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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

Don’t use garlic for yeast infections

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Public Health Specialist, Dr Orapeleng Phuswane-Katse has warned women against using garlic for yeast infections, citing risk for further infections.She explained that while there are a few studies to support the claim that garlic has anti-fungal properties, it is never safe to put anything that is not regulated in the vaginal area.

On Monday, a woman took to social media to seek a remedy describing her symptoms as itchiness and a white discharge from her private area. Out of the 375 comments that she got, almost half advised her to insert garlic into her genital area. The comments indicated that the symptoms would disappear within three days.

“I remember I had the same problem back in 2017, I could not stand the itchiness, a friend of mine advised me to insert garlic, and within two days it was gone,” wrote one commentator. Another one wrote: “Take a clove of fresh garlic and peel off the natural white shell that covers it, leaving the clove intact. At bedtime, put the clove in the private area. “In the morning, remove the garlic clove and throw it in the toilet. I did this one time, if the itchiness goes on, continue for one or two days until all the itchiness is gone.”

However, Dr Phuswane-Katse advised that the only alternative is to see a doctor when one has the symptoms.“The vagina is a fragile moist area that has bacteria that regulates the PH in there. Any foreign objects can cause laceration and even introduce unwanted bacteria that can cause more harm than good”. Furthermore, she added, “There is no regulated size of the garlic to insert and this may pose danger.

Questions like, ‘how many hours do you remove it, in what state should you insert it, crushed or whole’? Since its not regulated medicine, there can be no clear answer”. Dr Tebogo Oleseng, a gynaecologist and obstetrician said women need to be more careful, saying that the birth canal is the ‘perfect’ environment for the botulism bacteria to grow, which can be life-threatening.
Botulism, a condition caused by Clostridium botulinum bacteria, can be offset when someone eats food containing toxins because it has not been properly canned, preserved or cooked.

He advised women not to take medical advice from anyone recommending vaginal garlic for yeast or anything else because there are antifungal drugs specifically for yeast infection. He explained that garlic contains allicin, which in the lab has shown to have antifungal properties. “Bacteria from the soil can be pathogenic for the body. That is why we clean wounds. If you actually happen to have an inflamed yeasty vagina, soil bacteria would be more likely to infect it,” he said.

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Know Your Specialist

Caroline Gartland speaks on Children and Mental Health

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Tell us about yourself and your background
I’m originally from the UK but have been in Botswana for eight years so this is now home! I have a Combined Honours degree in Psychology an MSc in Mental Health and have had a pretty varied career.
I started off working with offenders doing rehabilitation programmes; went on to support the victims of domestic violence then ended up working in Child and Adolescent Mental Health Services for the National Health Service.
I’ve done a lot of work, mainly voluntary, in different fields since being in Botswana but my passion is now Early Childhood Mental Health.

What does your work entail?
Early childhood mental health is mainly working with parents, caregivers and teachers to help them understand how children develop and the best ways to support their mental health and brain development as they grow. It’s about providing training and opportunities for families to bond with their children and introducing new ways of playing and interacting.

What sparked your interest in early childhood mental health?
Quite simply, having my own children! My daughter was born five years ago and I was fascinated watching her develop and grow. It occurred to me that the younger you begin to consider mental health and provide tools for resilience against life’s adversities, the better outcomes you are likely to have.
I began reading everything I could get my hands on, and completed a diploma in Infant Mental Health. I’ve worked down the lifespan but I feel I’m now where I belong, working with babies and young children.

What mental health issues have you observed in children in Botswana?
Mental Health is still stigmatised around the world and Botswana is no exception. Most people immediately think of mental illness, but mental health is about so much more; we all have mental health and some days we are fine and able to deal with life’s challenges and some days we need more support and tools under our belt to help us cope.

Young children can experience mental health problems. Anxiety is a common one, but we are more likely to focus on the behaviour we see rather than how the child is feeling. An anxious child who refuses to go to school may be labelled as ‘difficult’ or ‘naughty’ but what they are expressing is a painful emotion that they need help dealing with.

Describe one thing you find fulfilling and challenging about working in this industry.
Working with children and families is a pleasure and a privilege. To make life a little bit easier for someone is all that matters, you don’t have to be out there saving the world to make a difference.
My major challenge is time. I would love to do more, I’d love to do an MSc in play therapy and a couple of other therapeutic techniques I’ve come across in Europe but that gets put on hold as I focus on my own family and business.

Can you share an anecdote about how mental health consultation works?
I think that education, understanding and connection are the three keys to giving a child the best start in life. Led by that, SensoBaby provides classes in the community for parents and caregivers to connect with their infants.

We offer workshops on parenting and play to foster understanding of child development and wellbeing and we are available to troubleshoot specific problems an individual or agency has with the young children in their care or the systems they have in place. When it comes to individual parents, mostly what they need is to feel heard, supported and guided in their parenting choices.
You can read all the baby books in the world but they won’t give you the answers you need for your child, through responsive parenting and connection, you’ll find you have the solutions you need.

What advice do you have for child-care providers or early childhood teachers who are at their wits’ end over a child’s challenging behaviour but don’t have access to a consultant?
Empathy is an important and undervalued skill – the ability to consider another’s viewpoint. What is that child feeling? Their behaviour might be challenging and hard to deal with but often the root cause is an unmet need. There’s a famous quote from an American Clinical Psychologist, “The children who need love the most, will ask for it in the most unloving ways.”

Does a mother’s mental health affect her foetus? How important would you say is paying attention to women’s well being during pregnancy as with their physical well being?
100% yes. It is so important to support a woman’s wellbeing during pregnancy. As an example, if the mother experiences significant stress and rising levels of cortisol (the stress hormone) during pregnancy, the foetus will be affected and in some cases will be more sensitive to stress in childhood or later in life.

Pregnant women and new families (Dads as well!) deserve nurturing care themselves and shouldn’t be afraid to ask for support. SensoBaby run FREE monthly coffee mornings to support pregnant and new mothers because we understand the importance of maternal wellbeing.

Do smart phones and television make our children mentally ill as is often purported?
I don’t think technology is always the villain it’s made out to be. The key is in the relationship with that technology. Moderate use of TV’s and smart phones are fine, as long as they aren’t a substitute for outdoor play, imaginative play and meaningful interactions. If a child is crying or upset and we hand them a device to keep them quiet then we have missed an important opportunity for connection, helping them process what is going on and supporting them to calm down and settle themselves.

Now, I know you are involved in an exciting programme that helps caregivers and children to bond and get the children off to the best start in life through play. Can you say a little bit about that work and just how you are seeing it play out?
SensoBaby is our baby; a project born from passion and a desire to support families in Botswana. We offer play-based classes for children and their caregivers that are underpinned by the principles of child wellness as well as early foundations for learning.

When you provide developmentally appropriate opportunities to play, you learn so much about your child. That understanding and observation builds strong connections, which will form the basis of that child’s future relationships and self esteem. Play is so much more than ‘a fun activity.’

We offer a number of trainings and workshops for parents, nannies and community stakeholders and hope to increase our offerings this year. Our community partnerships and voluntary programmes have been successful so far and we hope to see more impact in 2018.

We currently serve the Gaborone community but would like to expand throughout Botswana as opportunities arise. The response to SensoBaby has been fantastic so far and we can’t wait to see how far we can go with the concept!

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