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The pain of endometriosis – making a diagnosis (Part Two)

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In the previous installment of this essay, we explored some of the reasons for the delay in the diagnosis of endometriosis and diagnostic tools used.

Like all medical conditions, the diagnosis of endometriosis follows the well-established routine of history taking, physical diagnosis, and ordering targeted tests that can either rule in, rule out or confirm the diagnosis of the condition.

One key element of its nature is pain, wherever it may occur, coming during the menses. The pain of endometriosis may come a week or two weeks before the onset of the menses, become severe during the menses and wane after the period, only to repeat its course in subsequent cycles. The key here is the cyclicity of the pain with respect to the menses. As mentioned in the previous instalment, the severity of the pain has little to do with the stage (severity) of the disease. This week continues the discussion on the different diagnostic tools which included Vaginal scan, Endometriosis mapping and Barium Enema(Sepeiti).

COLONOSCOPY
Colonoscopy involves passing a camera into the large bowel up to the junction of the large and small bowel. This test can also be done in cases of bowel related symptoms of endometriosis including bleeding during bowel motions. Its advantage over a barium enema is its ability to take a biopsy (sample) of the lesion (diseased area) to confirm a diagnosis before the operation can be done.

MRI SCAN
Advanced testing with an MRI scan is possible in selected cases. An MRI scan is capable of detecting smaller endometriotic nodules in the bowel, bladder and uterine ligaments. It is great at picking endometriosis of the womb (adenomyosis). Like other investigations it can only pick large areas of fibrosis occasioned by endometriosis. A negative result does not rule out minimal and mild disease. The down side of this investigation is the considerable cost to the patient.

MRI AND EXAMINATION
UNDER ANAESTHESIA

Another important investigation is examination under anaesthesia. This involves doing a digital vaginal and rectal examination while the patient is sleeping under the influence of anaesthetic agents. The benefit of examination under anaesthesia is that the patient’s vaginal and pelvic muscles would be relaxed allowing thorough exploration of the vaginal wall, the pelvis, the bowel, uterine ligaments, assessment of the mobility of the uterus and ovaries. It also gives detailed information as to whether the window behind the uterus has been obliterated by this destructive disease.

A study comparing the ability of different tests to pick up endometriosis when present, comparing ordinary vaginal scan, a rectal scan, sigmoidoscopy (camera up the rectum and stopping only in the sigmoid colon), MRI and examination under anaesthesia found that the best tool for diagnosis was the use of the old digital vaginal examination under anaesthesia. The down side to this mode of investigation is that one has to incur theatre fees and a day hospital bed fee, making it more expensive.

It is possible however, that digital examination under anaesthesia may be offered in the outpatient setting in clinics with a procedure room and availability of an anaesthetist or nurse anaesthetist. Only in this setup is digital examination under anaesthesia cost effective. It is noteworthy that the normal digital examination without anaesthesia has its uses, but falls short of defining the extent of the spread of endometriosis in the pelvis thereby limiting holistic planning for the operation where different specialists may be required to co-operate on the management of the patient.

DIAGNOSTIC LAPAROSCOPY
The definitive test for endometriosis remains diagnostic laparoscopy. This is an operation through a key-hole in which the patient is not opened in the usual way. At laparoscopy 2-5 holes, wide enough to fit a pen are made on the tummy. The gynaecologist then gains access into the abdominal and pelvic cavities through these holes. A tiny camera is then inserted at the belly button which then becomes the eye of the surgeon through which he would then search for endometriosis in the pelvic cavity.

A biopsy of the endometriotic lesions would be required to make a definite diagnosis. Without a biopsy, diagnostic laparoscopy over-diagnose endometriosis in up to 50% of patients, leading to unnecessary treatment for a condition that is none existent. A diagnostic laparoscopy is valuable in defining the extent of the disease, the organs affected, and planning for the next stage in the treatment phase. It facilitates referral to a specialist surgeon and informs the kind of team that need to be assembled to tackle the menace that is endometriosis.

It however pales in significance in terms of cost savings, when compared to endometriosis mapping scan. As seen earlier, endometriosis mapping allows for a diagnosis of severe deep infiltrating endometriosis, defines the extent of disease, defines the team mixture of surgeons required to tackle the disease from the outset, cutting unnecessary diagnostic laparoscopic surgery. In the diagnosis of endometriosis, diagnostic laparoscopy has its place in non-deep infiltrating endometriosis which is the domain mostly of minimal, mild to moderate disease.
*In the next instalment, we will discuss treatment options for endometriosis and evaluate their effectiveness.

