Blog #7 Should we compare endo to cancer?
All things re cycle. History, fashion, design, even items of conversation. Aliking endometriosis to cancer is the latest re cycling topic among the endometriosis community.
I agree with our community regarding the injustices endometriosis and those with the disease endure. Poor understanding and awareness over decades has created a poorly sealed pressure-cooker situation. Frustration and anger continues to build within our community; temperatures rising in response to poor awareness, knowledge and interventions for the disease.
Validation of the disease, acknowledgement of the sufferer’s experience, impact on their families, peers and employers is looooooong overdue. Regardless of many similarities between endometriosis and cancer, should we be comparing them? The naked truth: to feel like, or want to die versus the uncertainty that you may, or know you will die can’t be compared.
Despite similarities between cancer and endometriosis, there are also differences. I’m not here to judge or condemn anyone who alikes endometriosis to cancer. However, I hope to expose each reader to physiological, societal, historical and cultural aspects that have, and continue, to influence how we perceive endometriosis. From my personal perspective, comparisons transpired from society’s ignorance of the disease and sufferers attempt to communicate it’s potential destruction.
Thankfully I’ve not faced a diagnosis of cancer. If I did, I imagine my first thoughts might be:
A diagnosis of endometriosis can be devastating. It does not directly threaten the life of a person, but for some, it threatens the ability to bring another life into the world. It can ruin intimate relations, impact ability to complete education, hold a job or career, hobbies, self/family care or household chores. Each in their own way, those with either disease often worry about passing along their disease genetically.
Undisputed evidence exists that inheritance plays a role in development of cancers and endometriosis. Our environment (nutrition, chemical exposure, stressors etc) also influences the activity of genes and development of DNA mutations that lead to disease.
Genetic changes that cause cancer can be inherited from our parents. They can also arise during a person’s lifetime as a result of errors that occur as cells divide or because of damage to DNA caused by certain environmental exposures. (1)
The heritability of endometriosis has been estimated at around 50% based on large twin studies. (2)
It has been demonstrated that first-degree relatives of women with this disease are more likely to develop endometriosis. And when there is a hereditary link, the disease tends to be worse in the next generation. (3)
Cancer is known to be a collection of multiple disease. “There are more than 100 types of cancer”.(1) In contrast, endometriosis is considered a single disease. However, international collaboration among numerous institutes and clinics across the globe are attempting to determine if endometriosis is really a ‘single disease’ or comprised of multiple subtypes.(4)
Tumors and lesions:
Most cancers form solid tumors; those of the blood, such as leukemia, generally do not. Cancers may be Benign or Malignant. Benign disease is encapsulated. They are most often limited to a single tumor, painless and upon removal, do not regrow.
“… benign tumors do not spread into, or invade, nearby tissues. Benign tumors can sometimes be quite large, however. When removed, they usually don’t grow back, whereas malignant tumors sometimes do. Unlike most benign tumors elsewhere in the body, benign brain tumors can be life threatening.(1)
Malignant disease consists of cells which rapidly reproduce, invade surrounding tissues and have potential to ‘break off’ (metastases), travel to other locations in the body, and continue to grow unregulated. The tissues invaded by metastatic tumors are predictable, according to the type of malignant cancer.
Cancerous tumors are malignant, which means they can spread into, or invade, nearby tissues. In addition, as these tumors grow, some cancer cells can break off and travel to distant places in the body through the blood or the lymph system and form new tumors far from the original tumor.(1)
The basics of cancer and endo:
Unlike benign cancer, endometriosis is rarely a single lesion. They are similar, in that if the entire lesion is removed, probability of regrowth in the same location is very low. Endometriosis, benign and malignant cancer can be silent or symptomatic.
Similar to malignant cancers, endometriosis lesions can invade local tissue.
Malignant cancers are divided into those which form solid masses or affect the vascular and lymphatic systems. Endometriosis consists of disease divided into three divisions: ovarian, superficial peritoneal and deep infiltrating endometriosis (DIE).
Expanding the prior topic about the classification(s) of endometriosis, an ongoing project by the World Endometriosis Research Foundation’s (WERF) goal is to establish subtypes of the disease (based on characteristics of lesions), acquire evidence suggestive of one or more origins of the disease, and develop individualized treatments based upon disease subtypes. In addition, subtyping endometriosis lesions may reveal relations of endometriosis and specific types of cancer (not just gynecological) beyond an ‘association as co-morbid diseases. To clarify our present knowledge:
Before endometriosis can be linked with evidence to any type of cancer, more methodologically-robust research will need to be undertaken.(3)
With exception of vascular and lymphatic disease, cancers develop from a primary site. Secondary sites result from a primary tumor ‘breaking off’, travelling to another location in the body (metastases). Primary and secondary sites of malignant cancers are genetically identical. Although some theories speculate endometriosis occurs from distribution of cells from a single primary site (the uterus) by way of retrograde menstruation, evidence of initial attachment and the genetic composition of endometrial cells of the uterus (eutopic) and those of endometriosis lesions (ectopic) are not genetically identical. Further, we know genetic variation occurs among endometriosis lesions within the same person. Both characteristics are a contrast to malignant, metastatic cancer.
Cancer cells are less specialized than normal cells. That is, whereas normal cells mature into very distinct cell types with specific functions, cancer cells do not.(1)
The risk of a benign tumor’s conversion to malignancy is dependent upon the type of tissue(s) the benign tumor developed from.(1) The risk of endometriosis (specifically ovarian) conversion to cancer is estimated at 1.8%.(3)
Sex hormones, cancer and endo:
Some forms of malignant cancers (breast, uterus, prostate, testicular) and endometriosis are sensitive to androgens (sex hormones). Exposure to sensitive specific androgens promote growth of specific types of cancer and endometriosis.
Director or influencer of self-growth?
Cancer and endometriosis manipulate their environment to meet their needs. However, each disease does so differently.
In regards to cancer, its cells ‘ignore’ the body’s attempts to control lesions division; that results in rapid growth of the cancer. Cancer influences, ‘orders’, surrounding tissues to grow blood vessels, bringing nutrients and oxygen, further promoting its growth.(1)
Endometriosis cells don’t ‘ignore’ the body’s orders to stop. Instead, endometriosis lesions produce products that reduce the number of ‘clean up cells’, ‘rubbish/trash collectors’ in the immune system. As a result, cell growth exceeds cell death, advancing lesion growth. Unlike cancers, endometriosis lesions create vascular and neural tissues independent of the tissue it invades.
Mortality and Morbidity Rates:
Cancer impacts children, men and women proportionally.
Cancer is among the leading causes of death worldwide. In 2012, there were 14.1 million new cases and 8.2 million cancer-related deaths worldwide. Approximately 38.4% of men and women will be diagnosed with cancer at some point during their lifetimes (based on 2013–2015 data).(1)
Endometriosis primarily impacts cis-females becoming symptomatic around menarche and can continue into post-menarche. It is estimated to affect 1:10 women around the globes. A small portion of cis-gender males and transgender persons develop endometriosis but the disease is predominantly limited to cis-females. The probability a woman will be diagnosed with endometriosis is 10%, among those with endometriosis, risk of endometriosis conversion to cancer is 1.8%. In contrasts, the probability for any cancer diagnosis during a cis-female’s lifespan is 38%.
What about the Pain?
Unless you’ve had both, is it appropriate to make comparative statements when you’ve not directly experienced both? It’s acknowledged that the degree of pain, symptom profile and other unpleasant experiences among both diseases are wide ranging. Some malignant cancers are silent. Some endometriosis is silent. It’s also widely acknowledged that non-invasive medical management for cancer is often more debilitating than the disease itself. In contrast, there is little awareness and acknowledgement of severe side effects that can occur with non-invasive medical management for endometriosis.
The type of pain varies with the form of cancer and treatment. Similarly, not all endo pain is the same. Both disease symptom profiles are associated to the organs and tissues involved. Similar systemic issues can arise with both diseases to include fatigue and anaemia. Further, both diseases may lead to the removal of body organs or cause organ dysfunction and/or death.
Is there a Cure?
Cure rate for cancer is dependent upon the type of cancer and it’s staging (stage 1-4). Some malignancies have no cure. The physiological advancement of cancer directly reduces the lifespan of many persons.
There is no cure for endometriosis. However, it’s important to reiterate, endometriosis does not directly shorten the life of a person through growth of the disease. (It’s vital to acknowledge a handful of special scenarios death from the disease has and can occur. A few cases include 3 deaths from bilateral renal death and 1 death due to a large lesion inside the heart. All (4) cases occurred prior to development of soft tissue imaging equipment. A true definition of ‘cure’ is not established for the disease. Ongoing critically ill cases with resolution are periodically reported in the scientific literature primarily with disease within the respiratory and urinary/excretory systems).
Treatments, often as bad, or worse than the disease:
(For sake of blog length, this section is limited to a simple overview).
Treatment for cancer may include any/all of the following: radiation, chemotherapy and surgical intervention. Endometriosis is treated with medical management and/or surgical interventions. Most people have a cursory understanding of cancer treatment, either through personal experience or that of a loved one. Hence, brief focus is paid to treatment for endometriosis:
Hormone suppression is not a cure but can suppress symptoms for some persons.
