March 2015

Review of Permanent Birth Control Options

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Margaret Aranda 2015

Ladies, here is a typical scenario of a happily-married couple with two children, who now desire permanent sterilization. They do not want children any more; she does not want a pregnancy now, nor in one year (i.e., the FDA’s definition of “permanent”). She and her husband want no more kids.

What are their options? Bilateral Tubal Ligation (BTL)? What is Tubal Ligation Syndrome? Does she take out her ovaries? Why can’t the man just get a vasectomy? Fifteen percent of men do. One study shows that a man undergoing vasectomy at a young age may lead to a more aggressive form of prostate cancer later in life. Not an option, young men.

For women, starting from the least “invasive,” to the most “invasive” (and not meant as a comprehensive list or as medical advice or treatment; most doctors would say that you need to talk this over with at least 2 doctors), here is a general outline of permanent birth control choices.

Things to remember as you review the possibilities of permanent birth control:

  1. Speak up and ask questions! These are not easy decisions and the choice you make will impact the remainder of your life. Do not let anyone make this decision for you.
  2. Understand all of the risks associated with the procedure you choose. Compare those to the risks associated with alternative options, including the option of not having the procedure done.
  3. Always seek a second opinion; and sometimes third and fourth opinions.
  4. Use social media to talk to other women who have gone through the procedure.

Bilateral Tubal Ligation (BTL) for Permanent Birth Control

Bilateral tubal ligation or BTL is the most common method of family planning for permanent birth control with up to 33% of married women worldwide opting for this method.

A BTL is best performed during or up to a few couple days after childbirth, when the uterus is still swollen, and the Fallopian tubes are just under the skin. There are many different types, all requiring spinal anesthesia for optimal pain control and patient satisfaction.

Bilateral tubal ligation involves surgery to block the fallopian tubes and prevent the ovum (egg) from being fertilized. BTL can be done by cutting, burning or removing sections of the fallopian tubes or by placing clips on each tube. It is 99% effective after the first year.

Risks Associated with Bilateral Tubal Ligation

Over time, the tubes can reconnect. This happens with 15 – 20% of BTLs performed. When the fallopian tubes reconnect, it is possible for the woman to become pregnant. This can lead to a tubal or ectopic pregnancy.

A tubal/ectopic pregnancy is a life-threatening condition that warrants immediate attention.

With an ectopic pregnancy, the fertilized egg remains in the fallopian tubes rather than implanting in the uterus. It cannot survive in the fallopian tube and without immediate surgery; the mom is at risk for bleeding to death. Emergency surgical removal of ectopic pregnancy is warranted.

Take heart, as you are NOT killing your baby. As an anesthesiologist against abortion, I have had many religious discussions with many concerned women. I assure them that I have never given anesthesia for an elective abortion because I think it goes against the Hippocratic Oath. I have only given anesthesia to SAVE THE LIFE of a mother with a tubal pregnancy. We usually pray before going into the operating room and the anesthesiologist gives sedatives. The patient should have no memory of even being in the operating room.

In addition to the risk of ectopic pregnancy, there are additional side effects and contraindications to consider with this form of permanent birth control. One of the most common ‘side effects’ is a set of symptoms called post-tubal ligation syndrome. The symptoms associated with post-tubal ligation syndrome include: increased menstrual bleeding, decreased libido, fluctuating mental health, and more pronounced PMS, abdominal pain, some leading to hysterectomy, and more. The validity of the symptoms associated this syndrome have been fodder for scientific debate for decades and decades. The research is mixed.

In 2005, Shobeiri et al (2) showed in 112 post-Pomeroy BTL patients vs. ‘normal’ patients that menstrual abnormalities did not differ. However, women in two age categories experienced statistically more uterine bleeding: ages 30 – 39; and ages 40 – 45. In 2011, Moradan et al studied 160 women, finding no changes due to BTL (3).

Although there may be an increased rate of hysterectomy due to increased menstrual bleeding after a BTL, nowhere in the medical literature can a biologic correlation be found as the culprit, except with the decrease in hormones produced after an oophorectomy. However, talk to individual women, glance through Facebook and other social media sites, who have had tubal ligation and developed post-tubal ligation syndrome, and see that these women are hurting and suffering. Their stories should be considered as one contemplates this form of permanent birth control.

For my part, perhaps what we need now is a study that includes an n > 10,000, since the rate of hysterectomies is so high in the United States.

Reversing Bilateral Tubal Ligation

Reversal of BTL requires microsurgery, and a fertility specialist may be consulted. Remember to get 2nd Opinions on any surgery, and take someone with you. It makes the most sense to go to a surgeon who does this frequently, rather than go to a surgeon who does this infrequently.

