Medsarticles. Medical Weblog

In most women, uterine contractions simply press the sloughed-off endometrial tissue down its usual path through the mouth of the womb (the cervix) and out of the body via the vagina. The woman prone to endometriosis, however, experiences another phenomenon: because she may have a contracted uterus or a right cervix, all the menstrual blood cannot easily How out through the vagina. Rather, some of the blood-filled endometrium is forced up through the fallopian cubes, pushes backward out of the tubes, and is sprayed into the abdominal cavity, where it may attach itself to pelvic organs, producing the condition of endometriosis. Menstrual cramps and pain—known technically as dysmenorrhea—the first symptoms of endometriosis, are the result of this retrograde menstrual bleeding.

Dr. John A. Sampson, a researcher and practitioner in Albany, New York, is responsible for naming the disease in 1927. Dr. Sampson theorized that this hacking up of endometrial tissue, which he called retrograde menstruation, was the most probable cause of endometriosis. Dr. Sampson proposed an explanation as to how the endometrial tissue is flushed out of the fallopian tubes and into the abdominal cavity; but there is still no explanation for why the endometrial tissue implants itself in these abnormal sites.

It has been proved that nearly all women will experience retrograde menstruation, but that many women will reject the tissue while others become victims of endometriosis. Their implants “suck.” Sampsons theory has yet to be disputed, although a number of other researchers have discovered immunological, hereditary, and structural connections, as well as a link between the amount of menstrual blood pushed through the tubes and the severity of the disease.

The tragedy of tins disease is that it can go undetected until it has done irreversible damage. Equally heartbreaking is a woman’s fatalistic attitude toward menstrual cramps. When endometriosis takes hold, it has a distinct way of invading every aspect of a woman’s life, and this invasion begins early on, with cramps. Most women who try to cope with monthly bouts of mild to severe and debilitating cramps will seek relief from the pain with familiar remedies: heating pads, hot water bottles, or over-the-counter painkillers like aspirin. They do not connect their cramps to any process other than menstruation.

It does not occur to them that they may have endometriosis because they do not know about it. Since they don’t know how endometriosis can incapacitate their reproductive system as well as other organs, they don’t seek medical help. But these women aren’t to blame. More than likely, they have been taught that menstrual discomfort, like contractions during childbirth, is not only natural but part of being a woman. Where seeking medical help for childbirth is understood, consulting a doctor for “just cramps” is often considered frivolous and self-indulgent.

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So far this chapter has dealt with pain management in general. However, dyspareunia — painful intercourse — is a problem that needs to be dealt with more specifically because of the physical and emotional stresses involved. This section has been written to give you some insight into the possible ways that might help you to overcome or cope with this particular problem.

When a woman does not want her partner to know she suffers from dyspareunia she may try to ‘put up with it’ for a number of reasons. Some women may feel they would be letting their partners down while others fear that their partner may leave them for someone else. For those who try to keep dyspareunia a secret from their partner, there is the possibility that when you try to avoid intercourse because of the pain, he is going to interpret this as rejection. For a woman wanting to become pregnant, avoiding sexual intercourse because of the pain is not going to help so she may pretend that everything is normal.

Equally, there may be problems when your partner is aware of dyspareunia. He may try to avoid sex so that he does not hurt you and this in turn may leave you feeling confused — particularly if your partner does not say why he is avoiding sex.

On an emotional level, it can destroy your self image — if you let it. The combination of a chronic illness and sexual difficulties is a tough hurdle to overcome. Add to this a decrease in libido

(sometimes caused by the hormonal treatment) and the problem of infertility and you can appreciate why this condition can cause so much heartache.

Dyspareunia can also be a result of other physical problems. Hormonal treatment can result in a dry vagina because of a lack of oestrogen and it may cause thrush which should be treated by your doctor. Some women may experience vaginismus which is an involuntary painful spasm of the vaginal muscles as a result of anticipated pain.