Ablation may address superficial endometriosis lesions (to a depth of 1-2 mm) but does not remove deeper disease. Ablation also leaves charred debri and eschar, properties known to activate the immune system, enhancing the inflammatory response. This leads into the topic of disease ‘recurrence’ vs ‘remaining unaddressed disease’. Its an important concern that should be considered when ‘new disease’ when there has been a prior surgical intervention. Further, scientific publications comparisons of ablation vs excision – report variable outcomes, but poor control for surgeon skill and experience. Excision of lesions (cutting out) the disease has lower ‘recurrence rate’ than ablation, among experienced surgeons with advanced training in the technique. At present, excision is the closest intervention to’ a cure’.
The requisite skills to surgically remove endometriosis, which often impacts the organs among multiple body systems overlap those used among oncology surgeons.
Development of long term side effects are troubling following some treatments for both cancer and endometriosis. A few shared side effects include fatigue, memory loss, altered bone density, joint pain and hair loss.
Historical perception and impact on today’s perception of disease:
For decades, the majority of health studies limited study participation and analysis to men. At the time, it was universally believed that the inability to control for the natural, biological process of menstruation and cycling of hormone levels in women would diminish data accuracy. For decades, data collected exclusively from males was erroneously applied to women. The scientific community has only recently (about the last decade or so) improved inclusion of women among studies of diseases that impact men and women.
Unfortunately, attention (to include funding) dedicated to Women’s Health specific remains severely neglected. Limited quantity of completed studies, data collected and allocated resources to conduct them remains a barrier to faster improvements in knowledge and treatment of women’s health conditions. Specific to endometriosis, a chronic lack of government funds toward research led to investments among pharmaceutical companies. This influenced the direction of research and emphasis of medical management approaches to treat endometriosis. These issues continue today.
The woman’s position and role in society: contribution to inequality of research, care and perception of women’s health concerns:
Inequality of women with respect to men is a global issue. With exception to a few nations, inequality of women is significant in every aspect: economic, social, health and cultural. A small portion of transgender persons and cis-males are also affected by endometriosis. The transgender community is also marginalized, similar to cis-women. Cancer also affects women. As clarified earlier, there is greater proportionality of those affected by cancers among the genders and life span. It is with sadness that greater than 1/3 (33%) of women will be diagnosed with cancer during their lifetime comparable to 1/10 (10%) with endometriosis.
Funding to investigate cancers has an expansive budget that dwarfs allocated resources for endometriosis. Cancer should receive greater funding than benign diseases. However, lets take a look at funding for a few other benign conditions and the 2017 mortality rate for each. Mortality rates are one factor used to establish the amount of funding a disease is allocated. The graph below represents distribution of funds through the National Institute of Health between 2017 and 2020. Comparatives for Endometriosis, Temporalmandibular Joint disease (TMJ), Interstitial Cystitis, Scleroderma and Uterine Cancer. All diseases are benign with exception to Uterine Cancer (5):
Other contributors to our perceptions of endometriosis:
- lack of accurate information about the disease taught in medical school.
- lack of accurate information distributed among authoratitive and influencial organizations (ACOG, teaching hospitals, etc. see Blog #2).
- lack of research funding independent of the pharmaceutical industry (above table).
- lack of patient advocate inclusion among policy and guideline discussions (the USA lags behind the United Kingdom, Australia and a few other countries).
- long term barriers of perpetuated myths and misinformation that continue to circulate in medical curriculum, stagnation to update didactic resources, professional continuing education coursework, traditional perception of a gynecological disease has kept pediatricians, general practitioners and other specialists from developing greater awareness and recognition of the disease, contributing to delayed and oft misdiagnosis.
- association of pelvic pain as a manifestation of mental and/or emotional difficulties. The ‘Wandering Uterus’.
Stigma associated with disease and its negative impact:
Stigma associated with Women’s Health still remains. Particularly those associated with menstruation. Although the current Menstrual Movement has improved public acceptance of the topic for conversation, culture and familial beliefs still impart a sense of shame among many menstruators . This makes it difficult-to-impossible for them to distinguish what is normal and abnormal. In addition, endometriosis has historically been perceived as a female reproductive system disease. A gynecological problem. In reality. This has led to silence, confinement behind closed doors or redirection from healthcare providers to the gynecologist to address concerns. In addition, adolescents may not approach their pediatrician about their concerns, which further delays acknowledgement of disease until the adult years.
Further complicating the issue is the poor awareness and recognition that endometriosis can impacts tissues, organs and systems outside of the female reproductive tract. Knowing this, it is vital these areas are included and integrated in the analogies and descriptions we use to convey what it is to have endometriosis.
Public response to ‘I have cancer’ is far different to ‘I have endometriosis’ or, ‘I have pain down there’. Of course we know many would respond with comments such as ‘Never heard of it’ or, ‘I get bad cramps (with my period) too’. Even, ‘My mom/friend/other had that. They just got a hysterectomy’. It’s sad that the conversation around endometriosis has remained virtually unchanged for decades. Sufferers of the disease still face belittling comments, that depreciate the real sufferers experience.
Where do we go from here? How do we convey the destructive nature of endometriosis without using cancer as a comparative?
We could build on a few established analogies many can relate to or conceptualize. A few of these, often reiterated by an endometriosis advocate leader, Nancy Petersen, RN (ret) include: The pain of endometriosis is –
“… ‘on par’ to acute appendicitis” (indicative of acute peritoneal quality pain)
“… on par to or worse than labour pains of birthing”
Members of our FB Support Group: Extrapelvic Not Rare, have provided a few analogies of their experience of endometriosis among a few extrapelvic organs:
Chest Cavity and Diaphragm:
Endometriosis is a benign disease, without direct threat to a persons’ lifespan. But, it should not be dismissed by the medical system and public for this. The review of its similarities to cancer reveal the disease to be far more complex than a simple ‘menstrual complaint’ and ‘inconvenience’. Endometriosis, like a few other benign diseases can be very destructive in all aspects of the person’s life AND negatively impact those around them. If we continue sharing personal testimonies, exchanging knowledge and establishing powerful analogies others can directly relate to or conceptualize, comparison to cancer wont be necessary.
You may decide this blog’s reinforced your perception that endometriosis as ‘alike’ to cancer and justifies comparison to it. OR It may have heightened your perception that endometriosis deserves greater respect and validation. We can develop a conversation that articulates the potential depth of physical destruction, loss of productivity, and quality of life endometriosis can steal with comparison to cancer.
As awareness, education and voices of personal experience create familiarity among all peoples’, the need or desire for comparison to cancer will diminish. Eventually, the adversities and hardship those with endometriosis face, will be conveyed in a ‘stand alone’ statement. I have cancer. I have diabetes.
Just what do we hope to convey exactly? Despite the average person’s lack of familiarity with intricacies of these diseases (cancer, diabetes), instant empathy and a sense of each disease’s potential destruction is understood. There is no need to compare cancer or diabetes to another disease.
I have endometriosis.
In reality, injustices toward endometriosis, those with the disease and women’s health have been present for centuries. They remain today. However, when we compare endometriosis to cancer, our attempt to validate the severity and nature of our disease, it invalidates cancer as a disease, its potential to take human life and the experiences of those with it.
Trish, January 21st, 2020 Tweet Trish’s Blog
1.) National Cancer Institute. http://www.cancer.gov (accessed January 10th, 2020)
2.) Recent Insights on the Genetic and Epigenetic on Endometriosis. Clinical Genetics. 2016. B. Borghese et al. https://doi.org/10.1016/j.fertnstert.2018.10.013
3.) Causes. Endometriosis.org. Hummulshoj L et al. (accessed January 17th, 2020)
4.) World Endometriosis Research Foundation. Endometriosisfoundation.org/ephect (accessed January 17th, 2020)
5.) Estimates of Funding for Various Research, Condition, and Disease Categories (RCDC). National Institute of Health (published April 19, 2019) (accessed Jan 17, 2020) https://report.nih.gov/categorical_spending.aspx
Blog #6: What does endometriosis have to do with the #1 killer of women?
It’s all a bad dream. Kinda like an out-of-body experience, but I’m watching myself living. No matter how loud I scream or move around, my real-self can’t see or hear me. Its awful. Watching the life I created wither. The life-long efforts to keep the ‘bad genes’ asleep. The ones that have plagued my family and ancestors. Its hard not having 100% control of my health. Despite diet, exercise, weight control and the usual healthy lifestyle choices, its frustrating that some diseases, like endometriosis, often require assistance from the healthcare community. What angers me, is the potential that many short-sighted treatments that target a specific organ or system TODAY may negatively impact other area(s) of a person’s body, oft not ‘clinically’ apparent, until TOMORROW.
I won’t go on about the plethora of consequences, like elevated risk for hip and vertebrae compression fractures from osteoporosis; memory loss and risk for dementia as a few long-term consequences possibly through TODAY’s offerings of endometriosis care. But.
- I AM going to WRITE about the impact of endometriosis, as a disease AND treatments that can contribute to the #1 global killer of women: Cardiovascular disease (CVD).(1)
- I AM going to WRITE about lack of attention to long-term side-effects with drug trials.
- I AM going to WRITE about scientific findings which suggest a better approach to treatment that could be a Win-Win against endometriosis AND CVD.
