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1/
ENDOMETRIOSIS
What
is endometriosis?
Endometriosis
is a
very common condition where cells of the lining of the womb (the
endometrium)
are found elsewhere, usually in the pelvis and around the womb, ovaries
and
fallopian tubes. It mainly affects women during their reproductive
years. It
can affect women from every social group and ethnicity. Endometriosis
is not an
infection and it is not contagious. Endometriosis is not cancer.
What
could endometriosis mean for me?
The
main symptoms of
endometriosis are pelvic pain, pain during or after sex, painful,
sometimes
heavy periods and, for some women, problems with getting pregnant.
Endometriosis
can
affect many aspects of a woman’s life including her general
physical health,
emotional wellbeing and daily routine.
Endometriosis
is
common and many women may have no symptoms. An estimated two million
women in
the UK have this condition.
Endometriosis
is a
long-term condition which affects women of all ages during their
reproductive
years (from the onset of menstrual periods to the menopause). It
affects women
from all social and ethnic groups.
Women
who do
experience symptoms may have one or more conditions:
- painful
periods (dysmenorrhoea) which do not respond to over-the-counter pain
relief. Some women have heavy periods.
- pain during
or after sexual intercourse (dyspareunia)
- lower
abdominal pain
- pelvic pain
which can be long-term
- difficulty in
getting pregnant or infertility
- pain related
to the bowels and bladder (with or without abnormal bleeding)
- long-term
fatigue.
Some
women do not
have any symptoms at all.
Pain
is a common
symptom of endometriosis. The pain can be a dull ache in the lower
abdomen,
pelvis or lower back. Pain affects each woman differently: where it
hurts, when
it hurts and how much it hurts. The pain, and the effects of
endometriosis, can
make you feel depressed.
Most
women with
endometriosis get pain in the area between their hips (known as the
pelvis) and
the tops of their legs. Some women get pain only at certain times, such
as
during their periods, when they have sex or when they open their
bowels. Other
women have pain all the time.
Some
women with
endometriosis become pregnant easily while others have difficulty
getting
pregnant. The pain may get better during pregnancy and then recur after
the
birth of the baby. Some women find that their pain resolves without any
treatment.
What
causes endometriosis?
During
the menstrual
cycle, under the influence of the female hormones estrogen and
progesterone,
the lining (endometrium) of the womb thickens in readiness for a
fertilised
egg. If pregnancy does not occur, the lining is shed as a period.
Endometriosis
occurs
when the cells of the lining of the womb are found in other parts of
the body,
usually the pelvis. Each month this tissue outside the womb thickens
and breaks
down and bleeds in the same way as the lining of the womb. This
internal
bleeding into the pelvis, unlike a period, has no way of leaving the
body. This
causes inflammation, pain and damage to the reproductive organs.
Reproductive
areas
where endometriosis can be found
Endometriosis
commonly occurs in the pelvis. It can be found:
- on the
ovaries where it can form cysts (often referred to as ‘chocolate
cysts’)
- in or on the
fallopian tubes
- almost
anywhere on, behind or around the womb
- in the
peritoneum (the tissue that lines the abdominal wall and covers most of
the organs in the abdomen).
Less
commonly,
endometriosis may occur on the bowel and bladder, or deep within the
muscle
wall of the uterus (adenomyosis). It can also rarely be found in other
parts of
the body.
Why
does endometriosis occur?
It
is not yet known
why endometriosis occurs. A number of theories have been suggested but
none has
been proved. The most commonly accepted theory is that, during a
period, light
‘backward’ bleeding carries tissue from the womb to the
pelvic area via the
fallopian tubes. This is called ‘retrograde menstruation’.
How
soon can I expect to get a diagnosis?
For
many women, it
can take years to get a diagnosis. Doctors say that this is because:
- no one
symptom or set of symptoms can definitely confirm a diagnosis of
endometriosis
- the symptoms
of endometriosis are common and could be caused by a number of other
conditions such as irritable bowel syndrome (IBS) and pelvic
inflammatory disease (PID)
- different
women have different symptoms
- some women
have no symptoms at all.
There
is no simple
test for endometriosis. The only way to make a definite diagnosis is by
a small
surgical operation known as laparoscopy (see What treatment can I
get?). This
is not performed on every woman.