In order to overcome dyspareunia you must communicate! Talk to your partner and share your feelings. Work together and be honest with each other. Help your partner to understand how the pain affects you. Understand that he has feelings and needs love and attention as well.

Relax and give yourselves time. Intercourse may be less painful if you take the time to become fully aroused beforehand. Deep penetration usually causes the most pain so experiment with different positions until you find one that is more comfortable.

Explore other satisfying sexual activities that do not involve penetration. Show affection to each other in different ways such as kissing, hugging, masturbation and massage.

If you are having difficulty coping with the many emotional and physical problems associated with dyspareunia do not feel too embarrassed to seek professional advice. Your gynaecologist or GP should be able to suggest appropriate sources of support.

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Most bowel symptoms are not due to the presence of endometriosis on the surface of the bowel itself, but rather are usually related to irritation from implants located on adjacent organs or tissues, such as in the Pouch of Douglas, or due to adhesions from these implants pulling on the bowel.

The range of bowel symptoms varies. The most common include diarrhoea and/or constipation, painful bowel movements, rectal pain, wind pain and abdominal bloating. Other less common bowel symptoms may include lower back pain, pain during rectal examinations, abdominal cramping, rectal bleeding, blood in the stools, urgency to open bowels, nausea and/or vomiting. These symptoms may be present throughout the month but are usually worse during menstruation. Exercise, sexual intercourse and vaginal examinations can also trigger these symptoms.

Research by the Endometriosis Association indicates that bowel symptoms are far more common than is generally acknowledged. In fact, 49% of women in its survey reported that they had experienced bowel pain prior to a diagnosis of endometriosis.

In the unusual cases where endometriosis is located on the bowel, the implants are usually confined to the outer layer of the bowel wall; it is uncommon for endometriosis to be found in the inner layer of the bowel wall. If implants are located on the bowel itself the symptoms experienced may include any of the symptoms mentioned above. In rare circumstances a partial obstruction of the bowel may develop as a consequence of scarring and adhesions from endometrial implants encircling and constricting the bowel.

Bladder symptoms-Implants on the bladder, or on adjacent organs, may cause a range of symptoms including bladder pain, blood in the urine, pain or burning when passing urine and urinary frequency.

Infertility-Infertility is one of the most common symptoms and is thought to affect approximately 30% to 40% of women with endometriosis.

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The bottom part of the womb, the cervix, changes quite dramatically during the menstrual cycle according to the hormones being produced. Understanding and recognizing these changes is one of the most important ways you can pinpoint the best time to have intercourse in order to conceive.

The mucus-secreting glands (crypts) which line the cervical canal produce mucus continuously but this fluid undergoes important changes during the menstrual cycle. During the first half of the cycle (the follicular phase), the mucus is thick and sticky. It forms a plug over the cervix, which stops semen entering. It also makes the vagina acid, which can kill off sperm within a few hours.

About three to four days before ovulation, as oestrogen levels increase, the mucus becomes clear and stretchy and the amount increases. Surrounded by this fertile mucus, sperm can live for up to seven days.

So it is possible to have intercourse on a Monday and actually conceive on a Friday! This fertile mucus turns the vaginal fluids alkaline, keeping sperm alive. It also provides nourishment for the sperm, in the form of increased amounts of sugar, amino acids, salt and water.

The other intriguing aspect of this fertile mucus is that it forms ’swimming lanes’ (or canals) through which the sperm can pass quickly. It also seems to act as a filter, allowing the healthy sperm to travel forward but effectively trapping the abnormal sperm (there are always some abnormal sperm in semen) and blocking their passage. Once ovulation has taken place and progesterone increases, the mucus again becomes thick and sticky (infertile mucus), protecting the cervix from sperm and also from any foreign bodies.