Surgical Methods for Tubal Ligation

  1. Bipolar Coagulation: cauterizes portions of the fallopian tubes
  2. Monopolar Coagulation: same as (A) + radiating current for more damage + cutting the tubes at the end
  3. Fimbriectomy: takes a part of the fallopian tube that is closest to the ovaries, preventing the tube from accepting an egg, and therefore from fertilization
  4. Irving Procedure: two ties are placed at a length on one fallopian tube; then the tube is cut between the ties, and sewn to the back of the uterus
  5. Tubal Clip: metal tubal clips made by Fishie(R), or Hulka (R): smashes the Fallopian tube shut, so the egg does not pass from the ovary to the uterus
  6. Tubal Ring: with a silastic Band or Tubal Ring, the Fallopian tube is doubled up and then surgically placed to clamp it shut
  7. Pomeroy Tubal Ligation: often referred to as having the Fallopian tube “cut, tied, and burned”
  8. ESSURE(R) Tubal Ligation*: Nickel-plated and fiber coils are screwed into each Fallopian tube through the vagina, under spinal anesthesia or pelvic block. An immune response is desired, causing inflammation and scar tissue, blocking the tube from receiving sperm. The FDA states that “permanent,” specifically with Essure(R), is “one year or more.” Controversy surrounds this metal device implant, which has been known to lead to side effects in individual patients (including but not limited to): breakage of coils into pieces; tubal pregnancies; perforation (i.e., poking a hole through) of the coils through the fallopian tubes; perforation of the uterus or colon; infants born with the coil going through the upper ear; colonic-vaginal fissure (a space or track leading from the colon to the uterus, whereby E.Coli stool can be passed through the vagina); hives; abdominal pain; back pain; hysterectomy, and more. For more information about Essure, see my article on Hormones Matter.
  9. Adiana Tubal Ligation: It is very interesting to note that Adiana Tubal Ligation is no longer used, due to a 2012 lawsuit and judgement announced by Conceptus(R) (the developer of Essure(R) procedure), against Hologic, Inc. (4).

Hysterectomy (LAP- HYS) for Permanent Birth Control

In the USA, women over age 45 have a 40% chance of having a hysterectomy. At 70 years of age, 70% have had a hysterectomy. One study showed 50% of hysterectomies were unnecessary upon 2nd Opinion; the other found that 90% were unnecessary.

Usually, the procedure is done as a laparoscopic procedure, where little slits in the abdomen are used to push in CO2 gas, blow up the belly, and insert instruments to cut and chop the uterus out. The risks of general anesthesia include vomiting, aspiration pneumonia, death, tooth chips or tooth breaks, heart attacks, and a multitude of complications. Your specific risk factors should also be explained to you in common language. Plan to have “referred” shoulder pain to your scapula; and to wear jogging pants for weeks before your belly shrinks down to size.

Hysterectomy with Morcellation

In addition to the risks of hysterectomy and anesthesia, the morcellator adds additional risks. The morcellator is almost like a vacuum machine that follows the ‘carpet’ of the uterus in a line, while water is slurped over it. It essentially turns the uterus into one long piece to remove it. The problem with morcellation is that it spreads potentially diseased tissue throughout the abdominal cavity.

It is impossible to know if the fibroids or other uterine growths common among women undergoing hysterectomy are cancerous or otherwise diseased prior to surgery. When the morcellator is used, the risk of spreading cancer increases. What once was Stage I (baby) cancer is now Stage IV (monster) cancer all because the surgeon whizzed that morcellator throughout the abdominal cavity.  For more information about problems with morcellation, read (5) and (6). The odds of having an undetected cancer may be 1:350. A newly published cohort study of 41,777 women shows there may be a link wherein younger women are less apt to have an underlying cancer before a myomectomy to remove fibroids with the morcellator, and keep the uterus intact (7). Elderly women may be at highest risk for a precancerous or a uterine cancer to be found.

Hysterectomy: What to do about the Ovaries

When considering a hysterectomy either for permanent birth control or for health issues, it is important to understand the role of the ovaries in women’s health. Some physicians will push for the prophylactic removal the ovaries under the auspices of protecting women against ovarian cancer (risk = 1.7%). The argument often includes a ‘we’ll be in there anyway; we might as well remove them’. This is not an acceptable rational for oophorectomy/ovary removal.

“Ovarian conservation” refers to the view that the ovaries belong in the pelvis, and are not to be taken out during a hysterectomy, if possible. There are risk factors for ovarian cancer in my book, so you assess your own risk at home. When considering hysterectomy with or without ovary removal, remember that this is an individual decision for each woman.

When we conserve the ovaries, hormone synthesis and secretion to continue. Ovaries can secrete hormones like estradiol, progesterone, and testosterone for up to 15 years after a hysterectomy, so ladies, they are NOT just decorations. The ovaries are an endocrine system in their own right. They protect against bone injury, fractured hips, memory loss, heart disease (America’s #1 killer), and more.

However, even with ovarian conservation, hormone issues arise. When the ovaries lose communication with the uterus as it disappears, the biofeedback loops between the uterus and the ovaries are lost. Ladies, we are living shorter lifespans for the first time in history. Men, on the other hand, are gaining lifespans. So put down that fried chicken and eat a salad. And keep your ovaries, if you can. 2nd opinion, again.

Hysterectomy with Oophorectomy (Ovariectomy; LAP-HYS with Oophorectomy)


OK, so your surgeon says you have to have “it all” taken out: uterus, both Fallopian Tubes, and both ovaries. You are at high risk for ovarian cancer, confirmed by a 2nd Opinion. After the surgery, you will be in full-on, surgical menopause, overnight.

With oophorectomy, you will be in surgical, menopausal “shock.” You don’t get 10 – 15 years for the ovaries to gradually lose their ability to secrete hormones. Nope. Just jump in a cold pool. “Surgical shock” involves hair loss, hot flashes, pain during intercourse, memory loss, depression and guilt, irritability, inability to sleep with sometimes severe insomnia, lashing out at your loved ones, decreased libido, among other symptoms. So check out the situation yourself; this is a monumental decision, not a small one. Find your Risk Factors for ovarian cancer in my book, and check off where you are. In my opinion, you should not get an oophorectomy unless you are at risk of ovarian cancer.