If
you have painful
periods and no other symptoms, your GP may suggest that you try pain
relief
before having further surgical investigation or treatments.
Living
without a
diagnosis can be distressing. Many women may fear the worst about why
they are
in pain or why they are having problems becoming pregnant. They may
think that
they have cancer (see Other organisations).
What
happens when I see a specialist?
At
your appointment,
you may be asked specific questions about your periods and your sex
life. It is
important that you provide as much information as possible, as this
will help
your doctor find the correct diagnosis. You may find it helpful to
write down
your symptoms beforehand and take your notes along to the appointment
with you.
In this way, you will be sure to provide all the information required.
Some
women find it helpful to take a friend or partner along with them as
well.
You
should also have
an opportunity to ask questions (for further information see
BestTreatment NHS
Direct in Useful organisations).
Your
gynaecologist
may examine your pelvic area, this will include an internal
examination. Your
doctor will discuss the best time to do this. This may be when you are
having
your period. If you have concerns about this, you should have an
opportunity to
discuss them.
What
types of tests might I be offered?
You
should be given
full information about the tests that are available. These may include:
Ultrasound
You may be offered a scan. This can identify whether there is an
endometriosis
cyst in the ovaries. A normal scan does not rule out endometriosis.
Laparoscopy
For most women, having a laparoscopy is the only way to get a definite
diagnosis; because of this, it is often referred to as the ‘gold
standard’
test. A laparoscopy is a small operation which is carried out under
general
anaesthesia. A small cut is made in your abdomen near your tummy button
(navel), then a telescope (known as a laparoscope), which is about the
width of
a pen, is inserted. This allows the gynaecologist to see the pelvic
organs
clearly and look for any endometriosis. This is usually carried out as
day
surgery.
As
with any surgical
procedure, there are risks and benefits. These should be fully
explained to you
when you are offered the test.
If
you have a
laparoscopy, you should be given full information about your results.
Making
a decision about treatment
You
should be given
full information about your options for treatment. This should also
include
information about the risks and benefits of each option.
Several
factors may
influence your decision about treatment. These include:
- how you feel
about your situation
- your age
- whether your
main symptom is pain or problems getting pregnant
- whether you
want to become pregnant – some hormonal treatments which help to
reduce the pain will stop you from becoming pregnant
- how you feel
about surgery
- what
treatment you have had before
- how effective
certain treatments are.
You
may decide that
no treatment is the best way forward. This could be because your
symptoms are
mild, you have not had problems getting pregnant or you are nearing the
menopause, when symptoms may get better.
What
treatment can I get?
The
options for
treatment may be:
Pain
relief
Pain-relieving drugs reduce inflammation and help to ease the pain.
Hormone
treatments
There is a range of hormone treatments to stop or reduce ovulation (the
release
of an egg) to allow the endometriosis to shrink or disappear.
The
hormonal methods
below are contraceptives and will prevent you from becoming pregnant:
- The combined
oral contraceptive (COC) pill or patch
These contain the hormones estrogen and progestogen and work by
preventing ovulation and can make your periods lighter, shorter and
less painful.
- The
intrauterine system (IUS): this is a small T-shaped device which
releases the hormone progestogen. This helps to reduce the pain and
makes periods lighter. Some women get no periods at all.
The
hormonal methods
below are non-contraceptive, so contraception will be needed if you do
not want
to become pregnant:
- Use of
hormonal progestogens or testosterone derivatives
- GnRH agonists
– these drugs prevent estrogen being produced by the ovaries and
cause a temporary and reversible menopause.
Surgery
Surgery can be used to remove areas of endometriosis. Surgery including
hysterectomy does not always successfully remove the endometriosis.
There are
different types of surgery, depending on where the endometriosis is and
how
extensive it is. How successful the surgery is can vary and you may
need
further surgery. Your gynaecologist will discuss this with you before
any
surgery.
- Laparoscopic
surgery
The gynaecologist removes patches of endometriosis by destroying them
or cutting them out.
- Laparotomy
If the
endometriosis is severe and extensive, you may be offered a laparotomy.
This is major surgery which involves a cut in the abdomen, usually in
the bikini line.
- Hysterectomy
Some women
have surgery to remove their ovaries or womb (a hysterectomy). Having
this surgery means that you will no longer be able to have children
after the operation. Depending upon your own situation, your doctor
should discuss hormone replacement therapy (HRT) with you if you have
your ovaries removed.