Not until the 4th or 5th decade, most of us don’t consider how CVD could impact our life. Even for healthcare providers, its often far removed from Today’s thoughts. The disjointed healthcare system of specialists, hyper-focused on one body part or system, tend to rely on a single ‘gatekeeper’ to take care of the person as a whole. This is a serious concern. Although development of specialties has led to greater depth of knowledge in their focus area, they must still maintain responsibility for impact of treatments they initiate, and their impact on other body systems.
“The GOOD physician treats the DISEASE; the GREAT physician treats the PATIENT who has the disease” – Sir William Osler
What will happen if I develop clinically apparent CVD? Will stairs and hills become obstacles I can’t overcome that lead to greater planning and limitation to where I can explore on foot, in my community, nearby woods and adventures in the mountains I have always loved? Will I be able to travel after retirement? Will I grow old with the person I love? Will I have to take medications? Will I be able to afford them? Will I have to live in a nursing home because I can no longer care for myself?
I WRITE this Open Letter:
To the appointed leaders in researcher, healthcare, pharmaceutical companies and medical organizations:
You hold the fate of over 176 million women, transgender people and rare cis-males who live with endometriosis in your hands. Their life is not limited to Today. Their life includes Tomorrow’s. The course of treatment Today, does impact life Tomorrow.
Urgency exists Today for greater knowledge of intrinsic, extrinsic processes, common line’s of pathogenesis and interactions of endometriosis and cardiovascular disease. It’s time to look beyond association. It’s not only a question of how and why the presence of endometriosis in the body impact’s on cardiovascular disease. There is concern for the impact of currently accepted treatment intervention for their deleterious impact on cardiovascular health. A related concern includes a consistently lack of long-term follow-up of risk factors across all phases of drug trials to include significant extension of the standard 6 mth to 1 year time period.
It’s with hope, sharing my perspective, supported by scientific evidence and observation of the fore mentioned concerns about endometriosis, its treatment options and development of cardiovascular disease will be factored into consideration of treatment options provided to persons with endometriosis, regardless of their age and current health status. To reiterate, CVD is the number one killer of women worldwide.
“In the last few years, several lines of research have focused their attention on the possibility of specific CV (Cardiovascular) involvement in women affected by endometriosis, documenting the presence of markers of sub clinical atherosclerosis in these subjects. (ref7-11 in 2)
The association of endometriosis and CVD has been well documented. Although there are some limitations for generalization of the largest and longest data collection from 116,430 women between 1989-2009 which analyzed the relationship of these diseases. As with any study, there are some considerations with generalization to the entire population. However, there are a few significant findings that deserve attention. All subjects entered the study upon referral for angiography that confirmed a diagnosis of Angina. Follow-up was attempted with all subjects ten years later. The number of cardiovascular events experienced among women with endometriosis was significantly higher than women without a history of endometriosis.(3)
As expected, it was determined that hysterectomy with/without oophorectomy contributed to development of cardiovascular events as consequence to the loss of estrogen induced cardiovascular protection. The investigators calculated a (46%) contribution to the frequency of cardiovascular incidents. Most interesting, a history of Birth Control Pills (OCP) was not associated with the incidence of cardiovascular disease among women with endometriosis. If hysterectomy w/without oophorectomy is responsible for 46% of the association, what factor(s) contribute to the remaining 54% association of endometriosis and cardiovascular disease?
Women still face the unresolved debate that a large portion of gynecology can’t get passed: treatment of endometriosis by removing a woman’s uterus with or without the ovaries. These procedures and belief still remain deeply rooted in practice among many parts of the world and based upon concept that endometriosis is due monthly menstrual debri entering the abdominopelvic cavity instead of passing out the body. Even worse, removing health organs and leaving active endometriosis lesions untreated, or possibly worse, superficially burned, to remain in the body. All of these scenarios creates conditions that accentuate development of cardiovascular disease. Just thinking about the consequences makes my bones, brain and heart hurt!
Despite decades of investigation and adherence to this practice, evidence of direct attachment of menstrual debri that has developed within a biological human female is still lacking. The accumulation of data that demonstrates endometriosis disease activity after hysterectomy has led more providers to approach treatment of endometriosis without removal of a normal uterus (and ovaries), if they are not diseased. In fact, recent discoveries suggest these organs aren’t limited to a role in reproduction. Evidence is accumulating of their impact on long term systemic wellness of biological females.(4) This brings us back to the decades-old approach to treatment for endometriosis. The provider, intently focused on a single system (reproductive) and concerns that brought the person with the disease to them, Today. What about the WHOLE person? What about Tomorrow?
Another mainstay among gynecology for treatment of endometriosis is hormone manipulation. The decades long debate: is endometriosis a surgical or medical disease? First, and foremost, the question must be asked and the answer acknowledged: What diseases in the body are ‘diagnosed’ based upon a response to a pharmaceutical agent? (For example: Diabetes clearly demonstrate abnormal blood values BEFORE intervention with diet modifications and supplemental insulin as needed.) Every disease I can recall off the top of my head demonstrates clinical and objective test results (imaging, blood values, saliva, urine samples etc, etc) reaches a diagnosis based upon objective findings. To date, all conservative attempts to diagnose endometriosis aren’t sensitive NOR specific enough.
The debate and argument applied by some stakeholders in attempt to justify pharmaceutical agents for ‘diagnose’ of endometriosis is frightening. To determine if a person has or does not have endometriosis based upon reaction to a hormone suppressant agent doesn’t take consideration for human variability. This is deeply concerning to me. Most particular based upon the personal experiences of myriad women I have interacted with and their shared experiences, some women with disease will be false negative. These women will not receive a diagnosis despite having endometriosis when they fail to have symptom reduction or resolution with hormone suppression. In contrast, other women will respond positively to hormone suppression yet don’t have endometriosis. These women would be false positive for endometriosis and given a diagnosis. A grave situation for women dismissed and active disease left untreated. A grave situation for women placed on hormone suppression with a range of positive relief, consequences with harms outweighing benefits, many not apparent until later in life.
Oral Contraceptives/Birth Control (OCP’s) are the most common pharmaceutical agents first used to treat endometriosis. OCP’s can cause side effects of identifiable risk factors for CVD. They include elevated blood levels of Low Density Lipoprotiens (LDL’s) (the Bad cholesterol), reduced levels of High Density Lipoprotiens (HDL’s) and increased blood pressure. OCP’s also increase the risk of Deep Vein Thrombosis (DVT’s), blood clot formation, which occurs most commonly in the lower leg.
Most providers either attempt multiple OCP’s of various hormone combinations to relieve a patients symptoms if the first agent is ineffective, or recommend use of stronger pharmaceutical agents, most designed to induce partial or complete cease of estrogen production by the ovary(ies). Among these agents, include GnRH agonists (ie. Lupron) and GnRH antagonists (ie. Orilissa).
Like BCP’s, hormone suppressants also increase CVD risk factors. In addition, hormone suppressants reduce or cease estrogen produced by the ovaries. The cardiovascular protection provided by estrogen is lost. Hormone suppressants compound risk for cardiovascular disease development. Between atherosclerotic build-up, inadequate repair of internal vessel walls and inability of the blood vessels for normal dilation, endometriosis lesions remain in the body. (More on this later.)
Risk factors of cardiovascular and other adverse conditions, are collected in most drug trials for treatment of endometriosis. However, data collection is commonly limited to 6 mths – 1 year following the study completion. The limited follow-up period of 6 mths – 1 year was a concern highlighted in the Institute of Clincal and Economic Review (ICER) public hearing for GnRH-antagonist Elegolix (Orilissa) held July 2018.(5) ICER gave recommendation for longer follow-up following drug-trial to clarify benefits vs long-term complications.
In addition to lengthening the post-trial follow-up period, the way data is grouped, analyzed and presented in pharmaceutical trials is at the discretion of the investigators (see example below).
Example: The most recent Elagolix (Orilissa) drug trial followed LDL, HDL and BP of each subject.(8) Initial Cholesterol levels among the majority subjects were in the ‘low’ risk group, a lesser number in the ‘normal’ risk group. No subjects were among the top three associated risk-levels for CVD prior to starting the drug trial. The investigators determined that the n# of subjects with cholesterol levels of ≥140mg/ml/cholesterol ‘high risk’ at the end of 6 mths would be compared to the n# of subjects < 140mg/ml. To explain this. A mean cholesterol level of 100mg/ml among subjects prior to test. A 40% increase in cholesterol levels over the 6 month test period would be required before the investigators considered the subject to experience significant increase in cholesterol. Instead of comparatives of each person pre/post values, the number of persons ≥140mg/ml/cholesterol was counted. This number would be compared to the group to determine if blood cholesterol levels were a ‘significant’ concern. Another way to view the data: The majority of subjects would blood cholesterol levels to increase three to four complete levels in a 6 month duration to be considered ‘significant’. Analysis of data using N number of persons instead of analysis of each subjects pre/post blood cholesterol changes provides drastically different information.
The freedom to include/remove and rearrange data and a lack of mandated submission of all raw data in addition to the final drug-trial report (which presents selective material) for FDA approval need reassessment.
To review: use of hysterectomy, with and without oophorectomy, and pharmaceutical agents for the treatment of endometriosis are associated with development of cardiovascular disease risk factors. Traditional measurements include blood cholesterol levels, blood pressure, presence of diabetes and familial history. More sensitive methods to detect sub clinical cardiovascular disease have recently been investigated, and validated for the use among women with endometriosis. These methods further the suggestion that the relationship between endometriosis and cardiovascular disease may be more than an association. (6,7) More to follow.
