Endometriosis - Dr. Raymond Schulte

This week one of my partners, Dr. Ray Schulte, is the guest blogger...here's some great info on a common gynecologic disease.

Endometriosis is one of the most common causes of pain in the female pelvis.  It is one of the more undiagnosed conditions leaving a lot of women to suffer from cyclic pain, as well as a myriad of other symptoms until finally the diagnosis is made.  Endometriosis is a condition wherein cells that are identical to the lining of the uterus, the endometrium, grow outside of the uterus.  This can be and is most commonly in the pelvis, in the cul-de-sac, the space behind the uterus, and in the fallopian tube and ovary.  However, it may also involve the appendix, bowel, and even more widespread areas in the body in small spaces.  It is also frequently found in a cesarean section incisional scar causing cyclic symptoms.  The endometriosis causes its problems because tissue that normally would drain out as a period is isolated in areas where it is impossible for the degenerating cells to drain from the body.  They go through the same cycle as the lining of the uterus, stimulated by ovarian hormones, but when they degenerate, instead of being shed, the body starts an inflammatory process to digest and devour these cells with the enzymes contained in inflammatory white blood cells.

This inflammation leads to a lot of localized symptoms.  The symptoms typically reflect the effects of endometriosis by causing cyclic pain with the cyclic pain being most typically pain around ovulation for a few days and then easing up and gradually worsening as you approach the menstrual period and lasting throughout the period with only the week after the period ends being relatively free of pain. As the disease progresses it may get to where the pain is continuous.  It may worsen but it does not ever diminish.  This pain frequently radiates to the back in the sacroiliac joint down low in the pelvis as frequently the implants are in the uterosacral ligaments and the nerves run to that area.  In addition to this most typical pain pattern, various patterns can emerge with pain after the period, severe pain throughout the period, and  deep dyspareunia.  Dyspareunia is defined as pain with intercourse, and in the setting of endometriosis, is usually with deep penetration.  The deep penetration pain will also follow the normal cyclic pattern of endometriosis, worse at ovulation and in the time leading up to the period and through the period.

Endometriosis also causes some effects that are less recognized.  It will frequently cause a decrease in the amount of progesterone produced after ovulation.  This may shorten the time from ovulation to the start of the period, which is normally 14 days.  It may also cause the periods to be much heavier, with clots and passage of more blood than just degenerative endometrial tissue as a normal period would be.  Along with this relative deficiency of progesterone, women will frequently have premenstrual symptoms which may be pain, depression, fatigue, irritability, and sometimes an acute urge to wipe out anyone close to them.  This can make work fairly difficult and makes home life difficult too, in that people are using all their coping skills putting up with the pain and have fewer coping skills because of the effect of decreased progesterone levels on the central nervous system causing depression and irritability.

Endometriosis may also cause cyclic symptoms with the bladder and bowel.  Again in the same pattern, women may have frequent urination or diarrhea in the week prior to the period and during the period.

Endometriosis also is associated with infertility.  There are several different ways that this occurs.  The most obvious mechanical cause is scarring of the tube and ovary which does not allow the tube to pick up an egg.  Sometimes the tubes are totally occluded by being scarred down behind the ovary, or the ovary is scarred against the side wall of the pelvis.  It may have an effect also from the inflammatory process on the normal motility of the tube which would normally move a fertilized egg through to the uterine cavity to implant about six days after ovulation and fertilization of the egg.  With the inflammatory process, the movement may be accelerated, and a fertilized egg may arrive in the cavity of the uterus too early, and fail to implant to create a pregnancy.  There also is the effect of the decreased progesterone causing the lining of the uterus not to grow and mature as it normally should to allow implantation.  One other effect it may have is that in some people, because of the white blood cells devouring these degenerating endometrial cells, the immune system may start forming antibodies against the endometrial cells.  Even if everything is corrected hormonally, the normal endometrial cells have antibodies that attach to them, keeping them from responding appropriately and growing to allow implantation.