What
if I am having difficulty getting pregnant?
Getting
pregnant can
be a problem for some women with endometriosis. Your doctor should
provide you
with full information about your options such as assisted conception.
Infertility Network provides information about this (see Other
organisations).
Are
there any side effects?
You
will be given
full detailed information about the risks and benefits of any
investigation,
surgical procedure and treatment suggested. The side effects will vary
from
woman to woman.
Living
with endometriosis
Not
all cases of
endometriosis can be cured and for some women there is no long-term
treatment
that helps. With support many women find ways to live with and manage
this
condition.
Support
Support
organisations
provide invaluable counselling, support and advice
Complementary
therapies
Complementary
therapies include reflexology, traditional Chinese medicine, herbal
treatments
and homeopathy. They may be effective at relieving pain. Many women
have found
that dietary changes such as eliminating certain food types, such as
dairy or
wheat products, may help to relieve symptoms. Therapies such as TENS,
acupuncture, vitamin B1 and magnesium help some women with painful
periods.
There is currently insufficient evidence to show whether such therapies
are
effective at relieving the pain associated with endometriosis.
Is
there anything else I should know?
- Taking the
combined oral contraceptive (COC) pill or contraceptive patch treats
the symptoms of endometriosis.
- If you become
pregnant, endometriosis is unlikely to put your pregnancy at risk.
- Some women
find that recreational exercise improves their wellbeing, which may
help to improve some symptoms of endometriosis (for further information
see
- No treatment
is guaranteed to work all the time for everyone.
- Support
groups are run locally for women with endometriosis (see Other
organisations).
- Internet
forums may be the first place many women turn to for support. The
quality of information can be variable.
2/ Surgery for stress incontinence: information for you
Key
points
- When you have
stress incontinence, you accidentally leak urine during normal everyday
activities (for instance if you cough, sneeze, laugh, exercise or
change position).
- What you do
about stress incontinence will depend on how far it affects you and
what you feel you can cope with. Physiotherapy and/or practical advice
from a continence nurse specialist on managing your daily life may
help.
- Not everyone
with stress incontinence needs surgery, but if your problems persist,
your doctor may suggest it.
- Surgery for
stress incontinence aims to give you more control over your bladder. It
cannot always cure the problem completely.
- There are a
number of possible operations; what is suitable for you will depend on
your circumstances.
- Surgical
procedures for stress incontinence are not usually suitable if you
still plan to have children, or think you might want to in the future.
About
this information
This
information is
intended to help women who have stress incontinence and are considering
whether
to have surgical treatment for it. It is based on the Royal College of
Obstetricians and Gynaecologists (RCOG) guideline
It
tells you:
- what stress
incontinence is;
- the
recommendations the guideline makes for the UK about the most effective
surgical treatments for stress incontinence .
It
aims to help you
and your health care team to make the best decisions about your care.
It is not
meant to replace advice from a doctor, nurse or continence adviser
about your
own situation.
It
does not look at
treatments for stress incontinence that do not involve surgery.
- Some of the
recommendations here may not apply to you; this could be because of
some other illness you have, your general health, your wishes, or some
or all of these things. If you think the treatment or care you get does
not match what we describe here, talk about it with your doctor or with
someone else in your health care team.
What
is stress incontinence?
The
muscles of the
pelvic floor (see diagram below) support the bladder and usually help
keep it
closed or open as necessary. Stress incontinence usually happens when
these
muscles become weak. So when there is sudden extra pressure
(‘stress') on your
bladder, it cannot stay closed as it should and some urine leaks out.
This
leakage happens during normal everyday activities, and most often when
you
cough, sneeze, laugh, exercise or change position. Whether you leak a
small or
large amount of urine, stress incontinence can be embarrassing and
distressing.
Stress
incontinence
can be triggered by pregnancy, childbirth or the menopause. If the
problem
develops while you are pregnant or after you have a baby, it usually
improves
with time for most women. Sometimes it happens again later on and a few
women
may need to consider surgery.
Side
view of a
woman's bladder, pelvic floor muscles and nearby organs
Do
I need an operation?