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HBV infection is passed on when body fluids or secretions from an infected person get into another person’s body through a break in the skin or a lining membrane. HBV has been found in blood, semen, vaginal secretions, saliva, urine, breast milk, discharges, sweat and even tears.

Hepatitis В is of particular concern for women because a woman who is a chronic carrier (see below) or who develops hepatitis В infection during pregnancy may pass the infection on to her baby, usually during birth. Children infected this way usually become carriers.

HBV is very easy to catch. You can pick it up through sexual contact, blood transfusion, sharing syringes and needles, contaminated instruments (such as those used for tattooing, ear piercing, acupuncture, dental and medical procedures), mouth-to-mouth contact and by contact of any infected fluid with a cut or abrasion on any body surface.

Hepatitis В is not strictly classified as an STD because it is not exclusively passed on by sexual contact, though this is probably the most common means of transmission in Western countries. Homosexual men and men or women with many sexual partners are those most likely to be infected through sex. Catching the virus from blood transfusion, which was once believed to be the most common means of infection, is now rare because of screening of donors. (Blood from transfusion services in Australia and many other countries is now tested for hepatitis В and C, HIV and syphilis). People at most risk of catching hepatitis В non-sexually include health workers who come in contact with blood or secretions from infected people, intravenous drug users and mentally handicapped people living in institutions.

Many women suffer silently and unnecessarily from urinary incontinence, which affects about 5-6 per cent of Australians – over 800 000 of us. Women are eight times more likely to be affected than men. Also, many more people experience occasional ‘accidents’ with involuntary loss of small amounts of urine. A recent survey in Sydney found that 54 per cent of women had experienced loss of bladder control at some time during their adult lives, so if incontinence has ever troubled you, you’re not alone.

Loss of bladder control is a humiliating experience. The possibility of unpredictable, embarrassing accidents can have a profound effect on confidence and self-esteem, and may lead to depression, anxiety, social withdrawal and isolation. Many sufferers are too ashamed and embarrassed to talk about their problem, even to their doctors.

The belief that they have too much facial and body hair is a distressing problem for many women. They may fear that they be a hormonal imbalance and become depressed and withdrawn, believing that their appearance is flawed by excessive hair. But how much is too much? This perception depends on your inherited background and where you live.

In our society the image of female beauty promoted by fashion, advertising and the media makes facial or body hair on women a disfiguring blemish. We go to all kinds of trouble to remove it even from sites such as our legs and armpits, where it is normal and inevitable that hair will grow. In other societies, where the majority of women have a genetic tendency to grow more and darker (and thus more noticeable) facial and body hair, moderate female hairiness is quite acceptable.

In the past excessive hair growth has often been considered a cosmetic rather than a medical problem. In recent years the factors that influence hair growth have become more clearly understood; most women with unwanted hair can now be helped by medical as well as cosmetic treatment.

Before discussing the problem of excessive hair, let’s look at a few facts about hair in general.

Types of hair

There are three types of hair. Lanugo hair grows prenatally and is seen mainly on premature infants – fine, darkish hairs that disappear shortly after birth. There are two types of post-natal hair: vellus and terminal. Vellus hair is fine, short and pale, and grows all over the body except on the palms and soles, around the nails and on some parts of the genitals. Terminal hair is thicker, longer, and often strongly coloured. It is seen after birth on the scalp, eyebrows and lashes.

The tiny organs, from which hairs grow, the hair follicles, lie below the surface of the skin. Hair growth is not continuous, but goes through cycles of growth and rest. At the end of the resting phase the hair falls out and a new hair begins to grow. The length of each phase of the cycle varies with the site of the hair. The growing cycle is longest in scalp hair (three years) and shortest in arm and thigh hairs (a few months), which explains why scalp hairs grow to greater length. Each follicle goes through its cycle independently of other follicles, resulting in constant slight hair loss rather than the seasonal moult that occurs in many animals.