For me? No thanks. I’m keeping my ovaries. What if we removed testicles in men prophylactically? Do you think they would SPEAK UP? So ladies, just SPEAK UP!

Permanent Birth Control for Men: Vasectomy

One permanent birth option lays the burden upon men. Vasectomy is the surgical procedure that ties and seals the male vas deferentia, preventing sperm from reaching ejaculate, effectively preventing insemination. It is a popular method, with 15% of American men undergoing vasectomy.  Its effectiveness is near 100% after a brief period of time. However, it is not without side effects. The most concerning is a correlation between vasectomy and prostate cancer. Prostate cancer is the second most common cause of death in American men, making this a Public Health issue.

Researchers here studied over 49,000 men for 24 years or less. 6,023 cases were diagnosed as prostate cancer, with 811 lethal cases. One fourth of all men had a vasectomy. Overall, the risk for men with a vasectomy having prostate cancer later on was 10%. And it wasn’t low-risk prostate cancer that was the association; it was an advanced risk of (20%) and lethal (19%), respectfully. Of men who had a regular PSA checked, a 56% chance of lethal prostate cancer was found, especially if the vasectomy was performed at a younger age (8).

To summarize this study, out of 49, 405 men studied over 24 years, 16 in 1,000 men were found to have lethal prostate cancer. Although statistically significant, it only translated to a “relatively small increase in absolute difference” for risk of prostate cancer.

There are also concerns about an increased risk of dementia in later life for men who have had a vasectomy. Though this and other risks have been disputed. So, the decision is a personal one to be discussed with the patient and a 2nd Opinion physician, weighing the risks and benefits.

The Final Decision Rests with You and Yours

Whatever you decide, do the research first and make a decision that you are comfortable with. If have already undergone permanent sterilization and suffer side effects affecting quality of life, you are not alone. Speak up and speak out so that other women can make their decisions with all of the evidence in front of them.

We cannot change the past, but we shall change the future. Our mothers wanted things to be better for us than they were for themselves…and what do we want? We want things to be better for our daughters and their daughters, too. I have a daughter. I wrote a book covering all these issues (and more) for her, because everyone thought I was going to die.

At a recent doctor’s appointment, the receptionist smiled at me not because she remembered me, but because I was still alive. My work, my book (9) is my legacy to my daughter, and therefore to you.

Still bedridden after 9 years, I am fighting to change the course of women’s healthcare. How much more can YOU do? Aim high. Persevere. And make me proud.

References

  1. Wikipedia: Tubal Ligation. http://en.wikipedia.org/wiki/Tubal_ligation. Last reviewed March 7, 2015.
  2.  Mehri Jafari shobeiri and Simin AtashKholii. The risk of menstrual abnormalities after tubal sterilization: a case control study BMC Womens Health 2005 Online May 2. doi: 10.1186/1472-6874-5-5
  3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112604/ Last reviewed March 7, 2015.
  4.  Sanam Moradanand Raheb Gorbani.. Is Previous Tubal Ligation a Risk Factor for Hysterectomy because of Abnormal Uterine Bleeding? Oman Med J.  2012 Jul; 27(4): 326-328. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464743/ Last reviewed March 7, 2015.
  5.  Nasdaq GlobeNewswire. Conceptus ® Announces Settlement of Patent Infringement Lawsuit with Hologic. Source: Conceptus, Inc.  http://globenewswire.com/news-release/2012/04/30/474765/253823/en/Conceptus-R-Announces-Settlement-of-Patent-Infringement-Lawsuit-With-Hologic.html   April 20, 2012. Last reviewed March 7, 2015.
  6.  Matthew Bin Han Ong. Harvard Physician, Whose Cancer was Spread through Morcellation, Seeks to Revamp FDA Regulation of Medical Devices. The Cancer Letter. July 3, 2014. http://www.cancerletter.com/articles/20140704_1 Last reviewed March 17, 2015.
  7.  Amy Orciari Herman. Cancer Risks from Uterine Morcellation Examined. NEJM  Journal Watch. February 7, 2014. http://www.jwatch.org/fw108455/2014/02/07/cancer-risks-uterine-morcellation-examined Last reviewed March 17, 2015.
  8.  Wright JD, et al. Use of Electric Power Morcellation and the Prevalence of Underlying Cancer in Women who Undergo Myomectomy. JAMA Oncology February 19, 2015. http://oncology.jamanetwork.com/article.aspx?articleid=2118570 Last reviewed March 17, 2015.
  9.  Mohammad Minhaj Siddiqui, Kathryn M. Wilson, Mara M. Epstein, Jennifer R. Rider, Neil E. Martin, Meir J. Stampfer, Edward L. Giovannucci and Lorelei A. Mucci Vasectomy and Risk of Aggressive Prostate Cancer: A 24-Year Follow-Up Study. Journal of Clinical Oncology; Published online before print July 7, 2014, http://medicalxpress.com/news/2014-07-vasectomy-aggressive-prostate-cancer.html  doi: 10.1200/JCO.2013.54.8446. Last reviewed March 7, 2015.
  10. Margaret Aranda, M.D. Archives of the Vagina: A Journey through Time. Tate Publishing, 2014. https://www.tatepublishing.com/bookstore/book.php?w=978-1-62854-116-8  Last reviewed March 18, 2015.