Endometriosis has two main types of treatment.  This first is medical treatment, which can be done with several medications but with the same final results.  All of them decrease the frequency of cycles so there are fewer times that the endometrial cells are degenerating and feeding into the inflammatory process.  Probably the simplest, cheapest, most able to be used for long-term treatment is a birth control pill used in at least 12 week cycles.  This limits a woman to about four periods a year, and the continuous progestin regulates the growth of endometrial cells both in the uterus and in endometrial implants.  There are two other medications commonly used for endometriosis.  The first is Depo-Lupron which causes a sort of menopausal state to occur.  This allows the inflammatory process some time to cool down and stops the growth of the endometrial cells, but the associated side effects are menopausal in nature.  The other medication is danazol, which is an androgenic or male-type hormone.  This also interferes with the menstrual cycle, but has side effects including increased muscle mass leading to weight gain, and it may cause acne to flare.  These last two medications are generally used for a six month time period in someone who has endometriosis to cool it down to have a window of opportunity for conception.  Neither are suitable for long-term suppression.

Surgical treatments are also possible and can range from separating adhesions that are caused from inflammatory changes to excision of the endometriosis to simply destroying the endometriosis with cautery of laser.  Any of these may be of considerable help in increasing fertility and relieving the symptoms, but all of these medical or surgical treatments are only temporary.  They will only work as long as suppression is continued or, in the case of surgery, until the endometriosis grows back, which nearly always occurs.

If someone has cyclic pelvic pain and the other symptoms described in this article, it would do you well to consult with a gynecologist who is experienced in making the diagnosis and treating endometriosis.

Here's some links to great sites for more information:
Womens Health - US Department of Health and Human Services Endometriosis Fact Sheet
WebMD overview of endometriosis, with visual guide

Common Birth Control Pill Myths

Many women take combined oral contraceptives, otherwise known as "the pill" for birth control or to help with other gynecologic problems.  I wanted to dispel some of the long-standing myths about birth control pills.  I have patients come in frequently who don't want to take the pill because of what they've heard might happen to their fertility, risk of cancer, etc...

Myth #1 "I don't want to take the pill because I'm afraid I won't be able to get pregnant later"

Past use of combined oral contraceptives (the most common type prescribed, containing both estrogen and progestins) has not been linked to infertility.  In a study published in 2002, fertility rates after discontinuing birth control pills were 75% within 6 months, and 90% within 12 months (about 5% HIGHER than for those women not previously on pills).  This is similar to the overall pregnancy rate without contraceptives.  Sometimes, taking the pill can control other diseases, such as polycystic ovarian syndrome or endometriosis, which can impair fertility.  This can make it easier to get pregnant when the pill is discontinued.

Myth #2 "I'm worried that taking the pill will cause me to get cancer"

Combined oral contraceptives are not associated with an overall increased risk of cancer.  In fact, birth control pills have been shown in multiple studies to decrease the risk of ovarian, uterine, and colorectal cancer.  There have been no findings of increased risk of breast cancer among former pill users in multiple population-based studies.  Even among women with breast cancer in their family, or who have known genetic mutations making them susceptible to breast cancer, the pill is considered not to increase risk.  The pill is not recommend, however, in women with a personal history of breast cancer. 

Myth #3 "I'm worried that the pill will cause me to gain weight"

This is probably the most common concern I hear in my office.  There is little evidence, though, for a significant weight gain after starting the pill.  On average in one study, women gained about 0.5 kg (about a pound).

Myth #4 "Antibiotics reduce the effectiveness of the pill"

There is only one antibiotic that has been shown to decrease the pill's effectiveness - rifampin.  Rifampin is an antibiotic used very rarely, usually to treat infections like tuberculosis.  The most commonly prescribed antibiotics, such as penicillins, sulfa drugs, cephalosporins, fluoroquinolones, have no effect on hormone levels and do not decrease the pill's effectiveness.  There is no need to worry about using back-up methods of contraception unless you are taking rifampin.

Combined oral contraceptives have many benefits and risks, but overall are a safe and effective form of birth control as well as an effective treatment for many other gynecologic conditions. 

Endometrial Ablation

Something a lot of women face as they get older is prolonged heavy periods.  It becomes an issue when women go off birth control because they have a tubal ligation, or their husband has a vasectomy, or when women get close to menopause.  It can be frustrating, embarrassing, and a real annoyance.

There are several ways to manage this.  First, though, an evaluation needs to be done to determine the potential cause for the abnormal bleeding.  This usually involves an exam, a pelvic ultrasound, and sometimes an endometrial biopsy to rule out precancerous or cancerous cells in the uterus if you are at high risk.  Based on this information, your doctor may recommend birth control pills, a Mirena IUD, surgery, or an endometrial ablation.