Dr Vincent G Molelekwa is Obstetrician, Gynaecologist, Fertility Specialist, Endoscopic Surgeon, Gaborone Fertility Clinic

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Sun Health

Tobacco also kills non-smokers

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This year’s world cancer day theme, ‘I Am and I Will’ is an empowering call to action, it is call to individuals to make a personal commitment to help reduce the impact of cancer.

We at the Anti -tobacco Network have heeded the call. We hereby call upon all citizens of this country to stand up against the monstrous impact of tobacco use in our society. We all know that tobacco kills. I want to tell everyone that tobacco kills non-smokers as well. Let us be clear about it. Second-hand smoke also kills. It is well documented through solid science that exposure to second-hand smoke causes cancer and contributes to various lung and heart diseases.

The World Health Organization estimates that approximately 700 million, or almost half, of the world’s children are exposed to second-hand smoke. In spite of what science tells us, however, in many places it is considered so acceptable to smoke, and so rude and unaccommodating to protest, that we dare not speak out against second-hand smoke. The time has come for us to speak out. We have a right to breathe clean air.

We have a right to good health and to protect our friends and family. We need to clear the air of second-hand smoke. Today, on this very important day, we are calling for a ban on smoking in public places. A ban that offers a comprehensive solution to keeping the air clean and safe for all people, both smokers and non-smokers. A ban that puts emphasis on people’s right to health and helps to make smoking the exception rather than the norm.

Whoever you are – a cancer survivor, co-worker, carer, friend, business leader, healthcare worker, teacher or student – ‘I A m and I Will’ represents the power of individual action taken now to impact the future. The power of lending your voice to this very important call. Your participation in this Call to Action is crucial to the cause. However you choose to take action, know that your efforts will be making a difference in the lives of many.

Dr Bontle Mbongwe is the Executive Director of the Anti-Tobacco Network (ATN), as well Head of Environmental Health Programme, University of Botswana.

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YOGA AN EFFECTIVE TOOL TO FIGHT NCDS

Rachel Raditsebe

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The ancient Indian practice of Yoga can definitely help in the prevention and management of non-communicable diseases (NCDs), which account for at least 70 percent of deaths worldwide.
This is the firm belief of Swami Purnachaitanya- Director of Programmes and Senior International Trainer with the Art of Living Foundation.

The World Health Organisation (WHO) statistics indicate that NCDs mainly cardiovascular diseases, cancer, diabetes and chronic respiratory diseases are the main causes of death with more than 36 million dying annually. And the trends in NCDs morbidity and mortality in Botswana are no different from the global picture.The high burden of NCDs is attributed to a change in population lifestyles, which include physical inactivity because of the changing nature of work, alcohol, smoking and substance abuse particularly among the youth and pollution.

While the problem of NCDs is a not an easy one because it is caused by so many factors including lifestyle choices, Purnachaitanya said exploring Yoga, as one of the possible solutions is worth it as it has the ability to bring together the body, soul and mind for a holistic approach to health and well-being, including physical, mental and spiritual realms of the human being.

Almost 80 percent of most health problems are entirely created by stress, according to Purnachaitanya. That is why a holistic intervention like Yoga can contribute to building resilience against NCDs. “It allows for ‘real’ rest, deep restoration which brings us to balance and allow our bodies into a healing place. Yoga can definitely influence our entire lives and help us make shifts to live in a way that is better for us and cope with the challenges of life with more harmony and vitality,” he said interview recently during a visit to Botswana.

“Yoga is not just a set of exercises. It is a philosophy of discipline and meditation that transforms the spirit and makes the individual a better person in thought, action, knowledge and devotion,” he said. Yoga, he added, is the most ancient practice that also increases the mental health and boosts immunity.

When we are stressed, Purnachaitanya explains, our minds get agitated and we produce certain hormones in the body, which lower our immune system, affect our digestion, blood pressure and many other organs in the body.

Highlighted in World Health Organisation’s Global Action Plan on Physical Activity 2018-2030, is that the routine practice of Yoga is a valuable tool for people of all ages to make physical activity an integral part of life and reach the level needed to promote good health.

It claims that regular practice of Yoga and meditation fights the free radicals, regulates the blood glucose metabolism and prevents any heart disease. “So just by regular practice of some breathing techniques, Yoga meditation, people the world over have had huge improvements”, shares Purnachaitanya.

The travelling teacher,who has dedicated his life to teaching Yoga around the world and serving humanity says, the practice of Yoga can also help fight stigma, especially the self-inflicted one. “It helps one to accept where they are in life and how they give meaning to life”.

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