Chronic pelvic pain and endometriosis

Endometriosis defined

Endometriosis is an estrogen-dependent disease frequently resulting in substantial morbidity, severe chronic or recurrent pelvic pain, multiple surgeries, and impaired fertility. Clinically Endometriosis is defined as presence of endometrial-like tissue (Endometrium lining like cells) found outside uterus/uterine cavity, resulting in sustained inflammatory reaction. Primarily the pelvic peritoneum, ovaries, and and the lowest abdominal cavity (rectovaginal septum, Pouch of Douglas) are affected.  Affecting 6%–10% of women of reproductive age, the stigmata of endometriosis include chronic pelvic pain in menstrual bleeding (dysmenorrhea), chronic pain while intercourse (dyspareunia), irregular uterine bleeding, and/or infertility The prevalence of this condition in women experiencing pain, infertility, or both is as high as 35%–50%. Yet endometriosis is often under or non-diagnosed and associated with a six to seven year mean latency from onset of symptoms to definitive diagnosis.

Symptomology

• Classic signs: severe dysmenorrhea, deep dyspareunia, chronic pelvic pain, Middleschmertz, cyclical or perimenstrual symptoms.
• Typically develops on pelvic structures, i.e., bladder, bowels, intestines, ovaries, and fallopian tubes.
• Less commonly found in distant regions, e.g., diaphragm, lungs (inducing catamenial pneumothorax), and rarely, areas far outside abdominopelvic region.
• Ovaries among most common of locations; gastrointestinal tract, urinary tract, soft tissues, and diaphragm follow.
• Degree of disease present has no correlation with severity of pain or symptomatic impairment.

Symptoms vary but typically reflect area of involvement and may include: 

• Dysmenorrhea (pain in menstrual bleeding).
• Heavy or irregular bleeding.
• Cylical/noncylical pelvic pain.
• Lower abdominal or back pain.
• Bloating, nausea, and vomiting.
• Dysuria (pain in urinating).
• Dyspareunia (pain while sexual intercourse).

Histiopathogenesis

• No single theory sufficiently explains pathogenesis.
• Genetics, biomolecular aberrations in eutopic endometrium, dysfunctional immune response, anatomical distortions, and proinflammatory peritoneal environment may all ultimately be involved.
• 5 key processes of development: adhesion, invasion, recruiting, angiogenesis, proliferation.

Epidemiology 

• More than 176 million women globally; 775,000 in Canada and 8.5 million in North America are affected.
• Infertility among chief clinical findings.
• No known prevention of Endometriosis.
• Specific menstrual characteristics may be associated; decreased risk with late age at menarche and shorter menstrual cycles with longer duration of flow.
• Family history cannot be undervalued; near 10-fold increased risk in women with first-degree relatives who have disease endometriosis.
• No particular demographic, personality trait, or ethnic predilection.
• Inverse BMI relationship.
• No definitive association with nutrition, exercise, personality traits, or other lifestyle variables.

Comorbidities  

• Adhesions.
• Risk of adverse pregnancy outcome and preterm birth.
• Up to 50% of those with endometriosis may suffer from infertility.
• Distorted pelvic anatomy/impaired oocyte release or inhibit ovum pickup and transport.
• Endocrine and anovulatory disorders.
• Characterized as sexual dysfunction manifesting as pain in the reproductive organs before, during, or soon after sexual intercourse.
• Though frequently depicted as psychogenic, dyspareunia (pain while intercourse) is actually often the result of organic, multidisciplinary cause and affects as many as 80% of endometriosis patients.

 Diagnosis

• Clinical diagnosis: pelvic examination and pain mapping, medical history.
• Imaging studies, ultrasound, MRI.
• Surgical diagnosis and staging.

Endometriosis Treatments

Surgical Intervention

• Laparoscopy/Laparotomy.
• Goals of conservative surgery include removal of disease, lysis of adhesions, symptom reduction and relief, reduced risk of recurrence, and restoration of organs to normal anatomic and physiologic condition.
• Laparoscopic excision has been demonstrated to significantly improve deep dyspareunia as well as quality of sex life.

