Wednesday, January 15, 2014
Endometrial polyps and adenomyosis link
"The presence of multiple endometrial polyps seemed to be associated with the presence of adenomyosis (p=0.016). The presence of cervical polyps was significantly associated only with presence of adenomyosis (p=0.002). The results clearly demonstrate an association between adenomyosis and uterine polyps. The pathogenetic role of adenomyosis in the development of polyps should therefore be investigated further." http://www.ncbi.nlm.nih.gov/pubmed/21470766
Wednesday, January 8, 2014
NSAIDS- proper use for effective pain relief
Article from endometriosis.org on NSAIDS:
http://endometriosis.org/treatments/painkillers/
"Painkillers
by Ros Wood and Ellen T Johnson
Theoretically, NSAIDs would seem to be a good choice for relieving menstrual pain because most of them work by blocking the production of all prostaglandins. The result is less pain, swelling, and inflammation. However, since NSAIDs work by stopping the production of the pain-causing prostaglandins, they must be taken before any of these chemicals are produced. In other words, you must start taking NSAIDs at least 24 hours before you expect to experience pain. If you delay taking them until after you feel pain, the medication cannot block the pain-producing chemicals that have already been released, so they will not alleviate pain.
If you are using NSAIDs for ovulation pain or menstrual pain, it is recommended that you start taking them as directed at least 24 hours before you expect to ovulate or 24 hours before you expect to start bleeding. If you have an unpredictable menstrual cycle, you may want to take them for a week or more before you expect menstruation to begin. To be effective, it is important to take NSAIDs regularly every six hours so that no pain-producing chemicals are produced during ovulation or menstruation. Another advantage of taking certain NSAIDs is that they decrease the amount of menstrual bleeding (1, 2).
There are many different brands of the NSAIDs available. Some are available over-the-counter at your local pharmacy, while some are available by prescription only. It is difficult to predict which type of NSAID will be effective for a particular individual, so you may need to try two or three brands before finding one that relieves your pain. Talk to your pharmacist or doctor about suitable brands to try. If you’ve already tried an NSAID without success, you may want to try again. If you were using them incorrectly before, try starting them well in advance of your pain so that no pain-producing prostaglandins are produced.
The most important thing to remember is that unlike analgesics, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins that produce the pain. Therefore, they must be taken before you feel any pain. And they must be taken every six hours around the clock if they are to work effectively.
Like many drugs, NSAIDs can have side effects – some quite serious. Because NSAIDs block all prostaglandin production, they also block the good prostaglandins responsible for maintaining the integrity of the stomach lining. That’s why the most common side effects of NSAIDs include nausea, vomiting, diarrhoea, irritation of the stomach, and stomach ulcers. To help reduce stomach irritation, NSAIDs should be taken with food. Newer NSAIDs called selective COX-2 inhibitors (Vioxx, Celebrex, Bextra) were originally thought to cause less bleeding and fewer ulcers than traditional NSAIDs. However, follow-up studies on these drugs have shown there is no clinically meaningful safety advantage over traditional NSAIDs. Therefore, COX-2 inhibitors should be used with the same caution as any other NSAID. If you are considering taking any type of NSAID, be sure to ask for a complete list of potential side effects, warnings, and possible drug interactions from your pharmacist or healthcare practitioner. Also be sure to inquire about the types of side effects that should be reported to your doctor immediately.
Finally, it’s important for you to know that the effects of “bad prostaglandins” can also be moderated in part by diet and supplements. As we’ve discussed in prior articles and interviews with Dian Shepperson Mills, reducing animal fats, caffeine, and alcohol, and adding flax oil, fish oil, and olive oil to your diet can increase the production of “good prostaglandins” and decrease the production of “bad prostaglandins.” If you cannot take NSAIDs (or choose not to), dietary changes may be a good option to try."
http://endometriosis.org/treatments/painkillers/
"Painkillers
by Ros Wood and Ellen T Johnson
Most of us with endometriosis know quite a bit about having pain. Unfortunately, we know a lot less about how to manage that pain. In our attempts to deal with pain, many of us have used various medications such as aspirin, Paracetamol, Panadol, or Tylenol. These drugs alleviate pain by reducing the body’s sensitivity to pain.Fewer of us are familiar with the use of the non-steroidal anti-inflammatory drugs (NSAIDs) for managing pain. Some of the more common NSAIDs include ibuprofen (ACT-3, Advil, Brufen, Motrin, Nurofen), naproxen sodium (Aleve, Naprogesic, Naprosyn, Naproxen), ketoprofen (Orudis KT), and mefenamic acid (Ponstan). These drugs can be effective in alleviating pain and inflammation, but to do so, they must be used correctly. Too often, women are prescribed NSAIDs without clear instructions about their use, so they use them the same way they use analgesic drugs. However, when used incorrectly, NSAIDs don’t work.
It is thought that much of the pain of endometriosis, especially menstrual pain, is due to inflammation that may be caused in part by high levels of “bad prostaglandins.” Prostaglandins are hormone-like chemicals that can be found in every cell of the body. Prostaglandins have beneficial effects (enhance immune function, block inflammation, relax muscles, maintain the integrity of the stomach lining, dilate blood vessels, etc.), as well as detrimental effects (produce inflammation, decrease oxygen flow, contract muscles, induce pain, etc.). The bad news is that women with endometriosis have been shown to produce an excess of a prostaglandin called PGE2, which causes inflammation, pain, and uterine contractions.Theoretically, NSAIDs would seem to be a good choice for relieving menstrual pain because most of them work by blocking the production of all prostaglandins. The result is less pain, swelling, and inflammation. However, since NSAIDs work by stopping the production of the pain-causing prostaglandins, they must be taken before any of these chemicals are produced. In other words, you must start taking NSAIDs at least 24 hours before you expect to experience pain. If you delay taking them until after you feel pain, the medication cannot block the pain-producing chemicals that have already been released, so they will not alleviate pain.
If you are using NSAIDs for ovulation pain or menstrual pain, it is recommended that you start taking them as directed at least 24 hours before you expect to ovulate or 24 hours before you expect to start bleeding. If you have an unpredictable menstrual cycle, you may want to take them for a week or more before you expect menstruation to begin. To be effective, it is important to take NSAIDs regularly every six hours so that no pain-producing chemicals are produced during ovulation or menstruation. Another advantage of taking certain NSAIDs is that they decrease the amount of menstrual bleeding (1, 2).
There are many different brands of the NSAIDs available. Some are available over-the-counter at your local pharmacy, while some are available by prescription only. It is difficult to predict which type of NSAID will be effective for a particular individual, so you may need to try two or three brands before finding one that relieves your pain. Talk to your pharmacist or doctor about suitable brands to try. If you’ve already tried an NSAID without success, you may want to try again. If you were using them incorrectly before, try starting them well in advance of your pain so that no pain-producing prostaglandins are produced.
The most important thing to remember is that unlike analgesics, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins that produce the pain. Therefore, they must be taken before you feel any pain. And they must be taken every six hours around the clock if they are to work effectively.
Like many drugs, NSAIDs can have side effects – some quite serious. Because NSAIDs block all prostaglandin production, they also block the good prostaglandins responsible for maintaining the integrity of the stomach lining. That’s why the most common side effects of NSAIDs include nausea, vomiting, diarrhoea, irritation of the stomach, and stomach ulcers. To help reduce stomach irritation, NSAIDs should be taken with food. Newer NSAIDs called selective COX-2 inhibitors (Vioxx, Celebrex, Bextra) were originally thought to cause less bleeding and fewer ulcers than traditional NSAIDs. However, follow-up studies on these drugs have shown there is no clinically meaningful safety advantage over traditional NSAIDs. Therefore, COX-2 inhibitors should be used with the same caution as any other NSAID. If you are considering taking any type of NSAID, be sure to ask for a complete list of potential side effects, warnings, and possible drug interactions from your pharmacist or healthcare practitioner. Also be sure to inquire about the types of side effects that should be reported to your doctor immediately.
Finally, it’s important for you to know that the effects of “bad prostaglandins” can also be moderated in part by diet and supplements. As we’ve discussed in prior articles and interviews with Dian Shepperson Mills, reducing animal fats, caffeine, and alcohol, and adding flax oil, fish oil, and olive oil to your diet can increase the production of “good prostaglandins” and decrease the production of “bad prostaglandins.” If you cannot take NSAIDs (or choose not to), dietary changes may be a good option to try."
Tuesday, January 7, 2014
Pain with Minimal Endometriosis
"Review of Pain Associated with Minimal Endometriosis"
From 2000 Journal of the Society of Laparoendoscopic Surgeons:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/
(bold and italics are mine)
**See below for a link to a video from Dr. David Redwine on the appearances of endometriosis- actual video from surgery showing what it looks like!)**
"A simple analogy that is often used to explain endometriosis to the patient is the example of the eyelash and the eye. The eyelash is a “normal” part of the eye and quite separate from the eyeball. Should a “normal eyelash” be placed on a “normal” eyeball, the eye becomes red with dilated corkscrew vessels. The eye becomes painful but continues to function, though not optimally. The eyeball returns to its normal state once the eyelash is removed. The body reacts in a similar manner when the “normal peritoneum” is exposed to the “normal endometrial tissue.” The peritoneal lining develops red lesions with dilated corkscrew vessels and becomes painful. The pelvic organs continue to function but not optimally, which can lead to infertility. The way to cure the problem is to find and remove the “normal endometrial tissue.” Although this analogy is not perfect, the patients seem to grasp the concept, since they have all experienced an eyelash in the eye scenario....
"Unfortunately, locating and removing the “normal endometrial tissue” has not been as easy as finding and removing the “normal eyelash.” In the early method of locating and treating endometriosis, laparotomy was the only approach to access the pelvis. Lesions, located with the naked eye, were biopsied and removed with marginal success5 in relieving the pain associated with endometriosis, since lesions, too small to be seen, were left untreated. With the advent of laparoscopy, new lesions were identified,6 including red and white lesions. Unfortunately, the identification of these new lesions did not improve the results of therapy to any great degree.7 Patients woke up from their surgery stating that there was no difference in the pain, or they had temporary pain relief for 6 to 24 months. More radical therapy, including hysterectomy and bilateral salpingoophorectomy, was recommended in the belief that the cramps originated in the uterus, and the endometrial tissue was encouraged to develop under the influence of estrogen from the ovaries. Although this improved the results of therapy, failures were noticed,8 and the pelvic pain and painful cramps persisted in many patients. Consequently, it was concluded that the pain and cramps must be of another origin since the uterus was removed. Patients were sent off for extensive bowel work-ups and were left with a diagnosis of irritable bowel syndrome, or were told that the origin of the pain was (“in her head”) psychosomatic.
