of all women who have endometriosis are infertile.
“This is a show about the patient,” Cathy told me when we spoke. “And while it focuses on endometriosis, it is about women’s health in general. My goal is to teach women to become their own activists when it comes to their health.”
After the jump: The challenges of diagnoses, and the intersection of drama, culture, and fertility.
Cathy doesn’t have to convince me. My endometriosis knowledge is not because of pre-interview research. I was diagnosed at age twenty one and since then, I’ve had two surgeries and even on days where I’m sure, to you, I look fine, I’m probably not. Endometriosis is not fatal but the pain is life altering. While learning how to decrease my own external symptoms of the disease, I saw nine doctors in six weeks. This is not uncommon, as Cathy confirmed.
“When I was in my twenties,” Cathy told me. “I suffered a lot of bizarre medical issues. My period was irregular and painful. I had a lot of stomach pain.” After two years of uncomfortable tests and probing by doctors, a nurse practitioner asked Cathy if she had ever heard of endometriosis.
“Ten to fifteen of women have this disease,” Cathy said. “And yet, it took two years for a medical professional to mention it [to me].”
Cathy became obsessed, something she and I have in common even though she doesn’t suffer from the disease. Laposcopic surgery showed she didn’t have the disease but she did have a ruptured cyst on her ovary. Once a surgeon cleaned that up and Cathy changed her diet, she felt much better. This is an illness that few doctors know about, and that has no cure. While wome speculate on the causes — and I find that those speculations come more from patients than from doctors -– there is no concrete explanation of where it comes from. 176,000,000 women suffer from this disease and yet, it has an average nine-year diagnosis rate: it takes nine years from the time a woman tells her doctor she has the symptoms of it to the time where a medical professional actually diagnoses her as having the disease.
Cathy and I talked about how endometriosis is a “silent” disease. It doesn’t have 5K races or marathons. It doesn’t have a designated ribbon. Mention it and women might have heard of it, or know someone who has it, but few can tell you exactly what it is or how it works.
While I believe that, among other things, that little is known because our society is so uncomfortable with talking about sex (one of the most common symptoms of endometriosis is painful sex for the woman with the disease), Cathy also thinks women’s relationship with fertility has a lot to do with it.
Cathy became interested in fertility while working on Female Troubles, the first version of which was her senior project at Montclair State University.
“In Western Culture,” Cathy says, “Women are obsessed with having a child. From a very young age, females are conditioned to have children. We are given dolls when we are kids and we are told to babysit when we are in high school. It is not always an easy thing to conceive a child and women don’t talk about that. It’s almost a taboo. But women are obsessed with it. You can see a Viagra commercial every time you turn on the television.” But no one is trying to sell you a drug to prevent your female parts from disintegrating during the next commercial break.
Her view on fertility is only one of Cathy’s sentiments that won me over. It is also something I can relate to. As an artist myself, I know that there are ways to create or give birth in today’s world that have nothing to do with giving birth to and raising a child however; as a victim of the disease (endometrial lesions were so heavy that they caused my fallopian tubes to fold over on themselves), infertility will always make me feel biologically broken.
“My hope is to be able to tour this piece to colleges and other spots where I can raise awareness about the disease,” Cathy said. “I’m not an ignorant person. I am educated and knowledgeable but until I dug deep into the research, I hadn’t even heard of the disease. With this piece, I want to raise awareness, explore why doctors know very little about women’s health and create an open dialogue to discuss these ideas.”
Female Trouble runs at 8:00 pm on Saturday, September 10 at 8:00 pm and at 2:00 pm on Sunday, September 11 at the Painted Art Bride Center, 230 Vine Street. $14.
–Jennifer Leah Peck
http://blog.livearts-fringe.org/2011/09/08/endometri-what-the-female-trouble
Monday, September 26, 2011
Early-Stage Endometriosis Diagnosis Possible With New Test
Main Category: Women's Health / Gynecology
Article Date: 22 Sep 2011 - 2:00 PDT
A new test has been developed by surgeons and scientists based at Southampton's teaching hospitals, that could transform they way early-stage endometriosis is diagnosed.
In an investigation funded by the Infertility Research Trust, Miss Ying Cheong, a consultant gynecologist and co-funder of the Complete Fertility Center in Southampton, together with Dr. Tracey Newman, an academic at the University of Southampton's faculty of medicine, used small particles marked with fluorescent markers to bring to light areas of affected tissue.
Endometriosis, a female health disorder that occurs when small pieces of the uterus grow on to different organs such as the ovaries and fallopian tubes, that can cause heavy bleeding, stomach and back pain as well as infertility, can take up to seven to surface. In the UK, approximately 2 million women are affected by this condition, several of whom are diagnosed between 25 and 40 years of age.
Click here to read the rest of the article: http://www.medicalnewstoday.com/articles/234802.php
Article Date: 22 Sep 2011 - 2:00 PDT
A new test has been developed by surgeons and scientists based at Southampton's teaching hospitals, that could transform they way early-stage endometriosis is diagnosed.
In an investigation funded by the Infertility Research Trust, Miss Ying Cheong, a consultant gynecologist and co-funder of the Complete Fertility Center in Southampton, together with Dr. Tracey Newman, an academic at the University of Southampton's faculty of medicine, used small particles marked with fluorescent markers to bring to light areas of affected tissue.
Endometriosis, a female health disorder that occurs when small pieces of the uterus grow on to different organs such as the ovaries and fallopian tubes, that can cause heavy bleeding, stomach and back pain as well as infertility, can take up to seven to surface. In the UK, approximately 2 million women are affected by this condition, several of whom are diagnosed between 25 and 40 years of age.
Click here to read the rest of the article: http://www.medicalnewstoday.com/articles/234802.php
Saturday, September 24, 2011
Surgical encounters in Endometriosis
From Ad-Lap surgical group
http://www.adlap.com/endoNodules.htm
Nodules, Cul-de-sac disease, endometriomas, Extensive endometriosis means bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriosis glands and stroma surrounded by fibromuscular tissue that has accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a longstanding chronic inflammatory response.
Cul-de-sac Obliteration
In the female without previous hysterectomy, the anterior peritoneal reflection on the rectum (rectouterine pouch or pouch of Douglas) folds at an average distance of 4 cm from the anal verge. The rectovaginal fascial septum separates the rectum from the vagina.
In 1921, Sampson defined cul-de-sac obliteration as “extensive adhesions in the cul-de-sac obliterating its lower portion and uniting the cervix or the lower portion of the uterus to the rectum; with adenoma of the endometrial type invading the cervical and the uterine tissues and probably also (but to a lesser degree) the anterior wall of the rectum.” (7) Cul-de-sac obliteration secondary to endometriosis implies the presence of retrocervical deep fibrotic endometriosis beneath the peritoneum. This endometriosis is located on or in the anterior rectum, posterior vagina, posterior cervix (the cervical vaginal angle between the upper vagina and the cervix), the rectovaginal septum, or the uterosacral ligaments; often one area predominates.
