Wendy’s Story: Wendy, a thirty-one-year-old manager of a Florida boutique, has been married for three years. She has been trying to get pregnant but has encountered many difficulties. Wendy described her crisis: ‘After doing a laparoscopy on me, my doctor told me 1 didn’t have endometriosis. He said I was okay, yet I’m in pain two weeks of every month. I want a baby, but its hard to fed sexy when you feel so bad. Even so, I’ve been pregnant three times in the last two and a half years, but I have miscarried each one. What could be wrong with me?”

Wendy’s plight is one many women with undiagnosed endometriosis understand all too well: pain, infertility, and no adequate explanation tor their symptoms. In the past, it was felt that endometriosis in a more advanced stage prevented pregnancy because cysts and massive adhesions set up a hostile environment for conception. Most recent research into the subject, however, has revealed that a one-to-one correlation between infertility and endometriosis exists at earlier stages, too. (A chapter devoted to this will explicate further.) This research on earlier-stage endometriosis is particularly relevant to Wendy’s case.

A team of doctors at the University of Kentucky Medical Center’s Reproductive Endocrinology Department in Lexington concluded, in their 1985 study, that women with mild endometriosis suffered twice the number of spontaneous abortions, or miscarriage, that women with the disease at a more serious stage suffered. In examining this phenomenon, Michael Vernon, Ph.D., and his colleagues speculated that early or milder endometriotic lesions might be more “metabolically active” and produce prostaglandins, the hormones that have been implicated in the activity of endometriotic tissue. Prostaglandins might be partially responsible for infertility and miscarriage, since they cause uterine and tubal cramping, thus making conception and full-term pregnancy more difficult.

In further testing, they examined various types of implants, from very mild to serious. These implants have, in fact, been classified on a rating system to standardize their description for doctors. Devised by the American Fertility Society this system charts and describes implants by color and degree of growth, and rates them on a scale of severity from I to IV. (See the illustration on page 66.) Implants may be red, reddish brown, dark brown, or black (also known as powder bum). The Kentucky team also discovered that the “mildest” implants produced and synthesized twice the amount of prostaglandin F that implants at an intermediary stage produced, which in turn produced more of the hormone than the powder-bum variety, (In some expertments, powder-burn implants produced no such hormone.) This explains why women with minimal endometriosis sometimes experience more pain than women with massive growths. (Massive growths arc simply easier to identify.)

Wendy’s doctor clearly suspected endometriosis—no doubt this reason for performing a laparoscopy. That he was unable to find any obvious trace of the disease led to his conclusion that she was free of it. My advice to Wendy is to return to her doctor to begin a program of Danocrine to halt endometriotic growth, and to start on a diet high in complex carbohydrates and rich in B vitamins—the vitamins that are important in combating stress and favoring conception.

*38\43\4*

Psoriasis, one of the commonest skin diseases, is also one of the most cosmetically disabling. Although it is very rarely fatal, it produces an immeasurable amount of misery. It affects people mainly at the peak of their working and reproductive lives, and has considerable adverse socio-economic effects on them and their families. The disease has been known for hundreds of years. Many of the diseases referred to in the Bible as leprosy are in fact thought to have been psoriasis.

Psoriasis is a skin condition in which red scaly patches develop on the skin. The areas most commonly affected are the elbows and knees, but the scalp and other areas of the body may also be affected. The main problem with the condition is that it is cosmetically unacceptable, both visually and on account of the scales which are shed from the spots. Fortunately the condition very rarely affects the face, and usually is mainly on areas covered by clothing.

If one parent is affected, it is estimated that there is a 25 per cent chance of immediate members of this family also developing the condition. If two parents are affected, then the likelihood increases to 65 per cent. Fortunately many generations in a family may escape developing the condition.

A number of factors are known to precipitate the onset or appearance of psoriasis. For instance certain infections, such as a streptococcal tonsillitis, are known to be implicated particularly with children. Trauma, due to such things as injuries or sun-burn, may also cause the appearance of psoriasis. It has been suggested that certain hormonal changes such as those occurring with puberty and menopause, may aggravate the condition yet certain other hormonal changes, such as those during pregnancy, may improve the disease. As with many otherconditions. psychological stress can certainly aggravate the disease.

There are various form of psoriasis. There is the acute or Curtate form of the condition, which is usually seen in children and which may be precipitated by tonsillitis.

Then there is the chronic or Plaque form which is the commonest manifestation, and which classically affects the elbows, the knees, the buttocks, and the scalp. In this latter area, it may easily be confused with severe dandruff.

Occasionally psoriasis is confined to the creases or flexures, and sometimes in infancy it occurs as a napkin psoriasis. Here it may be confused with a simple napkin dermatitis or eczema. Nail psoriasis can be most disfiguring. It may affect the nails only or be associated with other forms of psoriasis- Usually it causes lifting of the nail, with or without pitting, and eventually, disintegration. This condition may be misdiagnosed as a fungal infection, from which it must always be separated, as the treatment is very different. Most infrequently, psoriasis takes on a Pustular form, and then is mainly distributed on either the palms or soles, where it has the appearance of an infective process. It is not, however, infective or infectious.