Moving beyond medical management, laparoscopic surgery is the next treatment consideration. Most important, Laparoscopy IS the Standard Procedure (with a tissue sample) to Diagnose endometriosis; NOT pharmaceutical agents. Does laparoscopic surgery impact the development of CVD? Lets first clarify the two surgical techniques applied directly to endometriosis lesions: ablation and excision. Ablation is the use of thermal energy to ‘destroy’ endometriosis lesions. The advantages of ablation is the ease of use by board certified gynecologists, doesn’t require advanced skills to apply and shorter surgical times. Disadvantages of ablation include: limited depth of penetration to 1-2 mm (unable to ‘destroy’ deeper disease); limited to organs and tissues which energy can be applied to (hence endometriosis lesions on some organs cannot be treated) and residual eschar and debri can generate sustained inflammation after surgery. Advantages of excision include: removal of endometriosis lesion by using energy to ‘cut out’ the lesion and remove it from the body (clean margins without residual disease that can regrow/remain active); healthy tissue margins without diseased or injured tissue limits sustained inflammation following surgery. Disadvantages of excision include: longer operative time; significantly less providers available with excision skills to obtain care; often higher out-of-pocket costs due to lack of insurer coverage.
Back to Laparoscopy and impact on CVD development. Its plausible to deduce that retained endometriosis lesions, in addition to eschar and debri from ablation will not resolve the inflammatory process innate to endometriosis. As a result, the presence of endometriosis (debri and/or remaining active deeper disease of lesions deeper than 1-2 mm depth) will continue its association with development of CVD. This brings me to my argument for LAPEX (laparoscopic excision) as Gold Standard.
Among all of the treatment options for endometriosis, cutting out the disease is the ONLY intervention which is a Win-Win situation against Endometriosis AND CVD development. What evidence leads me to this position? Data collected from women who underwent gynecological surgery for endometriosis and non-endometriosis were monitored for cardiac risk factors prior to surgery with a 2 year follow-up.(8) Traditional cardiovascular risk factors were collected. Additional measurements of Force-Mediated Dilation (FMD) was included. The use of FMD is:
“very relevant because endothelial dysfunction, is one of the earliest markers of vessel wall deterioration in atherosclerosis, (and) has a prognostic relevance even in the absence of traditional cardiovascular risk factors.”(8)
Results of their study provide new opportunities to look into the relationship between endometriosis lesions and vascular wall dysfunction. Prior to surgery, those with endometriosis had a significant reduction for capacity of blood vessels to dilate, compared to women with other gynecological concerns. Two years following surgery, those who underwent gynecological surgery for other conditions, had no significant change in measurements. Those with endometriosis who underwent excision surgery had significant improvement of vascular dilation from their preoperative measurements AND their postoperative measurements were similar to the postoperative values of those who underwent non-endometriosis gynecological surgery.
“This study demonstrates, for the first time, that laparoscopic surgical treatment (excision) of endometriosis leads to improvement of endothelial function, with a consequent reduction of cardiovascular risk of women with endometriosis.”(8)
The investigators have established that the improved vascular ability to dilate are:
“…related to inflammation reduction after surgery, since both inflammation and endothelial activation serological markers reverted to values similar to controls. In particular, we can hypothesize that surgical excision of endometriosis lesions entails removal of the main source of inflammation; with regard to the observation that, in endometriosis, inflammatory processes are also linked to pro-inflammatory cytokine production by ectopic endometrial cells themselves.” (8)
It’s vital for medical providers to understand, despite a lack of traditional cardiovascular risk factors, inflammation associated with endometriosis, secretions from their lesions and now, evidence which suggests a shared genetic origin for both diseases require greater depth of counsel to patient’s. Full disclosure of ALL benefits and potential harms of each treatment and acknowledge the majority of interventions for endometriosis may contribute to cardiovascular disease.(9,10) It should also be recognized that their impact may occur at a sub clinical level for years. Women with endometriosis with early vascular wall dysfunction prior to development of atherosclerotic disease demonstrate significantly more ‘arterial stiffness’ than women without endometriosis.(7) The validation of FMD and baPMV measurements that reliably detects early vascular wall dysfunction and sub clinical atherosclerosis is a tool for closer monitor for early changes associate with CVD.
The relationship of endometriosis and cardiovascular disease must contribute to the prudence in selection of treatments. If data is true about the presence of endometriosis in the body and advancement of cardiovascular disease among these persons, it makes economic sense that an option for excision of lesions should be given. The enormity of healthcare burden, worldwide from cardiovascular disease, as the number one morbidity and mortality among females – even a portion of the estimated 10% of women with endometriosis in which CVD can be reduced or prevented with removal of endometriosis from their bodies is staggering to think about. Not only to remove the disease but also to improve the overall well-being of the individual whom may be able to integrate better exercise tolerance, earn wages and afford a more nutritious diet and lower stresses.
What we do and do not know about endometriosis, treatments and CVD:
- We KNOW At Least an Association exists between the presence of endometriosis lesions and cardiovascular disease
- We KNOW hormone suppression DOESN’T remove or stop disease.
- We KNOW hormone suppression reduces/ceases production of estrogen from the primary organ (ovary).
- We KNOW estrogen is protective for heart and vascular injury and repair.
- We DONT KNOW the likelihood for ovarian production of estrogen to return following various durations and doses of hormone suppressants.
- We DO KNOW that the lesions are STILL PRESENT in the body during and after hormone suppression.
- We DO KNOW the use of pharmaceutical agents to Diagnose endometriosis is NOT sensitive NOR selective at acceptable levels.
- We DO KNOW ablation surgery only penetrates 1-2mm depth. Ablation, cannot be applied to all areas where endometriosis may be present. The procedure creates inflammatory debri AND the endometriosis lesion remains in the body (and may be active).
- We DO KNOW excision surgery removes endometriosis lesions from the body. Skilled removal there is no residual debri or active tissue left behind. Excision removes the SOURCE of inflammation and contributing factors of cardiovascular disease.
The person sitting in front of you in the office with endometriosis may not be under your care in a year, decade or more. However, the treatments you offer and information you disclose about the pros and cons of each available intervention, can significantly impact this person Today AND Tomorrow. It’s very hard for all who provide medical care to consider implications of a treatment implemented Today that Can Contribute to life-altering cardiac and vascular concerns Tomorrow. As the relations between endometriosis, cardiovascular disease and treatment options gains more clarity, it’s with hope that prudence in selection of treatment approaches for Today’s concerns of endometriosis AND their potential impact on Tomorrow’s cardiovascular disease are routine. That tomorrow may not be far off for many. Isn’t it time to join the modern world? Lets cut to the chase. Why does the treatment of endometriosis continue around the roundabout (Blog 5)? Off in the horizon, the potential to significantly lower mortality and morbidity awaits. Not for one, but two disease processes. The fact that heart disease is the number one killer of women across the globe AND about 10% of the worlds female inhabits have endometriosis. Do the math.
A.) Expand on recent studies for the effect of endometriosis excision and risk factor for cardiovascular disease, to include measurement values of early vascular wall dysfunction and subclinical atherosclerotic disease.
B.) Investigate the relationship of the secretive properties of endometriosis lesions and endothelial wall disruption and restorative dysfunction.
C.) Mandate multi-year follow up on all drug trials. In addition, require data collection of cardiovascular disease risk factors, to include measurements of sub clinical atherosclerotic disease (using FMD and/or baPWV), blood pressure, circulating cholesterol levels (LDL’s & HDL’s). All pre/post experimental values compared as:
- ) experimental group vs control group collective
- ) between age groups of the experimental group
- ) between the same age group of experimental vs control
- ) disease stage.
D.) Mandate all drug trials require multi-year follow to determine long-term impact of hormone manipulation and suppression of ovarian estrogen production to establish the probability of full ovarian reserve and variations from 100% pre clinical testing.
Speaking for 176 million +
Trish (October 25th, 2019) Tweet Trish’s Blog
2.) Endometriosis and atherosclerosis: what we already know and what we have yet to discover. Clinical Opinion. Gynecology. AJOG. April 2015. Sanotor L et al.
3.) Endometriosis and Risk of Coronary Heart Disease. Circ Cardiovasc Qual Outcomes. 2016;9:257-264. Mu F., Rich-Edwards J, Rimm EB, Spiegelman D, Missmer SA.
4.) Hysterectomy Associated with Long-Term Health Risks. American Journal of Nursing. 2018;118(4):16. Potera C. .
5.) Endometriosis: Final Evidence Report- Elagolix for Treating Endometriosis. Institute of Clinical and Economic Review. https://icer-review.org/material/endo-final-evidence-report/ Release date: August 3, 2018.
6.) Increased asymmetric dimethylarginine and enhanced inflammation are associated with impaired vascular reactivity in women with endometriosis. Atherosclerosis.2011;219:784-788.
7.) Arterial Stiffness is increased in young women with endometriosis. J Obstet Gynaecol.2015;35(7):711-715. Tani A et al.
8.) Regression of endothelial dysfunction in patients with endometriosis after surgical treatment: a 2-year follow-up study. Gynaecology Hum Repro.2014;29(6):1205-1210. Santoro L et al.