Partial cul-de-sac obliteration (PCDSO) means that deep fibrotic endometriosis is severe enough to alter the course of the rectum, fusing it to a portion of posterior vagina. With complete cul-de-sac obliteration (CCDSO), fibrotic endometriosis and/or adhesions involve the entire cul-de-sac between the cervicovaginal junction (and sometimes above) and the rectum.
At laparoscopy, careful inspection of the cul-de-sac is necessary to evaluate the extent of upward tenting of the rectum. To determine if cul-de-sac obliteration is partial or complete, a sponge on a ring forceps is inserted into the posterior vaginal fornix (and a rectal probe in the rectum). The normal cul-de-sac will show a portion of vaginal wall between the cervix and rectum as a distinct and separate bulge. The utero-sacral ligaments will be of normal calibre and lateral. Partial cul-de-sac obliteration occurs when rectal tenting is visible but a protrusion from the sponge in the posterior vaginal fornix is noted between the rectum and the inverted “U” of the uterosacral ligaments. Complete cul-de-sac obliteration is diagnosed when the outline of the sponge in the posterior fornix cannot be visualised initially through the laparoscope: the rectum or fibrotic endometriosis nodules completely obscure the identification of the deep cul-de-sac.
Partial and complete cul-de-sac obliteration are the same disease, requiring the same surgical dissection. Both indicate that deep fibrotic endometriosis is present on the anterior rectum and the posterior vagina, areas from which it can be completely excised. Yet the American Society of Reproductive Medicine Classification makes partial obliteration Stage 1 and complete cul-de-sac obliteration Stage 4; go figure it!
Endometriomas
Preoperatively, transvaginal sonography is done to evaluate the ovaries in cases involving a pelvic mass, retrocervical nodules, or fibroids, and a CA 125 assay is obtained if persistent enlargement is documented. Ultrasound findings of a round shaped adnexal mass with thick wall and homogeneous, low-level echo pattern is highly suggestive of endometrioma. Another pattern has irregular margins with septations and an anechoic appearance. Intravenous pyelograms (IVP) are rarely necessary preoperatively, as ureteral dilation is readily evident at laparoscopic examination. An IVP is ordered postoperatively if abdominal pain persists after surgery on or near the ureter. Presently, there is no indication for CT scan or MRI prior to laparoscopic ovarian surgery.
In all cases careful inspection of the abdomen and pelvis is done. The ovaries are evaluated for visual evidence of malignancy. Washings are taken if indicated. Endometriomas are drained by mobilizing them from the pelvic sidewall.
Enlarged ovaries containing cysts are either free in the peritoneal cavity or attached to the pelvic sidewall, uterosacral ligament, or cul-de-sac. If attached to these structures, the cyst is frequently an endometrioma. An aquadissector is used to mobilize the ovaries by lifting them from the pelvic sidewall. Often this maneuver will result in drainage of chocolate-like hemosiderin filled fluid from the undersurface of the ovary. After this occurs, the ovary is completely mobilized from the pelvic sidewall to its hilum using aquadissection and careful blunt dissection to reduce pelvic sidewall peritoneal damage. If no endometrioma is readily identified, and the patient has “unexplained infertility” or pre- or postmenstrual spotting, a knife electrode connected to monopolar cutting current (70 W) is used to incise and drain areas on the ovary with superficial endometriosis and cysts suspicious for endometrioma. The clinical distinction between an endometrioma (pathology to be excised) and a corpus luteum cyst (normal, vascular tissue best left alone) may be difficult, and conservative discretion is advised to avoid the trauma and risk of removing normal tissue. An endometrioma has a thick white fibrotic capsule while a corpus luteum cyst capsule is yellow.
If an endometrioma is discovered by either of these two methods, the cyst cavity is rinsed with lactated Ringer’s solution and then excised using 5 mm biopsy forceps, grasping forceps, and sometimes scissors (Semm, Mettler 1980)(Reich, McGlynn 1986). Experience has proven that drainage is not enough. Ovarian endometriomas up to 15 cm are excised. The cyst wall is most firmly attached to the ovarian cortex in the area of cyst rupture during mobilization, i.e., the portion that was adhered to the pelvic sidewall or uterosacral ligament, and not to the portion near the ovarian hilum. To help create an initial plane between normal ovarian cortex and endometrioma cyst wall, cutting current (70 W) through a knife electrode tip is applied at the cyst wall-cortex junction to develop a dissection plane in this firmly attached area. This step is particularly useful near the utero-ovarian ligament as rough avulsion can lead to excessive bleeding. The laparoscope is brought close to the area of dissection, magnifying it to identify the cyst wall clearly. This incision is extended through the visible 360o opening if possible. The cutting current will destroy endometriosis at the ovarian cortex-endometrioma junction while making a divot of separation between the two structures. Thereafter, biopsy or grasping forceps are placed to stabilize the ovarian cortex and endometrioma cyst wall while traction is exerted on the endometrioma cyst wall to peel it from inside the ovary. If the cyst wall is felt to be incompletely excised, the cyst cavity can be desiccated or fulgurated to destroy any remaining endometrioma. Otherwise, the endometrioma may recur. Excision can be done with minimal bleeding from the cyst wall bed and the ovarian wall edges usually reapproximate quite well, though occasionally extracorporeal suturing is required, especially after removal of large endometriomas. Hemostasis is checked by underwater examination inside the ovary, and individual bleeders are identified using irrigation through an irrigating channel and coagulated with microbipolar forceps. When removal results in a large, asymmetrical defect, the ovary is suture repaired, usually with one purse-string absorbable suture, applied close to the utero-ovarian ligament in one direction and the infundibulopelvic ligament in the other. Although suturing is not thought to be necessary for reapproximation by many surgeons, anyone who has operated on many of these women realizes that the open ovary is very receptive to small and large bowel; I suspect that those who preach that all ovaries should not be suture repaired are not comfortable with suturing techniques.
In most cases of ovarian endometrioma, endometriosis of the pelvic sidewall and/or uterosacral ligament is present. These lesions should be excised after enucleation of the endometrioma to prevent recurrence. Pelvic sidewall endometriosis peritoneal excision usually requires ureterolysis to free the underlying ureter from the lesion.
Oophorectomy can also be considered for pain or mass arising from ovarian endometrioma in women not desiring future fertility. This is especially indicated for left pelvic pain if the left ovary is enmeshed in rectosigmoid adhesions because they tend to recur.
Before removal, the ovary is released from all pelvic sidewall and bowel adhesions. It is imperative that the surgeon visualize the course of the ureter. The peritoneum above the ureter is opened with sharp scissors. Smooth grasping forceps are then opened parallel and perpendicular to the retroperitoneal structures until the ureter is identified. Scissors can be used to further dissect the ureter throughout its course along the pelvic sidewall.
The uterus is anteverted and displaced to the contralateral side. The fallopian tube is grasped and pulled medially to stretch out the infundibulopelvic ligament containing the ovarian vessels. The anterior and posterior leaves of the broad ligament are opened with scissors lateral and medial to the infundibulopelvic ligament and a free ligature (2-0 Vicryl) passed through the window thus created and tied extracorporeally using the Clarke-Reich knotpusher. This is repeated twice until two proximal ties and one distal one are placed, and the ligament then divided. While applying traction to the cut distal pedicle, the broad ligament is divided to the round ligament just lateral to the uteroovarian artery anastomosis using cutting current through a spoon electrode. Two free ligatures are placed around the uteroovarian ligament, which is then divided.