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Endometriosis Plus Lyme Disease: A Horrible Combination

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Amber Evans

I am 30 years old and have been sick most of my life. That is something that is hard to wrap my brain around sometimes. So I just try to look to my future.  Having both endometriosis and an autoimmune disease has been very hard to come terms with over the years. It was especially difficult over the years I spent going from doctor to doctor being told there was nothing wrong with me, that it was all in my head and to seek help elsewhere. But where? If I listed all the doctors I have seen since I was a young child, it would be quite a long list. I know many sick women who have been on the doctor rollercoaster. I am lucky that I have had my parents and my best friend, who is like my sister, by my side.

Diagnosing and Treating Endometriosis

I was diagnosed with endometriosis when I was 17 years old but had felt the pain of endometriosis since I was 13. I thought I wasn’t normal. All the girls I was friends with had normal periods, and they came regularly and lasted a week, mine took me out of school, and the teachers were less than understanding.  I have had four laps (surgeries) for endometriosis and have been on every birth control known to woman. I have been on depo shots and had Lupron treatments. Nothing helped.

Complications Associated with Failed Endometriosis Treatments

I have a bowel-uterine fusion as well, that can reattach at any time and I now have serious bladder issues which I feel are complications from the surgeries I had. I had one surgery in 2000 while in high school, one in 2004, 2007, and one in December of 2011. The doctors now think I have interstitial cystitis (IC) or painful bladder. By whatever name it is given, it really hurts. I wasn’t getting answers from a previous surgeon who has taken on so many patients (like many physicians end up doing) so I am going to a special urology practice soon; one that has a special female treatment approach for women by women urologists. I am starting physical therapy or aqua therapy soon. I am hoping with my pain threshold and the lack of using my muscles for so long that this will be able to help me as well.

I regret having my last surgery for endometriosis because it did not go as planned. I felt awful afterwards and I think a lot of that had do with just starting to deal with an autoimmune disease. I should have weighed the risks more carefully.

Lyme Disease Too

In 2009, I was diagnosed with Lyme disease. Lyme disease affects everyone differently, and it is a disease that can hide for years until an illness or trauma brings it out, even just a stressful event.

They usually treat patients with Lyme disease with medications like doxycycline and Mepron. I have a more chronic form of Lyme disease. The Lyme disease was left untreated for years, and misdiagnosed and undiagnosed. I had such horrible GI issues (for a time, they thought I had Crohn’s or ulcerative colitis because my GI episodes would send me to the hospital regularly and sometimes even have me admitted to the hospital for a week at a time) that the Lyme antibiotics were out of the question.

I was lucky enough to find a physician who treats Lyme and also uses herbs and natural approaches. I know how some feel about that approach. I use to feel that way too actually. But this doctor opened my eyes to a world of healing; I am able to put herbal drops in my water that they use in low income third world countries to treat MRSA to treat one of my nasty co-infections known as babesia. Babesia was responsible for my night sweats and myriad of other symptoms. Yes, I got my Lyme disease from a tick bite which carry other things than just Lyme, but some people like a friend of mine got there Lyme from flea bites and are just as sick. White footed mice also carry the disease and they believe mosquito do too.

More Research Needed for Lyme Disease

The CDC has been at war with many Lyme patients for under reporting the cases of Lyme reported each year. But the CDC did recently up their yearly numbers of new Lyme cases from 300,000 to 1 million new cases. With one million new cases we are up there with AIDS but we are not getting the attention to the disease, research and patient care that we need. And I am not sure what is stopping it. I am hoping we can all come together and start shedding light on this devastating disease.

As of today, I have had three close friends infected, all from the same area I live in. My mother is very sick from Lyme disease and now my father is showing symptoms too. Lyme disease is everywhere, especially with birds now considered carriers, as a recent medical article stated. We must come together as a nation, and as citizens worldwide and start talking about the subject of Lyme disease before it is in every household.

Living with Lyme and Endometriosis

As of this month in 2015 and at the age of 30, I have a very positive outlook on my prognosis. I am making headway with my herbal treatments for my Lyme disease and its co-infections with my LLMD (Lyme Literate Medical Doctor). I definitely have less pain than I use to and I am able to drive again. There is hope with Lyme disease and Endometriosis.

I hadn’t driven a car in years, now I drive almost every other day, and I am able to help my family more. Again, I do not know where I be without my parents and my best friend.

In the near future, I am hoping to start volunteering at a near by horse rescue farm, and doing local pet care for families, as I have a great love for animals! I also want to go back to college and get a degree and start working.

These things are all possible with Lyme and Endometriosis; never give up hope as my best friend always says. It always possible.

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Pelvic Therapy for Endometriosis, Adhesions and Sexual Pain

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Belinda Wurn

While doctors disagree on the exact cause of endometriosis, theories include heredity, environmental problems, or retrograde flow of endometrial tissue from the uterus, out the fallopian tubes, and into the body. Whatever the cause, most doctors agree that endometrial implants and adhesions (internal scars) are frequently found together. Adhesions are tiny but powerful structures that act like straight jackets wherever they form, causing pain or infertility – or both; because adhesions do not appear on any diagnostic test (x-ray, MRI, CT scan), they can elude even the most savvy physician. Thus, our patients often tell us “my doctor says he can’t find anything” or even “he says it’s all in my head.” The truth is, the pain is exactly where you are feeling it.

Endometriosis adhesions
Endometriosis (left) and adhesions (right) can cause pain and infertility.