9.) Rahmioglu N, Nyholt DR, Morris AP, Missmer SA, Montgomery GW, Zondervan KT. Genetic variants underlying risk of endometriosis: insights from meta-analysis of eight genome-wide associations and replication datasets. Hum Reprod Update. 2014;20:702-716. doi:10.1093/humupd/dmu015. As reported in: Endometriosis and atherosclerosis: what we already know and what we have yet to discover. Clinical Opinion. AJOG. April 2015. Sanotor L et al.
10.) Uno S., Zembutsu H, Hirasawa A, Takahashi A, Kubo M, Akahane T, Aoki D, Kamatani N, Hirata K, Nakamura Y. A genome-wide associatoin study identifies genetic variants in the CDKN2BAS locus associated with endometriosis in Japanese. Nat Genet. 2010;42:707-710. As reported in: Endometriosis and atherosclerosis: what we already know and what we have yet to discover. Clinical Opinion. AJOG. April 2015. Sanotor L et al.
Last month (September 2019) the WHO released an updated chart to categorize your risk of CVD based upon a compilation of risk factors and occurrence of MI/CVA resultant in death across 21 global regions. An Risk Chart is established for each region of tbe globe. https://www.who.int/news-room/detail/02-09-2019-who-updates-cardiovascular-risk-charts
National Institute of Health Category Spending (Annual) Estimates of Funding for Various Research, Condition and Disease Categories (RCDC))
Blog #5 Endometriosis: stuck on a roundabout
If you’ve seen the movie National Lampoon’s European Vacation you may recall L’Arc de Triomphe roundabout (traffic circle) scene. If you haven’t seen or remember it, let me fill you in. The Griswold family departs America and arrives in Paris, France. The dad rents a car. They decide to drive the streets of Paris. Along the route, they enter the roundabout at L’Arc de Triomphe. Once they enter it, they can’t get off. They spend the rest of the night going around and around. They see the same sights over, and over, and over again.
When it comes to research and treatment for endometriosis, it’s the same thing. Those with authority and status to direct innovation and progress, all gathered in a Citreon, circling L’Arc de Triomphe. Over and over and over again. Their intentions appear good: to explore disease pathogenesis and expand treatment options, but are built on the same information that has been debunked. Driving on the same roads, previously tracked will not allow full exploration in a new city.
For the Griswolds, it’s a single night stuck on a roundabout. For the endometriosis community, passengers in the car, we’ve been stuck on that roundabout, driven by decision-makers, for DECADES. Passengers. Captives. At the mercy of the drivers. But why can’t we get off the roundabout? From where I sit, I have a few theories: they either don’t have the skills to exit the roundabout, understand the rules of the road and prioritize the needs of the most important stakeholders, or lack vision and ability to explore unfamiliar roads in a foreign land. We continue, around and around, no indication we’ll ever get off.
It’s maddening. Exposed to the same scenery over and over. In the world of endometriosis, that scenery is hormone suppression and ablation. Those committed to improve education, awareness and implement advanced skill set steeped from training beyond residency, are passengers and captives. We’re stuck in a system that continues to use the same methodologies for medical management ‘advances’, analysis of disease pathogenesis, descriptions of disease and care standards.
Methodology that is simply history repeating itself. Meanwhile, we, the passengers, are those with the disease, advocates and providers whose caseloads are nearly or all persons with endometriosis…we, and the generation before us, have not, and cannot, wait patiently for the drivers to finally exit the roundabout.
We may be passengers but we haven’t sat quietly. Those before us and today raise our voices in dissatisfaction for the quality of care, stagnation of innovation, concerns for the effects of current treatment standards and failure to acknowledge another surgical option to treat the disease. There have been petitions and protests. There have been requests to participate in development of policies and treatment standards for individuals with endometriosis. There have been requests to acknowledge body-wide disease and establish guidelines with multidisciplinary surgical as care standard.
Maybe those driving are too focused on disease of the reproductive system. They are, after all, obstetricians and gynecologists. However, the professional background of many drivers do not include significant degrees of endometriosis focused patient care, particularly complex disease that has invaded multiple body systems. We have drivers who haven’t endured the grand number of hours advancing their knowledge and surgical skills to methodically remove the disease from the body. Those drivers who do have interest in the disease are commended for their efforts in the laboratories. However, their limited number of hours in the operating room: treating multi-organ, multi-system complex endometriosis does not seem a comparable trade off to the hours spent in the laboratory where the conditions surrounding endometriosis lesions, or their components, are controlled. Many drivers continue to use Sampson’s Theory of Retrograde Menstruation as the backbone of their laboratory work. How much longer is endometriosis going to be stuck in the same lane? Are we ever going to get off this roundabout? Maybe the driver’s cant get off, but their passengers certainly can and are.
The passengers can no longer continue to wait. There is a change of direction that has been building. The thing is, its not the drivers who are steering. Its the passengers.
The digital age has bolstered passengers to build awareness and educate our community about all aspects and management of the disease. All aspects include extrapelvic disease.
Passengers are looking beyond the long-standing perception of endometriosis as a disease confined to the female reproductive system. Endometriosis can and does involve other body systems and organs. We are raising our voices. We are telling our stories. It’s time to stop labeling disease outside of the reproductive system as ‘rare’.
While the drivers continue to circle the roundabout with talks of hormone suppression, diagnosis without surgical confirmation and surgical ablation, passengers may be stuck in the car, but we’re on our laptops! We’re building and sharing knowledge, discussing and supporting each other.
Our numbers are growing. We meet in groups, search for and obtain validation from others with similar struggles. We flock to the few multidisciplinary surgical teams with the skills and knowledge to address disease throughout the body with excision. When we can get out of the car, we meet in person. We realize we are less frequent, but certainly not ‘rare’! Just because there is a lack of diagnoses for areas and frequencies of occurrence for many extrapelvic locations of disease, it does not equate to ‘rareness’. It equates to lack of acknowledgement and ignorance. Sad, but real, not all of us are able to travel and access surgery with a team of surgeons dedicated to excise endometriosis lesions body-wide (to include urinary, digestive, respiratory, cutaneous, peripheral nervous and muscular systems).
Where does this lead those with barriers to access surgical teams with excision skills? Back to the roundabout again; ablation and hormone suppression. A lack of innovation and ability to see beyond the roundabout leads drivers to more hormone suppression; despite evidence that every drug historically approved to ‘treat’ endometriosis have affected the same pathway (pituitary-gonads) and from the same drug classification. There is NO evidence the use of hormone suppression the shrinks endometriosis lesions or cures the disease.(1) Regardless of which hormone suppressant is used, “recurrence of endometriosis-associated pain after treatment cessation is common, even after the short follow-up times reported” was summarized from 29 studies.(1) The “mechanism of action of available treatments provide symptom relief only, and at the present there is no cure for the condition”.(2)
In addition, ablation (burning) of endometriosis lesions is <2 mm depth penetration, leaves eschar/surgical char/carbon deposits and active disease of deeper lesions.(3,4) Furthermore, lesions of non-reproductive organs (intestines, bladder, diaphragm etc) are often left untreated. This is where I make my case about the need to recognize that disease outside of the reproductive organs is not ‘rare’ and must not be left untreated. The fact is, imaging is not 100% sensitive or specific to detect endometriosis for all disease throughout the body. Furthermore, the ability to determine presence of deep and/or extrapelvic disease preoperatively can be a ‘gray area’. Hence, referral to a surgeon equipped with all the tools (advanced excision skills) reduces repetitive surgeries, healthcare costs, time off work and burden on the patient. Its vital to address ALL disease: superficial, deep pelvic and extrapelvic. Prepared with the appropriate skills is vital because “when endometriosis involves other organs, excision is the only surgical option”.(5)
Yet hormone suppression and ablation remain treatment standards, STILL! In addition, there is talk of changing the current diagnostic process for endometriosis. The current standard is direct observation and surgical biopsy confirmed histology. Despite inconsistent efficacy, there is talk about the use of hormone manipulation to diagnose endometriosis. I am gobsmacked at this idea! I know I am not the only person whom adversely responded to hormone manipulation and, based upon my clinical response with their use, would have been dismissed for endometriosis! It was bad enough to go three decades without a diagnosis. In my personal situation, a history of recurrent catamenial scapular and chest pain; catamenial pneumothoraxes and bowel and bladder symptoms are 95.9%,89.2% and 97.9% specific that endometriosis is present.(6) Yet despite all these, the general ob/gyn was convinced that my symptoms must diminish if I had endometriosis. This did not happen. Attempts with medical management escalated the rate and degree of disease activity!m
My story is not unique. There are many women who have been subjected to hormone manipulation as a ‘diagnostic tool’ for endometriosis yet these drugs have NEVER been approved for this purpose. And now, there is discussion to do just this.
Seriously! If the diagnostic pathway for endometriosis is modified to a non-surgical process with hormone manipulation as the foundation, I fear the number of women with endometriosis whom are dismissed of the disease. Yes, surgery has risks. But hormone suppression also has risks, and individual responses to their use is not consistent, along with unpredictable long-term side effects that cannot be determined prior to treatment intervention. The probability that persons with and without disease may not respond to use of hormone manipulation according to presence/absence of disease is a significant concern. Diagnosis and misdiagnosis without objective evidence normally acquired with direct observation obtained through surgery creates entirely separate concerns for potential malpractice with error in diagnosis, treatment and management.