Alternatively, Kleppinger bipolar forceps are used to compress and desiccate the infundibulopelvic ligament, the broad ligament, the fallopian tube isthmus, and the utero-ovarian ligament with bipolar cutting current (25-35 W). In most cases, 3 contiguous areas are desiccated. Laparoscopic scissors are used to divide the pedicle. (Reich H, 1987)
The free ovary is removed through the umbilicus or cul-de-sac. Large endometriomas are usually sufficiently cystic and pliable that, once separated from the pelvic sidewall, they can be removed through the umbilical incision.
When the ovary is retroperitoneal, embedded in the pelvic sidewall, a lateral approach is advocated. The peritoneum lateral to the ovary and the infundibulopelvic ligament where it crosses the iliac vessels is incised with dissecting scissors and the broad ligament opened by bluntly separating the extraperitoneal areolar tissues. The peritoneal incision is extended to the round ligament, lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is pulled medially with grasping forceps to expose the ureter at the pelvic brim where it crosses the common or external iliac artery. It may be necessary to reflect the ureter off the medial leaf of the broad ligament for a short distance to aid in its identification, although this is not always required. The infundibulopelvic ligament is ligated, divided, and its distal cut end put on traction with traumatic grasping forceps for the rest of the oophorectomy. The medial leaf of the broad ligament with its contained ovary is freed from the pelvic sidewall vessels and areolar tissue. The ureter is peeled off the retroperitoneal ovary for most of its pelvic course until the uteroovarian ligament can be isolated and divided.
--------------------------------------------------------------------------------
References
Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil.Steril. 1990;53:978-983.
Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil.Steril. 1991;55:759-765.
Koninckx PR, Barlow D, Kennedy S. Implantation versus infiltration: The Sampson versus the endometriotic disease theory. GYNECOLOGIC.AND.OBSTETRIC.INVESTIGATION. 1999;47
Martin DC, Hubert G D, Levy B S. Depth of infiltration of endometriosis. Journal of Gynecologic Surgery, 5:55-60, 1989.
Reich H, McGlynn F: Treatment of ovarian endometriomas using laparoscopic surgical techniques. J of Reprod Med 1986;31:577-84.
Reich H, McGlynn F: Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. J Reprod Med 1986; 31:609.
Reich H: Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tubo-ovarian disease. Int J Fertil 1987; 32:233-236
Reich H: Laparoscopic oophorectomy without ligature or morcellation. Contemp Ob Gyn 1989;9:34-46
Reich H. New techniques in advanced laparoscopic surgery. In Laparoscopic surgery. Sutton C, ed. Bailliere’s Clinical Obstetrics and Gynecology. WB Saunders, Philadelphia London. 1989;3:655-81.
Semm K, Mettler L: Technical progress in pelvic surgery via operative laparoscopy. Am J Obstet Gynecol 1980; 138:121
http://www.adlap.com/endoNodules.htm
Nodules, Cul-de-sac disease, endometriomas, Extensive endometriosis means bulky deep fibrotic endometriosis deposits that can often be palpated preoperatively as tender pelvic nodules. These nodules consist of endometriosis glands and stroma surrounded by fibromuscular tissue that has accumulated over many years in response to cyclic monthly activation of the endometriosis. They represent a longstanding chronic inflammatory response.
Cul-de-sac Obliteration
In the female without previous hysterectomy, the anterior peritoneal reflection on the rectum (rectouterine pouch or pouch of Douglas) folds at an average distance of 4 cm from the anal verge. The rectovaginal fascial septum separates the rectum from the vagina.
In 1921, Sampson defined cul-de-sac obliteration as “extensive adhesions in the cul-de-sac obliterating its lower portion and uniting the cervix or the lower portion of the uterus to the rectum; with adenoma of the endometrial type invading the cervical and the uterine tissues and probably also (but to a lesser degree) the anterior wall of the rectum.” (7) Cul-de-sac obliteration secondary to endometriosis implies the presence of retrocervical deep fibrotic endometriosis beneath the peritoneum. This endometriosis is located on or in the anterior rectum, posterior vagina, posterior cervix (the cervical vaginal angle between the upper vagina and the cervix), the rectovaginal septum, or the uterosacral ligaments; often one area predominates.
Partial cul-de-sac obliteration (PCDSO) means that deep fibrotic endometriosis is severe enough to alter the course of the rectum, fusing it to a portion of posterior vagina. With complete cul-de-sac obliteration (CCDSO), fibrotic endometriosis and/or adhesions involve the entire cul-de-sac between the cervicovaginal junction (and sometimes above) and the rectum.
At laparoscopy, careful inspection of the cul-de-sac is necessary to evaluate the extent of upward tenting of the rectum. To determine if cul-de-sac obliteration is partial or complete, a sponge on a ring forceps is inserted into the posterior vaginal fornix (and a rectal probe in the rectum). The normal cul-de-sac will show a portion of vaginal wall between the cervix and rectum as a distinct and separate bulge. The utero-sacral ligaments will be of normal calibre and lateral. Partial cul-de-sac obliteration occurs when rectal tenting is visible but a protrusion from the sponge in the posterior vaginal fornix is noted between the rectum and the inverted “U” of the uterosacral ligaments. Complete cul-de-sac obliteration is diagnosed when the outline of the sponge in the posterior fornix cannot be visualised initially through the laparoscope: the rectum or fibrotic endometriosis nodules completely obscure the identification of the deep cul-de-sac.
Partial and complete cul-de-sac obliteration are the same disease, requiring the same surgical dissection. Both indicate that deep fibrotic endometriosis is present on the anterior rectum and the posterior vagina, areas from which it can be completely excised. Yet the American Society of Reproductive Medicine Classification makes partial obliteration Stage 1 and complete cul-de-sac obliteration Stage 4; go figure it!
Endometriomas
Preoperatively, transvaginal sonography is done to evaluate the ovaries in cases involving a pelvic mass, retrocervical nodules, or fibroids, and a CA 125 assay is obtained if persistent enlargement is documented. Ultrasound findings of a round shaped adnexal mass with thick wall and homogeneous, low-level echo pattern is highly suggestive of endometrioma. Another pattern has irregular margins with septations and an anechoic appearance. Intravenous pyelograms (IVP) are rarely necessary preoperatively, as ureteral dilation is readily evident at laparoscopic examination. An IVP is ordered postoperatively if abdominal pain persists after surgery on or near the ureter. Presently, there is no indication for CT scan or MRI prior to laparoscopic ovarian surgery.
In all cases careful inspection of the abdomen and pelvis is done. The ovaries are evaluated for visual evidence of malignancy. Washings are taken if indicated. Endometriomas are drained by mobilizing them from the pelvic sidewall.
