ASK ESIG

(Endometriosis Special Interest Group)

Endometriosis Special Interest Group (ESIG) was formed by Endometriosis New Zealand (ENZ) in 2008 to act as advisors to ENZ on specific projects. ENZ governs ESIG. ESIG advise on issues relating to endometriosis, contributes to research and voluntarily support the organisation in its endeavours. Individuals who have a special interest in endometriosis, are appointed to ESIG through nomination by the ENZ Trust Board.

Find out more about the ESIG members here.


Adenomyosis

July 2018, Responses from: Professor Neil Johnson

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Adenomyosis

Painfully under-researched, poorly understood, often unrecognised, what is adenomyosis?

 

  • adenomyosis is probably best described as  ‘endometriosis of the wall of the uterus’.
  • there’s much overlap with adenomyosis and endometriosis. It’s rare to have only adenomyosis and no endometriosis
  • adenomyosis is often a marker of more severe endometriosis.  There’s much overlap with adenomyosis and stage 4 endometriosis including deep endometriosis (deep endometriosis has actually been nicknamed ‘adenomyosis externa’ reflecting a similar pathway to disease with these entities).
  • it can be hard to diagnose even by hysteroscopy and laparoscopy so the most reliable way to diagnose it for women who aren’t planning a hysterectomy is through imaging such as ultrasound or MRI.
  • it can cause all the typical pain problems that we associate with endometriosis and it can also cause heavy menstrual bleeding and / or spotting outside of periods, especially premenstrually.
  • it can be the reason why some women have persistent pain problems even after meticulous laparoscopic excision of endometriosis and why some women, such as Lena Dunham whose all-to-familiar story has been publicised recently, continue to have pain and symptoms and will often consider a hysterectomy to restore quality of life. It was adenomyosis that was highlighted in her case (https://globalnews.ca/news/4024985/lena-dunham-reveals-she-underwent-hysterectomy-to-battle-endometriosis/).

 

Adenomyosis is probably associated with fertility problems in some women, but this is again likely to respond to the same fertility treatments as endometriosis, indeed a lot of my patients with adenomyosis have had success with lipiodol, as has been proven to be the case for women with endometriosis-related infertility.

 

Laparoscopic surgery can sometimes help with adenomyosis, but realistically all adenomyosis can’t usually be removed without a hysterectomy.  Having said that, not all women with adenomyosis will ultimately need a hysterectomy.  It can often be managed, even long term, with some of the medical treatments for endometriosis and one treatment that I have found to be particularly useful for many of my patients with adenomyosis is the Mirena intrauterine system (as it releases progestin hormone locally to precisely where it is needed in the case of adenomyosis).

 

Internationally, there is now growing recognition that much more research is needed.

 

Neil Johnson

Professor of Reproductive Health, Robinson Research Institute, Adelaide

Gynaecologist and REI Subspecialist, Auckland Gynaecology Group and Repromed Auckland

President, World Endometriosis Society


Pelvic Floor Exercises

Leanne Wait, Responses from: June 2018

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Do you know of any exercises to help with my endo pain?

Pelvic floor release exercise – STOP, DROP & FLOP

With persistent pain like that experienced with endometriosis often comes a whole-body response where the nervous system becomes sensitive and certain muscles groups may become overactive as a type of protection. The pelvic floor is one such group. Commonly when I assess I find the pelvic floor muscles are tight, sore and they can be hard to release and relax.
When the pelvic floor is overactive doing pelvic floor strengthening usually compounds the problem making it tighter and sorer. Instead you may need to do the reverse which is like a reverse pelvic floor or kegal exercise. Can you release and lengthen your pelvic floor?
This can be a little tricky to master but the way I find most people understand it best is to talk about wind – (aka farting ;)).

Let’s try the Reverse Pelvic Floor which I call STOP, DROP & FLOP

  • STOP – Sit or lie comfortably and relaxed
  • DROP – Pull up like stopping the flow of urine and holding wind. Then let go and try and relax a little more like letting wind sneak out quietly as you might if you were in a meeting on an aeroplane or somewhere else you may no be able to excuse yourself from. This feeling of releasing wind is not pushing the wind out which usually makes a loud (fart) noise. It is a sensation often described as a softening, lengthening, opening, releasing and letting go feeling felt around the vaginal and anal openings.
  • FLOP- Also release your stomach and let it go floppy and relaxed
  • Spend a minute or 2 relaxed and belly breathing then continue with what you were doing.
  • Repeat STOP, DROP & FLOP every 1-2 hours during the day to help reduce overactivity in your pelvic floor muscles.

If you are unsure a pelvic health physio can help you to know if your pelvic floor is overactive and how to release.

Leanne Wait
Pelvic Health Physiotherapist


Endometriosis and Exercise

May 2018, Responses from: Heba Shaheed

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What are some suggested exercises for someone with endometriosis?
Endometriosis in women and girls is often accompanied by pain and discomfort in the pelvic region. The muscles and connective tissue in the pelvis, abdomen, back, hips and legs can become tight and sore. It’s important to keep the body moving to allow the muscles and connective tissue to lengthen, and to allow the nerves to slide and glide freely within the tissues.
Here are a few exercises that can be helpful to relieve the pain:

1. Pelvic floor drops:
Tension in the pelvic floor is common in women with endometriosis and pelvic pain. Pelvic floor drop exercises are essential to lengthen and relax the pelvic floor, especially with women who have pain with sex. Imagine the way a pebble drops into a pond, and imagine the ripples it makes outwards. Visualise this in your pelvic floor, and feel the way the pelvic floor muscles let go.
The following restorative yoga stretches are also beneficial. Spend some time in each of these poses whilst you breathe in deep and wide, and visualize your pelvic floor muscles softening down. You can complete the stretches in the following order.

Sphinx pose:

Modified pigeon pose:

Downward-facing dog pose:

Child pose stretch:

-Heba Shaheed, The Pelvic Expert


Anti-inflammatory diet and endometriosis symptoms

June 2018, Responses from: Courtney Hibberd

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Patient Question:

I know about FODMAPs and have tried reducing some of the foods that irritate my gut but there’s a lot of stuff on anti-inflammatory diets lately. Like we shouldn’t eat foods that inflame the gut. Seriously, what’s that about?” 

“In terms of managing functional gut symptoms that can run alongside endometriosis, a low FODMAP diet is still one of the most effective dietary interventions we can do.

It is important to note, that a low FODMAP diet is designed to be short-term (~6 weeks) and then a re-challenge is done. This helps to identify which of the four FODMAP groups you are most sensitive to and which groups you can liberate. The ultimate aim is a really varied diet, with only a few restricted foods to maintain good symptom control. It is an elimination diet, so seeing a FODMAPs experienced dietitian can really help make the diet easier to follow and ensure you are getting the best possible nutrition.

Including foods that naturally contain anti-inflammatory properties can easily be done on or off a low FODMAP diet.

Including foods such as walnuts, oily fish (salmon, sardines etc), linseeds (in small quantities as are high FODMAP) or flaxseed oil, leafy greens e.g. spinach, extra virgin olive oil and fruits such as blueberries, strawberries, oranges etc is a good place to start.

Fruits and vegetables such as leafy greens and blueberries are high in antioxidants and polyphenols-which are protective components found in plants, and foods such as walnuts and oily fish contain omega 3 fatty acids which also have anti-inflammatory properties.

If you are looking to overhaul your diet, a good place to start is by aiming for a more Mediterranean style of eating. This involves including higher intakes of fruit and vegetables (aiming for 5-7 serves per day – e.g. 1 cup salad veg or ½ cup cooked veg and a small palm-sized piece of fruit (no more than 2 serves/day)), extra virgin olive oil, nuts and seeds (~1/8th of a cup), a couple of serves of fish/week, decreasing red meat (<2x serves/week) and processed meats and including whole grains.

This style of eating can easily be combined with a low FODMAP diet for maximum gut benefits!”

-Courtney Hibberd BSc, PGDipDiet, Cert. Paed Nutr

NZ Registered Dietitian


Zoladex

December 2017, Responses from: Susan Evans and Neil Johnson

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QUESTION 1: How does the Zoladex injection affect my period? For instance, I thought it would stop my periods but that hasn’t happened.


Neil Johnson: It can sometimes take a cycle or two for Zoladex – which is a GnRH agonist and workd by switching off the pituitary gland releasing the hormonal drive to the ovaries – to stop menstrual bleeding, although most women’s periods have stopped by the second cycle of treatment.


QUESTION 2: My doctor has suggested I start a course of Zoladex but from what I have read, it’s a pretty gross drug with awful side effects. Wouldn’t it be better to excise my endometriosis properly as I have only had a diagnostic laparoscopy?


Neil Johnson: Zoladex does have potential side effects, including hot flushes, sweating episodes, vaginal dryness and mood swings or low mood, and if used longer term also loss of bone mass – in other words, menopause-type side effects – but some women experience little in the way of side effects. When given to treat pain symptoms, Zoladex is usually administered with add-back hormone therapy, usually involving estrogen and progestin hormone, which means that most women will not have any Zoladex-related side effects. When given to assist fertility outcomes, such as in the lead in to IVF, Zoladex is usually given without add-back hormone therapy, but the duration of the treatment course is usually short, typically only three months.


QUESTION 3: Is Zoladex the same as that horrible drug Lupron that they talk about in the U.S.?


Neil Johnson: Both Zoladex and Lupron are GnRH (gonadotrophin releasing hormone) agonists (or analogues). However both, if used properly as described in reponse to query (b), in most cases, neither tends to be horrible. They can both have side effects, but even if this is the case, often this is quite manageable. If not, then there are other treatment options.


