More on Endometriosis
Periodically I share new and relevant information about common deseases, treatments, and cures with my patients. I normally share this information by sending out an email to our confidential email list. However, the 2 articles I will discuss today present information that is very new so I thought it was important to share with all.
The Clinically Important Article
In February of 2009, an Australian team reviewed 3700 live births and were able to determine that women with endometriosis, specifically with endometriosis in the ovary, had a 2-fold risk of preterm birth. I thought this was interesting when I saw it but believed that there was not a whole lot of additional data to support their findings. Recently, I read an article in a medical newspaper (Ob.Gyn News vol 44 N0. 10) discussing data that was presented at the European Society of Human Reproduction and Embryology. The researchers looked at a database of over 1.44 million births between 1992 and 2006. They determined that women who had been diagnosed with endometriosis has a 33% higher chance of delivering preterm. More interesting, and just as clinically relevant, they determined that there was a higher chance of other complications such a placental abnormalities, bleeding, and preeclampsia.
Based on this knowledge, I tend to agree with the authors' conclusions that women with preconceptionally diagnosed endometriosis should be seen and managed (at least in consultation) by a board certified perinatologist (maternal fetal medicine specialist).
The (Well Sort Of) Interesting Article
In this months journal Human Reproduction there was a very interesting article that evaluated a diagnostic test for endometriosis. They compared endometrial biopsy (the endometrium is the inner lining of the uterus that is shed every month during menses) samples for the amount of microscopic nerve fibers and compared that to specimens obtained from inside the abdomen.
Currently, obtaining samples from inside the abdomen is the gold standard for diagnosing endometriosis. This requires an experienced laparoscopic surgeon and endometriosis diagnostician to obtain the proper sample. However, obtaining a sample of the lining of the uterus is very simple and requires no surgical skill in laparoscopy. So, there is a clear advantage to using endometrial biopsy if it proves to be a useful diagnostic adjuvant.
The current study suggests that there is a high degree of correlation between nerve fiber density on the endometrial biopsy specimens and the finding of endometriosis inside the abdomen and pelvis. If we could use endometrial biopsies to better diagnose endometriosis it would save a lot of patients from having unnecessary surgery and it would help us better plan for surgery in patients who do need surgical intervention.
I am reluctant to start using and relying on this technique at this time as this study has several weaknesses. There were weakness in their samples such that the overall quality of their samples we low (only 25% were "satisfactory"). They said in their article that they did not have all of the possible biopsies from inside the abdomen. Thus, they made some correlations based on visual diagnosis only - this creates a significant problem because instead of comparing apples to pears they are now comparing apples to pears plus oranges - further confounding the data.
I look forward to further study of this very promising technique.
Sunday, August 23, 2009
Thursday, April 16, 2009
Acupuncture and Nutrition: A way to improve symptoms associated with fibroids?
So, we work with a fantastic acupuncturist here is the office and I asked him what we could do to raise awareness of some of the ways in which acupuncture could possibly help women with various gynecologic conditions. The items below are for you information and were written by Robert Branch. He has over 20 years of experience in acupuncture and traditional Chinese medicine. I trust him to help you and welcome him into the fold of my network of specialists.
Fibroids or myomas are benign tumors found in approximately 20% of women over 35 years of age. Uterine myomas are the most common neoplasm of the female reproductive organs, and are associated with menstrual pain, heavy menstrual bleeding, and fertility problems (R.Lewis, P.hD., L.Ac.).One Chinese study used Traditional Chinese herbal medicine to treat 223 cases of uterine fibroids.
· Herbs were administered after menstruation. The authors reported a 72% reduction in the quantity of menstrual blood. Symptoms like abdominal pain, and backache were improved in 58.8%. The overall effectiveness rate was 92.4%. Myomas completely disappeared in 13% of the cases, were markedly diminished in 29%, slightly reduced in 19%, and unchanged in 28%.
Acupuncture is also recommended in the treatment of fibroids. Stimulation provided by acupuncture has been found to reduce proliferating fibroid cells.
Other natural treatments (potentially useful for symptoms associated with endometriosis), include:
· Rest and wear loose, comfortable clothing
· Perform deep breathing exercises and meditative practices
· Take warm baths (with aromatherapy if you wish.)
· Use essential oils like frankincense, myrrh, clary sage, peppermint, lavendar, rosemary,
juniper and thyme.