"Researchers persisted to perusing the cause of the pain. Dr. David Redwine theorized that the pain originated from the peritoneum, and, if one removed the entire peritoneum, the pain would resolve. Success was achieved, but due to the extent of the procedure, the risk of adhesion and subsequent pain was still present. However, a significant finding in the pathology specimens, was that microscopic endometriosis was present in “normal appearing” peritoneum, and this was confirmed by Dr. Dan Martin and others. Finally, an explanation for the recurrence of the symptoms of endometriosis was found. These microscopic implants in the normal looking peritoneum were not excised since they were not “seen” and, thus, later developed into larger lesions, with subsequent recurrence of the symptoms of endometriosis....
"Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum ((Figure 1). Therefore, if the surgeon only removed the lesion at its border, the microscopic disease in the previously identified normal looking peritoneum was left, and persistence or recurrence of the symptoms was encountered.
"Palpation of the lesions of endometriosis produced the cramps, not the uterus. Patients, postoperatively, reported that once they identified the cramps of endometriosis, they noticed that they were different than menstrual cramps. Furthermore, palpation of the endometriosis lesions on patients without a uterus and both ovaries removed reproduced the cramps of endometriosis. This confirmed the findings of other researchers who have concluded that a hysterectomy often does not change the course of the pain of endometriosis since it is the lesions, not the uterus, which are responsible for the cramp-like pain. The location of the lesion in relationship to the pelvis can, in most instances, reproduce the symptoms the patient experiences. Lesions on the utero-sacral ligament, when palpated, cause pain or cramps in the back. Palpation of lesions on the side wall of the pelvis result in pain or cramps radiating down the leg.
"What is most interesting is that right-left orientation of the pelvis does not exist in some patients.12 That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true. How many times has a laparoscopy under general anesthesia been done on a patient complaining of right-sided pain where the surgeon saw a normal looking pelvis on the right—only to wake up the patient and tell her, “I saw nothing on the right side of your pelvis that would cause your pain.” It now becomes apparent why the results of the survey of the Endometriosis Association's members revealed that the average length of time from the onset of symptoms to the treatment of the endometriosis was 9.28 years and an average of 2.3 operations.
"As has been shown over the years, results of therapy, based only on what the physician sees, is marginal at best, especially in minimal endometriosis (ie, stage 1 and stage 2).
"The data revealing the failure of the approach of “treat and see,” based on what the surgeon observed at laparoscopy under general anesthetic, is strong and reveals that a new approach is needed. An approach based on patient confirmed diagnosis and patient-based analysis of the results of therapy needs to be looked at in greater detail. The only person who knows where the pain starts and ends is the patient herself. She is also the only one who can confirm when the pain is no longer present." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/
Video from Dr. David Redwine on the appearance of endometriosis:
http://vimeo.com/62247222
From 2000 Journal of the Society of Laparoendoscopic Surgeons:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/
(bold and italics are mine)
**See below for a link to a video from Dr. David Redwine on the appearances of endometriosis- actual video from surgery showing what it looks like!)**
"A simple analogy that is often used to explain endometriosis to the patient is the example of the eyelash and the eye. The eyelash is a “normal” part of the eye and quite separate from the eyeball. Should a “normal eyelash” be placed on a “normal” eyeball, the eye becomes red with dilated corkscrew vessels. The eye becomes painful but continues to function, though not optimally. The eyeball returns to its normal state once the eyelash is removed. The body reacts in a similar manner when the “normal peritoneum” is exposed to the “normal endometrial tissue.” The peritoneal lining develops red lesions with dilated corkscrew vessels and becomes painful. The pelvic organs continue to function but not optimally, which can lead to infertility. The way to cure the problem is to find and remove the “normal endometrial tissue.” Although this analogy is not perfect, the patients seem to grasp the concept, since they have all experienced an eyelash in the eye scenario....
"Unfortunately, locating and removing the “normal endometrial tissue” has not been as easy as finding and removing the “normal eyelash.” In the early method of locating and treating endometriosis, laparotomy was the only approach to access the pelvis. Lesions, located with the naked eye, were biopsied and removed with marginal success5 in relieving the pain associated with endometriosis, since lesions, too small to be seen, were left untreated. With the advent of laparoscopy, new lesions were identified,6 including red and white lesions. Unfortunately, the identification of these new lesions did not improve the results of therapy to any great degree.7 Patients woke up from their surgery stating that there was no difference in the pain, or they had temporary pain relief for 6 to 24 months. More radical therapy, including hysterectomy and bilateral salpingoophorectomy, was recommended in the belief that the cramps originated in the uterus, and the endometrial tissue was encouraged to develop under the influence of estrogen from the ovaries. Although this improved the results of therapy, failures were noticed,8 and the pelvic pain and painful cramps persisted in many patients. Consequently, it was concluded that the pain and cramps must be of another origin since the uterus was removed. Patients were sent off for extensive bowel work-ups and were left with a diagnosis of irritable bowel syndrome, or were told that the origin of the pain was (“in her head”) psychosomatic.
"Researchers persisted to perusing the cause of the pain. Dr. David Redwine theorized that the pain originated from the peritoneum, and, if one removed the entire peritoneum, the pain would resolve. Success was achieved, but due to the extent of the procedure, the risk of adhesion and subsequent pain was still present. However, a significant finding in the pathology specimens, was that microscopic endometriosis was present in “normal appearing” peritoneum, and this was confirmed by Dr. Dan Martin and others. Finally, an explanation for the recurrence of the symptoms of endometriosis was found. These microscopic implants in the normal looking peritoneum were not excised since they were not “seen” and, thus, later developed into larger lesions, with subsequent recurrence of the symptoms of endometriosis....
"Initial work on mapping of pain associated with the endometriosis lesions resulted in some thought-provoking findings. The classic black lesions were found to be painful in only 11% of patients when the lesion was touched. Similarly, white lesions were painful in 20% of patients with red lesions at 37%, and clear lesions at 32% were the most painful (Table 1). These results added further reason as to why initial therapy had such poor results. Surgeons would only “see” the black lesions and removed them, but these were the least painful lesions. The most painful clear lesions were not “seen” at laparotomy and therefore remained, as did the pain. What became apparent next, while mapping the patient, was the fact that the pain extended 28 mm beyond the visible border of the lesion onto what looked like “normal” peritoneum ((Figure 1). Therefore, if the surgeon only removed the lesion at its border, the microscopic disease in the previously identified normal looking peritoneum was left, and persistence or recurrence of the symptoms was encountered.
"Palpation of the lesions of endometriosis produced the cramps, not the uterus. Patients, postoperatively, reported that once they identified the cramps of endometriosis, they noticed that they were different than menstrual cramps. Furthermore, palpation of the endometriosis lesions on patients without a uterus and both ovaries removed reproduced the cramps of endometriosis. This confirmed the findings of other researchers who have concluded that a hysterectomy often does not change the course of the pain of endometriosis since it is the lesions, not the uterus, which are responsible for the cramp-like pain. The location of the lesion in relationship to the pelvis can, in most instances, reproduce the symptoms the patient experiences. Lesions on the utero-sacral ligament, when palpated, cause pain or cramps in the back. Palpation of lesions on the side wall of the pelvis result in pain or cramps radiating down the leg.
"What is most interesting is that right-left orientation of the pelvis does not exist in some patients.12 That is to say, palpation of a lesion of endometriosis on the left side of the pelvis may produce pain that the patient perceives as being on the right side of the abdomen, and the opposite is also true. How many times has a laparoscopy under general anesthesia been done on a patient complaining of right-sided pain where the surgeon saw a normal looking pelvis on the right—only to wake up the patient and tell her, “I saw nothing on the right side of your pelvis that would cause your pain.” It now becomes apparent why the results of the survey of the Endometriosis Association's members revealed that the average length of time from the onset of symptoms to the treatment of the endometriosis was 9.28 years and an average of 2.3 operations.
"As has been shown over the years, results of therapy, based only on what the physician sees, is marginal at best, especially in minimal endometriosis (ie, stage 1 and stage 2).
"The data revealing the failure of the approach of “treat and see,” based on what the surgeon observed at laparoscopy under general anesthetic, is strong and reveals that a new approach is needed. An approach based on patient confirmed diagnosis and patient-based analysis of the results of therapy needs to be looked at in greater detail. The only person who knows where the pain starts and ends is the patient herself. She is also the only one who can confirm when the pain is no longer present." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015350/
Video from Dr. David Redwine on the appearance of endometriosis:
http://vimeo.com/62247222
Sunday, January 5, 2014
Uterosacral Nerve Ablation (LUNA)
What is uterosacral nerve ablation (aka LUNA)?
It is where the surgeon destroys the nerve fibers that go from the uterus to the uterosacral ligaments. "Laparoscopic uterine nerve ablation involves the destruction of the uterine nerve fibers that exit the uterus through the uterosacral ligament. Pre-sacral neurectomy refers to the interruption of the sympathetic innervation of the uterus at the level of the superior hypogastric plexus. Pre-sacral neurectomy is technically more challenging than LUNA because of the presence of large vessels and the ureters near the field of dissection." http://www.aetna.com/cpb/medical/data/700_799/0754.html
"LUNA was adopted by many practitioners because afferent nerves from pelvic organs pass through the uterosacral ligament and it was thought that disruption of these would reduce the perceived pain." http://www.medscape.com/viewarticle/708244
Does it work?
