Berkenaan Dengan Endometriosis

Biasanya kita manusia tidak akan mengambil tahu dengan mendalam akan sesuatu perkara, melainkan jika ianya terkena pada diri sendiri. Begitu lah yang terjadi pada diri aku. Setelah mendapat tahu ada sesuatu yang tak kena pada diri aku, baru lah aku mengelabah.

Sememangnya aku akan mengalami sengugut pada tiap-tiap bulan, tapi aku sangkakan ianya adalah normal kerana ia dialami oleh kebanyakan wanita. Tapi aku tidak begitu bernasib baik bila sengugut ku itu bukan normal, tapi sebenarnya penyakit yang dinamakan “endometriosis”.

Kesan dari “endometriosis”, ia menyebabkan rahim disebelah kananku diselaputi “choclate cyst” sebesar 8 cm, agak besar juga tu. Menurut Doktor Idris, dia terpaksa “repair” rahim di sebelah kananku yang ditumbuhi “cyst”, manakala tiub fallopianku disebelah kiri tersumbat dan membengkak juga terpaksa dibetulkan.

Selepas menjalani pembedahan, aku harus mengambil ubat danazol, selama tiga bulan. Rawatan dengan mengambil ubat hormon ini, dijangka dapat mengurangkan penyakit ini. Selepas rawatan ini, aku disarankan supaya mengandung secepat mungkin. Kerana penyakit ini, mungkin akan berulang, selagi darah haid aku ada. Aku selalu berdoa di setiap kali solat, semoga aku dikurniakan zuriat secepat mungkin. Semoga Allah memakbulkan doaku ini.. InsyaAllah.. sesungguhnya Dia maha Pemurah lagi maha Penyayang.

Betapa seksanya aku untuk untuk bergerak selepas pembedahan. Aku ditempatkan di wad selama seminggu dan diberi cuti sakit selama sebulan. Selama aku berpantang, banyak juga bahan bacaan berkenaan dengan penyakit ini aku baca. Bak pepatah melayu, Dah terantuk baru nak tergadah. Di sini aku nak kongsikan pengetahuan berkenaan dengan penyakit endometrosis nie.

What is endometriosis?

Endometriosis is a condition where the tissue that normally lines the uterus (endometrial tissue) occurs in other parts of the body. Stray endometrial tissue is often referred to as endometrial implants. Endometrial implants are most commonly found on the surface of the ovary, the ligaments that support the uterus and in the Pouch of Douglas (a small area between the uterus and rectum). Other areas include the surface of the uterus, fallopian tubes, bowel (eg. colon), cervix, vagina, vulva, ureters (the tubes connecting kidney to the bladder) and bladder. In some rare instances, endometrial implants have been found in areas of the body such as lungs, arms, legs, nose and other distant locations.

Studies suggest between 5 -10% of premenopausal women have the condition, with higher rates in infertile women.

What problems do endometrial implants cause?

Endometrial tissue which grows outside the uterus responds to hormones in the same way as the tissue which lines the uterus. That is, during every menstrual cycle the endometrial tissue thickens in readiness for ovulation and pregnancy and if pregnancy does not occur, the tissue breaks down causing bleeding. However, unlike the blood from the endometrial tissue lining the uterus, the blood from endometrial implants cannot escape the body. The trapped menstrual blood causes irritation and inflammation to the surrounding tissues and organs .

The body responds by trying to surround the ‘problem’ area with scar tissue to protect the rest of the body. The formation of scar tissue (adhesions) can result in the pelvic structures becoming stuck together, unable to move freely. Consequently, any movement such as that occurring in ovulation, sexual intercourse or emptying of the bowel can be painful. Over time, the endometrial tissue may also enlarge and form cysts, particularly in the ovaries. These cysts are often referred to as ‘chocolate cysts’ because they are filled with old blood which is chocolate-like in colour.

Symptoms

The symptoms of endometriosis vary widely from woman to woman. The severity of symptoms is not necessarily related to the severity of the endometriosis. For instance, a woman with extensive endometriosis may have few symptoms or none at all, while a woman with minimal endometriosis may have severe symptoms. Symptoms often depend on the location and depth of the endometrial implants. While women typically experience symptoms at the time of their period, if adhesions are present the symptoms may also occur at other times and can continue after menopause.
Women with endometriosis may not recognise they have the condition, believing their symptoms to be normal period pain and something “they just have to put up with”.