General comment about the three previous questions
Susan Evans: Yes, Zoladex only suits some people, and it can’t be used long term.
Actually it isn’t any more effective than continuous progestogen hormones.
I’d recommend dienogest (Visanne) 2mg daily every day without breaks, or if it isn’t available then norethisterone (primolut) 5mg instead


FURTHER INFORMATION FROM ENZ:
Our feedback on Zoladex suggests that doctors are now prescribing it less than they used to. There is more understanding now of the side effects and efficacy of the drug.

Some specialists might recommend a short course of Zoladex between surgeries where all the endometriosis could not be excised in one procedure. This can happen if there is advanced, deeply infiltrating endometriosis involving the bowel or other organs which could put the patient at further risk if the surgery were to proceed. They would probably recommend this to try and ‘dampen down’ the endo between surgeries.

Other specialists would choose not to use Zoladex at all and there are some who still recommend it as a first line treatment. Gynaecologists may prescribe other drugs to counteract the side effects.

Here’s one woman’s comment “Zoladex was great in reducing my pain, but the side effects were revolting and I couldn’t continue the course.”

There are no drugs which cure endometriosis but women often find their symptoms are controlled or improve taking certain drugs. Our recommendation is that you research the drugs being recommended to you. Ask your doctor why that particular drug is being recommended and the options available. Any treatment you are offered is about YOUR INFORMED CONSENT.


Adenomyosis

July 2017, Responses from: Michael East and Neil Johnson

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QUESTION 1: I was diagnosed (via a biopsy) with adenomyosis when I had my hysterectomy 7 years ago. My endo has just returned, despite a subsequent oophorectomy. My question is – is it possible for adenomyosis to return posthysterectomy (in places other than the uterus)?


Michael East: “Although adenomyosis is a term generally reserved for endometriosis like deposits found within the wall of the uterus, similar ‘lesions’ can be found in other places (see below). The term adenomyosis contains 3 parts, adeno (meaning glandular tissue, in this case similar to endometrial tissue), myo (meaning smooth muscle) and sis (coming from the Greek ending to indicate ‘a condition’). The uterosacral ligaments that run from the cervix to the lower spine (sacrum) can also contain adenomyosis like tissue, as can the rectovaginal septum (wall between the rectum and vagina). Both of these structures contain smooth muscle and both can have endometriosis (known in these places as adenomyosis) within them, that can survive after hysterectomy. If it is suspected at the time of hysterectomy that the uterosacral ligaments and rectovaginal septum contain adenomyosis / endometriosis, then it is usual for the surgeon to try to remove that as well. It is still possible for some to survive even then after hysterectomy, and cause ongoing pain. I would like to stress however that pelvic pain persisting after hysterectomy is more likely to be due to other causes than adenomyosis (for example musculoskeletal pain). Ongoing pain is best helped by a team of health professionals consisting of a physiotherapist, gynaecologist, chronic pain specialist and a clinical psychologist.

Sometimes further surgery can help, but equally it may fail or even make the pain problem worse! It is important to remember that every woman’s situation is slightly different and what may have helped a friend may not be the best option to help you. Talking about your options with the health team members mentioned above is often the next best step.”


QUESTION 2: Following a pregnancy, with C-section delivery, is there any indication of the time period over which the adenomyosis worsens? Does the data suggest adenomyosis gets worse soon after pregnancy and delivery?


Michael East: “How adenomyosis occurs is still an unanswered question. The suggestion that pregnancy causes adenomyosis is probably a medical myth (other that after C-section which I will come to later). Before ultrasound scans had been invented adenomyosis was only diagnosed in women who had undergone hysterectomy and the majority of those had borne children. Even when ultrasound scans became available the appearance on scan thought to indicate adenomyosis, was only seen in older women. Now that ultrasound scans offer much higher definition the appearance of adenomyosis can be seen as early as age 14 years. It is important to remember that adenomyosis can’t be diagnosed by an ultrasound scan or even an MRI scan. It can only be suggested by such scans, as tissue under a microscope is the only sure way to make the diagnosis. “To answer the question above more specifically however, I am not aware of any good evidence that adenomyosis becomes worse after a pregnancy. The exception to that is in the case of C-section where the very cut into the wall of the uterus may become a site of adenomyosis due to faulty healing where the womb lining can become caught up within the wall of the uterus. This is one of the reasons why women who have experienced a C-section delivery are at greater risk of having a hysterectomy in later life.”


Neil Johnson: “Adenomyosis should not return after a hysterectomy (as long as it wasn’t a subtotal hysterectomy and the cervix has also been surgically removed). Endometriosis associated with it can occasionally return after hysterectomy and oophorectomy … unfortunately.

“Data are very sparse on whether adenomyosis gets worse soon after pregnancy and even more sparse than the sparse data indication on the length of time for recurrence of endometriosis and related problems after pregnancy. Adenomyosis remains much less well researched than endometriosis. We can often apply the same lessons that we learn from endometriosis research to adenomyosis (in fact we often have to, otherwise there is an information vacuum regarding adenomyosis). It is largely based on experience/anecdote rather than primary research data, but this experience tells us that endometriosis (an adenomyosis) problems often resolve during pregnancy and for a variable time afterwards. In fact, there are some women whose endometriosis/adenomyosis-related problems do not recur after pregnancy. Unfortunately, there are also many women whose problems do recur, sometimes a short time (months) or a long time (up to many years) after having a baby. The length of time that women remain free from endometriosis problems after pregnancy is unpredictable. Having a caesarean section, rather than a vaginal delivery, has sometimes been claimed to be associated with earlier recurrence or more likely occurrence of endometriosis (www.hormonesmatter.com/endometriosis-vaginal-birth/). Probably the strongest study in the literature to support this was a Swedish cohort study (ref: Andolf E, Thorsell M, Kallen K. Caesarean section and risk for endometriosis: a prospective cohort study of Swedish registries. BJOG. May 13, 2013. doi: 10.1111/1471-0528.12236.)


FURTHER INFORMATION FROM ENZ:
Mr Michael East and Professor Neil Johnson have given a helpful response to these questions. ENZ recommends the gold standard approach to managing pelvic pain through multidisciplinary teams at Centres of Expertise. If such a centre or clinic is not available near you, look at the ASK ESIG files about pain management and ask your GP or specialist about a referral.


Psychological tools for managing pelvic pain

July 2017, Responses from: Hannah Blakely

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QUESTION 1: I have read the ASK ESIG files on pain following surgery (click here to view) but seriously, with a history of endometriosis and adenomyosis, what can I do to ease the ongoing pain?


Hannah Blakely: A team approach to pain management is the most effective in response to this question. A Clinical Psychologist may be useful to approach management of chronic pelvic pain in the context of ongoing management of pelvic pain. For example, many women experience persistent pelvic pain when the assumed source or reason for pain is surgically removed or medically managed. Often women express their distress, frustration and anxiety that pain remains feeling ‘over it’ and describe how it may negatively impact on their daily functioning. It may impact on mood, (low mood/depression and/or anxiety tolerance of pain, concentration and attention, physical activity, relationships sexual intimacy.

A common question is ‘how do I cope with living with this pain’. There are a number of effective management approaches including gaining the skills to tolerate and “turn the intensity of pain down”, finding out more about the psychological process of pain and how pain operates and learning about the meaning of pain to you. People perceive their pain differently. Some might think of it as harmful, unpredictable and uncontrollable. So, the way we perceive pain can affect our response to it.

Some strategies that may help living with chronic pelvic pain are increasing components of self-compassion, managing worrying and distressing thoughts through mindfulness and shifting our focus of attention. Learning about behavioural strategies and physical movement is also helpful to reduce the fear of pain and getting into the habit of avoidance.


FURTHER INFORMATION FROM ENZ:
Leanne Wait has some great advice about pelvic physiotherapy which is another TOOL for managing pelvic pain and compliments Hannah’s recommendations. At Insideout Physiotherapy in Hawkes Bay, she works with women who have endometriosis, adenomyosis, persistent pelvic pain and pre and post-surgical pelvic pain click here


Mirena or Jaydess?

June 2017, Responses from: Michael East

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QUESTION 1: I am 20 years old, have a diagnosis of endometriosis and have not had children. My gynecologist has suggested a Jaydess be placed at my next laparoscopy. Why a Jaydess and not a Mirena? I am confused. I have not had one of these
before. Please ASK ESIG for me. Thanks


Dr Michael East: Hi everyone, as a clinician who inserts a lot of Mirena intra uterine devices, I would like to share with you how it can help many women and also to point out how to recognise if it is not suiting you. Usually in my experience it is generally part of the solution and not part of the problem.

Firstly, let us consider what a Mirena consists of:

It is ‘T-shaped’ plastic (nylon) device that has a slow release hormone capsule attached to the ‘stalk’ of the T. It acts as a very efficient contraceptive and has a 5-year lifespan.  What are its properties? The ‘T’ serves to hold the hormone capsule inside the cavity of the uterus. It is chemically inert but as a foreign body it can act as an irritant to the uterus causing the uterine muscle to contract and cramp more often. This is more likely to occur in teenagers as the uterus is smaller and the ‘fit’ a little tighter. For younger women, the smaller Jaydess may be a better choice.

The hormone is a copy of the female hormone progesterone, and has two main actions:

  1. It causes relaxation of the uterine muscle (called smooth muscle) and as such, tends to decrease the irritant effect of the plastic ‘T’.
  2. It inhibits the growth of the uterine lining (endometrium) and any similar tissue (endometriosis and adenomyosis). This inhibition tends to reduce pain.