Enlarged ovaries containing cysts are either free in the peritoneal cavity or attached to the pelvic sidewall, uterosacral ligament, or cul-de-sac. If attached to these structures, the cyst is frequently an endometrioma. An aquadissector is used to mobilize the ovaries by lifting them from the pelvic sidewall. Often this maneuver will result in drainage of chocolate-like hemosiderin filled fluid from the undersurface of the ovary. After this occurs, the ovary is completely mobilized from the pelvic sidewall to its hilum using aquadissection and careful blunt dissection to reduce pelvic sidewall peritoneal damage. If no endometrioma is readily identified, and the patient has “unexplained infertility” or pre- or postmenstrual spotting, a knife electrode connected to monopolar cutting current (70 W) is used to incise and drain areas on the ovary with superficial endometriosis and cysts suspicious for endometrioma. The clinical distinction between an endometrioma (pathology to be excised) and a corpus luteum cyst (normal, vascular tissue best left alone) may be difficult, and conservative discretion is advised to avoid the trauma and risk of removing normal tissue. An endometrioma has a thick white fibrotic capsule while a corpus luteum cyst capsule is yellow.
If an endometrioma is discovered by either of these two methods, the cyst cavity is rinsed with lactated Ringer’s solution and then excised using 5 mm biopsy forceps, grasping forceps, and sometimes scissors (Semm, Mettler 1980)(Reich, McGlynn 1986). Experience has proven that drainage is not enough. Ovarian endometriomas up to 15 cm are excised. The cyst wall is most firmly attached to the ovarian cortex in the area of cyst rupture during mobilization, i.e., the portion that was adhered to the pelvic sidewall or uterosacral ligament, and not to the portion near the ovarian hilum. To help create an initial plane between normal ovarian cortex and endometrioma cyst wall, cutting current (70 W) through a knife electrode tip is applied at the cyst wall-cortex junction to develop a dissection plane in this firmly attached area. This step is particularly useful near the utero-ovarian ligament as rough avulsion can lead to excessive bleeding. The laparoscope is brought close to the area of dissection, magnifying it to identify the cyst wall clearly. This incision is extended through the visible 360o opening if possible. The cutting current will destroy endometriosis at the ovarian cortex-endometrioma junction while making a divot of separation between the two structures. Thereafter, biopsy or grasping forceps are placed to stabilize the ovarian cortex and endometrioma cyst wall while traction is exerted on the endometrioma cyst wall to peel it from inside the ovary. If the cyst wall is felt to be incompletely excised, the cyst cavity can be desiccated or fulgurated to destroy any remaining endometrioma. Otherwise, the endometrioma may recur. Excision can be done with minimal bleeding from the cyst wall bed and the ovarian wall edges usually reapproximate quite well, though occasionally extracorporeal suturing is required, especially after removal of large endometriomas. Hemostasis is checked by underwater examination inside the ovary, and individual bleeders are identified using irrigation through an irrigating channel and coagulated with microbipolar forceps. When removal results in a large, asymmetrical defect, the ovary is suture repaired, usually with one purse-string absorbable suture, applied close to the utero-ovarian ligament in one direction and the infundibulopelvic ligament in the other. Although suturing is not thought to be necessary for reapproximation by many surgeons, anyone who has operated on many of these women realizes that the open ovary is very receptive to small and large bowel; I suspect that those who preach that all ovaries should not be suture repaired are not comfortable with suturing techniques.
In most cases of ovarian endometrioma, endometriosis of the pelvic sidewall and/or uterosacral ligament is present. These lesions should be excised after enucleation of the endometrioma to prevent recurrence. Pelvic sidewall endometriosis peritoneal excision usually requires ureterolysis to free the underlying ureter from the lesion.
Oophorectomy can also be considered for pain or mass arising from ovarian endometrioma in women not desiring future fertility. This is especially indicated for left pelvic pain if the left ovary is enmeshed in rectosigmoid adhesions because they tend to recur.
Before removal, the ovary is released from all pelvic sidewall and bowel adhesions. It is imperative that the surgeon visualize the course of the ureter. The peritoneum above the ureter is opened with sharp scissors. Smooth grasping forceps are then opened parallel and perpendicular to the retroperitoneal structures until the ureter is identified. Scissors can be used to further dissect the ureter throughout its course along the pelvic sidewall.
The uterus is anteverted and displaced to the contralateral side. The fallopian tube is grasped and pulled medially to stretch out the infundibulopelvic ligament containing the ovarian vessels. The anterior and posterior leaves of the broad ligament are opened with scissors lateral and medial to the infundibulopelvic ligament and a free ligature (2-0 Vicryl) passed through the window thus created and tied extracorporeally using the Clarke-Reich knotpusher. This is repeated twice until two proximal ties and one distal one are placed, and the ligament then divided. While applying traction to the cut distal pedicle, the broad ligament is divided to the round ligament just lateral to the uteroovarian artery anastomosis using cutting current through a spoon electrode. Two free ligatures are placed around the uteroovarian ligament, which is then divided.
Alternatively, Kleppinger bipolar forceps are used to compress and desiccate the infundibulopelvic ligament, the broad ligament, the fallopian tube isthmus, and the utero-ovarian ligament with bipolar cutting current (25-35 W). In most cases, 3 contiguous areas are desiccated. Laparoscopic scissors are used to divide the pedicle. (Reich H, 1987)
The free ovary is removed through the umbilicus or cul-de-sac. Large endometriomas are usually sufficiently cystic and pliable that, once separated from the pelvic sidewall, they can be removed through the umbilical incision.
When the ovary is retroperitoneal, embedded in the pelvic sidewall, a lateral approach is advocated. The peritoneum lateral to the ovary and the infundibulopelvic ligament where it crosses the iliac vessels is incised with dissecting scissors and the broad ligament opened by bluntly separating the extraperitoneal areolar tissues. The peritoneal incision is extended to the round ligament, lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is pulled medially with grasping forceps to expose the ureter at the pelvic brim where it crosses the common or external iliac artery. It may be necessary to reflect the ureter off the medial leaf of the broad ligament for a short distance to aid in its identification, although this is not always required. The infundibulopelvic ligament is ligated, divided, and its distal cut end put on traction with traumatic grasping forceps for the rest of the oophorectomy. The medial leaf of the broad ligament with its contained ovary is freed from the pelvic sidewall vessels and areolar tissue. The ureter is peeled off the retroperitoneal ovary for most of its pelvic course until the uteroovarian ligament can be isolated and divided.
--------------------------------------------------------------------------------
References
Cornillie FJ, Oosterlynck D, Lauweryns JM, Koninckx PR. Deeply infiltrating pelvic endometriosis: histology and clinical significance. Fertil.Steril. 1990;53:978-983.
Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie FJ. Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil.Steril. 1991;55:759-765.
Koninckx PR, Barlow D, Kennedy S. Implantation versus infiltration: The Sampson versus the endometriotic disease theory. GYNECOLOGIC.AND.OBSTETRIC.INVESTIGATION. 1999;47
Martin DC, Hubert G D, Levy B S. Depth of infiltration of endometriosis. Journal of Gynecologic Surgery, 5:55-60, 1989.
Reich H, McGlynn F: Treatment of ovarian endometriomas using laparoscopic surgical techniques. J of Reprod Med 1986;31:577-84.
Reich H, McGlynn F: Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. J Reprod Med 1986; 31:609.