 Nonsurgical therapies

• Medical treatment and combination therapy may help improve symptoms.
• Gonadotropin-releasing hormone agonists (GnRH), oral contraceptives, Danazol®, Aromatase Inhibitors, and Progestins are mainstays.
• Mirena® intrauterine device shown to be effective in reducing pain and may be considered alternative to hysterectomy in adenomyosis patients.
• Alternative therapies, for example herbal medicine, physical therapy, diet and nutrition, acupuncture, specific supplements and other complementary approaches may result in reduction of pain.

Conclusion

• Endometriosis is a chronic, costly disease requiring long-term, multidisciplinary treatment.
• Profound personal and economic impact underscores urgent need for continued research and improvement in diagnostic and treatment modalities.
• Timely intervention and appropriate, multifactorial treatments may restore quality of life, preserve or improve fertility, and lead to long-term effective management in absence of permanent cure.

Dr. Amelie Hofmann-Werther

Specialist in Obstetrics & Gynaecology

(Facharzt Germany)

Cervical Dysplasia & Coloscopy

Master Class in Fetal Medicine

http://www.fetalmedicine.ae/#dr-amelie

The 💯 Faces Of Endometriosis

What is Endometriosis?

The uterus has a thick muscular layer called the myometrium. It is responsible for contractions during childbirth and those wonderful menstrual cramps we all know. The inner lining layer of the uterus is called endometrium and is the ‘functional’ part. The endometrium grows and sheds with each menstrual cycle and is responsible for the bleeding: during the first half of the menstrual cycle it grows and then breaks down in the second half of the cycle and finally sheds off during menstruation. 

Endometriosis is defined as patches of endometrium-like tissue that is found outside the uterus. Endometriosis is responsive to hormones just like the normal endometrium, so throughout the menstrual cycle, endometriosis grows and bleeds, but unlike the normal endometrium, the blood has actually nowhere to go because its inside the pelvic cavity. Whether or not endometriosis does actually ‘bleed’ can vary but the pure presence of endometriotic lesions does lead to inflammation and pain, depending on the extent and location of endometriosis in the pelvis. More important as what endometriosis is, is what endometriosis is not! Endometriosis is not an infection of any kind, it’s not communicable, it’s not a cancer and is not fatal, however just because something is not fatal, doesn’t mean it can’t take your quality of life away. For sure endometriosis is a very complex condition that requires a holistic and personalized approach.

Some women with endometriosis have painful periods, some don’t. One woman may have severe pelvic pain, depression, anxiety and bowel pain, whereas another woman may have no pain or psychological symptoms, but is infertile due to endometriosis, these two cases would require very specific and

different approaches.

What are typical symptoms of endometriosis?

Everything, nothing and all things in between! Some women are only diagnosed when they are having an operation for another condition, or when there is an investigation for something linked to endometriosis like fertility issues.

For those experiencing symptoms, the most common one is pain, such as dysmenorrhoea which is defined as excessively painful periods that cause interference to the daily life and massively clouds the overall emotional well-being. If periods are causing someone to regularly miss school/work/social occasions because they are so painful, this is not ok and could very well be a sign of an underlying medical condition, like endometriosis.

Another of the common symptoms associated with endometriosis is chronic pelvic pain. Chronic pelvic pain can be continuous or intermittent and can be associated with a variety of factors, for example exercise, specific foods or certain activities, or it may just come on randomly. Painful sex (also known as dyspareunia) is one of the symptoms of endometriosis that doesn’t get much

attention since it is a very personal and private matter, which can understandably be difficult to talk about. Endometriosis symptoms vary from person in frequency and severity, including leg pain, bloating, painful urination, painful bowel movements, heavy menstrual bleeding, spotting in between periods and fatigue. A lot of sufferers want to rest and be left alone.The pain takes so much out of them, sometimes taking a nap feels like the only option to escape. Trying to summon enough energy to continue with the day but for at least the first three or four days of period, they just want to sleep a lot.