· Use a heating pad or hot water bottle on your abdomen
· Apply warm castor oil packs on your abdomen to invigorate the blood, assist the lymphatic
symptom and balance hormone levels. Apply warm castor oil to the lower abdomen and
cover with plastic wrap two to three times per day during the premenstrual and menstrual
period.
· Take herbal supplements that invigorate the blood (and those for resolving concomitant
patterns as applicable.)
· Avoid all foods which have been treated hormonally.
· Consume soy and soy products like tofu.
· Buy only organic fruits and vegetables.
· Avoid refined, rancid and hydrogenated oils.
· Use only unprocessed plant sources of essential fatty acids.
· Use oils rich in both linoleic and alpha-linolenic fatty acids such as flax-seed, pumpkin-seed
and chia-seed oils, but only if they are recently cold-pressed and refined.
· Include dietary spirulina, evening primrose oil, and oil from black currant and borage
seeds.
· Avoid sources of arachadonic acid, which comes from animal meats, dairy products, eggs,
peanuts and seaweed.
· Decrease the amount of dietary animal products, except fish.
· If you do consume meat, make sure it is at least organic, and not hormonally treated.
· Eat walnuts, dark greens, saffron and cold climate crops.
· Foods which are especially good for resolving blood stasis include: Kelp, lemons, limes,
onions, Irish moss, and bladderwrack.
· Antioxidants (vitamins C, E, beta-carotene, selenium, zinc)
· Super antioxidants (grape seed extract, pine bark extract, red wine extract, bilberry
extract)
· Omega 3 fatty acids (fish oil and linseed oil)
So, we work with a fantastic acupuncturist here is the office and I asked him what we could do to raise awareness of some of the ways in which acupuncture could possibly help women with various gynecologic conditions. The items below are for you information and were written by Robert Branch. He has over 20 years of experience in acupuncture and traditional Chinese medicine. I trust him to help you and welcome him into the fold of my network of specialists.
Fibroids or myomas are benign tumors found in approximately 20% of women over 35 years of age. Uterine myomas are the most common neoplasm of the female reproductive organs, and are associated with menstrual pain, heavy menstrual bleeding, and fertility problems (R.Lewis, P.hD., L.Ac.).One Chinese study used Traditional Chinese herbal medicine to treat 223 cases of uterine fibroids.
· Herbs were administered after menstruation. The authors reported a 72% reduction in the quantity of menstrual blood. Symptoms like abdominal pain, and backache were improved in 58.8%. The overall effectiveness rate was 92.4%. Myomas completely disappeared in 13% of the cases, were markedly diminished in 29%, slightly reduced in 19%, and unchanged in 28%.
Acupuncture is also recommended in the treatment of fibroids. Stimulation provided by acupuncture has been found to reduce proliferating fibroid cells.
Other natural treatments (potentially useful for symptoms associated with endometriosis), include:
· Rest and wear loose, comfortable clothing
· Perform deep breathing exercises and meditative practices
· Take warm baths (with aromatherapy if you wish.)
· Use essential oils like frankincense, myrrh, clary sage, peppermint, lavendar, rosemary,
juniper and thyme.
· Use a heating pad or hot water bottle on your abdomen
· Apply warm castor oil packs on your abdomen to invigorate the blood, assist the lymphatic
symptom and balance hormone levels. Apply warm castor oil to the lower abdomen and
cover with plastic wrap two to three times per day during the premenstrual and menstrual
period.
· Take herbal supplements that invigorate the blood (and those for resolving concomitant
patterns as applicable.)
· Avoid all foods which have been treated hormonally.
· Consume soy and soy products like tofu.
· Buy only organic fruits and vegetables.
· Avoid refined, rancid and hydrogenated oils.
· Use only unprocessed plant sources of essential fatty acids.
· Use oils rich in both linoleic and alpha-linolenic fatty acids such as flax-seed, pumpkin-seed
and chia-seed oils, but only if they are recently cold-pressed and refined.
· Include dietary spirulina, evening primrose oil, and oil from black currant and borage
seeds.
· Avoid sources of arachadonic acid, which comes from animal meats, dairy products, eggs,
peanuts and seaweed.
· Decrease the amount of dietary animal products, except fish.
· If you do consume meat, make sure it is at least organic, and not hormonally treated.
· Eat walnuts, dark greens, saffron and cold climate crops.
· Foods which are especially good for resolving blood stasis include: Kelp, lemons, limes,
onions, Irish moss, and bladderwrack.