There WILL BE those with endometriosis whose symptoms are not reduced with use of hormone suppression and there WILL BE those without endometriosis whose symptoms are derived from other conditions but relieved with use of hormone suppression.
The way things stand today, it appears those in the drivers seat are not interested in moving over. Until they no longer control the direction of research and treatment of the disease, it seems we, the passengers are being forced to endure an ill-fated journey. But, I feel a growing restlessness among my fellow passengers to push the drivers out from behind the steering wheel and set a new course.
On behalf of 176 million sufferers,
Trish (September 19th, 2019) Tweet Trish’s Blog
(1) Becker CM et al. Reevaluating response and failure of medical treatment of endometriosis: A systematic review. Fertil Steril.2017;108(1). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494290/
(2) Casper RF. Introduction: a focus on the medical management of endometriosis. Fertil Steril.2017;107:521-
(3.) Ledger W, Schlaff WD, Vancaillie GT (Eds). Chronic Pelvic Pain. Cambridge University Press. Dec 11th, 2014. pp 66-67.
(4.) Kochhar PK, Ghosh P. A Comparative Study of the use of different energy sources in Laparoscopic Management of Endometriosis Associated Infertility. WJOLS. 2011;4(2):89-95. doi:10.5005/jp-journals-10007-1123
(5.)Martin Healey, MD Claudia Cheng, MB;BS Harvinder Kaur, MB;BS. To excise or ablate endometriosis? A prospective randomized double blinded trial after 5 years follow-up. JMIG. 2014;21(6):999-1004. 10.1016/j.jmig.2014.04.002
(6.) Rousset-Jablonski C., Alifano M., Plu-Bureau G., et al.Catamenial pneumothorax and endometriosis-related pneumothorax: clinical features and risk factors. Hum Reprod.2011;26(9):2322-9. doi: 10.1093/humrep/der189.
Blog #4 Aquatic Therapy for Endo?
As a practicing physical therapist, my appreciation for the water developed from experience and outcomes of patients.
I was blessed to treat patients across a spectrum of diagnoses and functional abilities at inpatient and outpatient centers. Those I most worked with involved neurological (ie. stroke, brain tumors, spinal cord injuries, guillaine-barre syndrome, parkinsons disease) or orthopedic conditions (ie. spine and degenerative conditions, joint replacements and overuse injuries), but other diagnoses were mixed in (ie. COPD, complex comorbid conditions).
I never treated a person for effects of endometriosis in a water environment. That is, until, the practitioner became the patient.
Let’s first discuss the unique properties of water and their application to rehabilitation. Water is a wonderful medium that can restore, improve or maintain strength, flexibility, body awareness, agility, coordination, endurance, cardiac and respiratory conditioning; all while promoting emotional and physical relaxation. Water’s unique properties include: bouyancy, density, hydrostatic pressure, turbulence and viscosity.
Moving slowly through water requires less effort than on land. Thanks to buoyancy. Buoyancy makes us to float. To move faster through water, more effort is required. Unlike movement on land, water causes movements to stop when effort is discontinued. This occurs due to viscosity. A body’s shape and speed as it moves through the water determines the amount of drag produced. Faster the movement, greater the drag.
Practical Demonstration:Stand up. Start with your arms straight, and by your sides. Swing one arm (from the shoulder) forward then continue backward one time. Once the arm reaches as high as you can behind you, stopping using any effort to make your arm move. What happened?
Expected Result on Land: On land, when you stop using effort after your arm reaches its highest point in the air, behind your back; force of gravity, and pull of stretched tissues will cause the arm to move downward and pass forward of your body passively. The arm may continue to move in progressively smaller forward-backward pendular motions until eventually stopping alongside your body, where it began.
Now, lets perform the same motion, completely submerged under water. What do you think would happen?
Expected result under water: When effort is stopped as the arm reaches its highest point in the backswing, the absence of inertia (present on land) prevents the limb from continuing pendular motions of progressively smaller arcs before the limb comes to rest. This can be advantageous for those whose symptoms are easily provoked. The limb may remain fairly stationary, behind you, near the height of where you stopped using internal effort. If the stretch of tissues across the chest and anterior limb are taut enough, it may cause the arm to drift downward a small amount toward the starting position but would not be sufficient enough to create any pendular motions.
Another property of water is hydrostatic pressure. The deeper you are immersed under the water’s surface, the greater the forces of hydrostatic pressure on your body. Hydrostatic pressure contributes to an elevated work of the cardiovascular system and efforts of the respiratory system.
When the body’s immersed below the water’s surface, pressure from the surrounding water results in a greater amount of venous blood flow back to the heart than that on dry land for the same position or activity. Deeper immersion equates to greater venous return. In depth at the shoulders/neck, immersion can increase venous blood return to the heart by 35% compared to the same task on land.
As returning blood flow increases, the heart adapts by increasing its stroke volume. (Stroke volume – the amount of blood distributed to the body during a single heart contraction). An increased stroke volume is the primary accommodation for greater blood returning to the heart. As a result, much less change occurs in blood pressure and heart rate with exertion under the water’s surface.
As more deoxygenated blood returns to the heart and lungs, more oxygenated, ‘good blood’ is available to working muscles. Up to an addition 1/3 of available nutrients and oxygen is available to individuals who are submerged midchest-to-shoulder depth when compared to land. The amount of additional peripheral blood flow parallels the depth of immersion (ie. waist deep immersion provides less of an increase in peripheral blood flow when compared to chest deep).
A water program can be an adjunct to a land-based program in the management and treatment of endometriosis symptoms and post-operative reconditioning. The following is my own testimonial of water’s impact on symptom’s pre and postoperstive, and its properties as they relate to rehabilitation of the condition. As the ‘great masquerader’, we know endometriosis and its comorbid conditions have a vast presenttion. Hence, each person’s needs and appropriate interventions will differ accordingly.
The Physical Therapist as the patient:
I had an appreciation for the water environment as a Physical Therapist.
I have Love and Deep Respect for water. It began when endometriosis took away my ability to work, manage our home, cook meals and walk without pain. Water was an excellent adjunctive therapy environment. My water sessions complimented my land treatments to address pelvic floor, abdominal viscera, diaphragm, thoracic and myofascial restrictions with a Women’s Health Physical Therapist. For many months prior to, and following excision surgery, the pool was a reprieve. Before surgery, I couldn’t walk, sit, lye down or move from one position to another without sharp pains emitting from adhesions of my ribcage, liver, abdomen and pelvis, nausea, even an odd vomit.
Simply sitting below the water’s surface was relaxing, yet my cardiopulmonary system was challenged.
The water slowed my movements waaaaaay down; more than I had already slowed in the preceeding years. However, the reduced speed of motion, coupled with warm temperature and pressure of the water, dampened the pain I usually experience walking on land. The water invited me to M-O-V-E . The deeper the water, the more effort was needed to work. Increased effort was needed to overcome water’s viscosity and the drag induced when moving at greater speeds. Hydrostatic pressure and buoyancy reduced the loading impact and pain associated with adhesions and also ‘cushioned’ my internal organs during movements. The deeper I immersed, the more sloth-like I moved. But it was gooooood.
The normal pain I experienced walking on land was much gentler under water. The best part; I had more control! Control, and the lack of it; something familiar to those with endo. In the water, I had far greater control of symptoms attributed to adhesions, hypersenstivity, exposure of my digestive and urinary systems and irritation of disease of the respiratory system. Slowing of movements under water and dampened pain sensation gave me extra time to assess and adjust to symptoms. The water was a great micromanager of symptoms through movements that could only be macromanaged on land; particularly with the additional effects of brainfog and anxiety for unexpected pain dividing my compromising my attention.
Water, Nervous System and Desensitization:
The warm water and submersion prompted me to relax and move! My sympathetic nervous system, ALWAYS on overdrive from self-perpetuating aspects of the disease, took short-term hiatus during my water sessions. It was during these sessions my parasympathetic nervous system was most active; providing both short and longer term benefits. Water sessions gave me a ‘feeling of wellness’. By progressing depth, amount of turbulence and duration of these sessions over many months, my sympathetic nervous system gradually became less ‘jumpy’.
Like many others with endo, my tolerance to touch or pressure across my abdominal area was poor. It was difficult to wear anything around my midsection or rest my hand on my stomach without a wave of nausea or stabbing sensations. By adjusting how deep I immersed myself in the water, I controlled the amount of hydrostatic pressure the water emitted on my body. Some days sessions were shallow, other days deeper immersion.
In the long term, I was able to progress to deeper and longer immersion consistently. The effects: my skin and visceral organs desensitized to pressure. My brain stopped interpreting pressure variations across my abdominal skin and organs as ‘bad’ and the nausea resolved. My sympathetic nervous system settled down. (There are numerous aquatic therapy techniques beyond the discussion of this blog for desensitization, relaxation, flexibility ie. Watsu https://www.watsu.com/ )
Water, Digestive and Urinary System:
Deeper immersion and greater movements of speed and range also encouraged my slowed digestive system to move along a bit quicker and with less ‘stressful’ bowel movements (yeah!!! goodbye Mirilax!). I felt like I received a bonus prize!