Generally, the hormone effect tends to dominate over the foreign body effect, and if that is so, then a Mirena tends to produce benefit to the user. If the foreign body effect is dominant, then cramps and bleeding can aggravate endometriosis symptoms.

The amount of hormone that leaks into the rest of a woman’s body is equivalent to taking one progesterone only contraceptive pill per week. As a result, most women do not experience hormone related side effects. Some women however are sensitive to this small hormone leak and experience a deterioration of acne or a flatness of mood. Some women find that their cyclical mood swings get worse, while others notice no difference or improvement.


Who do I advise to have a Mirena placed?

Most women undergoing surgery for endometriosis in my experience, benefit from having a Mirena placed at the time of surgery while they are asleep. They should be warned that it takes at least three months to ‘settle in’ and breakthrough bleeding can be an issue during this time, along with cramping. In other words, they need to ‘cut it some slack’ during that time. It tends to eventually add to the effectiveness of surgery and there is growing evidence that it decreases the number of women needing repeat operations for recurrent endo symptoms.


Who do I advise to avoid a Mirena?

Obviously if you are trying to become pregnant it is a no brainer. The main group of women that I suggest do not to have a Mirena are those who have a diagnosis of ‘polycystic ovary syndrome’ (PCOS), as it tends to aggravate acne or abnormal body and facial hair growth.


It a Mirena right for you?

The only real way to know is to try one and see.


Jaydess

This is made by the same company that makes the Mirena and is smaller in ALL dimensions. It is basically a ‘honey I’ve shrunk the Mirena’ option and lasts for 3 years. It’s smaller in size means that it is less likely to cause painful cramps in younger women with a smaller uterus and it better fits inside a smaller uterine cavity.

Otherwise it does the same job as a Mirena.

I could write so much more however I was instructed to be brief!

Best wishes.
Michael East.
Gynaecologist and Advanced Laparoscopic Surgeon Oxford Women’s Health at Forte
Health, Christchurch, New Zealand


Exercising without triggering pain and symptoms

April 2017, Responses from: Cate Grace and Leanne Wait

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QUESTION 1: Can you exercise without provoking or triggering more pain and symptoms?


Cate Grace: Absolutely! The research tells us that exercise can often help reduce pain and improve your quality of life but often because we are in pain, there’s a temptation to skip exercising. Everyone can do something, we just have to be mindful that exercising with pain is a fine balance, between doing too much and not doing enough.

Set out to discover what exercise you can do by discovering movement and activities you enjoy and can do without increasing your pain by more than two points from your baseline. It may look different than you knew before, maybe its walking instead of running, swimming instead of cycling, aqua class instead of hip hop. The possibilities are endless.

Seeking advice from physiotherapist or a registered exercise professional who understands chronic pain can assist in working out varied solutions and specific plans that work with your pain, and current levels of functioning. All the best and remember to keep in the back of your mind the benefits of exercising and aim for activities you enjoy doing!


Leanne Wait: Exercise has a well-established part to play in a management plan for anyone with persistent pain however there is a right type of exercise and amount for each individual. Too often patients are told to go and exercise so do too much or the wrong type of exercise which increases their pain and or symptoms and continues the cycle.

Current pain science tells us that for anyone experiencing pain for 3 months or more no matter what the cause will develop changes in their nervous system as the body tries to adapt, cope and protect us. This phenomenon is called “Central Sensitisation” and contributes to the complexity of persistent pain of any cause.

(See Leanne’s previous Ask ESIG answer for more information; How does pelvic floor physiotherapy actually help in women with Endometriosis, and what are the mechanics behind some of the muscular causes of pelvic pain that physios treat?)

If you have had pain for more than 3-6 months you should expect the increase in nerve signals to cause signs and symptoms to be worse with only minor triggers, last longer and things that would not normally cause pain will begin to trigger symptoms. If this is the case, then even simple small amounts of exercise can cause trigger pain and deterioration in symptoms. This in turn can lead to fear of movement as seemingly minimal exercise has previously triggered pain.

Exercise is an important part of any treatment plan as has many established benefits. Exercise can also help calm the nerves that are sensitised as long as the appropriate exercise, duration and intensity are chosen. Activity where there is a strong pelvic floor component like running, pilates, boot camp or core training in a gym are not usually helpful in anyone with pelvic pain due to in most cases overactivty in the pelvic floor. By working the pelvic floor more symptoms often increase – this could be noticed as bladder pain urgency or frequency, bowel pain, altered form of the bowel motion or bloating or increases in abdominal pain. Pain with intercourse or even pain with movement are also common when exercise has been overdone.

So the question is can you exercise without provoking or triggering more pain and symptoms?

The simple answer is yes! Where to start depends on how much you are currently able to move without provoking protective pain or symptom changes. Obviously, that means everyone is different. Sometimes we have to start with “graded motor imagery” where we imagine movement. Others can start with much more but either way the progression needs to be SLOW.

My experience is that any exercise needs to be individually tailored and graded which means a very slow gradual increase in activity with the focus on preventing flare ups and triggering an increase in symptoms. Sometimes my patients start with a 5-minute walk or 2 or 3 gentle yoga exercises prescribed to meet their individual needs. If they feel the benefits then after 3 trials we increase the intensity, load OR how long they exercise for. Understandably this can be very frustrating but is the way to your exercise or fitness long term goals. Fitness professionals not familiar with pelvic pain will be unaware of the potential to increase symptoms so inadvertently while trying to help often make the situation worse. It is therefore important to access pelvic health physios or fitness professionals familiar with this unique situation or even better work together to optimise individual client outcomes.

Contact Physiotherapy New Zealand http://physiotherapy.org.nz/about-us/contact-us/ to find an “Experienced Pelvic Health Physiotherapist” near you.


References
Nijs, J , Kosek, E, Van Oosterwijck, J, Meeus, M. (2012) Dysfunctional Endogenous Analgesia During Exercise in Patients With Chronic Pain: To Exercise or Not to Exercise? Pain Physician 15 (3 Suppl), ES205-ES213. 7 2012. http://www.painphysicianjournal.com/current/pdf?article=MTcxNw%3D%3D&journal=68

Nijs, J., Lluch Girbés, E., Lundberg, M., Malfliet, A. and Sterling, M. (2015). Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual Therapy, [online] 20(1), pp.216-220.
https://www.cme-online.nl/files/Artikel%20lezing%20Gert%20Dedel%20-%20Exercise%20therapy%20for%20chronic%20musculoskeletal%20pain.pdf

Evans S. (2013) Managing chronic pain in girls and women. Medicine Today 14 (5): pp54-58. http://www.drsusanevans.com.au/managing-chronic-pelvic-pain-in-girls-and-women/

Vandyken, C., MDT, C. and Hilton, S. (2012). The Puzzle of Pelvic Pain. Journal of Womenʼs Health Physical Therapy, 36(1), pp.44-54.
https://static1.squarespace.com/static/56e04de1e321405c5176b7c5/t/56effdea01dbae496bfd2587/1458568
685086/dianejacobsphoto.pdf


FURTHER INFORMATION FROM ENZ:
Cate Grace and Leanne Wait have given an excellent overview about exercise and its importance to those with endometriosis and for general well-being. However, we understand that exercise that provokes symptoms should be avoided and Leanne gives a good explanation.

Mobility is important so gentle and regular exercise is best until symptoms settle.


Sciatica and Endometriosis

April 2017, Responses from: Heba Shaheed

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QUESTION 1:
Lately I’ve been wondering about whether my sciatica could be related to my endometriosis, I first developed sciatic pain 3 years ago and it was initially triggered by intercourse and I went to the ER at the time only to be referred onto a spinal specialist. At the time, I could barely walk because the pain in my right hip was so bad and radiated all the way down to my foot and I had to use a walking stick for a few months. I’ve seen a spinal specialist, musculoskeletal specialist, physio and myofascial masseuse about it and have had MRI’s and the conclusion was that I didn’t have any spinal problems or muscular problems (such as disc bulges or piriformis muscle syndrome) that could be causing it. I was told that there was something wrong with my sciatic nerve and that the only thing I could do was to have the nerve burnt so it stopped sending pain signals. 7 months ago, I had my laparoscopy to diagnose stage 3 endo and lately Ive been wondering if my sciatica could be related? The pain in my right hip is chronic now and worsens significantly when I have my period, I know its rare but could it be extra pelvic endo? What is the best course of action to find out more about this as gynecologists seem to only want to treat the organs they are familiar with.

Heba Shaheed: There is a possibility that your sciatica is musculoskeletal driven by your pelvic floor and pelvic wall muscles. The sciatic nerve has a complicated pathway through your body – yes, it is partly spinal, however it also passes in a “loop-like” fashion through your pelvic floor and deep hip muscles.

SCIATICA AND ENDOMETRIOSIS - April 17

The sciatic nerve is usually treated with myofascial release work EXTERNALLY at the level where it passes across the PIRIFORMIS muscle. However, in some women the sciatic nerve passes THROUGH the piriformis muscle. It is important to note that parts of the PIRIFORMIS muscle can only be myofascially released INTERNALLY through the vagina – so if you have only had external muscle releases, this is not enough. The sciatic nerve also passes across another internal muscle called the OBTURATOR INTERNUS. Very often women who have pain or spasm associated with sexual intercourse, the obturator internus and the pelvic floor muscles have likely gone into spasm or are tight and painful. The fact that you are complaining of HIP pain further indicates that your OBTURATOR INTERNUS is likely the culprit. Chronic hip pain has been shown through research studies to be directly related to obturator internus and many physios, massage therapists, doctors, etc will miss this important muscle because it is located INTERNALLY. You need to see a women’s health physiotherapist who specialises in pelvic pain and is skilled in internal myofascial releases.