Which types of endometriosis do we know?

Endometriosis is usually categorized into stages (minimal, mild, moderate and severe) which depend on type, extent and location of the disease. The stage of disease does in no way correlate with the symptoms experienced, so a woman with severe disease can have no symptoms and a women with minimal disease can have debilitating symptoms and vice versa. Superficial endometriosis are lesions that can be found anywhere around the pelvic area, most frequently found on the surface of organs/ligaments/structures of the pelvis and can be as small as to be almost invisible to the naked eye, or about as large as a pea and any size in between. They often show scarry tissue associated with them which can pull or restrict the surrounding tissue leading to pain such as pain in emptying the bladder or in bowel movements, intercourse or sports.

Another entity type are endometriotic cysts. Most commonly found on the ovaries, these endometriosis cysts are filled with old blood that takes on a brown color, giving them the undeservedly pleasant name ‘chocolate cysts’. Endometriosis cysts can grow to be quite large, ranging from a few centimeters

to massive cysts in very rare cases.

The third type is called deeply infiltrating endometriosis (DIE). As the name suggests these lesions actually penetrate deep into the tissue of the pelvis and are known to cause the more severe symptoms associated with endometriosis.

Who can get endometriosis?

We do know that endometriosis affects more then 1 in 10 women of reproductive age, but endometriosis can affect anyone, of any age and of any race/socioeconomic background. Women with a family history of endometriosis are more likely. Still, because of a lack of awareness and education about endometriosis, the majority of sufferers remain not diagnosed.

What are treatment options?

Endometriosis is not a uniform disease so there are many treatment options pathways open for women with endometriosis and it is often quite a minefield of trial and error to find the right one for each woman. Endometriosis for sure requires a holistic approach to therapy that considers all aspects and impact the disease has on a person’s life.

There are several types of hormonal medication that women with endometriosis may be offered, the most common ones are: Birth control pills (BCPs), Progestin only pills (POPs), Gonadotrophin releasing hormone analogues (GnRHa), Aromatase inhibitors, complimentary therapies and surgical treatment options.I can’t emphasize enough the importance of education in endometriosis in order to find the best treatment for every single affected women.

Dr. Amelie Hofmann-Werther

Specialist in Obstetrics & Gynaecology

(Facharzt Germany)

Cervical Dysplasia & Coloscopy

Master Class in Fetal Medicine

http://www.fetalmedicine.ae/#dr-amelie

The Anomaly Scan at 18-22 weeks

An anomaly scan, also known as detailed morphology scan, intends to take a closer look at the baby and the uterus. 

The Fetal Medicine Specialist will check how the baby is developing plus the position of the placenta. 

Anomaly scan is often called a 20-week scan; however, a patient may have it any time between 18 weeks and 22 weeks. 

Although the main target of the scan is as mentioned above, the gender, however, may be revealed by the Fetal Medicine Specialist if desired by the patient.  By 12 weeks gestation, gender accuracy is 95% while at 16 weeks, it is 99%++.

The whole scan takes about 30 minutes for a single gestation.  The Fetal Medicine Specialist will assess the fetal organs.

Major organs are mostly checked by cross section and measured, these are:

·         

    The shape and structure of the head and brain.

·         The Face - Cleft lip and Palate are checked while focusing on the face.

·         The Spine, its length and in cross section, making sure that all the bones            align, and that the skin covers the spine at the back.

·         The Heart. Normal structure, location, normal rhythm pattern.

·         The Abdominal wall making sure it covers all the internal organs at the              front.

·         The Stomach.

·         The Kidneys, confirming that the baby has 2 kidneys and bladder is visible.

·         Fetal Extremities. Arms, Hands, Fingers, Legs, Feet, Toes

The placenta location and structure, umbilical cord and the amniotic fluid are also checked.

