Readers' questions are answered as examples of general problems commonly met in practice. It is a good rule in medicine that only their own doctors know the patient well enough to pontificate on the case as there are often other factors unknown to strangers.
Why is the Mirena intrauterine system not more widely prescribed to treat women suffering from endomestriosis? Following the birth of my third child I started to suffer from debilitating pain before and during my periods. These symptoms were miraculously alleviated once I had a Mirena inserted. I understand that it may not be ideal for pre-childbearing females, but for all others it would be a godsend, doing away with unnecessary and expensive hysterectomies. It truly changed my life - my friends and I regard it as one of the best inventions ever. Name and address withheld
I agree. Mirena is a modification of the IUD, but because it leaks levonorgestrel, a progesterone, it is technically described as an IUS, intrauterine system. It has many advantages over the standard IUDs as a contraceptive, but unfortunately is rather more expensive. Like any IUD, it shouldn’t be inserted if there is a possibility of the woman becoming pregnant or if she has an unusually large number of partners. IUDs are associated with an increased risk of infection but despite the need to observe these precautions there is evidence that its use doesn’t lead to uterine infection and pelvic inflammatory disease as frequently as other IUDs. I too have known it revolutionise womens’ lives.
Like any other successful treatment, there are invariably but occasionally side effects with Mirenas. If a drug has no side effects it is unlikely to be very useful either. A Mirena shouldn’t be inserted if there is any question of the patient being pregnant or liable to become pregnant, or if there is any genital infection or pelvic inflammatory disease. Nor is it recommended if there is a history of heart disease. Having a permanent foreign body tucked into the uterus can increase the chance of infections in the blood that may damage the heart valves and even muscles. A Mirena shouldn’t be fitted in people with liver disease, or if there is any history of malignancy. It is therefore always important to know the cause of any heavy bleeding before treatment is started.
A Mirena may increase the chance of thrombo embolic events (clots), so a Mirena wearer should be careful to take aspirin when flying, to wear tight stockings, to keep hydrated and to walk up and down the plane aisle. Remember that the risk of a DVT or pulmonary embolism is less than it would be than if the reader was on the Pill.
Its use in the treatment of menorrhagia (heavy bleeding) even when fibroids are the cause is well recognised but it is not always thought of as a possible treatment in endometriosis.
A Mirena helps many cases of endometriosis, as do any of the progestogens. The disadvantages of progesterone treatment for endometriosis are that there may be breakthrough bleeding, over-emotional behaviour or depression, but as the dose when using a Mirena is so small I would be surprised if they frequently caused these troubles.
I am 38 years old and have suffered from endomestriosis for ten years and want to have a baby before it is too late. Will the endometriosis affect my ability to have children? Name and address withheld
As you almost certainly know, but others may not, endometriosis is the strange condition in which the type of tissue that normally lines the uterus (womb) and is shed each month with the period, grows in other parts of the body. Endometrial tissue has been found in most extraordinary places but the usual sites are below the waist. Womb tissue may grow in the ligaments around the uterus, in the fallopian tubes, lining of the pelvic peritoneal cavity, on the bladder wall, within the bladder, in or in the small intestine, the pelvic colon, the rectum and tissue between the rectum and the vagina. Very occasionally it spreads to distant areas, and there are sometimes remote deposits found in the lungs, or less frequently in the kidneys. It grows surprisingly often in the umbilicus.
As the endometrial tissue may grow in or around the fallopian tubes, it may cause infertility for this reason alone. However, it is thought to be responsible for infertility in 20 to 40 per cent of patients with a diagnosis of endometriosis - a much greater proportion of patients than can be accounted for by obstruction of the tubes. The other possible reasons why endometriosis may cause reduced fertility are thought to be hormonal, or possibly related to changes in the prostaglandin levels in patients with endometriosis. Another theory is that this may trigger an auto-immune response that either makes implantation difficult or may induce early miscarriages. The changes induced by endometriosis may also have an adverse effect on sperm. Furthermore the pain during intercourse when endometriosis is around the genital tract, or in the rectum, may reduce the frequency of intercourse.
Liability to suffer serious infertility, rather than merely reduced fertility, is related to the severity of the endometriosis, and some authorities believe that the infertility, rather than some minor degree of reduced fertility, is the worst that many patients with minimal or mild endometriosis may suffer. Endometriosis is classified into four stages of severity, minimal, mild, moderate or severe.
My daughter has had endometriosis since she was in her twenties. She complains of a pain around her kidneys. Could this be related to it? She has read that the tissue that causes endomstriosis can migrate and stick to any organ. Is this an exaggeration and if my daughter’s pain is related to endometriosis can she do anything about it? Name and address withheld
The means by which endometriosis spreads has intrigued doctors for generations. The general view is that during a period some of the lining of the uterus escapes upwards and out through the fallopian tubes and into the pelvic cavity, rather than downwards through the cervix and vagina. This obviously can’t account for distant spread, and so it is proposed that in other cases the spread may be blood or lymph-borne to remote parts. A few gynaecologists believe that there are embryonic cells, similar to those in the uterus, in other parts of the body as well as the uterine lining, and that these develop into endometrial tissue in adult life. The most common time for endometriosis to develop is between 25 and 40, but an increasing number of younger women are being diagnosed with it.
Yes. Your daughter may be one of the very rare women who have endometrial deposits in their kidneys or renal pelvises, but it is much more likely that she has endometriosis of her bladder and, as a result, there is some obstruction to her urinary flow, and urinary tract infections. A word of warning. Once a patient has been diagnosed with endometriosis it is all too easy to attribute every untoward symptom to it. Your daughter’s renal pain should be carefully investigated. Only then can the best treatment be prescribed, and many are available. The hallmark of endometrial pain is that it gets worse premenstrually, and may be at its most acute when the period starts and bleeding occurs.
I have been suffering from endomestriosis since I was 25 when I qualified as a solicitor. If I were able to become pregnant, would this solve my problems? A friend told me that she read in a woman’s magazine that this might help. I am now 32 and my symptoms seem to be becoming rather worse. Name and address withheld
Yes, your friend is right. Because pregnancy causes such widespread and basic hormonal changes it is not unusual for minimal and mild and even the lesser stages of moderate endometriosis to be helped by pregnancy.
Your history is interesting. There has been a lot of discussion as to whether endometriosis is more common in women who have had a professional education, or could be described as being academic by virtue of having been to university. The current belief is that endometriosis has nothing directly to do with a woman’s intellect, her educational level or her temperament. On the other hand it is accepted that there is an indirect relationship. Women who have a professional or academic background tend to marry later, and once married are more likely to postpone pregnancy. The statistics therefore support your friend’s opinion that to avoid endometriosis women should marry early and have children when still young.
I have been told that I have endometriosis. Will this be harmful to my general health and is it in any way associated with cancer? Name and address withheld
Endometriosis has nothing to do with cancer. The tissue in endometriosis would be harmless and considered absolutely normal if it was in the womb. It causes damage because many of the places where it grows are not designed to tolerate swellings for several days a month and so the patient suffers pain. Blood is very irritant and pain provoking so that when the endometrial tissue bleeds this causes severe acute pain that can be so bad that the patient feels faint, can’t continue to work or even stand upright, and is also unable to sleep. This inevitably is unpleasant especially if the bleeding is into the bladder or the bowel. It is also difficult to maintain a sex life if the endometrial deposits cause pain during intercourse. The many adverse, even if not dangerous adverse effects of endometriosis frequently lead to patients being overtired, depressed and feeling unwell.