In regards to the bladder, after facing numerous episodes of interrupted pool sessions to emptying my bladder (and, despite immediately voiding before starting each pool session), my bladder underwent ‘retraining’ for premature urgency to void before the bladder was adequately filled (overactive bladder). The water’s hydrostatic pressure added indirect additional force’s externally to the bladder. This, in addition to the water’s promotion of increased urine production through kidneys was an efficient method to reduce my urinary urgency. It was annoying early on, having to leave the pool within a session to to void, but, over a period of time this improved did not interfere with extended pool sessions.
Water, Fatigue and Chronic Fatigue Syndrome (CFS):
Struggling with heavy fatigue and inability to move on land, the water encouraged me to move. I was not unlike many with endometriosis. We often find ourselves close to a bed, sofa, recliner, or not far from home. Excision of endometriosis lesions often resolves the immense fatigue that often accompanies the disease. For some, degrees of fatigue persists. There are many non-endo variables which can contribute to fatigue (beyond this blog’s focus) and should always be explored (ie. anemia, dietary sensitivities/allergies, autoimmune or other medical conditions).
Among other conditions (ie. fibromyalgia), endometriosis has a higher association with Chronic Fatigue Syndrome (CFS) than the average population. For those who experience fatigue, (with or without CFS), the properties of water can provide benefits for those intolerant to most dry land activities. As water facilitates deliver of oxygen and nutrients to muscles, (through increased peripheral blood flow), the amount of time needed post-activity to recover is reduced. There are also concerns for the use of a water environment for some with CFS. Some may have difficulty exiting the water as the effects of gravity become immediate; have an inability to monitor for waning energy to safely exit the pool; respond adversely to water temperature or a busy pool environment. If there is consideration to undergo an aquatic therapy program, it must be discussed with your physician and initiated and applied 1:1 by a certified Aquatic Physical Therapist.
Scientific Note: Aerobic vs Anaerobic Respiration and Concentric vs Eccentric Muscle Contractions
Evidence suggests dysfunction of the aerobic system (Krebs cycle) among those with CFS. This equates to an reduced ability to create ‘ATP’. ‘ATP’ is the body’s ‘energy molecule’ used by muscles to create a contraction. During normal activity, when we are not ‘oxygen starved’, the body breaks down energy stores with oxygen to generate ‘ATP’. It is theorized that a person’s with CFS defaults to creation of ‘ATP; from the less efficient and productive anaerobic cycle. Unlike the aerobic energy production system, the anaerobic system is only designed for brief periods of time. As a result, fatigue sets in and the production of ATP ceases. A water environment provides ease of slow movement and concentric muscle contractions, both which require less consumption of ATP. With an inability to produce a continuous supply of ATP that would be generated through normal aerobic kreb cycle production, sedentary immersion in chest to neck depth creates an elevated respiratory demand up to 60% greater than experienced on land. The increased workload on inspiratory muscles provides conditioning and endurance.
Recall that buoyancy makes it easier to move under water. Water also creates an environment in which body uniquely moves through concentric muscle contractions. Concentric contractions are easier for the body to repair, recover and build muscle tissue, compared to eccentric muscle contractions. Movements under water are created mostly through concentric muscle contractions, unless resistive devices are used. On land, movement is created from both concentric and eccentric muscle contractions. Eccentric contractions create more metabolic by-products and damage to the skeletal muscles. Those with CFS have limited spoons. Literally.
Effect of water temperature and recovery rate:
If water temperature too warm, it can result in the muscles creating byproducts faster than the blood stream can remove it, despite the enhanced venous return and stroke volume water provides. The effect leads to earlier fatigue and slower rate of recovery.
I am three years removed from time when water was central in my life (since excision surgery). After I reached a functional level, I didn’t stop entering the water. For many with fatigue, the water is easier to tolerate for conditioning than land based activities.
Always the practitioner treating the patient-in-the pool, never expecting to be THE patient-in-the-pool. Like many role reversing experiences, it can be life changing.
A special note about hydrostatic pressure and the respiratory diaphragm:
As mentioned, hydrostatic pressure rises as depth of immersion increases. As pressure rises, the position of the diaphragm changes. With higher hydrostatic pressure, the diaphragm resting position becomes more dome-like (arched). These changes increase the ease and ability to produce greater contraction force of the diaphragm. As the primary muscle of respiration, the enhanced position of the diaphragm created through hydrostatic pressure forces augments stronger more efficient contractions for inspiration. Meanwhile, supplemental and accessory muscles of inspiration undergo increased resistance from water’s counterpressure on the chest wall. Up to 60% greater effort is necessary for the intercostal and accessory inspiratory muscles to contract when submerged to mid-chest.
With water’s ability to optimize the position and shape of the diapragm many activities can be incorporated from a dry land program with guidance. A carefully graded program can improve endurance of the diaphragm and intercostals without recruitment of accessory muscles (ie sternomastoid, pectoralis minor, scalenes etc) that are less efficient and contribute to postural imbalances. Progression from land based pelvic therapy program can be carried over to further neuromuscular training of the pelvic floor and diaphragm movement through the respiratory cycle. The incorporation of functional movements can be overlayed , with enhanced body awareness provided by the water.
A special note about Osteoporosis:
Those with osteoporosis (natural or surgically induced menopause or from exposure to GnRHa use) CAN benefit from Aquatic Therapy. Although Hydrotherapy (Aquatic Therapy) does not promote bone density, it does promote cardiovascular conditioning, strength, coordination and agility; necessary traits for balance on land. Improved balance equates to reduced risk of a fall. Reduced fall risk equates to reduced risk for broken bones.
“…aquatic exercise does have a fitness role in women at risk for,or with osteoporosis as there is considerable data that such programs would build strength and endurance, and there is generally an accompanying improvement in balance skills, self-efficacy and well being” – Bruce E. Becker (2009)
Those with osteoporosis should still be encouraged to participate in some form of weight bearing, resistance activities on dry land with a supplemental water environment program.
Is Water Therapy appropriate?
- When is hydrotherapy inappropriate? For those with an acute or unstable heart condition or chronic fatigue syndrome (congestive heart failure, recent heart attack or CFS episode) hydrotherapy should not be considered.
- For those with sensitivity to warm temperatures (ie multiple sclerosis) a pool program can be beneficial if operating pool temperatures are cool.
- For those with indwelling catheters or ostomy bags, discussion with your care team and an aquatic therapist on limitations or requirements for their management are necessary.
For those post-operative: surgical clearance (ie. hysterectomy – is vaginal cuff healed; surgical incisions/ drainage sites (ie chest tubes) fully healed or covered with waterproof bandages).
Trish (July 29th, 2019) Tweet Trish’s Blog
(Note: The content of this blog is for discussion and should not be substituted for consultation with medical provider)
Aquatic Therapy: Scientific Foundations and Clinical Rehabilitation Applications. Bruce E. Becker, MD, MS. Phys Med Rehab. 2009;1:859-872. 10.1016/j.pmrj.2009.05.017
A Randomized Clinical Trial of Aquatic versus Land Exercise to Improve Balance, Function, and Quality of Life in Older Women with Osteoporosis. Arnold CM, Busch AJ, Schachter CL , Harrison EL, Olszynski WP. Physiother Can. 2008 Fall;60(4):296-306. doi: 10.3138/physio.60.4.296. Epub 2008 Nov 12.
The real story about chronic fatigue syndrome. Eric Ries (Associate Editor: PT in Motion). PT in Motion. September 2017. https://www.apta.org/PTinMotion/2017/9/Feature/ChronicFatigue/
How Physical Therapists are getting it about Chronic Fatigue Syndrome (ME/CFS) The Workwell Foundation Pt. 1. Cort Johnson. Oct 10, 2017. https://www.healthrising.org/blog/2017/10/10/physical-therapy-workwell-chronic-fatigue-syndrome/
Blog #3: FHCS vs Endometriosis:
Endometriosis of the diaphragm and/or liver can be mistaken for what? An STD?
Late last year an article about Pelvic Inflammatory Disease (PID) and associations with endometriosis was discussed online in the FB Group: Nancy’s Nook Endometriosis Discussion and Education Group. The article led me to recall a discussion with my primary care provider a few years ago. That discussion came during an office visit while reviewing intra-operative photographs of extensive thick white adhesions and scarring of the right upper abdomen, liver and diaphragm.
I know I’m not the first woman approached by a medical provider about PID. The topic caught me off guard. I knew about Fitz-Hugh Curtis Syndrome (FHCS) and its relationship to Pelvic Inflammatory Disease (PID) from my graduate studies. I never imagined being questioned about my own intimate behaviors and choices.
Given the professionalism of my provider, and his rapid dismissal of the possibility, I was blessed not to face a barrage of questions with inquisitive tone and facial expressions other women have, and will experience. However, I did have brief, internal feelings of embarrassment, uncleanliness and shame even though my personal behaviors and actions have never been conducive to acquire a Sexually Transmitted Disease (STD). I also knew my provider was not passing judgment or perceived me in any way to suggest I was a risk taker with multiple partners. However, about a week after this recalled memory, I experienced a second incident that centered around lack of awareness and misconceptions of endometriosis.