Reich H: Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tubo-ovarian disease. Int J Fertil 1987; 32:233-236
Reich H: Laparoscopic oophorectomy without ligature or morcellation. Contemp Ob Gyn 1989;9:34-46
Reich H. New techniques in advanced laparoscopic surgery. In Laparoscopic surgery. Sutton C, ed. Bailliere’s Clinical Obstetrics and Gynecology. WB Saunders, Philadelphia London. 1989;3:655-81.
Semm K, Mettler L: Technical progress in pelvic surgery via operative laparoscopy. Am J Obstet Gynecol 1980; 138:121
Friday, September 23, 2011
Thursday, September 22, 2011
Wednesday, September 21, 2011
Karen Stewards tries to shut down adhesion web site!
Karen Steward's attempt to shut down ARD web sites FAILS again!
Year after year Karen Steward "stews" and "obsesses" over ARD web sites that provide beneficial information to persons afflicted with Adhesion Related Disorder.
Her problem? These web sites make it hard for Karen and her cohort, Con Doc. Daniel Kruschinski to profit on the pain of those who are afflicted with ARD!
No ifs, ands or buts about it, in our opinion and experience, this is the reason behind her "attacks"on ARD web sites!
For years Karen has attempted to capitalize on ARD victims with items for sale, and soliciting the sale of a book she wrote about Con Doc Kruschinski, of Germany! Karen paid to have this book published, and it bombed right off the press losing her money spent on it!
Since then Karen seeks any means necessary to recoup her losses, and YES, she will take advantage of vulnerable victims of ARD and have no problem making them victims of her greed as well!
"Steward ARD Merchandise being sold in India by Doc Kru!
Karen has been saying for years that "she, and Doc Kru" were going to shut down the following web site http://www.adhesionrelateddisorder.com/" & "http://www.ihrt.com,/" among other ARD web sites. To date, they have not been successful!
You will see here in this post in an ARD web site that the web site one of Karen's "competition" is scratched out! Not to proffesional, but hey, neither is Karen or Kru in our opinion!
Karen is trying to paint others in a bad light, and sell her ARD loot, but all she succeeds in accomplishing is to show what she is made of.
Smells like some "Something Evil" is blowing out of Wetherford, Texas, and it reeks of a stinky Steward!!
Pssssst, some Steward facts: Karen Stewards daughter made more then one trip to Doc. Kru as did many others, some as many as 6 trips, and yes, paying cash to Kru each time!
Karen, if you think this is not a true statement, go read your book, as it says in there Melissa went to Kru more then once for surgery! Perhaps YOUR book is not truthfull????
Karen, if you think this is not a true statement, go read your book, as it says in there Melissa went to Kru more then once for surgery! Perhaps YOUR book is not truthfull????
(We will bring you more "Steward facts" in the future, so stop back if you want the truth!)
ENJOY the 2011 Rants of Karen Steward......
-----Original Message-----
From: abuse@hostway.com [mailto:abuse@hostway.com]
Sent: Wednesday, August 17, 2011 12:43 PM
Subject: (HW#14378200) Defamation of Character Complaint: adhesionrelateddisorder.com
From: abuse@hostway.com [mailto:abuse@hostway.com]
Sent: Wednesday, August 17, 2011 12:43 PM
Subject: (HW#14378200) Defamation of Character Complaint: adhesionrelateddisorder.com
Dear Customer,
We have been made aware of a defamation of character complaint against your web site adhesionrelateddisorder.com. The content in question is hosted at the following location:
http://www.adhesionrelateddisorder.com/BJD-Picture-Trail-pg2.html
Please review the complaint provided below. We request that you voluntarily remove the content or contact the complainant directly to resolve the matter. If you have any questions regarding defamation complaints, please contact legal@hostway.com. Feel free to let us know if you require any further assistance.
Thank you,
Abuse Department
Hostway Corporation
From: karen steward [karensteward@mac.com]
Dear Sirs,
The ip address above is the one found when I check this url:
http://www.adhesionrelateddisorder.com
The name of the person behind this website is Beverly Doucette of
Marinette , Wisconsin. This website is a front used solely for the
purpose of libeling numerous people across the world, myself
included. I, along with several other people, were successful in getting
this site taken down several years ago when Beverly was hosted through Bravenet.
Though the majority of the libel is written at http://www.ihrt.blogspot.com,
the url http://www.adhesionrelateddisorder.com is the
active springboard to the libelous blog.
I have contacted everyone from the FBI, to Beverly 's local police,
Wisconsin 's attorney general, etc. They all tell me to contact her
hosting, as she cannot achieve this evil without an available host.
I do have a case file with the FTC, as the purpose of adhesionrelateddisorder
is to monopolize a market of medicine, specifically, adhesions.
The man safely hidden behind Beverly 's skirt, is David Wiseman of
Dallas , Texas . In the link below, you will see that Beverly is tied to
David Wiseman and is the puppet in his diabolical crime of libeling
many innocent people across the globe.
http://www.adhesionrelateddisorder.com/BJD-Picture-Trail-pg2.html
The purpose of my email is to find out if you can help me in removing
this website from the internet since you are the host.
One man has committed suicide due to Beverly 's
libel against him and his wife. Beverly successfully destroyed his
online retirement internet business by her crude, libelous postings.
Their crime? His wife had gone to Germany for adhesions surgery and
innocently posted on the internet her joy at becoming well. The man,
nor his wife, knew David Wiseman of Beverly Doucette prior to the
attacks upon them. The same holds true for all of us who are
being libeled by these people.
Thanks for any help you can offer,
Karen Steward
Beverly Doucette's response to Hostway...
Subject: RE: (HW#14378200) Defamation of Character Complaint: adhesionrelateddisorder.com
There is no defamation, nor libel or slander in this web site. The entire contents is 100% validated and proven to be true as printed. http://www.adhesionrelateddisorder.com/
Material found in this web site absolutely exposes persons for criminal activity at national and International levels, however, all material within this web site is validated and true as stated. Some of the content is our opinion, and it is stated as just that, “Our opinion.” Mrs. Steward uses the word, “crime” three different times in her email to you, and accuses Beverly Doucette, AND Dr. David Wiseman of criminal acts, of defamation, which in my estimation tells me that she is angry with both of us, and though Dr. Wiseman has never once blogged or placed material in the web site which the complaint is being made against, she includes him in her accusations.
We could go tit for tat for years as to the reasons Mrs. Steward decided to send a complaint to your service, but I am far to busy for that, and not interested in all of this as for years, as she states, she had had a personal vendetta against Dr. Wiseman and myself thinking that she was left behind when we each choose this venue to educate and inform persons with ARD. She wrote a book about ARD, and she has stated before that it will not sell if web sites offer the same material in their web sites, though these web sites were up well before she came on the scene. ( Simple way to validate that is to look at the date of publication of her book and the dates our web sites first appeared in the Internet. She will continue to try to get ever ARD web site off the Internet if she could thus her book might sell. Simple fact.
Prior to placing material on this public web site we involved an attorney to proof material that is controversial, none was shown to be of a nature that would, nor could, prove to be considered libel, slanderous or defaming in nature.