Many
treatments for
stress incontinence do not involve surgery. Not everyone with stress
incontinence needs an operation. Whether you choose to have surgery
will depend
on how far stress incontinence affects your daily life and what you
feel you
can cope with. You may want to consider surgical options if other
things (such
as exercises to help strengthen the muscles in the pelvic floor) have
not helped.
Surgical
procedures
for stress incontinence are not usually suitable if you still plan to
have
children, or think you might want to in the future.
Your
doctor or nurse
should already have asked you about the problems you have been having.
You may
have had a urine test to check for infection. You may also have had
special
bladder tests (known as urodynamics).
You
should already
have had advice from your doctor or a continence nurse specialist about:
- adjusting
your daily routines to help you cope better
- how you can
help yourself by losing weight if you are overweight
- managing a
chronic cough if you have one
- •special
physiotherapy exercises to make your pelvic floor muscles stronger and
improve control of your bladder
- giving up
smoking
These
things will
also help to improve the results of surgery, if you have it.
If
you have seen no
improvement after doing pelvic floor exercises, your doctors may
suggest you
consider surgery. If you are offered the choice of surgery, it is up to
you to
decide if and when you should have it.
What
operation will I be offered?
Surgical
procedures
for stress incontinence aim to improve support for the muscles around
the
bladder entrance, in order to help the outlet (known as the urethra) to
stay
closed when it should and prevent it leaking.
No
operation can be
guaranteed to cure your stress incontinence, but most offer a good
chance of
making an improvement. The benefits of some last longer than others.
The risk
of developing extra problems (known as complications) also varies
depending on
the procedure.
You
can find more
information about the main operations used to help stress incontinence
in the
tables on the following pages. They are:
- Burch
colposuspension
- Vaginal tapes
You
can also find out
about procedures that are used less often. They are:
- Bulking
agents
- Sling
procedures
- Artificial
sphincters
- Anterior
vaginal repair.
Your
surgeon may
offer you a choice of one or two methods, depending on your
circumstances and
his or her own expertise. He or she will take into account such things
as your
general health, age, weight and previous operations and should explain
the
reasons for recommending a particular operation to you. Some operations
are
very specialised and are only offered in special centres.
If
your surgeon is
not able to offer the operation that best meets your individual needs,
you may
be able to find another who can. You should discuss this with your GP.
With
some operations
you may need to have a temporary catheter. This is a tube which is put
into
your urethra (the tube leading out of the bladder) or your lower
abdomen, in
order to empty your bladder when necessary. The length of time you need
to
spend in hospital after the operation will vary depending on the type
of
operation and how quickly you recover.
What
might happen if I don't have an
operation?
Your
problems may
remain the same, or get worse, or improve over time. There is no sure
way of
predicting this.
Are
there any
alternatives?
There
is often no
need to rush into having surgery. Some people prefer not to have an
operation
and find ways of adapting. Your continence adviser can tell you more
about
this.
New
surgical
techniques are being developed all the time. You should talk to your
continence
adviser and/or your consultant to find out if there is anything new
that might
be more suitable for you.
There
is not yet
enough evidence about a procedure called paravaginal repair to show how
effective it is. More research is needed.
Women
who have a
prolapse, where part of the bladder pushes through the vaginal wall,
may be
offered a procedure known as anterior repair. The surgeon makes a cut
inside
the front of the vaginal wall, to remove the extra tissue from the
prolapse and
restore the muscle support. If you also have stress incontinence,
however,
sling procedures are more effective than this operation.
Some
operations are
no longer recommended:
- Marshall-Marchetti-Krantz
(MMK) colposuspension used to be common but has been replaced by other
methods.
- Needle
suspension has been replaced by safer, more effective procedures.
Is
there anything else I should know?
- As you can
probably tell from previous sections, all operations carry some risks.
Your doctors should discuss with you the risks of any operation they
offer you.
- You have a
right to say whether there are any procedures you do not want the
surgeon to carry out.
- You have the
right to be fully informed about your health care and to share in
making decisions about it. Your health care team should respect and
take your wishes into account.
- No treatment
can be guaranteed to work all the time for everyone.
Sources
and acknowledgements
This
information is
based on the Royal College of Obstetricians and Gynaecologists (RCOG)
3/ An
abnormal Pap
smear result: What this means for you
http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cv-pap-smear-l
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