"After a median follow-up of 69 months, there were no significant differences reported on the visual analogue pain scales for the worst pain (mean difference between the LUNA group and the no LUNA group, −0.04 cm [95% confidence interval {CI}, −0.33 to 0.25 cm]; P = .80), noncyclical pain (−0.11 cm [95% CI, −0.50 to 0.29 cm]; P = .60), dysmenorrhea (−0.09 cm [95% CI, −0.49 to 0.30 cm]; P = .60), or dyspareunia (0.18 cm [95% CI, −0.22 to 0.62 cm]; P = .40). No differences were observed between the LUNA group and the no LUNA group for quality of life.
Conclusion Among women with chronic pelvic pain, LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation." http://jama.jamanetwork.com/article.aspx?articleid=184505
"Laparoscopic uterosacral nerve ablation and presacral neurectomy are ancillary procedures meant to further decrease endometriosis-associated pelvic pain symptoms. Presacral neurectomy, involving cutting the T10-L1 sympathetic nerves on the anterior surface of the sacral bone and paracervical uterine denervation, involving transection of the uterosacral ligament at its attachment to the uterus along with cutting the above-mentioned sympathetic nerves and the S1S4 parasympathetic nerves, which transmit pain stimuli from the supravaginal region into the uterine cervix.1 Surgery for the treatment of peritoneal endometriosis includes several options: electrocoagulation, laser ablation, plasmajet or excision of the lesions, all of which have similar efficacy in the therapy of endometriosis-associated pelvic pain.24 ...There was no significant difference in pain scores in women with non-menstrual pelvic pain, deep dyspareunia, or dyschezia with no endometriosis who underwent LUNA versus those who did not undergo LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in pain outcome. Johnson concluded that LUNA is effective for dysmenorrhea in the absence of endometriosis and that there is no evidence for the effectiveness of LUNA for chronic pelvic pain without dysmenorrhea or for any type of pelvic pain associated with endometriosis....Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain." http://laparoscopy.blogs.com/prevention_management_3/2011/04/laparoscopic-treatment-of-chronic-pelvic-pain-uterosacral-ablation.html
It is where the surgeon destroys the nerve fibers that go from the uterus to the uterosacral ligaments. "Laparoscopic uterine nerve ablation involves the destruction of the uterine nerve fibers that exit the uterus through the uterosacral ligament. Pre-sacral neurectomy refers to the interruption of the sympathetic innervation of the uterus at the level of the superior hypogastric plexus. Pre-sacral neurectomy is technically more challenging than LUNA because of the presence of large vessels and the ureters near the field of dissection." http://www.aetna.com/cpb/medical/data/700_799/0754.html
"LUNA was adopted by many practitioners because afferent nerves from pelvic organs pass through the uterosacral ligament and it was thought that disruption of these would reduce the perceived pain." http://www.medscape.com/viewarticle/708244
"After a median follow-up of 69 months, there were no significant differences reported on the visual analogue pain scales for the worst pain (mean difference between the LUNA group and the no LUNA group, −0.04 cm [95% confidence interval {CI}, −0.33 to 0.25 cm]; P = .80), noncyclical pain (−0.11 cm [95% CI, −0.50 to 0.29 cm]; P = .60), dysmenorrhea (−0.09 cm [95% CI, −0.49 to 0.30 cm]; P = .60), or dyspareunia (0.18 cm [95% CI, −0.22 to 0.62 cm]; P = .40). No differences were observed between the LUNA group and the no LUNA group for quality of life.
Conclusion Among women with chronic pelvic pain, LUNA did not result in improvements in pain, dysmenorrhea, dyspareunia, or quality of life compared with laparoscopy without pelvic denervation." http://jama.jamanetwork.com/article.aspx?articleid=184505
"Laparoscopic uterosacral nerve ablation and presacral neurectomy are ancillary procedures meant to further decrease endometriosis-associated pelvic pain symptoms. Presacral neurectomy, involving cutting the T10-L1 sympathetic nerves on the anterior surface of the sacral bone and paracervical uterine denervation, involving transection of the uterosacral ligament at its attachment to the uterus along with cutting the above-mentioned sympathetic nerves and the S1S4 parasympathetic nerves, which transmit pain stimuli from the supravaginal region into the uterine cervix.1 Surgery for the treatment of peritoneal endometriosis includes several options: electrocoagulation, laser ablation, plasmajet or excision of the lesions, all of which have similar efficacy in the therapy of endometriosis-associated pelvic pain.24 ...There was no significant difference in pain scores in women with non-menstrual pelvic pain, deep dyspareunia, or dyschezia with no endometriosis who underwent LUNA versus those who did not undergo LUNA. The addition of LUNA to laparoscopic surgical treatment of endometriosis was not associated with a significant difference in pain outcome. Johnson concluded that LUNA is effective for dysmenorrhea in the absence of endometriosis and that there is no evidence for the effectiveness of LUNA for chronic pelvic pain without dysmenorrhea or for any type of pelvic pain associated with endometriosis....Awareness of endometriosis as a disease with substantial morbidity is vitally important. Laparoscopic treatment of endometriosis is beneficial for reducing pain and improving fertility. Laparoscopic presacral neurectomy, but not laparoscopic uterosacral nerve ablation, is a useful adjunct to conservative surgery for endometriosis in patients with a midline component of pain." http://laparoscopy.blogs.com/prevention_management_3/2011/04/laparoscopic-treatment-of-chronic-pelvic-pain-uterosacral-ablation.html
Thursday, January 2, 2014
Effective endo surgery and treatment- what to look for
"When we say we want effective endo surgery, we are looking at a desire for prompt diagnosis, compassionate understanding of the severity of pain, and skilled removal of disease." -Nancy Petersen
Below is a post by a well known endometriosis advocate which includes things you would want to look for or ask a physician about when finding a doctor to treat your endometriosis.
"Nancy Petersen here:
Recently when I posted on this board that less than 100 out of the 52,000 gyns in the US had been identified as doing effective endometriosis surgery, I heard from a group of gyns who were offended by the comment. Yet as we discussed my comment, what came out were a variety of comments that support my position. They knew of "subtle appearances" and indicated that guided their practice. But some do not operate on colons, bladders, ureters or diaphragms nor did they have consultants to assist with disease in this area. Some did not feel removal of mild disease was even warranted. Still some do not operate in the lower pelvis, do not refer for pelvic pt, do not refer for pelvic pain management and despite the signs and symptoms of peritoneal inflammation do not believe in pain medicine to assist with coping of peritoneal quality pain. (bloating, paleness, severe pain, slowed bowel, nausea, restlessness, rebound tenderness or painful pelvic exams). Endo causes peritoneal inflammation and there is not a med student or nursing student on the face of the earth who have not been taught to recognize peritoneal signs and symptoms. Most would treat it aggressively. Some dismiss it as just her period. Try living with appendicitis constantly, or a dozen grains of sand in your eye for a lifetime.
To relieve pain, all disease must be removed. One has to know not only what it looks like, but where it is found. I was surprised to hear so many physicians will see it as a disease of the ovary, but statistically, the ovaries are 7th and 9th in order of frequency of involvement, not first. So knowing where disease is found is a big step toward being effective surgically. Additionally, having either surgical certifications to operate on all areas endo is found, or a stable of consultants able and willing to do so is another huge factor in outcomes. Recognizing endo lies beyond the pelvic cavity is also major.
Today in the support groups nearly every day, I hear from women who have been castrated (total hyst) and yet have endo type symptoms. Yet they are told over and over there is no way endo can be present after a hyst. Yet there are a number of studies that show us endo can and does persist after hyst if it too has not been removed. Too often the hyst was done to treat the endo. (without excision of endo implants elsewhere). There is ample evidence that removing normal tubes, ovaries and uterus does not ease endometriosis pain nor does endo dry up and go away after castration. There are good reasons to do a hyst, but endo is not one of them, and the long term impact of hysterectomy is not offset by estrogen replacement when it comes to bones and heart. (as I understand it).
What women seem to want is compassionate understanding of how severe the pain is, to not be told medical therapy treats endo (we know it doesn't), to not be hysterectomized for endo treatment when removing lesions skillfully works much better. If their doctor cannot do skilled excision surgery, they express a desire for referral for pelvic pt to a certified women's health therapist, and or to a surgeon doing skilled removal of disease.
Pain management may lead to dependence, but rarely abuse, and it often allows women to get up off the couch, put their heating pad away, and get back into life.
When we say we want effective endo surgery, we are looking at a desire for prompt diagnosis, compassionate understanding of the severity of pain, and skilled removal of disease. This comes out in the discussions every day, multiple times a day, and is critical for the industry to begin to understand. Drugs do not treat endo, most of the side effects are unpleasant to say the least, and the altered hormonal states unacceptable to most."
*From the Endometriosis Research Center (a wealth of information): Frequently involved areas of endometriosis are "the lower areas of the pelvis are first, cul de sac, pelvic side walls, uterosacral ligaments, bowel, rectum, bladder, ureters ." http://www.endocenter.org/
Q: Why excision?
A: "Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. SUMMARY: Laparoscopic excision is currently the 'gold standard' approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies." http://www.ncbi.nlm.nih.gov/pubmed/15232483
"...All the teenagers received “complete excision” (defined as above) by an expert and experienced surgeon. They were followed for up to 5 years, the mean interval being 2 years. Overall the pain scores and quality of life (perhaps more importantly) improved significantly. The rate of recurrent or persistent endometriosis on second-look laparoscopy was zero. This data indicates that complete excision is an important part of the management plan for pain. More importantly perhaps, is the implication that there is a potential for complete eradication of disease." http://endometriosis.org/news/opinion/endometriosis-morbidity-can-it-be-prevented-with-early-diagnosis-and-complete-excision/
A case in point:
"...A case in which CO2 laser ablation of endometriosis that had been causing deep dyspareunia did not alleviate symptoms. Because those symptoms persisted, the patient was referred to our center, where a second laparoscopy revealed deep nodules of endometriosis, 1 to 2 cm in diameter, extending from the right and the left uterosacral ligaments deep into the perirectal space, bilaterally.