The other thing is sometimes we can label any type of “nerve pain” as sciatica. But sometimes another nerve may be causing the pain e.g. the genitofemoral nerve or the obturator nerve or the pudendal nerve. It doesn’t really matter exactly which nerve it is but WHY the nerve is causing you pain i.e. what muscle is cramping around the nerve causing it to get overexcited and trigger pain signals. My advice: have the internal muscles investigated and released by a women’s health physio, attempt some basic hip and pelvic stretches such as child’s pose and buttock stretches, and try to relax down through your pelvic floor – imagine the way a pebble drops into a pond and the ripples it makes outwards and visualise that in your pelvic bowl. There is a possibility that it could be endometriosis though this is rare, so the best thing is to rule out the musculoskeletal system which is the more likely cause. All the best!

FURTHER INFORMATION FROM ENZ:
Heba’s response clearly outlines the possible cause of your pain. It is natural to think it is endometriosis causing the pain and further surgery is often performed, which can exacerbate the pain and cause further pelvic trauma. As well, the pain can be misdiagnosed as many will not consider the internal muscles. We know obturator internus can be an often-unforeseen culprit in causing pelvic pain. There is good information in the free downloadable eBook Pelvic Pain, on the ENZ website and there are chapters in the book ‘Endometriosis and Pelvic Pain’ available through ENZ. Dr Susan Evans treats many women with the kind of pain you describe and would recommend a multi-disciplinary approach to treatment including pelvic physiotherapy with someone who has the expertise. It is also a good idea to check whether you have had excision of your endometriosis by an advanced laparoscopic surgeon to rule out recurrent endometriosis. That done, other investigations should be explored and the best management applied. We can understand you being at your wits end with this persistent and challenging pain. We hope this helps and you access the care you need as soon as possible.


Advice for dietary choices

April 2017, Responses from: Clarice Hebblewaithe and Courtney Hibberd

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QUESTION 1: It can be hard to balance diet between multiple health conditions. Any advice on how to balance healthy food choices so that the food intake doesn’t seem really restricted? I’d love some advice on how to eat with IC (interstitial cystitis), as I and others I know do struggle with it.


Clarice Hebblewaithe: Ideally when planning a diet all health issues are taken into account. There may well be food intolerances and in the case of Endometriosis this may be to some of the FODMAP group of foods. Alternatively in the case of Endometriosis and Interstitial cystitis there could be intolerances to Histamine rich foods.

The key is to only eliminate suspects for a trial period and then re test them to ensure as much variety of foods stays in the diet. There must be improvements in symptoms to warrant staying on any restriction and over time foods may be introduced again. We now believe that it is best to keep small amounts of poorly tolerated foods in the diet as a way of building tolerance. The exception to this is food allergies resulting in severe symptoms including anaphylaxis.

Ultimately I believe the burden of a severely restricted diet must not outweigh the benefits on symptoms. All too often people are on an ever reducing number of foods and the stress of this and depletions of nutrients can undermine the benefits on health.

Whenever we look at eliminating foods we must equally look at all the foods that can be eaten and the financial, social and emotional impact of having more flexibility on eating. We should also be addressing ways to overcome food intolerance.

For both conditions of Endometriosis and Interstitial cystitis I do recommend dietary changes are done with the guidance of a dietitian specialised in intolerances and allergies.


Courtney Hibberd: Managing multiple medical conditions can be tricky especially if there are concerns that diet may be contributing towards the symptoms.

But eating a wide and varied diet is one of the best ways to keep yourself (mentally) and your body (physically) in tip top condition.

Undertaking an elimination diet to try and identify foods that may trigger a symptom is best done under the guidance of an experienced allergy and food intolerance dietitian. They will provide you with the tools to identify whether food is contributing towards a flare of your interstitial cystitis and or endometriosis symptoms; and at the same time, ensure your diet remains nutritionally adequate and as varied as possible. Keeping to fresh foods and decreasing pre-packaged or processed foods can help manage your symptoms as well as make it easier to identify what might be triggering a flare.

As with a lot of food intolerances, they are often dose dependent – i.e. the more you eat of a particular food the worse the symptoms are likely to be. However, small amounts spread out over the day or week are likely to be well tolerated. This also helps to prevent over restricting the diet.


QUESTION 2: I struggle with the concept of everyone panicking that they have to completely cut out lots of food groups (as is advertised in the so-called Endo diet), so I would like some more info on what is important with Endo and what we should be focusing on dietary wise. Does everyone with Endometriosis need to eliminate things from their diet, or do some people not have symptom improvement through diet?


Clarice Hebblewaithe: It’s true there are so many dietary approaches and many contradict each other. It can seem more confusing than ever. So, what may work for one person does not always fit another and may change at different stages of life.

More than ever the diet needs to be tailored to the person individually. One person may have the most vitality and be in optimal health being Vegan and another person feel the same way on a Paleo inspired diet.

Regarding the Endo diet, this is picking up on the themes of other ‘anti- inflammatory’ diets in which certain foods are seen as anti -inflammatory or pro- inflammatory. When the body has higher levels of inflammation typically this can lead to higher levels of pain in conditions including Endometriosis.

Here I’ll address some of the key points of the ‘anti- inflammatory’ diets:

  • It is certainly true that having a diet rich in many colourful vegetables and fruits containing phytonutrients help minimise oxidation in the body so lessen the levels of inflammation. So many advocate eating 5-8 serves a day of colourful fibrous vegetables and fruits, especially berries.
  • There is good agreement for health that reducing added sugars is a good idea for supporting good immune health and that added sugar can be associated with higher levels of inflammation.
  • It is also widely agreed that eating more omega 3 oily rich foods versus omega 6 oils can help reduce inflammation. So, incorporating omega 3 rich oils such as linseed, flax oil, oily fish and walnuts in place of the vegetable oils in our diet helps this ratio change in our body.
  • There is some research for reducing saturated fat from red meats and dairy foods in inflammatory conditions. Generally, we in New Zealand are eating much more red meat than is recommended given the sizes of our portions so reducing to smaller portions (i.e. 90 g) and replacing some red meat meals with vegetarian or fish meals is usually beneficial.
    In the case of reducing dairy, there are different reasons why this may be done. Some people are allergic or intolerant to dairy foods either because of the protein called casein or the sugar called lactose or histamine in fermented or aged dairy foods. There is also some research to show that cows’ milk has insulin growth like factors stimulating oestrogen effects in the body including that of Endometriosis.

In the Question 1 I explain about whether there is a need to eliminate foods from the diet.


FURTHER INFORMATION FROM ENZ:
To our knowledge and research, there is no ‘endo diet’ but there are foods which typically irritate the bowel in those women with endometriosis who also have bowel symptoms (like IBS).

Endometriosis is now being seen as an inflammatory disease therefore food which help reduce inflammation may help with related symptoms.

There was much debate arising from the authors of the paper ‘Consensus on the Management of Endometriosis’ and considerable evidence based research on this and many other topics. From that research, there was no evidence to show that endometriosis is intrinsically linked to diet nor that everyone with endometriosis needs to eliminate foods or change their diet.

We all understand the benefits of good nutrition and a varied healthy diet. What we should acknowledge is the number of opportunists in this field – some well-meaning and others who recognised the enormous market potential. We must also remember what works for some may not be appropriate or even sensible for others.

Reliable, credible and current info on nutrition is on our website and there are excellent
chapters in the book ‘Endometriosis and Pelvic Pain’.


Unresolved symptoms after surgery & mirena

January 2017, Responses from: Charles Koh and Neil Johnson

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QUESTION 1: (Summarised) Miss M (25yrs) Symptom onset in 2011 – 2016 – abnormal discharge, irregular bleeding, pelvic pain worsening symptoms over 5 years. Mirena placed. In Jan 2016 laparoscopy confirmed endo – ‘widespread but superficial’. Mirena left in place. Continues to experience discharge + bleeding. Pelvic pain improved. 10 days a month symptom free.

I need some advice! Is there anything that will help my irregularities and should I also have the Mirena removed.


Dr Charles Koh:
Charles asked the question: ‘was all the widespread ‘superficial’ endometriosis removed (excising) in an en bloc (all together) manner?’

It is the Mirena causing her irregular bleeding, unless she has a polyp which can be removed at the same time as removing the Mirena.

I suggest she considers asking her specialist gynaecologist whether a presacral neurectomy should be done if she undergoes further surgery to remove all the endometriosis.


Dr Neil Johnson: This is not at all an uncommon experience that Miss M has had.

The effect of the Mirena typically improves steadily to 6 months, sometimes taking up to 12 months before the full beneficial effect is seen. Improvements from Mirena after 12 months are rarely seen, so if there hasn’t been a satisfactory response (ie if the Mirena “hasn’t helped”) by 12 months, it’s unlikely that it will help. The Mirena works well for around 80% of women; not so well for up to 20% of women.

Of course, it’s possible that the Mirena may have moved or become dislodged, so it would be important to have the position of the Mirena checked- this can be done firstly by checking the length of the Mirena threads, but a transvaginal ultrasound is usually necessary to be confident about the Mirena siting. It would also be important to be confident that there were no organisms detectable that can be associated with pelvic infection – appropriate swabs by the doctor should exclude this.

Persistent irregular bleeding that are posing problems – once abnormal siting of the Mirena and infection have been excluded – would be reasonable justification to have the Mirena removed and for consideration for histology sampling of the endometrium (for example by Pipelle sampling). And sometimes simply removing the Mirena will resolve this problem.