To see how well the baby is growing, the HC (head circumference), AC (abdominal circumference) and FL (femur length-thigh bone) measurements should match up depending on when is the expected delivery date.

Authored by Dr. Afshin PourMirza, MD, PhD

Obstetrics and Gynaecology – Maternal Fetal Medicine

Managing Director of Feto Maternal and GenetYX Center

What to pack in your hospital bag before a C-section delivery

Opting for an elective c-section allows you to have more time to think and prepare what you will need to pack in your hospital bag.  

Instead of being worried and stressed, the best thing o is to ensure being prepared as you can be – and one of the things you may focus on is what to pack in your  hospital bag.

Being prepared can make all the difference to make certain your pre and post delivery experience is as smooth as possible.

Below are the top items to pack;

For mother:

• ·         A favorite pillow:  Or my "comfort" pillow
• ·         A few sets of Socks/a Cozy Blanket -  hospitals are known to be notoriously cold
• ·         A Compression binder – this can help to support the stomach muscles after surgery. These are also great to wear in the weeks following, though you may want to check this with your Physician!
• ·         Several disposable underwear (Vaginal bleeding is expected even after a c-section and disposable underwear means less fuss and more time to concentrate on your new little person).  
• ·         Slippers/flip flops – something easy to get on and off your feet.
• ·         Mobile phone – you're going to want to take lots of photos and send them to your loved ones back home
• ·         Toiletries (the usual - wash goods, toothbrush, hair brush etc)
• ·         x4 Loose long dresses
• ·         A bathrobe
• ·         Towels
• ·         A going home outfit – we recommend loose drawstring pants, a maternity bra, underwear and a loose shirt
• ·         Of course, don’t forget all your paperwork - photo ID, insurance card, medical papers/ antenatal reports etc. A file folder with  everything neatly in a clear folder to ensure everything was kept together and organized.
• ·         Other things you may wish to pack include; books, photographs of loved ones, magazines; portable devises (not forgetting their chargers/ power banks).

For your baby;

• ·         x4 receiving blankets
• ·         x4 sets baby clothes for the duration of the hospital stay – I brought stretchy onesies with snaps in front for easy diaper changes
• ·         A going home outfit ( a onesie and if his/her feet are exposed, be sure to bring a pair of socks or soft booties. I’d also recommend a soft hat – as babies can really feel the cold in their first few days).
• ·         A baby carrier (I’d recommend one which also serves as a car seat for the journey home)

Myleen R. Camama-Cerilla
Administrative Manager
Marketing Incharged
Feto Maternal and GenetYX Center

First Trimester Screening

Possible accidental chromosomal anomalies are one of these risky events of pregnancy. To overcome this risk a close well defined follow up of the fetus at different stages of development has been settled over the last decades by different western gynecological associations after a lot of studies. Each trimester should benefit from a particular fetal scan beside the traditional fetal checkup done by your own gynecologist.

Three important and essential fetal scans are recommended during pregnancy. One at 12-14 weeks of gestation known as NT scan, one at 20 weeks of gestation known as morphology scan and a third one at 28 weeks of gestation known as Doppler scan. A respect of these dates is fundamental to be able to detect specific fetal features.

The first scan is the Nuchal Translucency scan (NT scan = thickness of the fluid at the back of the neck of your baby). It is performed from 12 up to 14 weeks. During this scan fetal specialist will check for fetal heart beats, total length of the baby, nuchal translucency and presence of nasal bone. The accuracy of this scan is from 60-65% only. However, to increase a little bit the accuracy of this scan we usually perform a blood test with the scan.

Two different options exist for this blood test, the first one is to do biochemical test. It is a blood sample in which we are detecting the levels of two placental hormones {Free Beta Human Chorionic Gonadotropin (FBHCG) and Pregnancy Associated Plasma Protein-A (PAPP-A)}. Both hormonal levels are used to determine the condition of the placenta. Moreover, the biochemical risk and the ultrasound risk will be used together to determine the combined risk for major common chromosomal anomalies (trisomy 21, 18 and 13). This combined risk has a sensitivity of 90-92%.