Symptoms include:
*Period pain (dysmenorrhoea)
*Pain during sexual intercourse (dyspareunia)
*Pelvic and abdominal pain outside of menstruation
*Abnormal bleeding- including heavy bleeding, clotting, prolonged bleeding, irregular bleeding, premenstrual spotting
*Bowel disturbances - including painful bowel motions, diarrhoea, constipation, bleeding from the bowel
*Difficulty in getting pregnant
*Painful urination
*Lower back, thigh and/or leg pain
*Premenstrual syndrome
The anticipation of pain or discomfort, recurrence of symptoms following treatment and fertility problems can lead to feelings of depression, anxiety, anger and hopelessness and stress. It is important to acknowledge the mental and emotional symptoms that can be associated with having this condition.

Causes

The exact cause of endometriosis has not been established but a number of theories exist within the medical community. The most accepted theory is that of 'retrograde menstruation.' This theory proposes that during menstruation some blood moves in the wrong direction up along the fallopian tubes and into the pelvis (instead of down through the cervix and out the vagina) where it releases endometrial tissue fragments. These tissue fragments then implant and grow on the ovaries, fallopian tubes and the back of the pelvis. The retrograde menstruation theory is supported by the fact that endometrial implants are most commonly found in these areas. It appears, however, that the majority of women do have some degree of retrograde menstruation and yet not all develop endometriosis. It is, therefore, suggested that other factors such as a lowered immune response may also play a role.

Other theories suggest stray endometrial cells occur during the formation of the foetus or are spread through the body via the blood or lymphatic system or through gynaecological surgery. Research is also examining whether there is a genetic component.

Risk factors

Women can be affected by endometriosis from as early as adolescence. There are a number of factors that appear to increase the chances of developing endometriosis, including:

Menstrual pattern- The frequency, length and heaviness of menstrual periods influence a woman’s endometriosis risk. An early onset of menarche (first period), short cycle length (under 28 days), long duration of flow (more than seven days), regular periods and heavy periods are all associated with an increased risk.
Family history - Women who have a family member who has been diagnosed with endometriosis have a higher risk of acquiring the condition. Similarly, women with a family history of the condition are more likely to have severe endometriosis.

Reproductive history - As pregnancy and lactation reduce the number of menstrual periods (and the opportunities for retrograde menstruation) having no or few children increases a woman’s risk of endometriosis.

Immune factors - It appears that women who suffer from endometriosis also experience a higher incidence of autoimmune conditions like chronic fatigue, rheumatoid arthritis, multiple sclerosis, allergies and asthma.
Obstruction in outflow of menstrual blood -An obstruction (due to factors like congenital abnormalities, narrow cervix, etc) is thought to increase the likelihood of retrograde menstruation and, therefore, endometriosis.

Environmental toxins - Animal studies have suggested that environmental toxins like the chemical by-product dioxin may increase the risk of endometriosis. Dioxin may contribute to the development of endometriosis by mimicking the female hormone oestrogen and/or by compromising the immune system.

Diagnosis

Endometriosis can be difficult to diagnose as the symptoms may initially be attributed to other health problems like pelvic inflammatory disease, fibroids, kidney stones, stomach ulcers, irritable bowel syndrome and cystitis. As a result, women can experience significant delays between the time they report symptoms and the time they receive a diagnosis of endometriosis. Delays in diagnosis can leave women feeling frustrated, angry or depressed. Conversely, as it is known that some women with endometrial implants are asymptomatic there is the risk that a woman experiencing pain may be diagnosed with endometriosis on the presence of endometrial implants when, in fact, her symptoms are related to another condition.

A doctor may be able to detect signs of endometriosis during a pelvic examination. Tenderness in the pelvic region, a uterus that appears fixed and immobile (due to adhesions) and enlarged ovaries (from chocolate cysts) may all indicate the presence of endometriosis. If enlarged ovaries or a mass in the pelvis is detected, a vaginal ultrasound (which uses a probe inserted into the vagina) may be performed.