Social media platforms are great methods to amplify information and newsworthy material. Regrettably they create equal opportunity to distribute erroneous information. A lot of users post or respond based upon their perceptions, which are created through their experiences and information they have received (accurate or inaccurate). Through social media, I reached out to a politician in regard to women’s health funding and deficiencies specific to endometriosis. A response from a member of the public stated the disease could be ‘cured’ with ‘moral behavior’ and ‘better dietary choices’. It was also implied, those with endometriosis are 100% responsible for developing the disease. I have no words for what I felt at the moment. But…I can do something.
The recalled memory of my experience with a medical provider and written exchange with a member of the public prompts me to raise awareness about diaphragmatic endometriosis. Specifically, endometriosis of the diaphragm should be a differential diagnosis among females who present with right upper quadrant abdominal pain (with or without referred pain to the right shoulder) and/or adhesions viewed with imaging or surgery at the diaphragm and liver.
Advocates continue to speak out to correct the myriad persistent myths and misconceptions that stigmatize and cause, not only physical harm through delay and appropriate care, but also mental and psychological harm. An average 7-to-10 year delay (for some, decades) to diagnosis is unacceptable. To add further insult to those with endometriosis, the absurd premise still perpetuated today; persons with endometriosis are 100% to blame for their disease. Uninformed members of society still perceive those with endometriosis ‘had it coming’ and ‘reap what they sow’ through lifestyle choices and experiences. Among the more common myths: amoral sexual behaviors, sexual abuse, poor diet, exercise and stress management. The majority of healthcare organizations, associations and societies continue to disperse outdated, inaccurate information, myths and misinformation that reinforce misconceptions. These are all issues which harm the well being of women with endometriosis.
It’s important to clarify that PID and development of FHCS has occurred in ways other than unprotected intercourse. A few other ways documented include: insertion of an IUD, post-renal transplant with mycoplasma hominis infection, tubal ligation and appendectomy.(1,2,3) Although FHCS is more common among young female menstruators, it has occurred in women post-menopause,(2) and among men.(4,5,6) FHCS-like adhesions can also occur with Systemic Lupus Erythrematosis, Familial Mediterranean Fever (FMF),(1,2,7) Peritonitis, Acute Cholecystitis and Carcinomatosis(5) can present with FHCS-like adhesions. Not all cases with FHCS have been able to determine its original cause. (5,6)
What exactly is FHCS and why should healthcare providers and the endometriosis community know more about it? (To continue reading: FHCS vs Endometriosis: Endometriosis of the diaphragm and/or liver can be mistaken for what? An STD? )
Trish (June 11, 2019) Tweet Trish’s Blog
Blog #2: Another Awareness Month comes to an end
For those in our community, awareness is not confined to one month each year. A full month is a blessing to pack endometriosis awareness activities, educational events and projects into. It’s also a slippery slope for many to stay within the allotted spoons available versus spoons used. Awareness Month challenges advocates to vigilantly pace spoon use. To ration spoons through an entire Awareness Month is a herculean feat that most of the general population is oblivious to. Advocates oft’ navigate their own health issues toward the goal of greater good for others and future generations. Knowing a monstrous number of spoons were expelled among our community throughout the month of March, looking back, was it successful?
How do we quantify success?
- If success equals progress with updated care standards and treatment guidelines, then No.
- If success equals recognition of extrapelvic endometriosis and inclusion among care standards, treatment guidelines and FAQ’s among governing organizations of Gyn, then No.
- If success equals the media getting the definition of endometriosis correct, then Yes and No.
- If success equals acknowledgement of Endometriosis Awareness Month by the American College of Obstetrics and Gynecology, then No.
- If success equals an increase in financial resources for endometriosis research, if a ‘a wee bit’ is acceptable, then Yes. Elise Courtois, PhD ; Dr. Holly Harris
- If success equals the development of updated medical school curriculum about endometriosis, then No.
- If success equals the recognition of ‘excision’ as Gold Standard surgical treatment for disease, then No.
- If success equals recognition of endometriosis as a specialty (with established criteria of didactic, clinical and surgical skills for certification), then No.
- If success equals an increase in the number of grassroots patient advocates, groups and organizations with activities/events independent of pharmaceutical investment or influence, then Yes!
On that, we still have a lot of work to do. Work which will not wait until next March to begin again. Work which many, many unacknowledged persons use their precious spoons to address. What IS beautiful and successful…the rising up of those with this disease helping others with this disease.
All of our awareness events and projects have common purpose: provide correct information, acknowledge the battle, and through the use of various platforms and mediums, those without the disease have opportunity to feel and sense a little of our world.
Those with endometriosis are finding, and using their voices, telling their stories, less in isolation and more in collection. Expunging old myths, raising awareness to disease diversity, its potential for body-wide lesions and systemic dysfunctions.
‘Voices’ this month were raised in the form of public marches; a town hall meeting The Endometriosis Summit (video of event can be accessed at Lumenis FB Page ); educational and social gatherings in our communities across the globe; screenings of the documentary ‘Endo What?’ (Endo What?); art exhibitions (Beyond Invisible Art Exhibition ); journalism (How to support a loved one with endometriosis); provision of testimony to state and local governments (Endometriosis Advocates approach government officials about women); and release of a new publication (for those with endometriosis by those with endometriosis)! These are only a sampling of accomplishments this month.
What’s exciting about this new publication? FemTruths: Endometriosis Edition-Collection of Stories from Courageous Women (Editor: Silvia Young). It is the first in a series of personal, short stories and artwork from those with endometriosis. Stories gathered from around the world; This is the little-book-that-could. Within its pages, the reader is exposed to the parasitic nature of endometriosis on the human experience. The written thoughts and artwork powerfully portray reality of life with this disease. Unless you, or someone you care for has endometriosis, what you were told and thought you knew, are outdated, inaccurate or only a small portion of the disease. (Spoiler alert: among the books pages, includes the evolution of Trish).
As another Endometriosis Awareness Month has closed, our community remains the underdog. With limited resources to draw attention around the injustices we continue to endure, fighting for what is right, remains a driving force among our community.
But Wait…Today, the air stirs with a sense of unrest and forming cohesion. This is good. It is the continued injustices that give cause to why, “Still I Rise” – Maya Angelo
Trish (April 4th, 2019) Tweet Trish’s Blog
A serious flaw in the medical knowledge systems: when information is wrong, starting at the top.
We learn about our world through experiences; what we experience firsthand, read and watch streamed through various information and ‘quasi’ information platforms. Some is ‘self-selected’ and some is ‘spoon-fed’ to us with others controlling the content and direction of a given topic.
This is not limited to news organizations. Entertainment outlets attempt to share ‘important information’ as well, watered-down for appeal and easy reading. Unfortunate, but not unexpected, this often results in a product that is far from accurate. But what happens when authoritative ‘sources’ – presumed to be ‘gold standard’ are also out-dated?
Sadly, women’s health, THE most underfunded, neglected specialty, yet most important to ensure continuation of a healthy species, remains captive to the patriarchy and prisoner to the for-profit and personal interests of those who dictate the course for progression. The sub specialty of endometriosis has experienced almost no progress for decades. To wit:
I recently read an article in the Journal of American Medical Association (JAMA), THE journal most healthcare practitioners in America consider ‘Gold Standard’. Indeed, Jama states they are “the most circulated journal in the world with more than 320,000 JAMA recipients of the print journal, 1.2 million recipients of electronic tables of contents and alerts, and over 20 million annual visits to the journal’s website.” Unfortunately, the feature presented to the vast audience of practitioners, policy makers and members of the public was of the poorest quality [Peiris, AN, Chaljub E, Medlock D Endometriosis. JAMA.2018;320(24):2608] . As such, a response was necessary. Importantly, the premise of my response was not to attack the authors. Rather I sought to raise awareness on the pandemic proportion of misinformation that continues to plagues our knowledge systems at a time of ‘Evidence Based Medicine’.
It was with high hopes that this prestigious journal, with a massive following, would accept my Letter of Response to the article ‘Endometriosis’. Today I received notice, however, that the editorial team denied my submission on the grounds that it lacked ‘high enough merit’. They also cited less pertinent concerns (ie. ‘limited space’). The Response Letter can be read here: letter of response to jama.
As a writer, I expect denial. As an educated advocate, witnesses to the numerous injustices those with endometriosis continue to face year after year, for decades while other areas of healthcare evolve, I feel hostage to the system that revolves around the daily onslaught of misinformation that starts from the very top.
It is a system with intent to provide the most accurate information yet, those within the very system itself are blinded to the misinformation they promote. Perhaps they are aware of the concerns yet perceive the topic endometriosis – insignificant. Or perhaps, in the paltry 400 word limit, they allow, I should have used ‘shock and awe’ in my Letter of Response highlighting the destructive nature of endometriosis beyond menstruation. Destruction that includes kidney death, bowel obstructions, collapsing lungs and coughing up blood – conditions still perceived as ‘rare’, when in fact, they are not.
The plethora of injustices and complications which can occur with endometriosis provides endless topics for a writer. Unfortunately, always having to be the ‘reactor’ and ‘put the flames out’ within a tiny envelop to work in makes the mission of an advocate far more difficult than it should. When the system blindly gives a platform where millions of readers will access inaccurate information, I ask the system, when will we, as advocates and survivors, be given the equivalent platform to share accurate information?
Trish (January 29, 2019) Tweet Trish’s Blog
Thoughts? Please leave any comments below.
All Rights Reserved © 2019 Wendy Bingham, DPT. Extrapelvic Not Rare