"FIGURE 5 Deep nodules present a surgical challengeThese nodules of endometriosis on the right and left uterosacral ligaments (panel A) did not respond to CO2 laser ablation. Upon progressive resection, the implants were found to be deep, extending into the perirectal space (panel B). (See also VIDEO 3, resection of endometriosis from the left uterosacal ligament, close to the ureter.)FIGURE 6, illustrates endometriosis overlying the bladder and left ureter (see also VIDEO 4). Ablation of endometriosis in these areas may be inadequate if it is not deep enough, and dangerous if it goes too deep. As FIGURE 6 shows, excision assures the surgeon that the entire lesion has been removed and that underlying vital structures have been safeguarded."
http://www.obgmanagement.com/multimedia/video/article/strategies-and-steps-for-the-surgical-management-of-endometriosis/6ecce897772ba2a16447350f533269e5.html?tx_ttnews[sViewPointer]=1
Q: Why an expert?
A: "Excising deep and invasive endometriosis whilst preserving the health and functionality of surrounding organs can be extremely challenging...Griffiths comments: 'Endometriosis is non-malignant, but it is far from benign. It can have devastating health consequences for a woman, such as losing a kidney or a section of bowel or becoming infertile. There is a continuum from benign to malignant, and our understanding of endometriosis at the molecular level may open opportunities to help us understand metastatic cancer, and vice versa.' Cancer and endometriosis are very similar, both have endometrial cells that are able to migrate, vascularize and invade other tissues, some quite far away from the uterus. Griffiths explains: 'Through cell and tissue engineering we can begin to understand the behavior of these cells, such as the pathways they follow and why. That will help us develop therapies targeted precisely at the sub-cellular factors that lead cells astray.' Griffith and her team are developing research models that allow scientists to manipulate constellations of the factors involved in endometriosis, such as cytokines of the immune system, whilst observing their roles in the disease process. Endometriosis can affect any pelvic or extra-pelvic organ and when it occurs beyond the reproductive organs it generally affects the bowel or bladder but it has also been discovered in atypical sites (Virtual Poster 414), like the lungs (Virtual Posters 406 and 418)." http://www.medicalnewstoday.com/articles/236843.php
"We do not claim that surgery is always a ‘cure’ for endometriosis, nor that the disease cannot recur or be overlooked. However, we do believe that who performs the surgery and how it is performed impacts both the long and the short term success of surgical treatment. On the other hand, modern-day optics at laparoscopy and a well-trained eye have allowed the disease to be detected or seen in a way that has not been possible before [19]. Moreover, an expert surgeon can be expected to remove detectable disease in its entirety, even when found over vital organs.
Taken together, the data suggests that there is a potential to remove all relevant disease." http://endometriosis.org/news/opinion/endometriosis-morbidity-can-it-be-prevented-with-early-diagnosis-and-complete-excision/
Q: It's only minimal or superficial endo, so it shouldn't be causing that much pain, right?
A: Wrong. "Any amount of endometriosis can cause pain, and the disease does not need to be advanced to cause significant symptoms. Likewise, higher stage (3 and 4) disease may cause little to no symptoms in some women. Situations vary; moderate growth can trigger intense pain in some women while advanced growth causes less severe pain in others. Every woman's situation is unique and therefore expert medical evaluation is absolutely essential." http://www.endofound.org/endometriosis
"Endometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale." http://www.ncbi.nlm.nih.gov/pubmed/8566252
Q: Is endometriosis associated with other conditions?
A: Yes. "Women with endometriosis are at increased risk for a host of other diseases including chronic fatigue syndrome, multiple sclerosis, lupus, underactive thyroid, and rheumatoid arthritis,
according to new government findings....Compared with the general population of women, Stratton and colleagues found that women with endometriosis were more than 100 times as likely to have chronic fatigue syndrome, seven times as likely to have disease related to underactive thyroid, and twice as likely to have the muscular disorder fibromyalgia.
"Women with endometriosis frequently suffer from autoimmune inflammatory diseases, hypothyroidism, fibromyalgia (FM), chronic fatigue syndrome (CFS), allergies and asthma," lead author Ninet Sinaii, from the National Institute of Child Health and Human Development in Bethesda, Maryland, says in a news release. "These findings also suggest a strong association between endometriosis and autoimmune disorders and indicate the need to consider the co-existence of other conditions in women with endometriosis." http://www.medscape.com/viewarticle/442245
Q: What else could be contributing to my chronic pelvic pain?
A: Endo is often accompanied by other conditions such as:
1. pelvic floor dysfunction (and other musculoskeletal problems like levator ani spasms) http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-medicine-feature-articles/pelvic-floor-spasm-missing-l
2. interstitial cystitis, http://www.ichelp.org/AssociatedConditions
3. irritable bowel syndrome,
4. pelvic congestion syndrome,
5. adhesions,
6. adenomyosis,
7. vulvodynia,
8. ovarian cysts,
9. fibroids,
10. pudendal neuropathy,
11. pelvic inflammatory disease
12. and several others.
Q: Can pelvic physical therapy help?
A: Yes, most especially if your endometriosis has been removed. If it hasn't then the constant source of irritation and inflammation as well as adhesion formation will keep you from progressing as far.
"Endometriosis can be associated with pelvic floor dysfunction (PFD)....
Physical therapy helps most or all of the symptoms previously described through techniques such as myofascial trigger point release, scar tissue and connective tissue manipulation of the internal and external pelvic, abdominal, hip and back structures. Women with endometriosis commonly have trigger points in the abdominal wall as well as the pelvic floor, back and gluteal (buttock) muscles....
P.S. Also from an endometriosis discussion group is this list of things to ask your doctor:
"Who did you train under and for how long?
How is pain managed post op when I'm home/at the hotel?
How are the surgeries specifically done?
How many incisions would you use? Would you reuse an old one like the belly button? Why or Why not?
Does the doctor do laser vaporization or does he/she excise the endometriosis and the adhesions?
What do you use to cut the endo out?
What happens to all of the endometriosis and adhesions that are excised? Do they ALL get sent to pathology?
How many endometriosis surgeries does the doctor do in a week/month/year?
How many of those patients are stage 4 endo?
On average, how long time wise are the doctor’s surgeries for endometriosis?
Who would be assisting?
Would you be calling my husband/partner/family member/friend in the waiting area from the Operating Room to give them a status update and/or permission to remove organ(s)?
Does the doctor take care of all the endometriosis and adhesions?
Does he/she preserve organs?
Does the doctor take his/her time in the surgery to cut out all of the endo and adhesions that is there no matter how complicated the case is?
Immediately post op, will you be sitting down to talk to my husband/partner/family member/friend to talk about the surgery? Can they record it on a digital voice recorder?
Does the doctor track the results of his/her endo patients?
How many patients of his are pain free after 6 months, 1 year, 3 years, 5 years from endometriosis?
What is the rate of recurrence of endometriosis for his patients?
Does the doctor treat other types of patients as well or are all of his/her patients endo patients?
What hospital does the doctor do his/her surgeries at?
Can I get a copy of the doctor’s CV? *
Is he/she board certified? Through when? **
Has the doctor had any complaints against him/her? If so what were they and how were they resolved?
Does he/she have any lawsuits in the past 25 years? If so what were they and how were they resolved?
What happens if I have a question after my surgery and it's after hours?
How soon can an appointment be made?
Does the doctor have an email address to send any additional questions to?
*CV is the doctor’s resume. Every doctor should have one listing where they list their medical internship/residency where they got their medical degree, any journal articles they have written, and more
**board certification means that the doctor has had some extra training in his/her field. You can verify board certification at https://www.abms.org/WC/login.aspx . You’ll need to set up a log in account but it is worth it to check up on your doctors.
You can check up on the doctors to see if they have had any disciplinary actions taken against them, etc. You’ll head to http://www.docboard.org/docfinder.html and click on your state for more info."
Below is a post by a well known endometriosis advocate which includes things you would want to look for or ask a physician about when finding a doctor to treat your endometriosis.
"Nancy Petersen here:
Recently when I posted on this board that less than 100 out of the 52,000 gyns in the US had been identified as doing effective endometriosis surgery, I heard from a group of gyns who were offended by the comment. Yet as we discussed my comment, what came out were a variety of comments that support my position. They knew of "subtle appearances" and indicated that guided their practice. But some do not operate on colons, bladders, ureters or diaphragms nor did they have consultants to assist with disease in this area. Some did not feel removal of mild disease was even warranted. Still some do not operate in the lower pelvis, do not refer for pelvic pt, do not refer for pelvic pain management and despite the signs and symptoms of peritoneal inflammation do not believe in pain medicine to assist with coping of peritoneal quality pain. (bloating, paleness, severe pain, slowed bowel, nausea, restlessness, rebound tenderness or painful pelvic exams). Endo causes peritoneal inflammation and there is not a med student or nursing student on the face of the earth who have not been taught to recognize peritoneal signs and symptoms. Most would treat it aggressively. Some dismiss it as just her period. Try living with appendicitis constantly, or a dozen grains of sand in your eye for a lifetime.
To relieve pain, all disease must be removed. One has to know not only what it looks like, but where it is found. I was surprised to hear so many physicians will see it as a disease of the ovary, but statistically, the ovaries are 7th and 9th in order of frequency of involvement, not first. So knowing where disease is found is a big step toward being effective surgically. Additionally, having either surgical certifications to operate on all areas endo is found, or a stable of consultants able and willing to do so is another huge factor in outcomes. Recognizing endo lies beyond the pelvic cavity is also major.
Today in the support groups nearly every day, I hear from women who have been castrated (total hyst) and yet have endo type symptoms. Yet they are told over and over there is no way endo can be present after a hyst. Yet there are a number of studies that show us endo can and does persist after hyst if it too has not been removed. Too often the hyst was done to treat the endo. (without excision of endo implants elsewhere). There is ample evidence that removing normal tubes, ovaries and uterus does not ease endometriosis pain nor does endo dry up and go away after castration. There are good reasons to do a hyst, but endo is not one of them, and the long term impact of hysterectomy is not offset by estrogen replacement when it comes to bones and heart. (as I understand it).
What women seem to want is compassionate understanding of how severe the pain is, to not be told medical therapy treats endo (we know it doesn't), to not be hysterectomized for endo treatment when removing lesions skillfully works much better. If their doctor cannot do skilled excision surgery, they express a desire for referral for pelvic pt to a certified women's health therapist, and or to a surgeon doing skilled removal of disease.