We are all (men and women) born with the same number of hair follicles. During life various factors influence some of the vellus hair follicles to produce terminal hairs. The number and situation of follicles normally converted to terminal hairs depend on sex and other inherited factors, both racial and familial. At puberty the production of androgens (male hormones) in both sexes converts vellus hair to terminal hair in the armpits and pubic regions.

As males progress through puberty, androgens cause terminal hair growth to develop further in an orderly sequence on the upper lip, chin and cheeks, lower legs, thighs, forearms, abdomen, buttocks, chest, back, upper arms and shoulders. The amount of this hair growth is enormously variable between men: there are as many men with a sparse beard and little or no body hair as there are men with heavy beards and body hair.

Terminal hair also develops on the lower legs and forearms in the majority of women. Whether this growth is stimulated by sex hormones is uncertain, but as it tends to be proportional to the amount of terminal hair in other sites it seems probable that it occurs more in those women whose hair follicles are more sensitive to androgens.

Excessive hair growth

There are two types of excessive hair growth, hirsutism and the less common hypertrichosis.

Hirsutism refers to the androgen-stimulated growth of coarse terminal hair in women on the ‘man the abdomen and lower back and fronts of the thighs. Note that a few со hairs around the nipples are common a normal.

Hypertrichosis is excessive growth both vellus and terminal hair. It is usually not caused by hormones. The main causes
of hypertrichosis are certain drags, thyroid disorders, after inflammation of the skin and in some metabolic disorders. This sort of excess hair disappears six to twelve months after the cause is corrected. Hypertrichosis may also occur in patches, alone or associated with a mole.

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Bleeding between periods

Except for slight spotting at the time of ovulation, all bleeding between periods (and after sex) needs investigation. The most important causes to rule out are cancer of the endometrium or cervix. Other causes include infections and other inflammations of the cervix and uterus, polyps of the uterus and cervix, and hormonal disorders. Ectopic pregnancy and incomplete or missed abortion must be excluded if there is unexpected bleeding and any possibility of pregnancy.

Painful periods (dysmenorrhoea)

There are two types of period pain.

• Primary dysmenorrhea occurs in young women who have normal reproductive organs.

• Secondary dysmenorrhea is menstrual pain that develops in women who have previously had painless periods. It is always a symptom of problems in the reproductive organs.

There seems no doubt that mood сchanges around the menopause are influenced by a lack of oestrogen, but your feelings about
getting older and reaching the end of your fertile years also play a part in your emotional response. Physical symptoms can also affect your mood. If your sleep is disturbed by frequent sweats, it’s not surprising that you feel tired, lethargic and irritable during the day, and have trouble concentrating and making decisions.

Physical symptoms may make difficulties for you at home, at work or socially because your family, colleagues and friends don’t understand what’s happening to you. Some women may be embarrassed or unwilling to complain of menopausal symptoms because of the old attitudes (which still prevail in some quarters) that it’s bad form to speak of such things that women should ‘put up with it grow old gracefully’. There’s no graceful about drenching hot flushes,
splitting headaches or depression!

Other women have told me that; are afraid to admit to menopausal toms for fear of being assumed to be ‘over the hill’ or ‘past it’ and thus less competent, rather than being judged fairly on their performance. In a society that values promise and smooth face of youth maturity, older women are often caricatured as unattractive, ill-tempered or doddery figures of derision. Such attitudes don’t do anything for the self-esteem and confidence of middle-aged women. Other things may be causing emotional stress. Middle age can be hectic! You may lie worried about the health of your partner, elderly parents or others. Middle-aged women take on the biggest load of caring for the older generation. This can take a big toll on their physical and emotional energy.

Your own or your partner’s retrenchment may bring financial problems you didn’t expect. Retirement can be hard to adjust to.