Endometriosis Pain

While there is no consensus as to the cause of endometrial pain, increasing evidence from the studies published from our clinic and elsewhere indicates that the pain is caused, or significantly increased by adhesions – internal scars that form where endometrial tissues attach to underlying structures. In the past, the only method to treat endometrial adhesions was surgery. However, physicians and their patients are stymied by the fact that, no matter how skilled the surgeon, surgery to decrease endometriosis or adhesions tends to cause more adhesions to form as the body heals from surgery. A large retrospective study of post-surgical outcomes [Digestive Surgery, 2001] reported that between 50% and 100% of all pelvic anAdhesion Formation after Surgeryd abdominal surgeries created additional adhesions.

Thus, while the surgery may help some women, the relief may be temporary; recurring, and sometimes greater pain can appear as the body forms internal scars to heal from the surgery. Some evidence indicates that endometrial implants tend to recur with greater frequency at the surgical site.

 

Endometriosis and Pelvic Pain

In our own published studies, we have come to understand that the pelvic, abdominal, hip or back pain often associated with endometriosis comes from the pull of tiny but powerful cross-links, the building blocks of adhesions. Where endometrial implants appear, adhesions tend to bind the foreign tissue to the underlying structure. As the tissues swell with each menstrual cycle, the adhesions pull on the delicate underlying structures, causing pain. Our manual physical therapy appears to detach the adhesive bonds so endometrial tissues can expand and contract naturally, without pain from the adhesive bonds.

Post therapy release of endometriosis adhesionsHormone medications such as birth control pills can stop the menstrual cycle totally. Since the endometrial tissue does not swell, it does not pull on the adhesions and pain is relieved. However, if the woman wants to have a child, she has to stop the birth control pills and the pain returns. Thus, the medications address the symptoms, but not the cause of the pain.

 

 

Pain with Sexual Intercourse: Definitions and Therapies

Our patients tend to report three different types of intercourse pain:

  1. Pain with initial penetration
  2. Vaginal pain during intercourse
  3. Pain with deep penetration

The body creates adhesions (tiny internal scars) wherever we heal – whether due to an infection (e.g., bladder, bacterial, yeast, STD), a trauma (abuse, fall onto the tailbone or perineum), or a surgery (abortion, C-section, laparoscopy) – or due to inflammation from the endometriosis itself. These adhesions can be small enough that they form between muscle cells, causing pain when your partner pushes on them.

Vaginal pain and adhesionsBecause of its unique position in the body, a woman’s vagina is subject to numerous traumas in life. Falls onto your bottom cause adhesions to form. Once your body heals, the adhesions remain there for life, causing tiny but powerful straight-jackets that can cause pain when pressure is exerted on them – such as during intercourse.

With the warm, moist environment, the vagina tends to be a perfect place for bacterial infections. Again, adhesions form as the first step in the healing process – to help contain the infected area so your body can heal more easily. Once you have taken antibiotics or are otherwise healed, the adhesions that formed remain in the body for life – unless removed by a skilled physical therapist who specializes in work in this delicate area.vaginal pain and adhesions 2

Women who have pain with deep penetration say “it feels like my partner is hitting something,” – and he is! The usual cause for this deep pain is either a stenosed (adhered) cervix caused by adhesions following a healing event (shown in the drawing below), or a forward tailbone – caused by a fall, trauma, abuse or surgical scars.

Physicians are generally stymied to cure intercourse pain. Their prescriptions generally consist of any of a combination of therapies that address the symptoms, but not the cause. Physicians may suggest:

  1. Abstinence
  2. Pain relievers
  3. De-sensitizing drugs

These approaches do not help a woman get the pleasure or function (desire, lubrication, orgasm, pain relief) that should be hers. Many of our patients feel their lives deeply impacted; some are concerned that the pain will impact or even end their relationship with their partners.Sexual penetration pain adhesions

Fortunately, there is now a non-surgical, drug-free treatment for endometriosis pain. The Clear Passage Approach® has been examined for treating pelvic, menstrual and intercourse pain associated with endometriosis for decades. In a recent study update in the Journal of Endometriosis, this therapy was found as effective as surgery – even a year after therapy.

Besides studies in that journal, studies on this work are published in WebMD’s Medscape General Medicine, and housed in the U.S. National Library of Medicine (see study results below). In all of our studies, the treatment is a manual physical therapy that can feel like a deep massage. A brief look at the results are provided below. Learn more about treatment for endometriosis pain.

 

Improved sexual function after manual therapy for adhesions

Pain Decrease and Function Improvements from a study on the Clear Passage Approach, Published in WebMD’s Medscape General Medicine, 2011.

We are glad to provide 30-minute phone consultations to interested women, at no charge. Simply visit the website www.clearpassage.com.

Join us for our next posting on endometriosis and Infertility.

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Why is PCOS so Common?

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Lara Briden ND

We are in the middle of an alarming trend. More and more women are being diagnosed with polycystic ovarian syndrome (PCOS), an endocrine disorder that causes irregular periods, acne, hair loss, and hirsutism.

The disorder is not new, but it is increasing at a dizzying rate. Two decades ago, PCOS was infrequent amongst my patients. Today, I see it all the time. Polycystic ovaries are estimated to now affect close to one in five women, with an even higher incidence in teenagers. What is going on?

Insulin Resistance

A big part of the problem is insulin resistance which is is the hallmark condition of our modern age, affecting 1 in 4 adults. Insulin resistance is the result of too much sugar (concentrated fructose) in our diet, as well as smoking, obesity, trans fat, stress, and environmental toxins. Untreated, insulin resistance can lead to diabetes and cardiovascular disease.