Pain management may lead to dependence, but rarely abuse, and it often allows women to get up off the couch, put their heating pad away, and get back into life.
When we say we want effective endo surgery, we are looking at a desire for prompt diagnosis, compassionate understanding of the severity of pain, and skilled removal of disease. This comes out in the discussions every day, multiple times a day, and is critical for the industry to begin to understand. Drugs do not treat endo, most of the side effects are unpleasant to say the least, and the altered hormonal states unacceptable to most."
*From the Endometriosis Research Center (a wealth of information): Frequently involved areas of endometriosis are "the lower areas of the pelvis are first, cul de sac, pelvic side walls, uterosacral ligaments, bowel, rectum, bladder, ureters ." http://www.endocenter.org/
Q: Why excision?
A: "Large, long-term, prospective studies and a placebo-controlled, randomized, controlled trial suggest that laparoscopic excision is an effective treatment approach for patients with all stages of endometriosis. The result of such laparoscopic excision may be improved if affected bowel, bladder and other involved structures are also excised. SUMMARY: Laparoscopic excision is currently the 'gold standard' approach for the management of endometriosis, and results may be improved with careful use of appropriate techniques and suitable adjuvant therapies." http://www.ncbi.nlm.nih.gov/pubmed/15232483
"...All the teenagers received “complete excision” (defined as above) by an expert and experienced surgeon. They were followed for up to 5 years, the mean interval being 2 years. Overall the pain scores and quality of life (perhaps more importantly) improved significantly. The rate of recurrent or persistent endometriosis on second-look laparoscopy was zero. This data indicates that complete excision is an important part of the management plan for pain. More importantly perhaps, is the implication that there is a potential for complete eradication of disease." http://endometriosis.org/news/opinion/endometriosis-morbidity-can-it-be-prevented-with-early-diagnosis-and-complete-excision/
A case in point:
"...A case in which CO2 laser ablation of endometriosis that had been causing deep dyspareunia did not alleviate symptoms. Because those symptoms persisted, the patient was referred to our center, where a second laparoscopy revealed deep nodules of endometriosis, 1 to 2 cm in diameter, extending from the right and the left uterosacral ligaments deep into the perirectal space, bilaterally.
"As the bottom panel of FIGURE 5 shows, excised nodules were deep and large; neither laser nor electrosurgery would have been able to ablate or devitalize the deep endometriosis at the base of these 2-cm nodules...
"FIGURE 5 Deep nodules present a surgical challengeThese nodules of endometriosis on the right and left uterosacral ligaments (panel A) did not respond to CO2 laser ablation. Upon progressive resection, the implants were found to be deep, extending into the perirectal space (panel B). (See also VIDEO 3, resection of endometriosis from the left uterosacal ligament, close to the ureter.)FIGURE 6, illustrates endometriosis overlying the bladder and left ureter (see also VIDEO 4). Ablation of endometriosis in these areas may be inadequate if it is not deep enough, and dangerous if it goes too deep. As FIGURE 6 shows, excision assures the surgeon that the entire lesion has been removed and that underlying vital structures have been safeguarded."
http://www.obgmanagement.com/multimedia/video/article/strategies-and-steps-for-the-surgical-management-of-endometriosis/6ecce897772ba2a16447350f533269e5.html?tx_ttnews[sViewPointer]=1
Q: Why an expert?
A: "Excising deep and invasive endometriosis whilst preserving the health and functionality of surrounding organs can be extremely challenging...Griffiths comments: 'Endometriosis is non-malignant, but it is far from benign. It can have devastating health consequences for a woman, such as losing a kidney or a section of bowel or becoming infertile. There is a continuum from benign to malignant, and our understanding of endometriosis at the molecular level may open opportunities to help us understand metastatic cancer, and vice versa.' Cancer and endometriosis are very similar, both have endometrial cells that are able to migrate, vascularize and invade other tissues, some quite far away from the uterus. Griffiths explains: 'Through cell and tissue engineering we can begin to understand the behavior of these cells, such as the pathways they follow and why. That will help us develop therapies targeted precisely at the sub-cellular factors that lead cells astray.' Griffith and her team are developing research models that allow scientists to manipulate constellations of the factors involved in endometriosis, such as cytokines of the immune system, whilst observing their roles in the disease process. Endometriosis can affect any pelvic or extra-pelvic organ and when it occurs beyond the reproductive organs it generally affects the bowel or bladder but it has also been discovered in atypical sites (Virtual Poster 414), like the lungs (Virtual Posters 406 and 418)." http://www.medicalnewstoday.com/articles/236843.php
"We do not claim that surgery is always a ‘cure’ for endometriosis, nor that the disease cannot recur or be overlooked. However, we do believe that who performs the surgery and how it is performed impacts both the long and the short term success of surgical treatment. On the other hand, modern-day optics at laparoscopy and a well-trained eye have allowed the disease to be detected or seen in a way that has not been possible before [19]. Moreover, an expert surgeon can be expected to remove detectable disease in its entirety, even when found over vital organs.
Taken together, the data suggests that there is a potential to remove all relevant disease." http://endometriosis.org/news/opinion/endometriosis-morbidity-can-it-be-prevented-with-early-diagnosis-and-complete-excision/
Q: It's only minimal or superficial endo, so it shouldn't be causing that much pain, right?
A: Wrong. "Any amount of endometriosis can cause pain, and the disease does not need to be advanced to cause significant symptoms. Likewise, higher stage (3 and 4) disease may cause little to no symptoms in some women. Situations vary; moderate growth can trigger intense pain in some women while advanced growth causes less severe pain in others. Every woman's situation is unique and therefore expert medical evaluation is absolutely essential." http://www.endofound.org/endometriosis
"Endometriosis stage in the current classification was not related consistently to pain symptoms. The presence of vaginal lesions was associated frequently with severe deep dyspareunia. Dysmenorrhea and nonmenstrual pelvic pain were assessed with equal accuracy by a linear analog and a multidimensional scale." http://www.ncbi.nlm.nih.gov/pubmed/8566252
Q: Is endometriosis associated with other conditions?
A: Yes. "Women with endometriosis are at increased risk for a host of other diseases including chronic fatigue syndrome, multiple sclerosis, lupus, underactive thyroid, and rheumatoid arthritis,
according to new government findings....Compared with the general population of women, Stratton and colleagues found that women with endometriosis were more than 100 times as likely to have chronic fatigue syndrome, seven times as likely to have disease related to underactive thyroid, and twice as likely to have the muscular disorder fibromyalgia.
"Autoimmune inflammatory diseases such as lupus, Sjogren's Syndrome, rheumatoid arthritis, and multiple sclerosis were also more common in women with the endometriosis, as were allergies, asthma, and eczema. Some 61% of the women surveyed had allergies, compared with 18% of the U.S. population, and 12% of them had asthma compared with 5% of the U.S. population. And in endometriosis patients with another endocrine disorder or a chronic pain or fatigue syndrome, 72% and 88%, respectively, had asthma. The findings should serve to alert patients and their doctors to the link between endometriosis and diseases known or suspected to be associated with immune disorders, Stratton says. 'If a woman has endometriosis, she should probably be screened for other autoimmune diseases,' she says. "And if she has an autoimmune disease and pelvic pain, especially at a young age, she should be screened for endometriosis.' " http://women.webmd.com/endometriosis/news/20020926/endometriosis-linked-to-other-diseases
"Women with endometriosis frequently suffer from autoimmune inflammatory diseases, hypothyroidism, fibromyalgia (FM), chronic fatigue syndrome (CFS), allergies and asthma," lead author Ninet Sinaii, from the National Institute of Child Health and Human Development in Bethesda, Maryland, says in a news release. "These findings also suggest a strong association between endometriosis and autoimmune disorders and indicate the need to consider the co-existence of other conditions in women with endometriosis." http://www.medscape.com/viewarticle/442245
Q: What else could be contributing to my chronic pelvic pain?
A: Endo is often accompanied by other conditions such as:
1. pelvic floor dysfunction (and other musculoskeletal problems like levator ani spasms) http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-medicine-feature-articles/pelvic-floor-spasm-missing-l
2. interstitial cystitis, http://www.ichelp.org/AssociatedConditions
3. irritable bowel syndrome,
4. pelvic congestion syndrome,
5. adhesions,
6. adenomyosis,
7. vulvodynia,
8. ovarian cysts,
9. fibroids,
10. pudendal neuropathy,
11. pelvic inflammatory disease
12. and several others.
Q: Can pelvic physical therapy help?
A: Yes, most especially if your endometriosis has been removed. If it hasn't then the constant source of irritation and inflammation as well as adhesion formation will keep you from progressing as far.
"Endometriosis can be associated with pelvic floor dysfunction (PFD)....
Physical therapy helps most or all of the symptoms previously described through techniques such as myofascial trigger point release, scar tissue and connective tissue manipulation of the internal and external pelvic, abdominal, hip and back structures. Women with endometriosis commonly have trigger points in the abdominal wall as well as the pelvic floor, back and gluteal (buttock) muscles....
The overall goal of treatment is for the patient to learn how to relax (or, down train) the muscles, which in turn helps break the pain cycle. This, in conjunction with the manual therapy described previously will help the muscles to return to their normal resting tone. Women with endometriosis should try to maintain their energy level by participating in some cardiovascular activity. The physical therapist will also guide the patient on various exercises, stretches, massage and relaxation techniques that can be performed at home. Once the muscles and tissue structures return to their normal tone, core stabilization exercises can be added to maintain the proper muscle function. Such exercises will give the patient the support needed for activities such as walking or sitting and decrease the likelihood of injuring themselves. It is important for women with endometriosis to see a properly trained physical therapist to determine whether or not they would benefit from this type of treatment. However, not all physical therapists are trained in treating pelvic floor dysfunction and symptoms related to endometriosis. Various organizations such as the APTA Section on Women’s Health, International Pelvic Pain Society and the Endometriosis Association, would be able to assist you in finding a physical therapist to meet your specific needs.
We also suggest asking the following questions:
• What patient population do you treat?
• What percentage of your patients are diagnosed with endometriosis?
• How often do you treat the pelvic pain patient population?
• What techniques do you use (such as manual therapy and biofeedback?)