Another possible blood test during this visit is Non Invasive prenatal test (NIPT). This test will detect cell free fetal DNA fragments coming from fetal chromosomes (Chromosomes 13, 18, 21 and sex chromosomes) and circulating in maternal blood. Its sensitivity varies from 97-99%. It is considered as a screening test but has a high accuracy. It is usually recommended with advanced maternal age (above 35 years old mothers) and when mild fetal variations are detected by NT scan.

If major fetal anomalies are detected in the NT scan, an invasive prenatal test is recommended in order to obtain a piece of the placenta or some of the amniotic fluid and do fetal genetic analyses according to the ultrasound findings. 

Dr. Azza Abd El Moneim Attia Mohamed

French Board

Consultant Clinical Genetics

Feto Maternal and GenetYX Center

I Am Offered Screening Tests, why?

Different screening tests are offered at different times during pregnancy.  

It can be an ultrasound scan, blood test or history (clinical) based assessment. Screening is done to allow the obstetrician to categorize whether the pregnancy is at higher chance, or risk, of a problem or not.

The tests can help decide further tests and care or treatment during pregnancy or after the baby's born.  This means earlier, possibly more effective, treatment or informed decisions.   

Let's say, advanced maternal age or a history of diabetes in the family can put one at risk for high blood pressure (preeclampsia) or pregnancy related diabetes respectively.

Screening literally means recognizing people at risk. It cannot diagnose the problem. However, it can be give the signal for the need for further investigations. The downside of screening tests is it cannot detect all the conditions.  Screening tests do not give us a yes or no answer. In most scenarios, further definitive tests will be required to confirm the diagnosis.

It is very important to understand that the risk assessments are derived from population-based data and modified by the individual’s test results. Once should understand the concept and the obstetrician or Geneticist should explain this in-depth to avoid misconception.

It is all about you and your unborn baby's safety to assure a smooth journey through the pregnancy and giving both parents that peace of mind.

Dr. Afshin PourMirza, MD, PhD
Medical Director

Obstetrics & Gynaecology
Feto Maternal Medicine Specialist

www.fetalmedicine.ae

Feto Maternal and GenetYX Center 

Your question…Am I pregnant?

You missed your period, a question comes into your mind, am I pregnant?  Next thing you do is take a pregnancy test by using one of those over the counters.  You got 2 lines!  Does this mean you are soon to be a mother? 

It is important to know what positive or negative result means.  If you get a positive result, you are pregnant, no matter how indistinct the line, color, or sign is.  Most of the time, since you doubt the result, you tend to repeat an over the counter pregnancy test.  If you get a positive result, a visit to the obstetrician and taking folic acid are advised.  In fact, if you are really planning to have a baby, you should start folic acid right away.

On your visit to the obstetrician, your blood will be taken to test for bhCG (beta-human chorionic gonadotropin).  This is a quantitative test wherein the result is given as a number, indicating the measured concentration of the hormone in the blood.  At this stage, your result will be <400mIU/ml.   You will be asked to comeback since the bhCG level usually doubles approximately every 2 days.  If the levels are getting high, it is a clear indication of pregnancy and you will therefore be scheduled for your ultrasound scan between 6-8 weeks.  

A trans-vaginal scan will be performed to:

• confirm a viable intrauterine pregnancy by achieving a visible embryo pole with a fetal heart beat
• know the age of the pregnancy by measuring the crown lump length (CRL) or measurement from the top of the head to the bottom of the fetus
• confirm if it is single or multiple pregnancies

An internal scan is needed.  In this way, the probe gets much closer to the womb thus a clearer image.  This is more commonly needed in the early stages of pregnancy, if the mother is overweight or have a retroverted uterus.

Dr. Afshin PourMirza, MD, PhD
Medical Director

Obstetrics & Gynaecology
Feto Maternal Medicine Specialist

www.fetalmedicine.ae

Feto Maternal and GenetYX Center