It’s worth mentioning also that, even when the Mirena works well initially for endometriosis pain problems and bleeding problems, it doesn’t always last the typical five years for which the Mirena works effectively as a contraceptive. I commonly have to replace a Mirena after 3-5 years when my patients are using it to control endometriosis symptoms.


FURTHER INFORMATION FROM ENZ:
There’s a great ASK ESIG question about Mirena, which was answered by Mr Michael East, gynaecologist, Oxford Women’s Health Christchurch and Ascot Hospital Auckland. https://nzendo.org.nz/esig-ask-an-expert/mirena-or-jaydess/


Advice for adolescents with period pain and other symptoms

September 2016, Responses from: Susan Evans and Simon Edmonds

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QUESTION 1:
I’m the mother of 16 year old Abby and I am desperate to know what to do about Abby’s bad periods. Abby has at least 2 days off school every month and is now having pains at other times. Her periods started at 12 and they have always been bad. I have a diagnosis of endometriosis which was a real battle to have treated and I still suffer. But to see my daughter now heading down the same path, is so upsetting. We have been to two GP’s and the story seems to be the same – take the pill and it will settle. Well, we’ve tried that for several years and her periods are regular but the pain and other symptoms are still bad. She tried taking the pill continuously and even when she’s not getting a period, she still has awful pain. She’s frightened about going to the toilet now because it hurts so badly. The doctor has said we probably won’t get into the health system and even if we do, nothing can be done and surgery never works. I’m sure Abby has endometriosis but I don’t know what to do. We don’t have health insurance and I can’t afford to see someone privately. I’d love you to help us by
offering advice.

PS. Abby hasn’t had a boyfriend yet and spends most of her time at home where she used to be a really outgoing and sporty girl. The doctor has put her on anti-depressants.


Dr Susan Evans:
Regarding Abby: for a start, this is what I would suggest:

  • Norethisterone instead of the pill, 5mg one daily continuously starting in day 3 of her period to minimise periods more effectively than the pill and keep any endo quiet. If it doesn’t suit, then Visanne 2 mg instead. This may not be available in NZ yet.

For the muscle pain she will also have at this time:

 

For her parents:


Dr Simon Edmonds: It can often be very distressing for women who have been given a diagnosis of endometriosis, to then see their daughters go through some of the same problems with their periods and pelvic pain.

There is certainly a familial/genetic linkage with endometriosis, but this is not always the case. If Abby has tried the pill and also taken it continuously, without improvement in her pain, then referral to a gynaecologist would certainly be appropriate. There may be other causes for the continuous pain throughout the month and the gynaecologist will take a careful history and exclude these.

There is no ‘correct’ time to perform the 1st laparoscopy to try and diagnose or exclude endometriosis, but we try to explore more conservative options in younger girls as this often works.

If not, then laparoscopy at least gives an answer as to the way forward, but it would be unusual to see severe disease in this age group. Insertion of a mirena coil at the same time, is also another option as this can give better control of the periods. Improving diet and exercise regimes can also help in this age group.

If you do not have private cover, all public hospitals should offer this service and a least a consultation to discuss the way forward.


FURTHER INFORMATION FROM ENZ:
There’s a lot we don’t know about endometriosis but one thing we all agree on is – endometriosis starts early! Ignore it at our peril.

Abby’s pain is beginning to be experienced on other days of the month rather than only with her period which means that her pain is showing signs of becoming persistent with other challenging symptoms. Developing a persistent pelvic pain condition at the tender age of 16, must be taken seriously and managed effectively. Abby’s symptoms are now affecting her mentally and socially as well as physically and emotionally.

We urge you to contact ENZ and ask for one of our teenage menstrual diaries so that Abby can ‘keep a track’ of her symptoms. This is useful information to show your GP. You may be able to change your GP to someone who understands women’s health and pelvic pain, however we realise this is not always possible if lists are full and doctors are not taking new patients. If this is the case, return to your GP and ask for a referral to a gynaecologist who specialises in endometriosis. Take ENZ resources and her pain diary with you. The letter from the GP to the hospital must be quite specific and stress how Abby’s life, well-being and schooling are compromised because of her symptoms. If a generic letter is sent, the team who are responsible for triaging patients at the DHB, may not consider her symptoms to be bad enough for gynae review on a public waiting list. You can request to see a particular gynaecologist but it’s not always possible to have your choice granted. If its possible, you can see a gynaecologist with expertise in treating endometriosis privately (as a paying patient) and go on their public list which they can arrange for you. However, you need to make sure that the gynaecologist you see privately also works in the DHB as most are in private practice only.

Abby’s pain needs to be managed better, together with re-assessment of OCPs. With exercise, It’s always hard to ‘get off the couch’ when you’re feeling miserable and in pain, but we recommend a daily walking routine. Kirstie James (ENZ athlete) has some tips for exercise when you’re feeling totally unmotivated. Have Abby read Kirstie’s story here. See if the school can guide and help. There may be a social sports team Abby can join – through the school or a club. Abby is only 16 but she can take some responsibility for doing the things she can to feel better. There may be some help you can access for her around this and once again, the school will hopefully be able to advise. It would be a good idea to have an appointment with Abby’s school and in particular the Dean of her year group. Falling behind in her studies or assignments can put further pressure on her and the more behind she gets, the worse things can become generally.

Next step is to have a think about health insurance. There will be a stand down time for Abby as, even without a diagnosis, her symptoms would be considered a pre-existing condition. Adelphi Insurance ( http://www.adelphiinsurance.co.nz/ ) will be able to advise you about this at no charge and with no pressure to ‘sign up’. If you do proceed to get health insurance for her, even with a stand down time of 3 years, Abby will still be under 20 and can access the specialists with expertise to treat and manage with gold standard best practice. It may not be as expensive as you think and it’s only a phone call to find out.

The ‘me’ program in schools addresses these problems and we are advocates for early intervention so that girls and women’s lives are not compromised. We’re working with government and the clinical directors to develop clinical pathways to ensure symptoms are recognised early and timely intervention is sought. Is ‘me’ in Abby’s school? There will be others like her suffering similarly and the school can contact us to make arrangements.


RESPONSES FROM ENZ FACEBOOK MEMBERS (NAMES OMITTED):

  • We had to save for it but my mum sent to a private person for the initial first appointment and when he suggested surgery for endo diagnosis, my mum requested to have me put on the public system. It took a little longer but it worked.
  • Go and see another GP. My doctor spent years telling me I was fine. I knew for a long time something was wrong, and thought it was endo. He finally sent me to a specialist when it got so bad he was prescribing me tramadol. You could also try family planning. Keep trying, eventually somebody will send you to a specialist. I have been, and am going through the public system and they made sure I saw a psychologist, pain specialist, physio and gyno.
  • I would recommend getting health insurance for her in case she has problems later in life. She is at this stage only having painful periods. I luckily had health insurance before developing Endo. I am stage 3 and take a supplement which is the only thing that has helped (apart from surgery which has helped a lot but it is a battle keeping on top of the growth with multiple surgeries) for pain & balancing my hormones, Oestrogen feeds Endo so you need to get her hormones levelled out so she doesn’t develop it & also to stop the pain.
  • So sorry to hear about Abby’s pain and your own battles.
    The continuous pain is concerning. I would recommend medical insurance and a specialist gynae who is experienced treating Endo, understands pain management and treating young adults. Not all GPs have a good understanding of Endo – my previous GP thought I had appendicitis and after treatment failures took the initiative to get training for the medical team.
    It is natural that a young person would feel depressed when their body is out of control. Find out as much quality info as you can (not crap off Google) and talk closely with Abby about options to manage her feelings, particularly anxiety and selfesteem. If Abby is still at school her School Guidance Counsellor or Nurse may be able to help with strategies to keep up with her school work and stay connected with friends.
    There could be many reasons for pain going to the toilet. My own experience was scarring that ‘glued’ my bowel to my pelvic floor and distorted my anatomy causing other related problems and bleeding.
    Not getting on to adequate pain management and treatment can lead to vestibulitus and psychological trauma, all totally treatable but unnecessary.
    The FODMAP diet can also help with pain relief, as well as regular gentle exercise and activities with a ‘flow’ element where you focus on something else instead of pain. Get on to a good specialist recommended by NZ Endo as soon as you can.
  • Dear Abby’s Mum, I have seen my Mum in the same position that you are, as she has had Endo for a long time and was struggling trying to get anyone to listen to get me diagnosed between the ages of 14 and 20 (I’m 23 now). I’m not sure whereabouts in
    NZ you live, but my best suggestion is to do some research on the internet, read up about different Gynaes and try to find one that has an interest in Endo. If you can find someone who works in both the private and public systems, you could see someone privately for the first appointment (if you can afford to), and then ask them to refer you to their public list for surgery and ongoing care. I’ve been in the public health system for almost 3 years, and it can be a battle, so try to get continuity of care if you can and request to see the same Gynae every time you go so that you don’t get shunted around seeing different doctors all the time. Also, try and find her a new GP that is supportive of her and will be more proactive about helping her get to the next stage in diagnosing and treating her Endo. It’s a hard lesson to learn, but you have to ‘shop around’ and find the Doctor that you feel comfortable with and know is going to be of help to you and your daughter. Perhaps look at websites of GP Practices in your local area and look for someone with an interest in Women’s Health? Other natural things that help me are using heat packs (heat sometimes helps my pain more than pain meds) and trying to keep active throughout the month with gentle exercise such as walking, yoga and swimming. Maybe work with your daughter to try and find a more gentle form of exercise that she can gradually build up to doing on a regular basis. Having Endo can be so hard, as you can feel like you lose a part of yourself as you struggle to do the things that you used to, but you will figure out what works for her with medical help. Most importantly, support her to try and show her body love and care, even on the days when it is causing her pain. I remind myself that it’s not my body causing the pain, but the Endometriosis, and that helps me to support my body both physically and mentally. Sending you both big hugs.
  • My biggest mistake was not getting a second opinion. Once we changed Dr, who was pro endo we had much better results. When the Drs at the hospital gave up our Dr would fight for her to be seen again. So my advice would be second opinion. Also since being diagnosed with gluten and dairy allergy on top of it, which apparently is common with endo patients. She has had much less hospital time. She is also in the depo injection to stop her periods all together which she gets 8 weekly. Getting on top of it quickly is the answer for a better outcome for sure.