Loneliness may follow marriage breakup or death of your partner. Your children maybe growing up and moving away from home, leaving a gap in your life that’s hard to fill, though I think the ‘empty nest’ has been overemphasized as a cause of depression in middle-aged women. Many women are relieved when the children become independent, leaving them extra time (and funds!) to devote to themselves and their partners and friends, careers and other interests. Nevertheless, when the children leave home, it certainly changes the marriage dynamics. It’s a time of life when everything that happens points unswervingly to the fact that we are no longer young: grey hairs! wrinkles! spectacles needed for reading! grandchildren! And then there’s the menopause, a clear signpost that we have arrived at middle age.

Reaching middle age means taking a new look at yourself and your place in your family and community. Be proud of your maturity: don’t deny it! It’s time to review what you want from the rest of your life; time to make some plans so that you can enjoy the years ahead to the full. Let one of these plans be to take steps to ensure the best possible health for the rest of your life.

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Leg cramps

Night-time cramps in the legs can be a problem. They really hurt and can have you hopping around the bedroom in misery until that agonizing knot relaxes. We don’t know why leg cramps occur more in late pregnancy. It may be a combination of altered amounts of salt and calcium in the blood and reduced blood flow in the legs.

People will tell you different ways to prevent or relieve leg cramps. I found that running warm water over my leg helped to stop the spasm. Some people swear by a knob of camphor in the bed for prevention. This didn’t work for me, but it’s cheap and harmless so worth a try. If friends advise you to take something by mouth to prevent cramps, check with your doctor first.

Itchy skin

Skin that is stretching quickly, such as over the abdomen and breasts, can become itchy. A cream containing something to relieve the itch will help; ask your pharmacist. More severe itching can result from an increase in bile salts in the blood, as occasionally happens when the liver is overloaded in pregnancy. The itch affects all skin, including the palms and soles. If you become itchy all over, see your doctor promptly. You may need blood tests to confirm the diagnosis, and treatment to bring the bile salts back to normal.

Stretch marks

Wearing a firm support bra and an abdominal support can help reduce the chance of stretch marks forming.

Backache

As your baby and your uterus get bigger, your centre of gravity moves forwards. Your upper spine bends further and further back to stop you from toppling over. This puts a strain on the muscles and joints of the spine. Also, the hormones of pregnancy soften and loosen the ligaments of your lower spine and pelvis in readiness for delivery. It all adds up to a high chance of back tiredness and aching in those later weeks.

Your antenatal exercises and advice given on posture will help improve the strength of your back muscles; your physiotherapist will advise you how to move and lift things to reduce back strain. If back problems are really troublesome, speak to your doctor or physiotherapist. A maternity corset or back support may help.

Shortness of breath

As your uterus rises in your belly, there’s less room for your diaphragm to move down when you breathe in; thus your lungs expand less and oxygen intake is decreased. This won’t worry you excel when you’re exerting yourself (such as when walking up stairs and hills), when
shortness of breath and aching muscles may slow you down.

If you get short of breath without or on slight exertion, see your doctor. It may be a sign of anaemia or other disorder.

‘I never feel comfortable’

During the last five to six weeks there may
be discomforts from pressure on your
lower ribs and the weight of your uterus on your pelvic organs and tissues. It’s hard
for some women to find a comfortable position for sitting or lying down. That big belly seems to get in the way, no matter what you do. A straight-backed chair helps for sitting, and you can experiment with extra pillows for more comfort in bed.

Ankle swelling

Pregnancy hormones also increase the amount of fluid in your body, more so as pregnancy advances. This, plus increased pressure in the veins in your legs, often leads to swollen ankles at the end of the day in the latter weeks. Swelling is aggravated by hot weather and prolonged standing.

When you lie down at night the fluid around your ankles drains back into your blood and is passed as urine. You may find that you have to get up more frequently than in the early weeks! Putting you feet up in the afternoons and evenings may help to make your nights less disturbed.

If ankle swelling extends up over your shins or if your fingers become swollen, see your doctor. If rings start to feel tight, take them off straight away – if they get stuck they may need to be cut off!

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