• Do you assess all of the pelvic muscles, including the internal pelvic floor muscles?"
"Who did you train under and for how long?
How is pain managed post op when I'm home/at the hotel?
How are the surgeries specifically done?
How many incisions would you use? Would you reuse an old one like the belly button? Why or Why not?
Does the doctor do laser vaporization or does he/she excise the endometriosis and the adhesions?
What do you use to cut the endo out?
What happens to all of the endometriosis and adhesions that are excised? Do they ALL get sent to pathology?
How many endometriosis surgeries does the doctor do in a week/month/year?
How many of those patients are stage 4 endo?
On average, how long time wise are the doctor’s surgeries for endometriosis?
Who would be assisting?
Would you be calling my husband/partner/family member/friend in the waiting area from the Operating Room to give them a status update and/or permission to remove organ(s)?
Does the doctor take care of all the endometriosis and adhesions?
Does he/she preserve organs?
Does the doctor take his/her time in the surgery to cut out all of the endo and adhesions that is there no matter how complicated the case is?
Immediately post op, will you be sitting down to talk to my husband/partner/family member/friend to talk about the surgery? Can they record it on a digital voice recorder?
Does the doctor track the results of his/her endo patients?
How many patients of his are pain free after 6 months, 1 year, 3 years, 5 years from endometriosis?
What is the rate of recurrence of endometriosis for his patients?
Does the doctor treat other types of patients as well or are all of his/her patients endo patients?
What hospital does the doctor do his/her surgeries at?
Can I get a copy of the doctor’s CV? *
Is he/she board certified? Through when? **
Has the doctor had any complaints against him/her? If so what were they and how were they resolved?
Does he/she have any lawsuits in the past 25 years? If so what were they and how were they resolved?
What happens if I have a question after my surgery and it's after hours?
How soon can an appointment be made?
Does the doctor have an email address to send any additional questions to?
*CV is the doctor’s resume. Every doctor should have one listing where they list their medical internship/residency where they got their medical degree, any journal articles they have written, and more
**board certification means that the doctor has had some extra training in his/her field. You can verify board certification at https://www.abms.org/WC/login.aspx . You’ll need to set up a log in account but it is worth it to check up on your doctors.
You can check up on the doctors to see if they have had any disciplinary actions taken against them, etc. You’ll head to http://www.docboard.org/docfinder.html and click on your state for more info."
Saturday, December 28, 2013
Pain and depression medications
So if your doctor suggests putting you on an antidepressant to help with your chronic pain, should you be offended, thinking they're saying that you don't really have a reason for pain? Should you look at them like they've just reenacted the scene from Moonstruck?
Before you do, let's look at it a little first. Pain is a complex process.
How does pain work?
First you have a source of stimuli (an injury, inflammation, infection, etc)- these are called noxious stimuli. Appropriate name I say! "There are three categories of noxious stimuli:
These chemicals activate special nerves, called nociceptors, which send a signal to your brain via the spinal cord. When this signal reaches the spinal cord it determines whether immediate action is necessary- like if you stick your finger on a hot oven and you jerk it away- your instant reflexes are from your spinal cord. Even if the spinal cord signals you to jerk your finger away, that signal still travels to your brain. Now up until it reaches the brain, your body uses special fibres to differentiate the type of pain or "stimuli" called C fibres and A delta fibres.
http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
Once the signals get to the brain, certain neurotransmitters take over. "In order for the pain impulses to be transmitted across the synaptic cleft to the NDHN, excitatory neurotransmitters are released, which bind to specific receptors in the NDHN. These neurotransmitters are:
[Side note: "Neurotransmitters are biochemical messengers that carry pain signals from one nerve cell to the next. The three main neurotransmitters that send pain signals to the brain are substance P, NMDA (n-methyl-d-aspartate), and glutamate. Excess amounts of these chemicals, especially substance P, make it easier for pain signals to reach the brain." http://www.painandwellness.com/how-pain-works]
So, the signal goes to your thalamus to be directed to different areas for a complete analysis. Think of it like the CSI tv shows- everything gets analyzed! ("New imaging techniques have mapped out at least 200 areas of the brain that respond to different types of pain." http://www.rsdcanada.org/parc/english/RSD-CRPS/pain.html) Your brain keeps and catalogs everything about that pain experience- how was it compared to other pain, what was happening at the time, how quickly did it resolve, any complications.... Your brain is a pack rat of 1930's Depression baby quality-- "I might need this one day..."! Because the thalamus sends the signal to be analyzed by different areas of the brain, you experience pain in several different ways. "Perception of pain is the end result of the neuronal activity of pain transmission and where pain becomes a conscious multidimensional experience. The multidimensional experience of pain has affective-motivational, sensory-discriminative, emotional and behavioural components." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
"The modulation of pain involves changing or inhibiting transmission of pain impulses in the spinal cord. The multiple, complex pathways involved in the modulation of pain are referred to as the descending modulatory pain pathways (DMPP) and these can lead to either an increase in the transmission of pain impulses (excitatory) or a decrease in transmission (inhibition).
Descending inhibition involves the release of inhibitory neurotransmitters that block or partially block the transmission of pain impulses, and therefore produce analgesia. Inhibitory neurotransmitters involved with the modulation of pain include:
(Notice that serotonin and norepinephrine in there? That helps inhibit pain signals from reaching the brain? Remember that!)
After an injury is healed the nociceptors should stop firing. However if they are constantly excited, like in endo, you get chronic pain. Sometimes even once an area is healed, the nociceptors will keep firing.
"The exact mechanisms involved in the pathophysiology of chronic pain are complex and remain unclear. It is believed that following injury, rapid and long-term changes occur in parts of the CNS that are involved in the transmission and modulation of pain (nociceptive information) (Ko and Zhuo, 2004). A central mechanism in the spinal cord, called ‘wind-up’, also referred to as hypersensitivity or hyperexcitability, may occur. Wind-up occurs when repeated, prolonged, noxious stimulation causes the dorsal horn neurones to transmit progressively increasing numbers of pain impulses." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
"The gate theory says that as these pain messages come into the spinal cord and the central nervous system (before they even get to the brain), they can be amplified, turned down or even blocked out. There are many accounts of how people injured on the battlefield or in sports games don’t feel any pain from their injuries until afterwards. This has to do with the brain being busy doing other things and shutting the gate until it can pay attention to the messages. Large diameter nerve fibres (A-beta fibres) responsible for transmitting signals of touch to the brain have the ability to close the pain gate and so block signals from other smaller diameter nerve fibres which transmit pain. An example of this would be when a child falls over and hurts her knee — if she rubs her knee, the signal from that sensation of touch temporarily blocks the pain signal travelling from the injured knee to the brain....
"At the cellular level, several processes can contribute to pain becoming chronic.
Now to tie in that thing about serotonin and norepinephrine helping block pain signals and depression medications:
"Clinical symptoms of depression can be grouped into three basic categories: emotional (depressed mood, lack of motivation, disinterest in social activity, anxiety), cognitive (inability to concentrate, poor memory), and physical (insomnia, headache, fatigue, and stomach, back, and neck pain)....Theories about the biologic basis for depression have evolved over more than 25 years. The principal biochemical basis for depression has focused on two neurotransmitters: serotonin and norepinephrine.[9,10] These two neurotransmitters have also been implicated in the underlying pathophysiology of chronic pain.[4–7] Serotonergic and norepinephrine neurons overlap in the brain, and these two systems interact biochemically and neuroanatomically. In patients with depression, alterations or reductions of these two neurotransmitters and their respective receptors become dysfunctional over time, leading to a dysregulated system....
"The link between the higher brain centers involved with depression and pain and the peripheral body regions occurs in the brain stem, with neurotransmission relayed through the spinal cord. Abnormal body activity and functions (e.g., musculoskeletal) are suppressed from the consciousness by the serotonin and norepinephrine descending pathways in the spinal cord that originate in the brain stem.[12,13] ...A painful stimulus from the periphery can affect multiple pathways, eliciting the complex set of mechanisms leading to and found within the central nervous system....
"As stated earlier, numerous receptor systems located on these two nociceptor pathways exist that form the starting point of pain and its interactions with depression. Glutamate, a major excitatory neurotransmitter, affects both pathways and could serve as one common pharmacologic model for the rapid action of the Ad fibers and the slower actions of C fibers.[5] Many other receptor systems and their corresponding stimuli complete this discussion of the circuitry of pain modulation that incorporates depressive symptomatology. This discussion focuses only on serotonin and norepinephrine pathways. Other models are certainly involved, most notably, enkephalin and opioid peptide links....
"For many years, antidepressants have been used in different chronic pain syndromes with or without the presence of clinical depression....The studies also indicated that the antidepressant's beneficial effect on pain does not seem to be related to its effect on mood....Based on the interrelationship between pain and depression, the serotonin and norepinephrine reuptake inhibitors (SNRIs) may be preferred over other antidepressant pharmacologic classes (e.g., selective serotonin reuptake inhibitors [SSRIs]) because of their dual action on noradrenergic (norepinephrine) and serotonergic (serotonin) activities in the central nervous system. Animal models have shown a dose-dependent response with SNRIs' ability to decrease pain sensitivity, whereas SSRIs were ineffective....Most of the above-mentioned clinical trials were conducted mainly with duloxetine and other agents in a double-blind, placebo-controlled environment. These studies demonstrate that antidepressants are safe and effective treatments of physical painful symptoms whether or not comorbid depression and/or anxiety are present for a relatively short time period of up to 12 weeks. An early response was noted during the first few weeks, with continued benefits throughout the study." http://www.medscape.com/viewarticle/565763_2 http://www.medscape.com/viewarticle/565763_3
"Physical pain and depression have a deeper biological connection than simple cause and effect; the neurotransmitters that influence both pain and mood are serotonin and norepinephrine. Dysregulation of these transmitters is linked to both depression and pain. Antidepressants that inhibit the reuptake of both serotonin and norepinephrine may be used as first-line treatments in depressed patients who present with physical symptoms." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486942/
[Lengthy quote below is courtesy of http://www.webmd.com/depression/managing-pain?page=2]
"Living with chronic pain should be enough of a burden for anybody. But pile on depression -- one of the most common problems faced by people with chronic pain -- and that burden gets even heavier.