Return of symptoms and repeat surgery

August 2016, Responses from: VP Singh, Keith Harrison, Neil Johnson and Hannah Blakely

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QUESTION 1: When is it the right time to discuss the possibility of further surgery?

My last lap was 2 years and 3 months ago. I’ve tried many medical therapies with some success, but symptom relief only ever lasts a couple of months at most, before bleeding starts and symptoms return with a vengeance. I have tried diet, naturopathy and various natural things as well, but haven’t found any lasting relief. I feel like there’s something inside me that’s constantly fighting whatever I try to do to ease my symptoms, and in the end the pain and bleeding always return. My Gynaecologist hasn’t ruled out further surgery, but wants to try everything else she can first. I realise that it’s always best to avoid surgery if possible, but I’m at my wits end and am wondering if it’s time to broach the subject?

So, in short, my question is, when do symptoms and failure of medical therapies to ease symptoms indicate that surgery could be required?


Dr VP Singh: It is such a common question and yet there is so much variability amongst practitioners.

In my view the first surgery is the best surgery and if the disease has been comprehensively excised then there is little point in going back in within 5 years. Concerted effort in managing pain with hormones, neuropathic pain medications, CBT, physio, exercise and diet will see most patients enjoy a comfortable and productive life. Jason Abbots study demonstrated the law of diminishing returns after the first surgery. Also it tends to reinforce the view that chronic pain can be cut out by surgery which is not the case. It is not uncommon for me to see patients who have had 7-8 surgeries on annual basis with worsening pain after each surgery. Setting up right expectations of ‘relief’ not ‘cure’ and Chronic pain management pathways generally succeed in these patients.

I think all endometriosis surgeons need to up skill in chronic pain management.


Dr Keith Harrison: Good question! I would consider repeat surgery at the point that symptoms become intolerable again and non-surgical treatments have failed which seems to be where this woman is currently at. I would want to know the extent and duration of symptom relief from her last surgery as a guide. Like this persons’ gynaecologist, I try to delay repeat surgery as long as possible especially in younger women


Dr Neil Johnson: Interesting question and, yes, one commonly asked …

The gynaecologist is wise to explore non-surgical options. These would doubtless include evidence based options such as progestin hormones or the oral contraceptive pill, the Mirena intrauterine system, even GnRH analogue injections with addback hormone therapy. Prior to a new medical therapy, have dietary and lifestyle factors been reviewed such as more ‘natural’ evidence based alternatives, such as vitamin B1 and B6, magnesium and fish oils and acupuncture as an evidence based complementary approach? The holistic multidisciplinary approach may include pelvic floor physiotherapy and / or psychology given the often distressing toll chronic or persistent pain can take.

Repeat surgery – especially in the same setting – is normally associated with less successful results than primary surgery. Sometimes consultation with a recognised advanced laparoscopic surgeon might be worthwhile. And if repeat surgery is considered to be required and is undertaken, it is often useful to combine this with another intervention (such as Mirena insertion at the same time, although there are other options) in the context of a recurrence of symptoms after primary surgery.


Hannah Blakely: Manging these decision making processes can be challenging in knowing when the timing is right. People who live with endometriosis may experience chronic pain. This is often described as persistent pelvic pain that lasts for over six months with pain on more days than most.
One consideration may be the impact of pain and other physical symptoms on your mental health. If pain becomes overwhelming and is not adequately managed it may be time to look at other treatments and support. One of these may be discussing further surgery. In addition to this, seeking psychological support for help in management of anxiety and/or mood problems may be appropriate.

Indicators of anxiety becoming a problem may be the following: Finding yourself worrying about your endometriosis/health/pain/and its impact etc., frequently for periods in the day or night. When worrying you have trouble shifting your attention to the things you are doing or wish to and/or it gets in the way of you attending to the things you want to be doing. The worry has been present and distressing to you for a period of months and feels uncontrollable.

Mood and symptoms of depression can be a common problem for women managing endometriosis. Things to consider when checking in with your mood are: feeling down, depressed or irritable most days, more often than not, consistently over a two week period. Lacking pleasure or enjoyment in the things you would normally do as well as a change in sleep, appetite, motivation and energy levels for example.

Other things that can be impacted upon by chronic pain and endometriosis is sexuality, intimate and general relationships, and sleep.

Psychological treatment for these difficulties provide strategies to reduce symptoms of anxiety and depression and manage problems in other areas, which may occur before after or in spite of surgical treatment options. Some women find one to two sessions to ‘check in’ with how they are coping is enough, for others more than a few sessions is helpful, and for most, knowing you’re doing the best you can is important.


FURTHER INFORMATION FROM ENZ:
We think this is an excellent question and one that crops up very regularly all over the world.

There is a ‘move away’ from performing multiple surgeries, as the general results of doing such lack evidence in showing improved outcomes for patients long term and can cause further pelvic trauma. This is why we emphasise the importance of surgery being best performed by a gynaecologist with advanced laparoscopic skills who can fully excise endometriosis. Excision is the gold standard surgical treatment. The aim is that the first surgery should be the best surgery. All the endometriosis must be removed and the anatomy restored to normal for best outcomes. Recurrent endometriosis may mean that the disease was not fully removed or resected in previous surgeries. However, endometriosis remains an enigma and sometimes endometriosis will recur following excision, even by the most experienced, advanced laparoscopic surgeons. This is also why we encourage you to consider having private health insurance as most gynaecologists who are advanced laparoscopic surgeons, work in private practice. In other words, not all surgeries are the same and not all gynaecologists perform the same gold standard technique. You can find out more about private health insurance for you or your family by clicking here http://www.adelphiinsurance.co.nz

The truth is, we just don’t know the true recurrence rate. However, we do know that it varies enormously from around 10% to over 50% (we have heard 80% mentioned) and the bias depends on many factors including the setting and the gynaecologist / surgeon. It is wonderful to see WERF (World Endometriosis Research Foundation) developing tools for international use so that the data can be captured in longitudinal studies. http://endometriosisfoundation.org/ephect/ Even in very well designed studies, the bias is confounding and can include patients being lost to follow up and whether the surgeon undertook the surgery in a centre offering expertise in treating endometriosis. In such cases, recurrence is usually much lower and this makes a big and positive difference to the patient.

In cases where the pain is experienced on most days and has lasted longer than 6 months, the condition has often become more complex to treat. A multi-disciplinary management plan is best practice which can include reviewing whether further surgery is now the right option. However, this should also be considered together with other interventions, where there is a persistent pelvic pain condition, as surgery on its own is unlikely to resolve all the symptoms. Muscles and nerves are probably now involved and pelvic physiotherapy can be integral to this treatment. Bowel and bladder function require assessment and management (refer nutrition on the ENZ website) and the long term psychological impact requires assessment and those interventions considered.


How a Clinical Psychologist can help

July 2016, Responses from: Leena St Martin and Hannah Blakely

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QUESTION 1: It can be so challenging trying to manage the fluctuating emotions that endo brings. I can feel fine one day and then the next I wake up feeling anxious or melancholic. What advice or suggestions can you give on how to manage these fluctuating emotions?

Leena St Martin: Regarding managing fluctuating emotions, the first point I would make is that it is entirely normal to experience a broad range of emotions. Usually it is helpful to acknowledge and explore the emotion rather than brush it away. In the therapy session I might use the following steps to help people work through why they are feeling a particular way. Firstly, I ask my client to notice what was happening just before they began to feel melancholic, anxious etc.  Was there a particular thought, memory or image which passed through their awareness?  Is their mood also affected by physical pain, lack of sleep, hunger, or other physical/environmental factors?  If so, what do they need to do for themselves to support their body and brain in the given moment?  (e.g. they might need to eat, apply a heat pack, change their position, reduce noise/stimulation etc.)

If there was no particular physical/environmental factor triggering their mood change, then I encourage my client to explore the emotion further by asking more about it e.g. how intense is the melancholy, what size is it, what shape is it, what attention does it require?  Do they need to recollect a sad experience and do some journaling? Do they need to visit a special place to honour the emotion? Do they need to discharge the emotional intensity physically first? If the client is in a situation where it is simply too overwhelming or unsafe to explore the emotion, then techniques like distraction and distress tolerance have a part to play. There are some excellent on-line tools describing these techniques

 

Hannah Blakely: Emotions may fluctuate for a number of reasons, including management of both physical (e.g. pain, bloating, medical management) and psychological (e.g. fear and pain avoidance, sleep disturbance, relationship and sexuality) aspects of endometriosis.

Try not to supress or push emotion away. The more we try to avoid and supress, through perceived relief in the short term the more likely our emotions will ‘bubble up’ and have an effect with greater intensity than before. Research has shown when we feel melancholic, anxious or flat in mood, depending on how tolerable or intense they are; doing enjoyable activity mindfully can help change and improve our emotion. First, notice the emotion you feel. Try not to judge that emotion as we know the attributions or judgement we make is the part that sticks for future experiences of the same emotion. Following noticing, the next step is shifting your attention from focus on mood to doing something else that you may get pleasure from. If we remain focused on the unpleasant emotion it can continue – a bit like ignoring a child tantrum- keep an eye on it – notice what is occurring but not giving attention to it!