The only way to definitively diagnose endometriosis, however, is through laparoscopy. Laparoscopy is a surgical procedure which involves inserting a long, thin telescope (laparoscope) into the abdomen through an incision near the navel. Gas is then pumped into the abdomen to separate the organs for better visualisation. The surgeon will look for signs of endometriosis and may take tissue samples for testing. A person’s endometriosis will be classified from mild to severe (stage I-IV) according to the location, amount, depth and size of the endometrial implants. Endometrial implants may also be removed at this time (see surgical treatment section).

Treatment options

Treatment for endometriosis depends on a number of factors including the severity of symptoms, the extent of the endometriosis, the woman’s age and the outcome she wishes to achieve (ie. pain reduction, improved fertility). There is no definitive cure for endometriosis but a combination of regular medical follow-up, drug treatment, surgery, diet and exercise and complementary therapies can help control the condition.

One of the common misconceptions concerning endometriosis is that having a baby will cure the condition. While endometriosis is generally suppressed during pregnancy, 50-60 percent of women will experience a recurrence within five years, with some women’s symptoms returning as soon as their periods resume. Some women actually experience a worsening of symptoms in the first few months of pregnancy.

Drug treatment

Drugs used for endometriosis can be divided into those simply providing pain relief and hormonal treatments. As endometrial implants are found to regress during pregnancy and menopause the majority of hormonal treatments are designed to mimic the woman’s hormonal state at these times. It is important to note that while drug treatments can shrink endometrial implants they have no effect on adhesions and do not improve fertility.

The possible risks, benefits and side effects should be discussed with a doctor at length before commencing treatment. Endometriosis can recur following drug therapy with the recurrence rate higher in women with a more severe condition. A number of other drug treatments are currently being trialled for the treatment of endometriosis.

Nonsteroidal anti-inflammatory drugs (NSAIDs) - These drugs block the production of prostaglandins in the body. Prostaglandins have a number of functions, including making the uterus contract during menstruation to help with the shedding of the endometrium. These contractions can cause pain. It is thought that women with endometriosis may produce more prostaglandins than women without the condition. NSAIDs only work effectively if they are taken before the body produces prostaglandins and so it is best to start taking them the day before a period is expected. Women may need to try different formulations before they find one that is effective for them. Common side effects of NSAIDs include nausea, vomiting, diarrhoea, stomach upsets and stomach ulcers. These can be reduced by taking the drugs with food or milk.

Combined oral contraceptive pill - The combined oral contraceptive pill contains a combination of the hormones oestrogen and progestogen. Oral contraceptives may be useful for women with milder symptoms, particularly adolescents and women who do not wish to take the other drugs available. In the treatment of endometriosis oral contraceptives are sometimes given continuously for several months (skipping the sugar pills). Taking oral contraceptives continuously eliminates the withdrawal bleed and, therefore, the incidence of period related pain. It also reduces the amount of blood and the possibility of further endometrial implants occurring by retrograde menstruation. Common side effects of the combined oral contraceptive pill include fluid retention, nausea, breast tenderness, headaches, vaginal discharge and decreased sexual drive.

Progestogens - Progestogens act as anti-oestrogens, inhibiting the growth of endometrial implants. Progestogens are available as tablets, injections, an intra-uterine system (Mirena) or an implant (Implanon). Side effects differ for each delivery methods but may include weight gain, fluid retention, nausea, breakthrough bleeding, depression and fatigue (less likely with the intra-uterine system).

GnRH agonists - These drugs are a modified version of Gonadotropin-releasing hormone (GnRH), which is a naturally occurring hormone. GnRH agonists work by stopping the ovaries producing the female hormones oestrogen and progesterone, inducing an artificial menopause. The lack of oestrogen causes the endometrial implants to degenerate. GnRH agonists are administered by injection or nasal spray.

Side effects of GnRH agonists include menopause-related symptoms and a reduction in bone density. Although this latter side effect is largely reversible after ceasing medication, treatment with GnRH agonists is generally limited to a six month course to minimise the risk. “Add back” therapy, adding back low doses of hormone replacement therapy (HRT) can be used to overcome some of the side effects. GnRH agonists should not be taken during pregnancy or breastfeeding.

