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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

Women living longer than men

Rachel Raditsebe

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Life expectancy has been increasing over the past two decades across the world with several nations in Sub sub-Saharan Africa rebounding from high death rate due to HIV/AIDS.

In Botswana women have a longer life expectancy than men, living to an average of 68.4 years compared to 63.6 for men. Between 2005 and 2016, death rates from HIV/AIDS decreased by 42% and malaria by 43% while Pre- birth complications and maternal disorders decreased by 30% and 29% respectively. However, this progress is said to be threatened by increasing number of people suffering health challenges related to obesity, high blood sugar, alcohol and drug abuse. This is according to a health research conducted at the University of Washington’s Institute for Health Metrics and Evaluation (IHME).

The study, which examined the Global Burden of Disease (GBD), injuries and risk factors, the years that one lives in good health and those that one lives with an injury or illness, analyzed 300 illnesses and injuries in 195 countries between 1990 and 2016. The results were published on Thursday in the journal, The Lancet.

For most countries, changes in healthy life expectancy for males and females between 1990 and 2016 were positive, but in dozens of others, including Botswana, Belize and Syria, healthy life expectancy in 2016 was not significantly higher than in 1990. Healthy life expectancy takes into account not just death rates but the impact of non-fatal conditions and considers years lived with disability and years lost due to premature mortality.

According to the study, in 2016 Botswana’s disease burden was found to arise from unsafe sex, high fasting plasma glucose, high systolic blood pressure, high body-mass index and alcohol use.
HIV, respiratory infections, diarrhea and tuberculosis were the diseases most prevalent among men. For women, lower respiratory infections (such as pneumonia and bronchitis), and congenital anomalies were the most prevalent illnesses. Congenital illnesses are conditions that one is born with, which can affect one’s development and general well-being.

Maternal and child Deaths
The study has also found that from 1980 to 2016, giving birth has gotten less safe for mothers in Botswana. The ratio of maternal deaths grew from 74 per 100,000 live births in 1990 to 118 in 2016. Globally, the ratio of maternal deaths fell 30% over the same time period, from 282 to 196 per 100,000 live births. One of the co-researchers of the study, Dr Charles Shey Wiysonge, said it was encouraging that Batswana are living longer. However, he lamented that the high number of maternal deaths, “have overshadowed significant gains against HIV/AIDS”.

Dr Wiysonge is a GBD collaborator from South Africa who serves as a Professor of Clinical Epidemiology at the Faculty of Medicine and Health Sciences, Stellenbosch University. Dr. Nicholas Kassebaum, Assistant Professor, IHME said, “in many nations, improvements in maternal health are accelerating, but in others, women face daunting challenges, including the absence of trained professionals to assist with pregnancy and childbirth, and deal with life-threatening emergencies. As a result, reproductive health care must be a higher priority, including the expansion and improvement of reproductive health and family planning services and, for complications in childbirth, more advanced obstetric care.”

The study says that in 2016,1550 children under the age of 5 died, a ratio of 28.2 deaths per 1,000 live births. This ratio has been falling by 2.6 % each year since 1990. On the global level, 5.8 million children under age 5 died, representing a 52% decline in the number of under-5 deaths since 1990. In 2010 for example, the highest risk factor to good health among children under the age of five was being underweight, while among those aged between 15 and 49, the highest risk factor was alcohol abuse.

The researchers also examined the role that socio-demographic status – a combination of income, age, fertility rates and average years of schooling – plays in determining health. They noted that socio-demographic status is much less responsible for the variations seen for ailments, including cardiovascular disease and diabetes.

“Factors including income and education have an important impact on health but don’t tell the full story. Looking at healthy life expectancy and health loss at the country level can help guide policies to ensure that people everywhere can have long and healthy lives no matter where they live.” said IHME Director Christopher Murray.

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Know Your Specialist

Surviving endometriosis with natural remedies

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What is your professional background?
I am a medical officer at Princess Marina Hospital and have been working there for almost two years. I’m currently in the Obstetricians & Gynaecologist department working as a General Practitioner. It’s one of my areas of interest plus my boss is awesome and LOVES to teach.

What got you interested in food?
I went to a med school in China, and around the area I studied in, they were very passionate about their food intake, as it is with all Chinese but particularly in my city, Changsha. So we were blessed as students to be exposed to different remedies all the time. I got very ill whilst there, and they treated me with amazing methods. The only other people I know that use mother- nature as their healer are my grandparents in Lesotho. So I guess that’s where my motivation comes from, plus my mum practices alternative medicine all the time.

What is one of the wackiest nutrition myths you have heard of?
That swallowing gum may stay in your stomach for seven years. My mum loved saying that to me hence I am not a big fan of chewing gum.

What are some of the changes and trends you have observed in the food world over the last 20 years?
I am not a certified nutritionist, I’m just a person interested in using what earth has given us. It saved my life. The dependency of pills and a lot of pharmaceutical products scare me. The world has woken up to see that we don’t live as long as we used to. Take the Asians, they outlive us and are very active in their old age and their diet is a big factor to that.

You have been diagnosed with stage 3 endometriosis. Take us through that experience.
I was shocked but I was relieved at the same time, that at least I was not going crazy about my pain and the heavy menses. Plus, I had had a myomectomy, the surgical removal of uterine leiomyomas, also known as fibroids, done last year and that was horrible experience; so being diagnosed with Endometriosis was hard but a relief in the same breath.

How do nutrition and endo relate? Can diet improve the symptoms of endometriosis?
Honestly, regarding to this, there needs to be more information for the public. Since I’m not a nutritionist I cannot answer but can advise around it. There are so many theories of what causes endometriosis. So you need to understand your body first to derive a conclusion. In my case I first developed fibroids and did the necessary tests to try and find the cause. Then worked backwards from there.

In addition, research has shown that women with endometriosis often have higher levels of estrogen, and that estrogen can encourage tissue growth. Can an anti-inflammatory type of diet eliminate excess oestrogen from the body?
When attempting to relieve endometriosis symptoms naturally, begin by eliminating foods that lead to inflammation. This includes dairy, processed foods, refined sugars, caffeine and carbohydrates.
Eliminate these foods from your diet for at least three weeks, paying close attention to your body changing throughout the process.
Alcohol, soy and other high-estrogen foods should also be eliminated from your diet because of their estrogenic effects. Which means more super anti-inflammatory foods.

It is important to track symptoms so that potential triggers can be identified. Hence why journaling your progress is so important. Honestly those are some of the things I do which have been of big help. If you want more follow my page Dr. Tumie violet Mphusu. So we can discuss more.

Is there something specific that has made the biggest change in your health? A treatment plan you have formulated for yourself, maybe?
I am a big fan of natural remedies. When I get sick I always go to Mother Nature before seeking pills. So with my case, I realized that when explored the Daniel fast, follow my page for more details, my menstruation became normal. The first month, I remember thinking I was just lucky, but when I reintroduced certain foods in my life, the old horrific cycle returned.
The flow, my pain, my fatigue and other related symptoms. Diet is the key to how our lives will pan out in the future. You are what you eat.

Your last word?
Please remember there is no cure for endometriosis, and surgical or medical treatments remain the most effective methods of managing the condition. However, making dietary changes is a complementary approach that may help some women manage their symptoms. Keep in mind that just as symptoms of the disease vary from person to person, treatments that work best for one woman may not be right for another.  Take your time to experiment with different remedies to find the approach that’s right for you.

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