Insulin resistance is estimated to affect between 50-70% of PCOS-sufferers [1], and is generally understood to be a major contributing cause of the condition [2]. Excess insulin causes polycystic ovaries because it impairs ovulation and stimulates the ovaries to make testosterone instead of estrogen.

We have an epidemic of insulin resistance, so it makes sense that we also have an epidemic of PCOS. Except that not all PCOS sufferers have insulin resistance, so what else is going on?

Misdiagnosis by Ultrasound

Proper diagnosis of PCOS requires clinical evidence such as irregular periods, combined with a blood test that shows high androgens. There may or may not also be the ultrasound finding of polycystic ovaries, but that finding alone cannot be used to diagnose PCOS. Why? Because polycystic ovaries occur in up to 25% of normal women, and also in many women on on the birth control pill [3].

Would a family doctor or OB/GYN really attach the label of PCOS to a normal woman solely based on one ultrasound finding? Sadly, the answer is Yes in many cases, and that can lead to a lot of unnecessary confusion and heartache. I almost never accept a diagnosis of PCOS at face value. Instead, I order extra blood tests form my patients to confirm that they do have high androgens.

Fortunately, there are calls to rename the condition, and to re-educate doctors about the relevance of the polycystic finding.  According to Dr. Robert A. Rizza from the Mayo Clinic:

“[The name PCOS]..focuses on a criteria—namely the polycystic ovarian morphology—that is neither necessary nor sufficient to diagnose the syndrome. It is time to assign a name that reflects the complex metabolic, hypothalamic, pituitary, ovarian, and adrenal interactions that characterize PCOS.” [4]

Post-Pill Syndrome

There is one more reason for the increasing incidence of PCOS: The Birth Control Pill. In my clinic, I speak to so many women who simply cannot get their periods going again after stopping the Pill. Some of them did not have regular periods before taking the Pill, so, in their case, stopping the Pill has merely unmasked a preexisting problem. Then there are the women who did have regular periods before the Pill, but now they’re gone. For these women, the Pill seems to be a clear cause of PCOS and hypothalamic amenorrhea.

We don’t yet know exactly how the Pill causes PCOS because that research has not yet been done. We do know that the Pill causes insulin resistance, which in turn, causes PCOS [5]. We also know that the Pill suppresses the pituitary-ovarian communication, which of course it’s designed to do, but that suppression is supposed to be temporary. It’s supposed to be temporary, but some women experience an ongoing elevation of the pituitary hormone LH (even in the absence of other PCOS markers such as insulin and androgens). Without treatment, post-Pill LH elevation can persist for months or even years after stopping the Pill.

What to do about PCOS

If you or your patient has been diagnosed with PCOS, then first find out if it was diagnosed by ultrasound alone. If it was, then the PCOS diagnosis is not certain.  Ask for further blood testing to see if there are high androgens, and most importantly: If there is insulin resistance.

When it can be determined that insulin resistance is the cause of PCOS, the best treatment is to eliminate concentrated sugar (desserts) from the diet, and also to supplement nutrients (such as magnesium) that improve insulin sensitivity.

When insulin resistance is not the cause of PCOS, things get a little more complicated. Non-insulin-resistant PCOS is often the result of the Pill (as discussed above), but it can also be the result of other underlying health issues such as chronic inflammation. I explore the natural treatment of PCOS in my new book Period Repair Manual.

References

  1. Ibricevic D et al. Frequency of prediabetes in women with polycystic ovary syndrome. Med Arch. 2013;67(4):282-5. PMID: 24520755
  2. Dunaif A et al. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev. 1997 Dec;18(6):774-800. PMID: 9408743
  3. Clayton R et al. How common are polycystic ovaries in normal women and what is their significance for the fertility of the population? Clin. Endocrinol. 1992 37 (2): 127. PMID 1395063.
  4. http://www.highbeam.com/doc/1G1-323971757.html
  5. Diamani-Kandarakis E et al. A modern medical quandary: polycystic ovary syndrome, insulin resistance, and oral contraceptive pill. J Clin Endocrinol Metab. 2003 May; 88(5): 1927-32. PMID: 12727935

 

 

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Endometriosis Awareness Month: A Wish Noted

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Philippa Bridge-Cook

Everyone who lives with endometriosis as a patient, or as a family member, partner, or friend of a patient, has something (or sometimes many things) they wish for, with respect to this disease. In March, as part of their Endometriosis Awareness Month activities, The Endometriosis Network Canada asks people from across Canada to send them their wishes with the hashtag #awishnoted, which is an anagram for “what is endo?” These wishes are displayed as a digital “wall of wishes,” and as an actual physical wall at the Endomarch Canada event in Toronto. Wishes range from wanting better medical care, to wishing for a baby, to wishing for continued strength while dealing with endo.

I also have an endometriosis wish, and it is a big one. But as William Arthur Ward said: “If you can imagine it, you can achieve it.” My wish starts with all teenagers being educated about the signs and symptoms of endometriosis, so that people would be aware of the possibility of endometriosis as soon as they start developing symptoms. The primary care practitioners would also be educated about endo, and would refer to a specialist when they suspect the disease.

The specialist care would be delivered at a multidisciplinary centre of expertise in endometriosis. This care would include the appropriate medical expertise, such as skilled excision surgeons, and other medical specialties as required, such as urology and gastroenterology. In addition, endometriosis patients would receive care from women’s health physical therapists and nutritionists, and other alternative/complementary medical practitioners as needed. Pain management specialists would also be an option for care if required. Counselors would be available to help patients deal with the emotional impact of the disease, and patients would be referred to support groups, for peer support from others who are dealing with endometriosis.