The reason Mrs. Steward has been unsuccessful in having this web site removed after she had it investigated by all those she listed as contacting, is because there is nothing in it that constitutes breaking a law of any sort.
Though you state that you were "made aware of a defamation of character" located in this web site, you do not show where this defamation occurs within the site, nor do I know of any such defamation. If there is a specific portion within this web site that this woman deems is defaming, it would be more advantageous to direct your attention(and mine)to that particular material and location of it in the web site, which if proven to be of an illegal nature, will then be removed by me immediately. If you deem the web site to be improper, contact me with specific reasons for the action, and to give me the chance to rectify any errors. I will also seek legal advice prior to any changes I will allow to be made in the services I paid for. The email sent to you by Mrs. Steward does not contain anything that validates any action against the web site http://www.adhesionrelateddisorder.com by your team.
The material in this web site has at no time caused any person to "kill themselves," and though I am aware of this claim against the web site, upon investigating the person who supposedly killed himself due to my web site in fact had been dealing with depression and severe financial issues, and did not commit suicide, but rather appeared to have had a long term health/psychological issue. The most important thing here is that at no time did I ever mention this person, and had never heard his name prior to Mrs. Steward's accusation. Simply was not a true accusation, and there is nothing in this web site that even mentions this person. Note she does not offer up that name or dates for you to investigate prior to taking any action to remove this web site let alone accept her comments without validating them.
The web site link as seen here is located on many, many links within the Internet, http://www.adhesionrelateddisorder.com not just in this link.
http://www.ihrt.blogspot.com/. If there was any criminal material in the IHRT link, Google would remove the web site, however, none was ever found in the IHRT web site. Google did however remove a web site owned by Mrs. Steward. No matter what Mrs. Steward thinks of the IHRT blog, it has nothing to do with the allegations she is making against my web site and thus cannot be used as a reason to remove my web site..
Any associations I have with anyone does not a defamation make. Nor does having acquaintances' create libel, or slander, or anything else for that matter. It appears that Mrs. Steward doesn't care for my acquaintances, however her dislike of my associations have no bearing on her accusation as submitted to you. (Unless you can show me just cause that person's I associate with is validation of her accusations of defamation, even IF defamation is found to exist within this web site, my acquaintances would absolutely have no bearing on it. Mrs. Steward says” “In the link below, you will see that Beverly is tied to David Wiseman and is the puppet in his diabolical crime of libeling many innocent people across the globe.”
The date of this complaint must be taken into consideration as to why now is Mrs. Steward choosing to bring this to your attention when this web site has been up for a number of years without change. Another interesting caveat here is that Mrs. Steward seems to be confused as to whom she is accusing of the defamation complaint. Is it me, Bevery Doucette, or is it the “diabolical Dr. Wiseman” who she is accusing of the crime of libel? Isn’t Mrs. Steward committing defamation of Dr. Wiseman in her statement regarding him? (The answer is NO, though she is not stating it is her opinion, she is actually making the claim that “David Wiseman is diabolical and involved in the crime of libeling many innocent…etc,” however, unless comments made against another causes them to lose money and reputation in a court of law, there is no defamation. Also, once someone is deceased, they have no rights, thus anything said about them cannot be deemed anything! ( Though at no time has material in this web site defamed a person.) Mrs. Steward is again using the word crime when speaking of this person, "One man has committed suicide due to Beverly 's libel against him and his wife. “ Beverly successfully destroyed his online retirement internet business by her crude, libelous postings. Their crime?”
If there is anything even remotely of a defaming nature in this link, it shall be, or can be, removed, however, I see nothing of that nature in this link. I was at these congress’s not Mrs. Steward, and every word in this link is absolutely fact. As for the pictures, they speak for themselves! I too encourage you to visit the link as submitted by Mrs. Steward as it does validate the validity that the web site is geared to educate and inform persons with ARD how best to “Be Their Own Dr.”
http://www.adhesionrelateddisorder.com/BJD-Picture-Trail-pg2.html
Next “his accusation of “monopolizing a market of medicine, specifically, adhesions”
is very easy to rule out in the http://www.adhesionrelateddisorder.com/BJD-Picture-Trail-pg2.html by visiting Mrs. Stewards web site, which is also an education and information web site for those who are afflicted with ARD. In fact, the ONLY people making money on ARD with the
"www.adhesion relateddisorder.com" web site is Hostways being paid each year to host it!
There exists many, many web sites offering the same material that you will find in the ARD web site and Mrs. Stewards web site. http://www.karensteward.com/
Simply take a look at her web site if you want to see someone trying to corner the market on ARD! And for profit no less!
You will never fund that existing in any of the ARD web sites I am associated with! Absolutely not!
If the following charge were true in this statement by Mrs. Steward, I am certain one of the agencies she contacted would have contacted you with a legal notice to have this link removed from the Internet, and they would not have asked that of you, they would have directed you to do it based on law!
“The man, nor his wife, knew David Wiseman of Beverly Doucette prior to the attacks upon them. The same holds true for all of us who are being libeled by these people.” I am of the opinion that Mrs. Steward file a class action against me using her accusations as stated to you in her email. I am certain that if there is actual defamation in the web site, any literate Atty. Could locate it and manage a class action. I do know that she has made claims of doing this, but like the other contacts, she was informed that no criminal activity is taking place in my web site, and her opinion or the web site nor her dislike of me and others she is accusing, doesn’t make her accusations fact. She needs to prove her accusations, as does your team before taking any actions against it,and an investigation of your team would be of benefit to me as this lady will continue to seek ways to shut other “ARD” websites down , and her agenda is a personal as her book is not selling, from what I hear.
You will not find one single word of defamation, slander or libel in the following link, nor within the contents in any of it. http://www.adhesionrelateddisorder.com/BJD-Picture-Trail-pg2.html
I would expect a thorough investigation from your legal team to show just cause for any changes in your services of hosting the web site AdhesionRelaterDisorder. In the event you do not, or will not, put forth an effort to prove or disprove the allegations made against the web site, I would expect that you considered my explanations as presented here to be fact, thus closing the issue.
The fact of the matter is that I have not edited material to the web site and the web site manager relocated years ago thus rendering it in a state of inactivity and usable by me.
Please indicate to me as to any other action you wish from me regarding this communication in the event I misunderstood your directions.
Thank-you for informing me of this matter,
Beverly Doucette
"Okay then, THIS bombed! What do will Karen do next to corner the ARD market to sell her ARD loot?
We never could figure out the obsession, in our opinion, is between Kru and Karen,
and we still don't!
What could it be between these two after all these years???
"GINGIRL"
Lets get to know Doc Kru a little better now that Karen brings this up again!
SLUMDOG "SUGAR DADDY" Dr. Daniel Kruschinski
The OSCAR goes to......
"SLUMDOG DOCTOR in GERMANY"
In the latest escapades out of Endogyn, IHRT cought SLUMDOG "SUGAR DADDY" Dr. Daniel Kruschinski slumming with his NEW and IMPROVED "DADDY'S GIRL" after meeting her through "XING.com! Here you will see the NEW "Endogyn" infrastructure Con Kru has in India!
Complete with the "Abdolift" exclusive to his surgeries!