· Antioxidants (vitamins C, E, beta-carotene, selenium, zinc)
· Super antioxidants (grape seed extract, pine bark extract, red wine extract, bilberry
extract)
· Omega 3 fatty acids (fish oil and linseed oil)
Sunday, August 3, 2008
On contraception: Why make would anyone make an incision?
In today's world of contraception women have more choices than they ever did. Those choices include oral contraceptives (birth control pills), patches, vaginal ring, IUD (the most commonly used form of contraception in the world), condoms, male sterilization, hormone implants, every 3-month injections, and female permanent contraception.
For women who choose female permanent sterilization they have already made a choice to never have another child. In support of that choice a woman's physician should encourage her to make the choice that comes with the fewest complications and equivalent efficacy to other methods of permanent sterilization. Problematically, though, many physicians are doing just the opposite.
When a woman chooses permanent sterilization (tubal ligation) as her means of contraception and she is not having the tubal ligation immediately after a Cesarean delivery, she has 2 major choices.
One choice is to go to the operating room in a hospital, have general anesthesia with a tube in her throat, and allow someone to breathe for her. Then a gynecologic surgeon will make 1-2 small incisions in the abdomen and place a camera to visualize the fallopian tubes while expanding the abdomen with gas (carbon dioxide). From this point several different methods may be used from burning the tubes to placing rings or clips on the tubes. She will then go to the recovery room for usually 1-2 hours to recover from the anesthesia and receive pain medication for the abdominal pain. She is likely to have some post-operative nausea and vomiting. She will then be discharged to home and may miss up to 2 weeks of work while she recovers*.
The second choice is to go to an office setting, take some Valium to relax, have an injection of pain medication in the arm and some in the cervix and stay awake for the procedure. The gynecologic surgeon will place a camera slightly smaller than a straw into the uterus and place implants in the fallopian tubes that will eventually serve to block the tubes. This procedure is called an Essure. The only pain associated with the procedure has been described in my office as moderate menstrual cramping that goes away in a short period of time (sometimes up to 4 hours). A woman who has had an Essure procedure in the office can go back to work the next day*. In 3-months time, an additional test is required to ensure the tubes are closed. This test is called a hystersalpingogram which is like an x-ray of the fallopian tubes.
I ask my patients who have chosen tubal ligation to think about what they would like. An incision, general anesthesia, and several weeks of discomfort and missed work? Or, a simple office procedure that takes a few minutes with minimal pain and a test 3-months later to guarantee there has been success.
You make the choice!
Visit us at www.pelvicpainnewyork.com to learn more.
*(No set of outcomes is ever guaranteed for any surgical procedure. Please discuss the risks, benefits, outcomes, and complications of all procedures with your physician)
For women who choose female permanent sterilization they have already made a choice to never have another child. In support of that choice a woman's physician should encourage her to make the choice that comes with the fewest complications and equivalent efficacy to other methods of permanent sterilization. Problematically, though, many physicians are doing just the opposite.
When a woman chooses permanent sterilization (tubal ligation) as her means of contraception and she is not having the tubal ligation immediately after a Cesarean delivery, she has 2 major choices.
One choice is to go to the operating room in a hospital, have general anesthesia with a tube in her throat, and allow someone to breathe for her. Then a gynecologic surgeon will make 1-2 small incisions in the abdomen and place a camera to visualize the fallopian tubes while expanding the abdomen with gas (carbon dioxide). From this point several different methods may be used from burning the tubes to placing rings or clips on the tubes. She will then go to the recovery room for usually 1-2 hours to recover from the anesthesia and receive pain medication for the abdominal pain. She is likely to have some post-operative nausea and vomiting. She will then be discharged to home and may miss up to 2 weeks of work while she recovers*.
The second choice is to go to an office setting, take some Valium to relax, have an injection of pain medication in the arm and some in the cervix and stay awake for the procedure. The gynecologic surgeon will place a camera slightly smaller than a straw into the uterus and place implants in the fallopian tubes that will eventually serve to block the tubes. This procedure is called an Essure. The only pain associated with the procedure has been described in my office as moderate menstrual cramping that goes away in a short period of time (sometimes up to 4 hours). A woman who has had an Essure procedure in the office can go back to work the next day*. In 3-months time, an additional test is required to ensure the tubes are closed. This test is called a hystersalpingogram which is like an x-ray of the fallopian tubes.