As if that isn’t enough to be wishing for, I also wish that the general public had a much greater awareness of endometriosis, how devastating it can be, and how wide-reaching the emotional effects are. If this were the case, in addition to receiving excellent healthcare at a centre of expertise, endometriosis patients would also receive better support from people in their daily lives.

However, the reality of living with endometriosis today is far different from this vision of what could be. In my work with The Endometriosis Network Canada, I am privileged to interact with many endometriosis patients. They are all incredibly strong people who continue to fight for a better quality of life, on a daily basis, despite all the obstacles around them. Many of them fought for years to obtain a diagnosis, usually hearing along the way from doctors “there is nothing wrong with you,” or “your problems are not physical, they are in your head,” or “I can’t/don’t know how to help you.”

Even once endometriosis has been diagnosed, often the care women have received is horrifying. I have talked to women who have been butchered by inept surgery, suffered complications that could have been avoided, or who have had unnecessary hysterectomies during surgeries that are supposed to treat endometriosis, where all or most of the endometriosis was left in the body but healthy organs were removed. Many endometriosis patients have been refused care by specialists, for reasons unknown. Some have been offered anti-psychotic medication or sedatives instead of painkillers, as a “treatment” for endometriosis or chronic pain. My vet once commented to me that animals receive better care than women with endometriosis.

For many endometriosis patients, they have no support network around them. They may have partners, family, and friends who do not understand the medical effects of endometriosis, and definitely do not understand the emotional consequences of living with chronic pain and other debilitating symptoms. Some have lost jobs, partners, and custody of their children as a consequence of their disease. Many are depressed and anxious, or worse, suicidal.

This state of affairs is not ok. We are capable of doing more for people with endometriosis, except that not enough people care about the current state of affairs for things to start changing. It is hard for me to imagine that if most people really knew about what life is like for many people with endometriosis, they would be ok with abandoning over 176 million women worldwide to this kind of suffering and medical mismanagement.

This is why March, as Endometriosis Awareness Month, is important. Most people with endometriosis face the task all year long of educating those around them about their disease. However, in March, endometriosis patients come together, and make their voices heard even more loudly, as a united group. We are tired of suffering and being ignored. We want people everywhere to understand what endometriosis is and why it is a major healthcare crisis, and we want people to care enough to start demanding the changes in our education system, in our medical education system, in our insurance systems, and in our healthcare delivery systems, that would make my wish become a reality.

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The Match Game of Healthcare That Works: Understanding Insurance

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health insurance

Understand What Insurance Is and Is Not

Finding healthcare resources – people, treatments, care – is a match game. Your quest is to find resources to partner with you to feel better, heal and experience the life you want to live.

Reading “match game,” the vision that probably came to mind involves perusing a list of “providers” your insurance company included in a thick volume of paperwork. Or maybe you wish you at least had an opportunity to have access to such a list. You see lists organized by “specialty” (which you may or may not understand) and geography; and you hope you can find someone with solutions for your needs – someone to help you feel better – from this paltry information.

The Traditional Match Game: The Insurance Company Sets the Playing Field For “Health”

Health insurance is not healthcare. Insurance is business. Health insurance is a payment system.

In the framework of the traditional match game, the insurance company sets the rules with four basic things: 1) a list of “providers” – people who meet the company’s contractual requirements; 2) a list of acceptable services (your “benefits”) the providers can offer for certain ailments; 3) acceptable fees for such services; and finally 4) a means to parse the payment/cost burden. This is so familiar that perhaps we didn’t even question this until prices sky rocketed and services diminished.

Playing the well-being match game within this familiar framework puts the insurance corporation in a position of power. Playing the match game this way immediately puts a corporation, a payment system, in control of your well-being. Through their contractual relationships they determine what constitutes health, who is allowed to serve your needs, and what treatments or medications are acceptable. Insurance companies narrow the field of possibilities and choices for your path to well-being.

By engaging in this match game we’ve been attempting to attain well-being from a system in which the rules have been set by companies that are focused on payment and profit. Pause and think about that for a moment. We have been lulled into looking to a payment system as a means to experience vitality.

You may have had very good success with this structure. While this may work well for some, and may work some times; for many it is a challenge to find care that works. That challenge can take a further toll on health.

In this traditional match game it is very difficult to insert your personal needs, values, and beliefs about health and well-being into the framework of a payment system. It can be a challenge to find the right partner in healing, the right practitioner, who supports your personal journey to live your best life.

Time To Shift the Paradigm

If it doesn’t work for many, if not most, people to look to a payment system as a means to experience well-being, what do we do? It requires a change in the fundamental nature of the match game. In the next article we’ll explore this shift. It begins with identifying your personal concept of the essence of health, well-being and healing. This will vary for each person, and can vary over time. This shift puts each person back into control of their health.

About the author: Deb is co-owner of Experience In Motion, which equips organizations with tools to curate meaningful experiences for customers and employees. Deb’s personal journey from decay to well-being inspired an emphasis in improving healthcare experiences for patients and practitioners by focusing on experiences that heal and self-caring as a way of organizational being. www.experienceinmotion.net.