Before you do, let's look at it a little first. Pain is a complex process.
How does pain work?
First you have a source of stimuli (an injury, inflammation, infection, etc)- these are called noxious stimuli. Appropriate name I say! "There are three categories of noxious stimuli:
- mechanical (pressure, swelling, abscess, incision, tumour growth);
- thermal (burn, scald);
- chemical (excitatory neurotransmitter, toxic substance, ischaemia, infection)." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
- prostaglandin;
- bradykinin;
- serotonin;
- substance P;
- potassium;
- histamine." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
These chemicals activate special nerves, called nociceptors, which send a signal to your brain via the spinal cord. When this signal reaches the spinal cord it determines whether immediate action is necessary- like if you stick your finger on a hot oven and you jerk it away- your instant reflexes are from your spinal cord. Even if the spinal cord signals you to jerk your finger away, that signal still travels to your brain. Now up until it reaches the brain, your body uses special fibres to differentiate the type of pain or "stimuli" called C fibres and A delta fibres.
| C fibres | A-delta fibres |
Receptor type:
| Receptor type:
|
Once the signals get to the brain, certain neurotransmitters take over. "In order for the pain impulses to be transmitted across the synaptic cleft to the NDHN, excitatory neurotransmitters are released, which bind to specific receptors in the NDHN. These neurotransmitters are:
- adenosine triphosphate;
- glutamate;
- calcitonin gene-related peptide;
- bradykinin;
- nitrous oxide;
- substance P.
[Side note: "Neurotransmitters are biochemical messengers that carry pain signals from one nerve cell to the next. The three main neurotransmitters that send pain signals to the brain are substance P, NMDA (n-methyl-d-aspartate), and glutamate. Excess amounts of these chemicals, especially substance P, make it easier for pain signals to reach the brain." http://www.painandwellness.com/how-pain-works]
So, the signal goes to your thalamus to be directed to different areas for a complete analysis. Think of it like the CSI tv shows- everything gets analyzed! ("New imaging techniques have mapped out at least 200 areas of the brain that respond to different types of pain." http://www.rsdcanada.org/parc/english/RSD-CRPS/pain.html) Your brain keeps and catalogs everything about that pain experience- how was it compared to other pain, what was happening at the time, how quickly did it resolve, any complications.... Your brain is a pack rat of 1930's Depression baby quality-- "I might need this one day..."! Because the thalamus sends the signal to be analyzed by different areas of the brain, you experience pain in several different ways. "Perception of pain is the end result of the neuronal activity of pain transmission and where pain becomes a conscious multidimensional experience. The multidimensional experience of pain has affective-motivational, sensory-discriminative, emotional and behavioural components." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
"The modulation of pain involves changing or inhibiting transmission of pain impulses in the spinal cord. The multiple, complex pathways involved in the modulation of pain are referred to as the descending modulatory pain pathways (DMPP) and these can lead to either an increase in the transmission of pain impulses (excitatory) or a decrease in transmission (inhibition).
Descending inhibition involves the release of inhibitory neurotransmitters that block or partially block the transmission of pain impulses, and therefore produce analgesia. Inhibitory neurotransmitters involved with the modulation of pain include:
- endogenous opioids (enkephalins and endorphins);
- serotonin (5-HT);
- norepinephirine (noradrenalin);
- gamma-aminobutyric acid (GABA);
- neurotensin;
- acetylcholine;
- oxytocin.
(Notice that serotonin and norepinephrine in there? That helps inhibit pain signals from reaching the brain? Remember that!)
After an injury is healed the nociceptors should stop firing. However if they are constantly excited, like in endo, you get chronic pain. Sometimes even once an area is healed, the nociceptors will keep firing.
"The exact mechanisms involved in the pathophysiology of chronic pain are complex and remain unclear. It is believed that following injury, rapid and long-term changes occur in parts of the CNS that are involved in the transmission and modulation of pain (nociceptive information) (Ko and Zhuo, 2004). A central mechanism in the spinal cord, called ‘wind-up’, also referred to as hypersensitivity or hyperexcitability, may occur. Wind-up occurs when repeated, prolonged, noxious stimulation causes the dorsal horn neurones to transmit progressively increasing numbers of pain impulses." http://www.nursingtimes.net/nursing-practice/clinical-zones/pain-management/anatomy-and-physiology-of-pain/1860931.article
"The gate theory says that as these pain messages come into the spinal cord and the central nervous system (before they even get to the brain), they can be amplified, turned down or even blocked out. There are many accounts of how people injured on the battlefield or in sports games don’t feel any pain from their injuries until afterwards. This has to do with the brain being busy doing other things and shutting the gate until it can pay attention to the messages. Large diameter nerve fibres (A-beta fibres) responsible for transmitting signals of touch to the brain have the ability to close the pain gate and so block signals from other smaller diameter nerve fibres which transmit pain. An example of this would be when a child falls over and hurts her knee — if she rubs her knee, the signal from that sensation of touch temporarily blocks the pain signal travelling from the injured knee to the brain....
"At the cellular level, several processes can contribute to pain becoming chronic.
- Pain receptors and neurones along the pain pathway may become too easily activated.
- Connections between the neurons in the pathway can be altered.
- The brain and spinal cord may fail to dampen down the pain signals.
- Pain receptors that are normally silent (dormant) can become activated by inflammation.
- After nerve injury, nerves may regrow but function abnormally.
Now to tie in that thing about serotonin and norepinephrine helping block pain signals and depression medications:
"Clinical symptoms of depression can be grouped into three basic categories: emotional (depressed mood, lack of motivation, disinterest in social activity, anxiety), cognitive (inability to concentrate, poor memory), and physical (insomnia, headache, fatigue, and stomach, back, and neck pain)....Theories about the biologic basis for depression have evolved over more than 25 years. The principal biochemical basis for depression has focused on two neurotransmitters: serotonin and norepinephrine.[9,10] These two neurotransmitters have also been implicated in the underlying pathophysiology of chronic pain.[4–7] Serotonergic and norepinephrine neurons overlap in the brain, and these two systems interact biochemically and neuroanatomically. In patients with depression, alterations or reductions of these two neurotransmitters and their respective receptors become dysfunctional over time, leading to a dysregulated system....
"The link between the higher brain centers involved with depression and pain and the peripheral body regions occurs in the brain stem, with neurotransmission relayed through the spinal cord. Abnormal body activity and functions (e.g., musculoskeletal) are suppressed from the consciousness by the serotonin and norepinephrine descending pathways in the spinal cord that originate in the brain stem.[12,13] ...A painful stimulus from the periphery can affect multiple pathways, eliciting the complex set of mechanisms leading to and found within the central nervous system....
"As stated earlier, numerous receptor systems located on these two nociceptor pathways exist that form the starting point of pain and its interactions with depression. Glutamate, a major excitatory neurotransmitter, affects both pathways and could serve as one common pharmacologic model for the rapid action of the Ad fibers and the slower actions of C fibers.[5] Many other receptor systems and their corresponding stimuli complete this discussion of the circuitry of pain modulation that incorporates depressive symptomatology. This discussion focuses only on serotonin and norepinephrine pathways. Other models are certainly involved, most notably, enkephalin and opioid peptide links....
"For many years, antidepressants have been used in different chronic pain syndromes with or without the presence of clinical depression....The studies also indicated that the antidepressant's beneficial effect on pain does not seem to be related to its effect on mood....Based on the interrelationship between pain and depression, the serotonin and norepinephrine reuptake inhibitors (SNRIs) may be preferred over other antidepressant pharmacologic classes (e.g., selective serotonin reuptake inhibitors [SSRIs]) because of their dual action on noradrenergic (norepinephrine) and serotonergic (serotonin) activities in the central nervous system. Animal models have shown a dose-dependent response with SNRIs' ability to decrease pain sensitivity, whereas SSRIs were ineffective....Most of the above-mentioned clinical trials were conducted mainly with duloxetine and other agents in a double-blind, placebo-controlled environment. These studies demonstrate that antidepressants are safe and effective treatments of physical painful symptoms whether or not comorbid depression and/or anxiety are present for a relatively short time period of up to 12 weeks. An early response was noted during the first few weeks, with continued benefits throughout the study." http://www.medscape.com/viewarticle/565763_2 http://www.medscape.com/viewarticle/565763_3
"Physical pain and depression have a deeper biological connection than simple cause and effect; the neurotransmitters that influence both pain and mood are serotonin and norepinephrine. Dysregulation of these transmitters is linked to both depression and pain. Antidepressants that inhibit the reuptake of both serotonin and norepinephrine may be used as first-line treatments in depressed patients who present with physical symptoms." http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486942/
[Lengthy quote below is courtesy of http://www.webmd.com/depression/managing-pain?page=2]
"Living with chronic pain should be enough of a burden for anybody. But pile on depression -- one of the most common problems faced by people with chronic pain -- and that burden gets even heavier.
Depression can magnify pain and make it harder to cope. The good news is that chronic pain and depression aren't inseparable. Effective treatments can relieve depression and can help make chronic pain more tolerable....
"Pain provokes an emotional response in everyone. Anxiety, irritability, and agitation -- all these are normal feelings when we're hurting. Normally, as pain subsides, so does the stressful response.
But what if the pain doesn't go away? Over time, the constantly activated stress response can cause multiple problems associated with depression. Those problems can include:
- chronic anxiety
- confused thinking
- fatigue
- irritability
- sleep disturbances
- weight gain or loss
"Some of the overlap between depression and chronic pain can be explained by biology. Depression and chronic pain share some of the same neurotransmitters -- the chemical messengers traveling between nerves. They also share some of the same nerve pathways. The impact of chronic pain on a person's life overall also contributes to depression. 'The real pain comes from the losses' caused by chronic pain, according to Feinberg. 'Losing a job, losing respect as a functional person, loss of sexual relations, all these make people depressed.' Once depression sets in, it magnifies the pain that is already there. 'Depression adds a double whammy to chronic pain by reducing the ability to cope,' says Beverly E. Thorn, professor of psychology at the University of Alabama and author of the book Cognitive Therapy for Chronic Pain....