Rarer still, is the exfoliative form of psoriasis, where the entire body skin is shed, and the patient becomes extremely ill. Another of the rare complications of psoriasis is an arthritis, which mainly affects the finger or toe joints, and occasionally the cervical spine, or lower back joints. Psoriasis, however, is not contagious, nor does it affect the blood, or cause cancer.

The basic pathology of psoriasis is related to increased rep rod activity of the cells in the skin and increased production of DNA in the epidermis and dermis. How this comes about is as yet uncertain, although much research work is being done in order to try and elucidate the basic fault, so that hopefully one day it may be corrected. As a result of these abnormalities in the skin there is a marked increase in the rate of cell ‘turnover’. The abnormal cells reproduce approximately ten times more quickly than the normal cells, which results in a build-up of cells which appears as thick scale.

The treatment of such a disfiguring condition is obviously of considerable importance—a society which extols the virtues of physical beauty as much as ours makes people with psoriasis feel very self-conscious. The question is always asked, ‘Can psoriasis be cured?’ Unfortunately it can no more be ‘cured’ than can high blood pressure, schizophrenia, or diabetes. However, and this must be stressed, in most cases it can be completely controlled so that there may be no evidence of the condition at all for long periods of time. Even though the condition may recur, it can once again be brought under complete control.

*66\44\4*

These have been developed on the premise that sweetness without calories would assist fat loss, but the link appears to be tenuous, at best. Because carbohydrate, including sugar, naturally suppresses appetite, the rationale for artificial sweeteners for fat loss is limited for most people. The biggest users of artificial sweeteners are obese people and research suggests that people who use artificial sweeteners do so to express their fat-loss concerns rather than decrease energy intake (i.e. They may make up for the loss of calories somewhere else). There is some concern that artificial sweeteners increase appetite, but a comprehensive look at all the research on sweeteners by Professor Drewnowski shows there is no evidence that sweetener use per se causes increases in food intake by increasing the appetite. The use of artificial sweeteners in conjunction with other dietary strategies may be useful in limiting energy intake and there is no substantive evidence to suggest any ill-health effects from use of sweeteners, in moderation.

*119\186\4*

Most endometriosis sufferers have felt depressed at some stage for one reason or another. Suddenly you have to come to terms with having a chronic illness. There is the constant tiredness and the frustration of feeling lethargic. Sexual relations are put under enormous stress if you suffer pain during intercourse. Pain may also interrupt your lifestyle.

Treatment may not be effective and you worry about what alternatives you may be faced with. So many of your questions seem to go unanswered and at times you really feel as though you are unable to get on with your life.

For those who have fertility problems there is the concern that perhaps you may never have a child. And if you are lucky enough to get pregnant will you miscarry? Will the disease hinder a normal delivery?

Many of us become depressed thinking about the future management of the disease. Will you be faced with more hormone treatment? Will you require more surgery?

*108\83\2*

Diagnosed with endometriosis at the age of 2 7,1 was told that the best treatment was to take the male synthetic hormone, Danazol. I had to take 600 milligrams a day for nine months. I was a little apprehensive about taking Danazol but realised that not all women suffered the side effects that I had read about. I decided that if the Danazol was going to get rid of the terrible period pain I was suffering every month then I was prepared to take the tablets.

Every day whilst on the medication I looked for side effects from the drug. I jumped on the scales every morning to see if I had gained weight. I peered in the mirror to see if I was growing a beard and I inspected my skin to make sure

I wasn’t developing acne.

I was surprised that I actually felt good during the time I took Danazol. For the first time that I could remember my whole life didn’t revolve around my menstrual cycle. No periods and no pain for nine months was sheer bliss. I did develop a few side effects, but the relief I obtained from the pain far outweighed the side effects.

I gained about six kilograms in weight. This gain appeared to be more a body building, muscular weight increase which didn’t bother me. I experienced some nausea and occasional vomiting but it wasn’t a major problem.

The only other side effect I experienced which, unfortunately, has been irreversible was a deepening of my singing voice. My upper range decreased four tones. Luckily, I am not a professional singer but I still get frustrated occasionally at the change. At the end of the Danazol treatment, a laparoscopy revealed no evidence of endometriosis and I subsequently had two children. Seven years later I had another laparoscopy and was again diagnosed as having endometriosis.

This time I took the trial drug Buserelin, one of the GnRH agonists. It was in the form of a nasal spray. I took the drug for six months and during that time had no side effects. I had been told by my doctor that I might experience hot flushes, dry vagina, depression or headaches. Luckily, I didn’t experience any of them. Another laparoscopy at the end of the Buserelin treatment revealed that apart from one endometrial cyst, the endometriosis had disappeared.

Six weeks after this laparoscopy I was back in hospital having the cyst and left ovary removed. Although I was a registered nurse and familiar with hospital environments, I was still nervous at the prospect of major surgery.

I need not have worried — everything went according to the plan my doctor and I had discussed. I had a continuous morphine infusion for the first 24 hours after the operation — it was great, I experienced very little pain. I was up walking around the day after surgery and drinking and eating the day after that.

I was discharged from hospital five days after the operation and was back at part-time work and playing sport six weeks after the surgery.

Three years later I feel great. I still get some ovulation and period pain every month, but nothing like the severe, debilitating pain I experienced before I had treatment.

*50\83\2*