Note: This is part of an ongoing series to equip you with a process, a path, to identify and experience healthcare that works for you. Other articles in this series are:

The heart of healthcare that works: know your personal worldview of health   

Find your Inner Chris Columbus

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HRT ‘Largely or Wholly Causal’ in Ovarian Cancer

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Chandler Marrs

Think about that quote for a minute. Hormone Replacement Therapy or HRT may be largely or wholly causal for a significantly increased risk of ovarian cancer in women, according to authors of a recently published study, Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. ‘Largely or wholly causal’ is very strong statement; one that makers of HRT are sure to dispute, but one that nevertheless was supported by data.

Ovarian Cancer Risk with HRT Use

Based upon prospective (17 studies; 12,110 cases) and retrospective (35 studies; 9,378 cases) epidemiological data reviewed by the Collaborative Group of Epidemiological Studies of Ovarian Cancer in Oxford, England and published in the Lancet, out of the 21,488 post menopausal women with ovarian cancer, 9303 had used HRT, most more than 5 years. From a statistical standpoint, the risk for ovarian cancer was significantly greater in women who had ever used HRT versus those who had never used HRT and even greater in those who were currently using HRT or had recently used HRT than those who had ceased HRT years prior. In other words, HRT use accounted for almost half of the cases of ovarian cancer. Moreover, the risk for HRT induced ovarian cancer was greatest while on the medication and soon after ceasing, but declined as time passed. This is an big finding.

Historical Associations between HRT, Cancer and Disease

Since the Women’s Health Initiative (WHI), debate about the safety of HRT has been forefront among millions of women. WHI demonstrated an increased risk of breast cancer and all sorts of other adverse reactions to menopausal hormone replacement therapy. Despite the findings of the WHI, drug companies and supporters were quick to point out that participants in the WHI were largely older, thus skewing the data. In fact there were and continue to be studies and critiques suggesting only minimal risk if younger women were to utilize HRT immediately upon menopause and for a shorter duration. Ovarian cancer was not considered among those risks.

The current study dispels the notion that younger women (those around the age 50) can use HRT safely and adds to the growing constellation of HRT mediated cancers and ill-effects. Indeed, age did not contribute to the overall risk for ovarian cancer, neither did other commonly considered factors like weight/BMI, smoking or oral contraceptive use. Only use versus non-use and recency of HRT usage were found to increase the risk of ovarian cancer.

Another common argument in support of HRT suggests that estrogen only HRT medications are more strongly associated with negative outcomes and that by adding a progestin, the risk for these side effects is minimized. While that may be plausible for some negative side effects, it was not true for ovarian cancer. Both types of HRT, estrogen only and estrogen plus progestin had equally high rates of ovarian cancer.

Utilizing the data reviewed in this study, the authors calculated the relative risk for ovarian cancer and death from HRT in England. The numbers are striking. For every 1000 women who utilize beginning at around 50 years of age and for approximately five years, we can expect one additional case of ovarian cancer and 1/1700 death rate, per year. When HRT is used more chronically (10 years), that risk increases significantly – one in every 600 women will develop ovarian cancer with death in one in 800 of those cases, per year.

An additional finding was the type of ovarian tumors most influenced by HRT. Ninety-eight percent were epithelial, the majority were serous tumors, followed by endometrioid tumors.

HRT, Breast Cancer and Other Risks

When combined with the increased risk of breast cancer (19 in 1000 per the Million Women Study), stroke, embolism, heart attack, gallbladder disease (Cochrane Review, 2012), one wonders why these medications are yet on the market. They are, however, and 6 million women in the US and UK use them regularly for years. From a statistical standpoint, the risk for any one of these side effects is relatively low. With breast cancer for example, HRT use accounts for 8-12% of the total cases each year.

By any standards, a 0.08% increased risk of breast cancer for each year of HRT use is extremely low. After 10 years of use, the cumulative 0.8% increase in risk is still low, but it has become a reasonable fraction of the 8% to 12% total risk of breast cancer diagnosis. Nationally, with millions of women taking HRT, many thousands will presumably have HRT-associated disease…Ken Muse, MD 

Many thousands, indeed, will develop HRT induced breast cancer or HRT induced ovarian cancer each year and some will die. The question one has to ask, is the need to decrease hot flashes, night sweats and vaginal dryness and other symptoms of menopause greater than the increased risk for breast or ovarian, heart attack and stroke and the host of other side effects associated with HRT? Can we not come up with safer therapeutic options to temper menopausal symptoms without increasing the risk for cancers and other diseases. Menopause is a temporary state of hormonal fluctuation, cancer, heart attack and stroke are more permanent.

HRT Post Oophorectomy

Perhaps, even more importantly, what are the risks for cancers and other disease processes in women who have had their ovaries removed and who must replace the hormones lost using HRT? Unlike natural menopause, where hormones decline gradually over years, with oophorectomy, hormones decline rapidly and almost completely (other sources of hormones synthesis are yet available, though generally insufficient to account for the loss of the ovaries). Certainly, their risk for ovarian cancer sans ovaries is eliminated but what about their risks for HRT-induced breast cancer, cardiovascular disease, gallbladder disease, dementia and cognitive decline? Have we removed one risk only to add five others?

The answers to these questions may be especially troubling in those women whose ovaries were removed without consent and/or because of some ill-conceived notion of protection against ovarian cancer. Prophylactic oophorectomy as archaic as it sounds is still quite common. Does this practice predispose an otherwise healthy woman to an exponentially increased risk for cancer and other diseases? It might. Without even the limited production of endogenous ovarian hormones to temper the onslaught of synthetic HRT, I fear we have increased the risk for many disease processes, of which we know little.

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