The enjoyable activity need not be excessive, but must be manageable and achievable. For example; some people find going for a walk helps to shift their attention and focus from internal emotion to focusing on the external environment (what’s going on right now around you). Others enjoy reading, taking a hot bath, using a special hand cream, baking etc. When doing the activity take a moment to notice any change in your emotion. It may not occur the first time however, keep trying as over time this may help shift that mood that’s dragging you to one that could help you get on with your better day.

 

QUESTION 2: What are some good ways to support people I know with Endo who also have depression or anxiety (or both) as a consequence of their health issues?

Leena St Martin: Supporters can be helpful to the endo-sufferer who is experiencing depression and anxiety by listening attentively and validating their emotional experience (e.g. by making statements like “it makes sense you feel x today”, “what could you do for yourself today to feel better/differently?”). If suicidal thoughts are mentioned, take these seriously and ask whether the sufferer would agree to speak to a professional. Once again, there are excellent on-line tips available

 

Hannah Blakely: Living with endometriosis may feel for some at times emotionally overwhelming and among other things may contribute to anxiety and depression symptoms. To support those who are struggling with depression or anxiety the following tips may be helpful.

Being available to listen and validate their experience can be very therapeutic. Using phrases and questions like “it sounds like this is really difficult for you…” or “what would you like me to do to support you right now…” may let them know you are interested in what’s happening for them.
Depending on how they respond another idea may be getting them involved in activity to help shift the focus from their mood to being closer to focusing on other things – and potentially feeling better.
Checking how your friend is feeling is important particularly if their mood’s low and they are having suicidal thoughts or talking about harming themselves. In this case encouraging them to tell their family or friends and visit their GP who can support them to get specialist help.

 

Further information from ENZ:

When pain has lasted longer than 3 to 6 months and is experienced on most days, it has become a persistent (chronic) pain condition.  Girls and women with endometriosis and persistent pelvic pain can also have bouts of acute pain.  Persistent pain conditions can evoke emotional responses that can lead to changes in behaviour, mood and the way we function and think about ourselves and others. It’s just one of the aspects of endometriosis that make it so cruel and often debilitating. When a condition becomes persistent, it can be more complex to treat.  When things become this bad, often surgery alone is not enough to remove all the pain or suppress symptoms. This is often despite the gold standard excision technique, practiced by gynaecologists who have expertise in treating endometriosis. However, good surgery is absolutely key and with your endometriosis excised and anatomy restored to normal, there will usually be some symptomatic improvement. You can now find out about the other evidence based practices and therapies which can help you reach that ‘well place’ you want to be.  Hannah Blakely and Leena St Martin (Clinical Psychologists) have responded to ASK ESIG questions about how they help you re-focus, and retrain the brain with various practices and CBT.  ENZ advocate a multi-disciplinary approach to treating endometriosis.

 


How Pelvic Physiotherapy can help

June 2016, Responses from: Leanne Wait

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QUESTION 1: How does pelvic floor physiotherapy actually help in women with Endometriosis, and what are the mechanics behind some of the muscular causes of pelvic pain that physios treat?


Leanne Wait: This is a great question because the role of the muscles and pelvic health physio (who provide pelvic floor physiotherapy) is often poorly acknowledged. Women with endometriosis experience pain for many reasons and the reasons and science behind how this all fits together is complex and can be confusing. So let’s take a closer look at some of the mechanisms of pain that physiotherapy can help with.

  • When you live with persistent pain for more than 3-6 months we know that the nerves transmitting the signals go through a process of ‘wind up’ where they become more and more sensitive. As a result of this the surrounding nerves which may go to other tissues like the bladder or bowel or to muscles and joints also become very sensitive and can react by either causing pain in that organ/area or other symptoms like bloating, urgency, painful bowel motions or pain with sex. When the nerves become sensitive our tissue responds differently so that things that are not normally painful become painful and things that usually would hurt, hurt much more than they used to. This process is called ‘central sensitisation’.
  • Living with pain also means you live with your body in protection mode all the time. This is like your body being on alert all the time which can cause muscle guarding, altered breathing patterns, an inability to relax and disturbed sleep patterns and even anxiety and poor coping.
  • We also know that the pelvic floor muscles respond to any imminent or potential threat by contracting and squeezing. A threat could be something stressful, pain, a scary movie, a fright etc. Often when you have persistent pain the pelvic floor muscles stay contracted and switched on and in most cases you don’t realise it is happening. Overtime this can lead to a ‘hypertonic’ or ‘overactive’ pelvic floor where the muscles don’t release and relax. This can cause pain internally that can be felt in the vagina but also with in the pelvis and abdomen. This is also often part of the reason that sex is painful.
  • Surgery to resect endometriosis does not address the likes of ongoing signals from other sensitive structures like the bowel or bladder or muscles. These often still need to be addressed to support your overall wellbeing and a good long term outcome as they can still cause pain despite the removal of the endometriosis.

Physiotherapy can help in many cases but each person presents with a mixture of similar but different signs and symptoms and we all have different goals of what we would like to change or achieve.

  • My patients all learn about pain and the nerves and the signals they send and how our body/brain tries to protect us. There is very good scientific evidence that suggests even learning about pain reduces pain. We also recommend things like TENS and exercise and teach better breathing and relaxation to help settle the sensitive nerves.
  • Pelvic health physios also assess all the systems in the pelvis like bladder, bowel, vagina muscles and nerves to see how much they may be contributing to pain. Even constipation can trigger more pain because after a long period of pain the nerves of the bowel may also be very sensitive. Likewise, sensitive bladder nerves can cause urgency, bladder pain or even incontinence that can often be managed much better with the help of a pelvic health physio.
  • We also assess for and treat tight sore muscles including the pelvic floor muscles. For this you may be given stretches, pelvic floor relaxation exercises or the muscles may require massage and release soft tissue work.
  • Sometimes we also do scar release work or deep abdominal or visceral work to release any tight structures that maybe pulling or adhered causing pain.
  • If you have problems with sexual function pelvic health physio can also help with this in many ways depending on the reason. Often at some point we will teach you how to use trainers(dilators) which can be very effective to help you get used to the muscles stretching without your muscles responding with pain.
  • As you may now see we have a large scope but there is ‘no one size fits all’. Individual symptoms require individual care.
  • The key can be as simple as adding things gradually and doing a bit more and a bit more slowly to avoid triggering a pain response. This could be with various treatments or even exercise. Often I see women who are told to exercise so they start walking on hills fast for an hour when they have been inactive for a long time – then they hurt so they stop when in reality ‘motion is lotion’ – as long as you start at the right level for it not to hurt or trigger hurt. Also when adding things to your recovery apply the same principles. Add one stretch for a few days and see how you feel after doing several times then add or try another take it slowly it generally has taken awhile for your symptoms to develop so they are likely to also take time to recede.

 

Pelvic health physios are great listeners, we spend a lot of time listening to our patients, caring for their well-being and being a great source of support and encouragement. I hope this has given you some insight into how we may help you.


Surgery: Does the skill of a surgeon matter?

June 2016, Responses from: Guy Gudex, Simon Edmonds, Michael East and Neil Johnson

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QUESTION 1: “I am considering paying for my second laparoscopy myself. I want to know whether it is worth seeking out the best laparoscopic surgeon? Does the skill of the surgeon make a difference to the recurrence of endometriosis?”


Dr Guy Gudex: “The experience and skill of a surgeon can make a difference with respect to the chance of recurrence of endometriosis, particularly depending on the site of the endometriosis.

If the endometriosis is involving the bowel or the space between the vagina and rectum (recto-vaginal septum) then the extent to which that is treated may vary from surgeon to surgeon based on the age of the patient, symptoms, whether fertility is an issue or not and the experience and training of the surgeon.

Endometriosis in the ovary (endometrioma) can recur up to 10% of the time no matter which method is used to treat them surgically and again surgical management can vary depending on the particular circumstances of the patient.

If you are concerned you should ask about the relevant experience of the surgeon you have been allocated in the public system. Most District Health Boards have gynaecologists with a special interest in laparoscopic surgery.”


Dr Simon Edmonds: “All gynaecologists in New Zealand are trained to a basic level of laparoscopic surgery as per the RANZCOG training programme. This should include making the diagnosis of endometriosis and performing diathermy and minor excision of disease.

Some gynaecologists have specialized further either by having an interest and experience in managing endometriosis, or by undertaking a fellowship training programme. For the last 4 years, the AGES (Australasian Gynaecological Endoscopic Surgery Society) has endorsed a 2-year structured training Fellowship programme in Australia and New Zealand. There are a number of other good quality informal laparoscopic fellowships for trainees across the country.

Many public hospitals across NZ will have a lead consultant in this type of surgery and you should ask if unsure.

For more advanced endometriosis, particularly involving the rectum (rectovaginal endometriosis), or for women with refractory pain, a multidisciplinary approach is required, with involvement of other specialties such as colorectal surgery, urology, pain teams, health psychologists, dietitians and physiotherapists.

If you wish to see someone in the private sector using insurance or self pay, then the advice as above should still apply. You can ask your GP and past patients who they would recommend or check out the ESIG page on the Endometriosis NZ website. Many surgeons will have information on a website. This may help you to find the most appropriate clinician.”