Only in IHRT will you find the facts as "Dr. Daniel Kruschinski – Endogyn, Germany" reveals his “perverted” side for all the world to see, and it appears to be without shame!
!!!!!CAUTION…BEWARE… CAUTION…BEWARE…!!!!!
PORNO MATERIAL WILL TAG YOUR PC AT THE ABOVE WEB SITE
(IHRT cautions you that going into these web sites, your PC WILL get porno pop ups, curtsey of Kruchsinski! Even if you use a different email address, the PC going into these web sites WILL get tagged!)
><><><><><><><><><><><><><><><><><><><><><
*** FACES OF A PERVERT ***
DR. DANIEL MARIAN KRUSCHINSKI lives life on the shady side with his new "Daddy's Girl" as he slums with her all over Germany after meeting her in "XING.com"... (Ouch!)
Seems they now run a web site that assists "Young Girls" to meet "Old Men!" (Yuck!)
Looks like the "OLD USED UP" Mistress Micheala Katzer is OUT of a "Sugar Daddy" and the "YOUNG SEXY" Janine Gessner is IN with a new "Sugar Daddy!"
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Meet the "NEW FACE" in Dr. Daniel Kruschinski's life......“Janine Gessner"
><><><><><><><><
"Hi, DANNY BOY" .........
Janine seems to be saying to her new "Sugar Daddy..
(Wait until she finds out her DOCTOR is really nothing but a bankrupt, lying, washed up, smelly alcoholic, married OLD perverted fart..oh, IHRT forgot that Kruschinski is GAS-LESS, at least Janine has THAT going for her! (LOL! LOL!)
https://www.xing.com/profile/Janina_Gessner
<<<<<<<<>>>>>>>>
B.Z. stellt die speziellsten Flirtseiten im Internet vor Für reife Männer - Frauen, die graue Schläfen lieben, finden hier ihr Objekt der Begierde. Als eines von 2500 Mitgliedern muss man als Lady unter 30, als Mann über 40 Jahre alt sein:
http://www.reif-trifft-jung.de/
Janina Gessner Premium-Mitglied
CRM work Firma:(sichtbar nur für registrierte Mitglieder)
10587 Berlin, Deutschland
<><><><><><><><><><>
Über michBerliner Zeitung
Dass ältere Herren oft ein Faible für wesentlich jüngere Damen haben, liegt in der Natur der Sache. Viele Promis über 40 "schmücken" sich mit Schönheit und Frische solcher Grazien. ... Auch für den Durchschnittsbürger gibt es Möglichkeiten, ohne Millioneneinkommen und Promibonus mit jüngeren Frauen anzubandeln. Vielen Frauen ist ein erfahrener Partner lieber, da er über eine gewisse Lebenserfahrung verfügt und Sicherheit sowie Geborgenheit symbolisiert. Spezielle Wünsche, besondere Börsen So verwundert es nicht, dass es sogar Kontaktbörsen für diese spezielle Beziehungskonstellation gibt... Eine dieser Börsen ist "Reif-trifft-Jung.de": Über 1000 Damen zwischen 18 und 30 sind hier bereits registriert und schauen sich nach einem erfahrenen Partner von 40 Jahren und älter um. Eine solche Kontaktbörse bietet für eben diese Partnerkonstellationen eine gute Möglichkeit zum Kennenlernen. Denn hier suchen und finden sich junge Frauen und ältere Männer... [Quelle: Hombrero.de v. 8.1.2008]
<><><><><><><><><>
Babel Fish Translation….
Ripely young meets The fact that older gentlemen have often a Faible for substantially younger ladies lies in the nature of the thing. Many Promis over 40 " schmücken" itself with beauty and freshness of such Grazien. … Also for the average citizen there are possibilities, without million-incomes and Promibonus with younger Mrs. anzubandeln. Many women is rather an experienced partner, since it symbolizes security as well as security had a certain life experience and. Special desires, special stock exchanges Thus it does not surprise that there are even contact contacts for this special relations constellation… One of these stock exchanges is " Hoar frost meet Jung.de": Over 1000 ladies between 18 and 30 are registered here already and look themselves after an experienced partner of 40 years and older over. Such a contact stock exchange offers a good possibility for evenly these partner constellations to becoming acquainted with. Because and are young women and older men search here…[Quelle: Hombrero.de v. 8.1.2008]
GAME ON KAREN..TAG YOUR IT!
ENDOGYN, abdolift, gasless, abdominal pain, debilitating, hidden disorder, enslaving, ARD awareness, hopelessness, Jill Ronsley
Tuesday, September 20, 2011
Rectal Endometriosis Causing Colonic Obstruction and Concurrent Endometriosis of the Appendix
From Journal of Medical Case Reports
Rectal Endometriosis Causing Colonic Obstruction and Concurrent Endometriosis of the Appendix
A Case Report
N Katsikogiannis; AK Tsaroucha; K Dimakis; E Sivridis; CE Simopoulos
Authors and Disclosures
Posted: 09/14/2011; J Med Case Reports. 2011;5(3) © 2011 BioMed Central, Ltd.
Click link below to read more
http://www.medscape.com/viewarticle/748886
Abstract and Introduction
Abstract
Introduction: Endometriosis is a clinical entity which presents with functioning endometrial tissue at sites outside the uterus. Bowel endometriosis is usually asymptomatic, but it may show non-specific symptoms. The presence and/or association of appendiceal endometriosis, concomitant with rectal endometriosis, is possible.
Case presentation: A 36-year-old Greek woman was admitted to the emergency room of our hospital with signs of acute abdomen. On physical examination, our patient had a painful distended abdomen. Digital examination revealed an empty rectum and bowel obstruction was diagnosed. Our patient underwent exploratory laparotomy and rectum stenosis (almost complete obstruction) was observed. The bowel stenosis was resected, and temporary colostomy and appendectomy were performed. The pathology report showed endometriosis of the colon and the appendix, and our patient received medical treatment for endometriosis. Six months after this operation our patient had another surgery for restoration of large bowel continuity. No endometriosis was found. Our patient was doing well at the one-year follow up.
Conclusion: Endometriosis of the bowel is a disease that may cause large bowel obstruction. In women of reproductive age, the surgeon should consider endometriosis as a differential diagnosis in case of various gastrointestinal symptoms.
Introduction
Endometriosis is a clinical entity, which was first described by von Rokitansky Kitansky as the presence of functioning endometrial tissue at sites outside the uterus.[1,2] Endometriosis occurs in 3–10% of the general female population of reproductive age, 40–80% present symptoms such as pelvic pain, infertility, or both.[2,3] Endometriosis rarely involves the small intestine, the appendix, the colon, the lung or other tissues.[4,5]
Bowel endometriosis is usually asymptomatic, but it may show non-specific symptoms, such as abdominal colic-like pain, nausea, vomiting, and general symptoms of intestinal obstruction.[6,7] Circumferential endometriosis of the rectum should be differentially diagnosed from inflammatory or malignant diseases.[5] Endometriosis of the appendix usually presents with abdominal pain.[8] The presence and/or association of appendiceal endometriosis, concomitant with rectal endometriosis, is possible, because endometriosis could occur in more than one anatomical location at the same time.