"The fact that chronic pain and depression involve the same nerves and neurotransmitters means that antidepressants can be used to improve both chronic pain and depression. 'People hate to hear, 'it's all in your head.' But the reality is, the experience of pain is in your head,' says Feinberg. 'Antidepressants work on the brain to reduce the perception of pain.' Tricyclic antidepressants have abundant evidence of effectiveness. However, because of side effects their use is often limited. Some newer antidepressants are prescribed by doctors to treat certain painful chronic syndromes and seem to work well with fewer side effects.
Physical Activity
"Many people with chronic pain avoid exercise. 'They can't differentiate chronic pain from the 'good hurt' of exercise,' says Feinberg. But, the less you do, the more out of shape you become. That means you have a higher risk of injury and worsened pain. The key is to break this cycle. 'We now know that gentle, regular physical activity is a crucial part of managing chronic pain,' says Thorn. Everyone with chronic pain can and should do some kind of exercise. Consult with a physician to design an exercise plan that's safe and effective for you. Exercise is also proven to help depression. 'Physical activity releases the same kind of brain chemicals that antidepressant medications release -- [it's] a natural antidepressant,' says Thorn." http://www.webmd.com/depression/managing-pain?page=2
So, yes, antidepressants could help improve your pain levels. If you think about it, things that increase the good/helpful neurotransmitters and decrease the excitatory/make ya hurt neurotransmitters like eating healthy (think lots of fresh fruits, veggies, omega 3's, etc etc, less processed food) and exercise (yay endorphins!) and things that help control your stress (yoga, meditation, something that makes you laugh) can help too. So, remember to make taking time to take care of yourself a priority. If you don't, you will have a hard time taking care of the ones you love. So take care of yourself for their sake! :)
Saturday, November 30, 2013
Let's Talk Food! (among other things)
I love food. It doesn't always love me, but I don't care, I love it anyway.
What we eat can either help us or hinder us, especially when you have a chronic illness like endometriosis. As Hippocrates said:
So how can food, herbs, vitamins, and supplements be our medicine for endometriosis? Let's start with the basics of food. Most of us know the more fresh fruits and veggies we have the better. We also realize that a lot of processed food, red meat, sweets, etc are not good. And naturally, alcohol, tobacco, and too much caffeine are not helpful. What you may not have been told is that women with endometriosis can have a lot of food sensitivities. This can be compounded by the fact that a lot of endo ladies also have problems with irritable bowel syndrome, interstitial cystitis, and other immune problems. Generally the first culprits to ferret out are dairy, wheat (gluten), corn, soy, preservatives, and food additives. Google the FODMAPs diet if you have bowel symptoms or IC diet if you have bladder symptoms for more particulars on those.
Here's a great list of vitamins and how they can help endo (so check it out!): http://www.articlesbase.com/womens-health-articles/endometriosis-part-ii-how-to-treat-endometriosis-with-vitamins-1127429.html
And they also have one on minerals (cool!): http://www.articlesbase.com/womens-health-articles/endometriosis-part-x-how-to-treat-endometriosis-with-minerals-1160644.html
About those vitamins and minerals. (note: the below quotes are from http://info.spectracell.com/bid/87780/Nutrient-Correlation-Wheel-on-Estrogen) A good source of information on specific nutrients is World's Healthiest Foods (see http://www.whfoods.com/nutrientstoc.php). Food sources are the best way to get your vitamins and minerals et al, as you get a good combo that often works in tandem for their beneficial effect (one vitamin that helps you absorb/use another are often found together in food!). Taking a pill form can be good, but these should be discussed with your health care practioner first!
Let's take them alphabetically:
B vitamins help convert estrogen to its weaker form (by helping your liver) and convert omega-3's into healthy and helpful prostaglandins (anti inflammatory and relaxes uterine muscle). It particular folate (B9) "regulates estrogen’s effect on genes". B6 has been shown to decrease menstrual pain and "protects genes from estrogen-induced damage thus lowering risk of hormone related cancers; Detoxifies excess estrogen via methylation pathway; Estrogen-based oral contraceptives cause B6 deficiency."
What we eat can either help us or hinder us, especially when you have a chronic illness like endometriosis. As Hippocrates said:
Here's a great list of vitamins and how they can help endo (so check it out!): http://www.articlesbase.com/womens-health-articles/endometriosis-part-ii-how-to-treat-endometriosis-with-vitamins-1127429.html
And they also have one on minerals (cool!): http://www.articlesbase.com/womens-health-articles/endometriosis-part-x-how-to-treat-endometriosis-with-minerals-1160644.html
About those vitamins and minerals. (note: the below quotes are from http://info.spectracell.com/bid/87780/Nutrient-Correlation-Wheel-on-Estrogen) A good source of information on specific nutrients is World's Healthiest Foods (see http://www.whfoods.com/nutrientstoc.php). Food sources are the best way to get your vitamins and minerals et al, as you get a good combo that often works in tandem for their beneficial effect (one vitamin that helps you absorb/use another are often found together in food!). Taking a pill form can be good, but these should be discussed with your health care practioner first!
Let's take them alphabetically:
Vitamin A- good for your skin, eyes (night vision!), mucous membranes, a strong man against viruses (yay immune system!), helps with inflammation, also "helps metabolize the biologically active estrogen (estradiol) to an inactive form (estrone)."
B vitamins help convert estrogen to its weaker form (by helping your liver) and convert omega-3's into healthy and helpful prostaglandins (anti inflammatory and relaxes uterine muscle). It particular folate (B9) "regulates estrogen’s effect on genes". B6 has been shown to decrease menstrual pain and "protects genes from estrogen-induced damage thus lowering risk of hormone related cancers; Detoxifies excess estrogen via methylation pathway; Estrogen-based oral contraceptives cause B6 deficiency."
Vitamin C is great for the immune system, helps your blood vessels, prevent cataracts, and even reported to lower lead blood levels. Also "Increases the most potent estrogen (estradiol) in women on hormone therapy; Lowers aromatase (enzyme that converts testosterone to estrogen) in ovaries."
Ah, the sunshine vitamin! Actually it's a steroid hormone. Vitamin D helps your bones and teeth (by regulating calcium and phosphorus by means of your parathyroid), is good for your immune system, helps prevent chronic fatigue, helps your muscles, helps inflammation- what a work horse! "Regulates synthesis of estradiol and estrone; Enhances estrogen’s protective effect on bones."
Vitamin E is a good little antioxidant, it even protects vitamin A from oxidizing! It protects your cells' DNA from being damaged, good for your artery walls, good for diabetes and your brain. "Deficiency impairs estrogen detoxification pathway; Some forms of vitamin E inhibit estrogen action, especially in breast tissue; Low levels linked to higher estrogen."
I wondered why I feel better when I eat more spinach. Now I know. It not only protects your bones, your liver, prevent calcification of your arteries, helps your blood clot, but it also "inhibits estrogen activity by binding to estrogen receptors; Lowers the ratio of estradiol (strong estrogen) to estrone (weaker estrogen)."
But enough about vitamins- time for some minerals!
Calcium- we know it's good for bones and teeth. It also is needed for muscle contractions, nerve function, hormone secretion, acid/alkaline balance, and "Calcium-D-glucarate lowers estradiol levels; Helps breakdown estrogen in the liver and convert it to a less toxic form."
Magnesium- key in metabolism (anyone got fatigue? yes? I thought so), important in bones, energy production, nerves, controlling inflammation and blood sugar, also is a "cofactor for the enzyme that removes toxic forms of estrogen (catechol-O-methyltransferase); Estrogen alters magnesium levels throughout menstrual cycle." Magnesium helps your muscles to relax (I'll take a magsini- shaken, not stirred).
Selenium helps you produce your thyroid hormones, acts as an antioxidant, lowers joint inflammation. "Estrogen levels affect how selenium is distributed to various tissues in the body."
You may have read that zinc is good for your immune system (and it is), but did you know it helps your body "read" your genes correctly? Another interesting thing- it helps you taste and smell! It's also good for your metabolism and blood sugar. "Estrogen lowers risk of zinc deficiency; Zinc dependent proteins metabolize estrogen."
Let's broaden our scope a little bit here.
Probiotics = happy gut. But they also are good for your immune system as your gut plays a big part in your immune system.
Co Q 10 is an antioxidant and therefore good for your immune system. It helps protect your cells, produce energy, and protect your heart.
Omega 3's help decrease inflammation (specifically help reduce cytokines), supports your immune system, they are also good for those healthy and helpful prostaglandins, and are important in balancing out your omega 6 intake. (Zinc and B6 help them work even better!)
And never underestimate the power of clean, fresh, pure, delicious water! After all, we're around 60% water!
Another good thing is to get the least processed possibly- including less pesticides.
"Foods tainted with certain chemicals appear to encourage the implantation of cells in the abdomen. Those chemicals include polychorinated biphenyls (PCBs), which were commonly used in electrical equipment, hydraulic fluid, and carbonless carbon paper, and organochlorine pesticides, which were commonly used in agriculture. Data from a 2005 study show that women exposed to PCBs may have a higher prevalence of endometriosis. Organochlorines bind to estrogen receptors and mimic hormones that in turn can affect endocrine pathways and alter hormonal function.8
These chemicals presumably do their dirty work by impairing the immune defenses against abnormal cells. Indeed, the natural killer cells and other white blood cells that are supposed to maintain a constant lookout for any abnormal cells have been shown to be weakened in women with endometriosis....These toxins tend to accumulate in animal fat, and the major route of human exposure is through food, particularly fish, as well as other meats and dairy products.10 Chickens, cattle, pigs, and other animals fed grains treated with pesticides and sometimes contaminated with other organochlorines tend to concentrate these compounds in their muscle tissues and milk. While there may also be organochlorine pesticide residues on nonorganic fruits or vegetables, they are less concentrated and easier to remove. Organic produce is grown without chemical pesticides .Lipid-rich foods such as fish and meat are major sources of organochlorines and PCBs, while plants have considerably lower levels of these contaminants." http://www.pcrm.org/health/health-topics/endometriosis
On an ending note, chocolate is good for you.
There's so much more out there, but we'll call it a day. Take two chocolates and call me in the morning. (I will take my own advice on this one!)
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