Dr Michael East: “The persistence of symptoms and the persistence of disease may not be one and the same thing. Skill level is important especially when one is dealing with stage 3 and 4 disease. However once any kind of treatment surgery has been performed, a very careful appraisal is required before subjecting oneself to further surgery. Remember, surgery itself is a trauma and the law of diminishing returns, definitely exists with regard to repeated surgeries. The strategy for improving your quality of life needs to be multifaceted regarding investigations and treatments. The most important thing you can do now is to read widely and then seek a management opinion from a well respected clinician who is known to work in a multidisciplinary centre that at least includes physiotherapists and dietitians etc.”


Dr Neil Johnson: “The WES consensus statement – into which there was considerable consumer input, reinforces some of the points already made and makes other points that at least have a level of consensus concerning surgery and secondary surgery. Here’s the link to an overview of the Consensus Statement. A link to the full publication:
http://endometriosis.org/news/research/first-global-consensus-on-the-management-of-endometriosis/”

Best practice, gold standard surgery is excision or resection to remove the endometriosis. The skill of the gynaecologist does matter! The first surgery should be the best surgery. Multiple surgeries are now ill advised and can cause further pelvic trauma.

We are fortunate to have several gynaecologists who are also advanced laparoscopic surgeons in New Zealand, some of whom also work in the DHBs. Follow the advice of Dr’s Guy Gudex, Simon Edmonds, Neil Johnson and Michael East (all of whom are advanced laparoscopic surgeons and excise the endometriosis) and ASK your gynaecologist about their relevant surgical experience. Given that most gynaecologists who have expertise in treating and managing endometriosis and who offer a multi-disciplinary approach work in private practice, you may want to consider getting private medical insurance. It is available to you even if you have a diagnosis of endometriosis. You can contact Adelphi Insurance Brokers who understand about surgery for endometriosis and can advise you at no cost. http://www.adelphiinsurance.co.nz


Symptoms of endometriosis and hyperemesis during pregnancy

May 2016, Responses from: Charles Koh and Neil Johnson

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QUESTION 1: Does getting pregnant help women get rid of Endometriosis? I have heard from other people that symptoms go away while pregnant and while breast feeding, but I haven’t found any solid information on this or if having a child can sometimes get rid of Endometriosis all together.


Dr Charles Koh: Pregnancy may suppress symptoms temporarily but these return after delivery. So the old ‘advice’ to get pregnant to get rid of endometriosis is untrue.


Dr Neil Johnson: You’re right, solid information is sparse. But our experience is that most women’s symptoms may disappear (or at least improve) during pregnancy and breastfeeding. Anecdotally there is a permanent improvement in symptoms for some women.


QUESTION 2: Does having endometriosis subject a pregnant woman to being more prone to hyperemesis? What hormone is responsible AND, for those not diagnosed, could it be a ‘heads up’ symptom of endometriosis?
FYI – Hyperemesis Gravidarum is a complication of pregnancy characterised by severe nausea and vomiting leading to weight loss and dehydration. It is more severe than morning sickness.


Dr Charles Koh: None of these are true.


Dr Neil Johnson: There is no known association between endometriosis and hyperemesis gravidarum, so as far as we know, this can’t be considered a ‘heads up’ symptom of endometriosis. The hormonal cause – probably a combination of beta hCG and progesterone.


Is fibromyalgia caused by endometriosis?

April 2016, Responses from: Charles Koh, Neil Johnson and Susan Evans

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QUESTION 1: I have had a hysterectomy / bi-lateral oopherectomy and now have fibromyalgia. Many of those I know with endometriosis who have had similar treatments, also have this condition. Is this a pattern caused by endometriosis?


Dr Charles Koh: “It is an association sometimes, not a causation.”


Dr Neil Johnson: Although there is not a strong association recognised between endometriosis and fibromyalgia, because of the autoimmune features of both conditions, there is some overlap. So yes, women with endometriosis are more prone to having fibromyalgia. We’re not aware of any causative link of surgery such as hysterectomy/bilateral oophorectomy and the development of fibromyalgia.”


Dr Susan Evans: “recommendations for fibromyalgia:

  1. Exercise – paced, regular, gentle to start with. Regular exercise is essential.
  2. Trial of low dose amitriptyline – with use of nortriptyline if they find the amitriptyline too sedating. http://www.pelvicpain.org.au/information/take-medications/take-amitriptyline/
  3. Testosterone replacement. When you have the ovaries removed, testosterone levels fall and this may be related to the fatigue and pain. So, if you have a blood test that shows that your testosterone is low, then using testosterone can improve these symptoms, either as cream, lozenge or implant, as long as it does raise the blood levels to high normal levels.

Is irregular bleeding a symptom of endometriosis

February 2016, Responses from: Michael East

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QUESTION 1: Is irregular bleeding a symptom of endometriosis?


Michael East: In my experience ‘dysfunctional bleeding’ is very common among endometriosis sufferers and in many cases unresponsive to the combined contraceptive pill (COC) or Depo Provera or even Mirena. The bleeding often predates the period proper and is ofter dark and ’tar like’ in consistency. We know the normal lining of the uterus (endometrium) is affected my endometriosis elsewhere probably caused by the inflammatory molecules that it produces. Not getting your period every month however may be due to other causes that may interfere with regular egg release. You should discuss any such concerns with your medical team.


Supplements, endometriosis and fertility

December 2015, Responses from: Phill McChesney and Lakshmi Ravikanti

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QUESTION 1: I’m 23 and my husband is 28. We’ve been trying to conceive for a year with no luck. In that time I’ve had 2 surgeries to treat mild endo as well as an early miscarriage. Does anyone know if there are medications other than folic acid and iodine, to help conceive and stay pregnant? My doctor has said to go back in April 2016 if we’ve had no luck. So I’d love your advice.


Dr Phill McChesney: “In terms of conceiving and staying pregnant in the setting of mild endometriosis, unfortunately there are no simple medications that clearly benefit. Taking folic acid supplementation is important for all women trying to conceive and iodine is mainly important once pregnant.

For most women, an early miscarriage is a chance event (in the order of 15% at a young age) due to chromosomal abnormality of the pregnancy, and is not related to any pelvic pathology. There is a high chance of a normally progressing pregnancy in the future, without doing anything differently. Maintaining a healthy weight and lifestyle for both partners is usually all that needs to be done.
Fertility is a complex issue and when there is a delay or anxiety, a thorough investigation of both partners by a fertility specialist is the most appropriate way forward. Once investigation is complete, there may be various options available to hasten conception.”


Dr Lakshmi Ravikanti: “If you have not conceived after trying for 6 months, you should consult a fertility specialist. You can do this by contacting a fertility clinic and making an appointment. This 23 year old woman would be eligible for a publicly funded consultation. Both the woman and her partner need further investigations.

When a woman is trying to get pregnant she should continue taking folic acid 0.8 mg a day until she is 14 weeks pregnant to prevent neural tube defects in baby. She can start taking Iodine as soon as she gets a positive pregnancy test.”


The use of the Mirena

November 2015, Responses from: Michael East

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“I read the comments recently posted by some of you regarding your experiences with Mirena. Many were negative as is often the way when someone who has suffered from its use, asks for comments from others. Such comments tend to be mainly from fellow sufferers. As a clinician who inserts a lot of Mirena intra uterine devices, I would like to share with you how it can help many women and also to point out how to recognise if it is not suiting you.” – Michael East


Michael East: Usually in my experience it is generally part of the solution and not part of the problem. Firstly let us consider what a Mirena consists of:
It is ‘T-shaped’ plastic (nylon) device that has a slow release hormone capsule attached to the ‘stalk’ of the T. It acts as a very efficient contraceptive and has a 5 year lifespan.


What are its properties?

The ‘T’ serves to hold the hormone capsule inside the cavity of the uterus. It is chemically inert but as a foreign body it can act as an irritant to the uterus causing the uterine muscle to contract and cramp more often. This is more likely to occur in teenagers as the uterus is smaller and the ‘fit’ a little tighter. The hormone is a copy of the female hormone progesterone, and has two main actions:

  1. It causes relaxation of the uterine muscle (called smooth muscle) and as such, tends to decrease the irritant effect of the plastic ‘T’.
  2. It inhibits the growth of the uterine lining (endometrium) and any similar tissue (endometriosis and adenomyosis). This inhibition tends to reduce pain.

Generally, the hormone effect tends to dominate over the foreign body effect, and if that is so, then a Mirena tends to produce benefit to the user. If the foreign body effect is dominant, then cramps and bleeding can aggravate endometriosis symptoms.

The amount of hormone that leaks into the rest of a woman’s body is equivalent to taking one progesterone only contraceptive pill per week. As a result most women do not experience hormone related side effects. Some women however are sensitive to this small hormone leak and experience a deterioration of acne or a flatness of mood. Some women find that their cyclical mood swings get worse, while others notice no difference or improvement.


Who do I advise to have a Mirena placed?
Most women undergoing surgery for endometriosis in my experience, benefit from having a Mirena placed at the time of surgery while they are asleep. They should be warned that it takes at least three months to ‘settle in’ and breakthrough bleeding can be an issue during this time, along with cramping. In other words they need to ‘cut it some slack’ during that time. It tends to eventually add to the effectiveness of surgery and there is growing evidence that it decreases the number of women needing repeat operations for recurrent endo symptoms.


Who do I advise to avoid a Mirena?
Obviously if you are trying to become pregnant it is a no brainer. The main group of women that I suggest do not to have a Mirena are those who have a diagnosis of ‘polycystic ovary syndrome’ (PCOS), as it tends to aggravate acne or abnormal body and facial hair growth.


It a Mirena right for you?
The only real way to know is to try one and see.

I could write so much more however I was instructed to be brief!

Best wishes.
Michael East.


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