Danazol and Dimetriose - Danazol is a mild anabolic steroid that contains a weak form of testosterone, the male hormone. It creates a menopause-like state. Most of the women who take Danazol stop having a menstrual period and many experience other side effects. Side effects include those related to a drop in oestrogen (vaginal dryness, hot flushes and night sweats) and those related to an increase in testosterone (weight gain, decrease in breast size, acne or oily skin, increase in facial and body hair and voice changes). Muscle cramps, headaches, irritability, depression, decreased libido and increased cholesterol can also occur.
Dimetriose is a steroid which results in a menopause-like state. The side effects are similar to Danazol, although Dimetriose is reported to have fewer masculinising side effects. Both Danazol and Dimetriose should not be taken during pregnancy or breastfeeding.

Surgical treatment

Surgical treatment of endometriosis provides relief from symptoms for a significant percentage of women but, as with drug treatments, symptoms can recur in time. Unlike drug treatments, surgical treatment may improve women’s fertility.

The surgical removal of endometrial implants and adhesions can often be carried out at the time of the diagnostic laparoscopy. Accessible endometrial implants and adhesions are removed using a range of different instruments. Like with any surgical procedure, there are risks associated with the use of anaesthetics. The most common side effect experienced by women following laparoscopic surgery is pain and discomfort in the abdomen and/or shoulder due to residual carbon dioxide gas.

Other side effects may include the development of adhesions and, rarely, damage to pelvic structures. In addition, there is the possibility that not all the endometriosis was visualised and, therefore, some still remains. Most women will be able to go home the same day they have the operation. They will generally take between 5-7 days to feel better and will be able to return to work sometime in the second week.

If a woman has extensive endometriosis, adhesions or other circumstances which make using a laparoscope difficult, a laparotomy may be recommended as it provides greater access than a laparoscopy. A laparotomy is a major surgical procedure involving an incision in the abdominal wall. This procedure carries with it greater risks and a longer anaesthetic. A laparotomy will require 3-5 days in hospital and 3-5 weeks to fully recover.

If a woman’s symptoms persist despite drug and conservative surgical treatment a hysterectomy may be suggested (see the Centre’s factsheet on hysterectomy for further details). This type of surgery is usually only chosen as a last resort and in cases where all other forms of treatment have failed. If the ovaries are unaffected by endometriosis they may be retained to avoid a surgically induced menopause. However, studies show that women who keep one or both of their ovaries often experience a recurrence of symptoms with some requiring further surgery. Women should discuss the pros and cons of keeping their ovaries at hysterectomy with their doctor.

If women have both ovaries removed at hysterectomy they are often prescribed hormone replacement therapy (HRT) to relieve menopausal symptoms. However, as HRT contains oestrogen there is a concern that it will lead to a persistence or recurrence of endometriosis. It is often recommended that women are not given HRT until several months after surgery to ensure that any remaining endometrial implants have time to completely regress.

Diet and exercise

A healthy diet and regular exercise help to maintain physical and emotional well being. Women with endometriosis are encouraged to eat more fresh, unprocessed foods like fruit, vegetables, grains, legumes, nuts and seeds, while reducing the consumption of salt, sugar, fat, caffeine and alcohol (13). A well balanced diet plays an important role in assisting recovery following surgery as well as combating the side effects of drug treatments. The many benefits of regular exercise include more stable hormonal levels and stress and pain reduction.

Complementary therapies While there is limited scientific evidence supporting the use of such therapies for endometriosis, many women report finding complementary therapies helpful. There are a number of therapies available but those used most commonly in the treatment of endometriosis are herbal medicine, Traditional Chinese Medicine (TCM), aromatherapy, homeopathy, massage, yoga and meditation. Complementary therapies can assist in balancing hormone levels, relieving pain and reducing feelings of stress and depression often associated with the condition.

Women interested in using complementary therapies should consult a qualified practitioner who can properly advise them on a course of treatment. It is also important that women disclose their use of any complementary therapies to their doctor, particularly if they are also undergoing medical treatment for endometriosis.

Emotional support

In addition to the drug, surgical and complementary therapies available, women may find the services of a professional counsellor experienced in working with endometriosis helpful. They can help women address some of the issues associated with an endometriosis diagnosis. Similarly, women may consider joining a support group. Support groups can provide women and their families with information on endometriosis, coping strategies as well as contact with other people who are experiencing similar problems. Being able to talk to others also affected by endometriosis can reduce feelings of isolation.