I ask my patients who have chosen tubal ligation to think about what they would like. An incision, general anesthesia, and several weeks of discomfort and missed work? Or, a simple office procedure that takes a few minutes with minimal pain and a test 3-months later to guarantee there has been success.
You make the choice!
Visit us at www.pelvicpainnewyork.com to learn more.
*(No set of outcomes is ever guaranteed for any surgical procedure. Please discuss the risks, benefits, outcomes, and complications of all procedures with your physician)
Monday, June 16, 2008
Endometriosis: Missing the Pain Boat
There are several surgeons in the NY area and many more around the country and world that understand the need for surgical resection of endometriosis when it is implicated in chronic abdominal / pelvic pain. I am included in this group. So, why is it so hard to manage endometriosis?
The simple answer is - it's not the endometriosis that's difficult to manage - it's the associated pain that is difficult to manage. It's critical that your surgeon (hopefully that person also offers you a comprehensive pain management plan for the long term) educates you to the fact your problem is not only endometriosis. It's critical for you to understand that you also have a pain problem.
A pain problem?!?
Yes - you likely have, in addition to the pain generators associated with endometriosis, a central pain syndrome that has developed over many years such that your brain and spinal cord have changed. So, if an expert in endometriosis removal does the best surgical procedure possible you may still have pain!
Ok, so what else? Well, when pain exists for a long time other - secondary - problems may exist such as interstitial cystitis / painful bladder syndrome (IC / PBS), irritable bowel syndrome (IBS), depression, pelvic floor muscle spasm and a host of less common problems. If your surgeon does a radical removal of endometriosis and your pain does not go away you likely have one of these problems (70% of patient with endometriosis also have IC / PBS). Yet, the surgeon may have no explanation for you.
If your surgeon does not understand these concepts then you may consider finding a new surgeon or consulting with an expert in the multidisciplinary evaluation and multimodal treatment of chronic pelvic pain.
Visit us at www.pelvicpainnewyork.com to learn more.
The simple answer is - it's not the endometriosis that's difficult to manage - it's the associated pain that is difficult to manage. It's critical that your surgeon (hopefully that person also offers you a comprehensive pain management plan for the long term) educates you to the fact your problem is not only endometriosis. It's critical for you to understand that you also have a pain problem.
A pain problem?!?
Yes - you likely have, in addition to the pain generators associated with endometriosis, a central pain syndrome that has developed over many years such that your brain and spinal cord have changed. So, if an expert in endometriosis removal does the best surgical procedure possible you may still have pain!
Ok, so what else? Well, when pain exists for a long time other - secondary - problems may exist such as interstitial cystitis / painful bladder syndrome (IC / PBS), irritable bowel syndrome (IBS), depression, pelvic floor muscle spasm and a host of less common problems. If your surgeon does a radical removal of endometriosis and your pain does not go away you likely have one of these problems (70% of patient with endometriosis also have IC / PBS). Yet, the surgeon may have no explanation for you.
If your surgeon does not understand these concepts then you may consider finding a new surgeon or consulting with an expert in the multidisciplinary evaluation and multimodal treatment of chronic pelvic pain.
Visit us at www.pelvicpainnewyork.com to learn more.
Monday, May 19, 2008
Defining Solutions
A few days ago a patient asked me my opinion of the best solution to treat her fibroids. I gave her my opinion and she didn't seem happy with my answer. I had explained to her that the best options is the one that is going to give her the outcome she desires. If the desired outcome is only to decrease bleeding then I may have a bets solution for that. If the desired outcome is only to decrease pelvic pressure and associated pressure related symptomes such as urinary frequency then I may also have a solution for that. In then end, it seemed her fibroids weren't really bothering her. None of the above problems were issues for her.
She explained to me she was more surprised at, than she was displeased with my original recommendation - "do nothing". "Do nothing" is usually an appropriate option when there is no problem to fix. She left seemingly comfortable with the new plan of observation.
Please remember to ask your doctor why you require treatment for your fibroids if they are not bothering you.
Visit us at www.pelvicpainnewyork.com to learn more.
She explained to me she was more surprised at, than she was displeased with my original recommendation - "do nothing". "Do nothing" is usually an appropriate option when there is no problem to fix. She left seemingly comfortable with the new plan of observation.
Please remember to ask your doctor why you require treatment for your fibroids if they are not bothering you.
Visit us at www.pelvicpainnewyork.com to learn more.
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