A PubMed search revealed less than 20 reported cases of large bowel obstruction due to endometriosis in the last 10 years. In none of these reports was the appendix involved. We add here an additional case report. We present a case of rectal endometriosis and bowel obstruction, together with appendiceal endometriosis, diagnosed after surgical treatment in a female patient of reproductive age.
Section 1 of 5
Rectal Endometriosis Causing Colonic Obstruction and Concurrent Endometriosis of the Appendix
A Case Report
N Katsikogiannis; AK Tsaroucha; K Dimakis; E Sivridis; CE Simopoulos
Authors and Disclosures
Posted: 09/14/2011; J Med Case Reports. 2011;5(3) © 2011 BioMed Central, Ltd.
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http://www.medscape.com/viewarticle/748886
Abstract and Introduction
Abstract
Introduction: Endometriosis is a clinical entity which presents with functioning endometrial tissue at sites outside the uterus. Bowel endometriosis is usually asymptomatic, but it may show non-specific symptoms. The presence and/or association of appendiceal endometriosis, concomitant with rectal endometriosis, is possible.
Case presentation: A 36-year-old Greek woman was admitted to the emergency room of our hospital with signs of acute abdomen. On physical examination, our patient had a painful distended abdomen. Digital examination revealed an empty rectum and bowel obstruction was diagnosed. Our patient underwent exploratory laparotomy and rectum stenosis (almost complete obstruction) was observed. The bowel stenosis was resected, and temporary colostomy and appendectomy were performed. The pathology report showed endometriosis of the colon and the appendix, and our patient received medical treatment for endometriosis. Six months after this operation our patient had another surgery for restoration of large bowel continuity. No endometriosis was found. Our patient was doing well at the one-year follow up.
Conclusion: Endometriosis of the bowel is a disease that may cause large bowel obstruction. In women of reproductive age, the surgeon should consider endometriosis as a differential diagnosis in case of various gastrointestinal symptoms.
Introduction
Endometriosis is a clinical entity, which was first described by von Rokitansky Kitansky as the presence of functioning endometrial tissue at sites outside the uterus.[1,2] Endometriosis occurs in 3–10% of the general female population of reproductive age, 40–80% present symptoms such as pelvic pain, infertility, or both.[2,3] Endometriosis rarely involves the small intestine, the appendix, the colon, the lung or other tissues.[4,5]
Bowel endometriosis is usually asymptomatic, but it may show non-specific symptoms, such as abdominal colic-like pain, nausea, vomiting, and general symptoms of intestinal obstruction.[6,7] Circumferential endometriosis of the rectum should be differentially diagnosed from inflammatory or malignant diseases.[5] Endometriosis of the appendix usually presents with abdominal pain.[8] The presence and/or association of appendiceal endometriosis, concomitant with rectal endometriosis, is possible, because endometriosis could occur in more than one anatomical location at the same time.
A PubMed search revealed less than 20 reported cases of large bowel obstruction due to endometriosis in the last 10 years. In none of these reports was the appendix involved. We add here an additional case report. We present a case of rectal endometriosis and bowel obstruction, together with appendiceal endometriosis, diagnosed after surgical treatment in a female patient of reproductive age.
Section 1 of 5
Saturday, September 17, 2011
Thursday, September 08, 2011
Endometriosis can Reach Your Bowel and Bladder
Endometriosis can Reach Your Bowel and Bladder
By Deborah Ross August 31, 2011 - 2:25pm
Having endometriosis is tricky business. For many women, it’s something you have to “look forward to” every month. Sometimes friends and family don’t understand the pain you are enduring with your cycle. And sometimes endometriosis is causing abnormalities in your reproductive area, pelvis and gut that you can’t even feel.
As defined by the American Congress of Obstetricians and Gynecologists, endometriosis occurs when the tissue that normally lines the uterus and gets shed during menstrual cycles for some reason is found growing outside the uterus, usually on the ovaries, fallopian tubes or other pelvic structures. In many cases that endometrium -- the lining -- can cause problems such as chronic abdominal pain, pressure or fullness in the pelvis, debilitating menstrual cramps, pain with intercourse and, sadly, infertility, according to ACOG.
Endometriosis can be an issue not only in a woman’s reproductive area, but also in the bowel and bladder. That’s because the displaced tissue responds to changes in hormones and can break down and bleed each month just as if it were in the uterus. Scar tissue, or adhesions, can form, sometimes binding organs together with painful results.
So, for many women having endometriosis, it’s not just the discomfort of a menstrual cycle but also pain that extends outward toward the digestive system. During a menstrual period, there can be diarrhea, constipation, bloating, nausea, aches in the lower back, and pain during bowel movements and urination.
More than 5 million American women have endometriosis, with it most often hitting women in their 30s and 40s, according to a fact sheet from womenshealth.gov .
The fact sheet also noted that sometimes women can have endometrial growths in a number of areas outside the uterus yet feel no pain. On the other hand, some women with endometriosis have only a few abnormal growths and still feel severe pain.
Researchers are looking at associations between endometriosis and a number of conditions, including allergies, autoimmune diseases, chronic fatigue syndrome, certain cancers and yeast infections.
Read the rest by clicking here: http://www.empowher.com/endometriosis/content/endometriosis-can-reach-your-bowel-and-bladder
By Deborah Ross August 31, 2011 - 2:25pm
Having endometriosis is tricky business. For many women, it’s something you have to “look forward to” every month. Sometimes friends and family don’t understand the pain you are enduring with your cycle. And sometimes endometriosis is causing abnormalities in your reproductive area, pelvis and gut that you can’t even feel.
As defined by the American Congress of Obstetricians and Gynecologists, endometriosis occurs when the tissue that normally lines the uterus and gets shed during menstrual cycles for some reason is found growing outside the uterus, usually on the ovaries, fallopian tubes or other pelvic structures. In many cases that endometrium -- the lining -- can cause problems such as chronic abdominal pain, pressure or fullness in the pelvis, debilitating menstrual cramps, pain with intercourse and, sadly, infertility, according to ACOG.
Endometriosis can be an issue not only in a woman’s reproductive area, but also in the bowel and bladder. That’s because the displaced tissue responds to changes in hormones and can break down and bleed each month just as if it were in the uterus. Scar tissue, or adhesions, can form, sometimes binding organs together with painful results.
So, for many women having endometriosis, it’s not just the discomfort of a menstrual cycle but also pain that extends outward toward the digestive system. During a menstrual period, there can be diarrhea, constipation, bloating, nausea, aches in the lower back, and pain during bowel movements and urination.
More than 5 million American women have endometriosis, with it most often hitting women in their 30s and 40s, according to a fact sheet from womenshealth.gov .
The fact sheet also noted that sometimes women can have endometrial growths in a number of areas outside the uterus yet feel no pain. On the other hand, some women with endometriosis have only a few abnormal growths and still feel severe pain.
Researchers are looking at associations between endometriosis and a number of conditions, including allergies, autoimmune diseases, chronic fatigue syndrome, certain cancers and yeast infections.
Read the rest by clicking here: http://www.empowher.com/endometriosis/content/endometriosis-can-reach-your-bowel-and-bladder
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