Endometrial ablation involves destroying the endometrium, the layer of cells in the uterus that builds up every month and is shed when you have a period.  The cells can be destroyed in many different ways, including burning them with electrocautery, freezing them, or heating them.  In our office, we predominantly use two types of endometrial ablation, namely Novasure and HydroThermal Ablation (HTA).  There are other systems available as well.  This procedure can be safely performed in the office setting, under local anesthesia with pain medications, avoiding the risks of general anesthesia.

Endometrial ablation is very effective.  About 2/3 of women stop having periods after having had an ablation, and almost all other women return to "normal" periods.  Rarely,  women will continue to have heavy bleeding, and will eventually require a hysterectomy to control their symptoms.

It is important to be certain that you are finished with childbearing before you have this procedure.  Since the cells that would normally support a growing pregnancy are being destroyed or weakened, if a pregnancy were to implant into the uterus after an ablation, the placenta could implant more deeply into the uterine wall, leading to a potential pregnancy loss and/or catastrophic hemorrhage at delivery.   Women who have active infections of the reproductive tract, or anatomical abnormalities also may not be candidates for ablation.

The procedure involves a paracervical block - local anesthetic injected around the cervix, then hysteroscopy (looking into the uterus with a camera through the cervix) and then a 2-10 minute ablation.  Usually then surgeon repeats the hysteroscopy to make sure the endometrium is sufficiently destroyed and that there have been no complications.  The entire procedure takes roughly 30 minutes.

Complications are unusual but could include uterine perforation (meaning a hole is made through the uterine wall which could result in injury to internal organs), infection, and bleeding.  These risks are similar to IUD insertion, and in general less dangerous than risks encountered for hysterectomy.

Endometrial ablation has been a very safe and effective alternative to hysterectomy for management of abnormal uterine bleeding.  If this is an issue for you, talk to your doctor to discuss your options.

Here are links for more information:

Novasure Endometrial Ablation

HydroThermal Ablation

Vitamin D

I get asked a lot in the office about whether people should be screened for vitamin D deficiency.  This is not something we learned to routinely do in medical school, but is more the "Vitamin of the Day" in pop culture.  It seems every few years, a different vitamin or supplement is the hot topic and is thought to prevent cancer, stop heart disease, or give an overall sense of well-being.  So, I set to work to investigate this topic, and decide who, if anyone, should be screened and treated for vitamin D deficiency.

To start off, vitamin D is important in helping your intestines to absorb calcium.  Calcium, as we all know, is vital for bone health, and deficiency can lead to osteoporosis and an increased risk for fractures.  You can get vitamin D in two ways:  it can be absorbed through the intestine (dietary sources, vitamin supplementation) or your skin can produce the active form of vitamin D through sunlight exposure.  So it naturally follows that those people who are not exposed to sunlight or who have poor dietary intake of vitamin D or poor intestinal absorption might become deficient.  

Let's talk about intestinal absorption of vitamin D first.  Vitamin D is found in many foods, including fortified milk (about 100 IU/cup), fatty fish, and eggs.  Some cereals and breads are also fortified.  You can also get vitamin D through supplements (usually in pill form).  People who have intestinal malabsorptive disorders such as celiac disease and Crohn's disease among others, have difficulty absorbing fat-soluble vitamins (such as vitamin D).  

People who are not exposed to sunlight are also at risk, because they are then unable to convert vitamin D to its active form.  No one knows exactly how much sun exposure is needed to produce adequate amounts, but it is thought that as little as 15 minutes per day of direct sunlight without sunscreen is enough.  Kidney and liver disease can also affect vitamin D levels because those organs are also responsible for the production of the active form of the vitamin.

The RDA for vitamin D is 600 IU/day, this is true for all people, ages 1-70, including pregnant or lactating women.  After age 71, the recommended amount increases to 800 IU/day.  The vitamin D content of breast milk is low, so many pediatricians also recommend supplementing exclusively breastfed infants.  I just checked my women's One-A-Day vitamin, and it has 1000 IU per tablet.

There are no recommendations from any major health organization to suggest that routine screening is necessary for vitamin D deficiency, nor is there agreement on what vitamin D level defines deficiency.  However, most people think that the minimum level should be 25-30 ng/mL.  You can have too much of a good thing, too.  Too much vitamin D can lead to pain and bone demineralization, too much calcium in the blood, and brain injury.  It seems you have to take a lot of the vitamin to see signs of intoxication (around 60,000 IU/day).   The upper limit of intake recommended by the Institute of Medicine is 4000 IU/day for adults.

At this point, groups at high risk for deficiency include those who are institutionalized (due to low sunlight exposure), dark-skinned individuals (decreased sunlight absorption), and those with intestinal malabsorption.  If you are found to have a vitamin D deficiency, you should supplement, and recheck the levels in about 3-4 months.  For most people, though, meeting the RDA of vitamin D is sufficient.

If calcium intake isn't adequate, vitamin D will likely not improve bone health.  For that reason, all adults  should make sure they are getting 1000-1200 mg of calcium per day.

It should also be noted that although there is much speculation that vitamin D deficiency could lead to heart disease, cancers, diabetes, and cognitive impairment, no well-designed studies have proven a link.

Here's a helpful link for more information:

National Institutes of Health Vitamin D Factsheet

Cord Blood Banking

After a long holiday hiatus, I'm back...

Recently, I've had a few couples in my office ask about cord blood banking.  This seems to be one of those topics that people hear about, but don't really know if they should consider.  I'm going to try to help sort it all out...

Cord blood has what are called "hematopoietic stem cells".  These are cells that are the precursors to all blood cells, so if for some reason your bone marrow was wiped out, these cells could be transplanted to help regenerate your blood.  The situations in which cord blood transplants have been used include inborn errors of metabolism, cancers such as leukemia and lymphoma, and other genetic disorders like sickle cell anemia.  These same hematopoietic stem cells are present in our bone marrow, they continue to replenish our own blood cells, and can be donated through bone marrow aspiration.

The benefit of using cord blood instead of bone marrow is that it is obviously MUCH less painful to procure the cells, and there is a decreased incidence of transplant rejection.  The only disadvantage is that there are fewer stem cells in cord blood than in bone marrow, so multiple units often have to be pooled to be used for adult bone marrow transplants.

It is easy to collect cord blood at the time of delivery.  If you're interested, you just call a company that stores the blood, and request a collection kit.  After the baby is born, but before the placenta is delivered, a needle is used to puncture an umbilical vein and the cord is drained of blood into a bag, which is then returned to the facility for storage.  There is no pain involved.

Before collection, though, you have to decide how and where you want it to be stored.  There are public and private cord blood banks.  Public banks are like blood banks.  The blood is collected, and is available to anyone who needs it - as long as they are a match.  This is just like donating your blood or signing up to be an organ or bone marrow donor.  There is no charge to collect or store cord blood in a public bank.  Similar to donating blood, potential donors are screened prior to donation, and not everyone qualifies.  This blood is not directly linked to the donor, so if your family member would need stem cells, there is no way to ensure that your cord blood is given to them.

Private banks store the cord blood for a fee, to be used only by the donor or his/her relatives.  The chance that a family member would actually use a stored unit of cord blood is relatively rare, about 1 in 2700.  This would be a good idea, though,  if there is already a known disease that can be treated with hematopoietic stem cells in a family member. There is a collection fee and yearly storage fees.  The collection fee is around $2000, with an annual storage fee of around $125.   Many of these facilities are "for-profit".  I want to note that I have no financial or other interests in private cord blood banks.

It's also important to note that it is not known how long cord blood can be stored.

Another new development is the ability to collect umbilical cord tissue which contains mesenchymal stem cells that can be used to grow cartilage, tendon, and bone.  This is an area of research, and there are no current therapies using cord tissue.  Cord tissue is only stored in private banks at this time.

There are several good websites to get more information:

American College of Obstetrics and Gynecology
http://www.acog.org/~/media/For%20Patients/faq172.ashx?dmc=1&ts=20120117T1033244345

National Marrow Donor Program
http://marrow.org/Get_Involved/Donate_Cord_Blood/How_to_Donate/Where_to_Donate.aspx

National Cord Blood Program
http://www.nationalcordbloodprogram.org/donation/public_vs_private_donation.html

Private banks:

Cord Blood Registry (CBR)
http://www.cordblood.com/

Cryo-Cell International
http://www.cryo-cell.com/

ViaCord
http://www.viacord.com/

Hope this helps those of you who are trying to decide whether this is right for you...