Helps Pregnancy Cure Endometriosis
Dr. Ewald Becherer
Endometriosis is one of the most common female diseases of puberty. It is estimated that endometriosis can be found in 10 to 15 percent of these women and that around 40,000 new cases occur in Germany every year. It is defined as the presence of uterine lining-like tissue outside the uterine cavity. This tissue can settle in different areas in the abdomen, mainly in the peritoneum of the pelvis, on the ovaries and fallopian tubes, in the muscle layer of the uterus, in the bladder and intestinal wall and between the vagina and rectum.
This definition relates solely to one finding, namely the occurrence of this tissue in places where it actually does not belong. It says nothing about whether or how seriously the women who have this finding are ill are. In about 50 percent of these women, the finding seems to be a harmless secondary finding without any disease significance. Other women with this finding have mild discomfort, and many women with endometriosis have very massive discomfort and impairment of their quality of life. In some patients, the disease can only be temporary, but it can also remain present for years or recur after treatment.
In my opinion, the actual disease "endometriosis" therefore covers three aspects: On the one hand, the findings of endometriosis foci, which are used to define the disease, on the other hand, the pain or infertility associated with it - not always - and finally the tendency that such foci and the pain keeps recurring.
Endometriosis is estrogen-dependent and occurs during sexual maturity. The peak of the disease is in the 27th year of life. As the body's own estrogen production decreases during menopause, endometriosis usually comes to a standstill.
There appears to be a hereditary component, since a familial accumulation of the disease could be established. In a study of endometriosis patients, endometriosis was also found in 6.9 percent of the first-degree relatives, i.e. mothers or sisters, compared with only one percent in the control group. The inheritance is unclear.
Theories of origin and manifestations
There are several theories about the causes of endometriosis, none of which can explain the various aspects of endometriosis and the variety of its occurrences. Different factors are likely to be intertwined.
The so-called “transplant theory” states that rejected cell aggregates from the uterine lining with the menstrual blood reach the abdomen via the fallopian tubes and can accumulate there due to unclear immunological changes. According to the "metaplasia theory" - metaplasia means cell conversion - certain cells of the peritoneum can convert into uterine lining cells.
Another theory is based on the assumption that increased natural movement of the uterus - a so-called "hyperperistalsis" - leads to the tearing out of small tissue associations in its mucous membrane. These tissue associations are vital and have a high growth potential. Through the increased movement of the uterus or through the menstrual blood flowing "backwards" via the fallopian tubes, they get into the abdomen or into the deeper muscle layers of the uterus.
Changes in the local immune system are required at the same time so that the non-local cell clusters of the uterine lining can grow and multiply in atypical locations.
Endometriosis manifests itself in the form of endometrial foci of different sizes, colors and numbers. With some women one finds only single herds, with other women several or a large number of such settlements. Usually they are dark red to blue-black or dark brown; but they can also be glassy, light brown, reddish or yellow. Endometriosis foci can superficially affect the peritoneum as peritoneum endometriosis and grow into the abdominal cavity like a pinhead as small vesicles or mucous membrane islands. As ovarian endometriosis, they can form cysts that are hemorrhaged in, which can be several centimeters in size and are known as "chocolate cysts" because of their dark brown, viscous content. Endometriosis can also grow nodularly downwards from the peritoneum, in which case one speaks of “deeply infiltrating endometriosis”. The nodes can grow to a few centimeters and affect the organs below the peritoneum such as the bladder and intestines. Endometriosis can also affect the muscle layer of the uterus diffusely or in individual foci, which is called "adenomyosis".
Countless immunological and inflammatory changes in the abdominal fluid are associated with all of these forms. These can lead to parts of the peritoneum or the affected organs sticking together, which can lead to adhesions and ultimately to scar tissue. This can impair the functioning of the affected organs. For example, one fallopian tube may not move enough to bring the sperm to the egg to be fertilized. Or its walls can stick together completely so that the sperm can no longer get to the fertilizable egg.
The growth of most endometrial foci is dependent on estrogen. However, many older and scarred foci have lost this sensitivity to hormones.
The most common symptoms include painful menstrual bleeding, although the pain can often appear a few days before the bleeding starts. There may be pain during sexual intercourse, which is often position-dependent. Some women complain of pain when urinating or when defecating and some also have very unspecific abdominal pain. Sometimes you experience bleeding disorders and heavy menstrual bleeding. If an ovary is infected with endometriosis, typical ovarian cysts can occur, which cause pain but can also be painless. Sometimes the urine or intestinal bleeding may be bloody. Endometriosis rarely occurs in scars or in the navel, where pain and bleeding can also occur.
The occurrence of symptoms depends on where the endometrial foci are located. The listed complaints can occur both individually and together with others. They can only be subtle or they can also be very massive.
30 to 50 percent of women with endometriosis can have difficulty getting pregnant, and some of them may even be sterile at the time of diagnosis or become sterile as the disease progresses. Quite a few women with endometriosis have no symptoms at all and can get pregnant without any problems.
All of the above symptoms can be caused by endometriosis - but it does not have to be. That is what makes diagnosis so difficult. At http://www.endometriose-liga.eu/endo-test women can use a questionnaire to check how likely it is that they have endometriosis.
Sometimes the suspicion of endometriosis arises from the conversation with the gynecologist and his examination. An ultrasound examination of the genital organs and the abdomen is usually used for further diagnostics, although small endometrial foci cannot be shown. Depending on their position, larger foci of endometriosis can be clearly seen in the ultrasound. Endometriosis cysts are usually easy to see, but sometimes it is difficult to tell them apart from other cysts. The ultrasound examination usually only provides indications of an endometriosis in the uterine muscle layer, which is called "adenomyosis", which does not always allow a reliable diagnosis.
The most important method for diagnosing endometriosis is a laparoscopy, the "laparoscopy". During this operation, under general anesthesia, a pencil-thick lens is inserted over the navel into the abdominal cavity. This allows the surgeon to look at the genital organs, the urinary bladder, the intestine and the abdomen. However, he only sees the abdominal cavity-side wall of these organs and cannot look through the wall, as is possible, for example, with ultrasound. Adenomyosis, small foci in the wall of the urinary bladder or intestine without connection to the peritoneum and foci on the pelvic wall beyond the peritoneum, cannot always be diagnosed with certainty, even with a laparoscopy. With small instruments that are brought into the abdominal cavity via thin stems, samples can be taken from the endometrial foci and the visible endometrial foci can be removed as completely as possible. Diagnosis becomes a therapeutic option.
In individual cases, it is difficult to prove whether an endometriosis infection and certain complaints are actually causally related.
Surgery, usually performed as a laparoscopy, is required when endometriosis is suspected and the diagnosis needs to be confirmed or another condition needs to be ruled out. An operation makes sense if there are severe symptoms and these cannot be adequately treated with rather simple therapeutic options. The decision must always be made individually. If, for example, there is severe menstrual pain and taking a suitable pill does not improve the symptoms, an operative diagnosis should be carried out. When looking for the cause of infertility, a laparoscopy can be an important diagnostic step. In addition to looking for endometriosis, a laparoscopy can also check the patency of the fallopian tubes.
In principle, the decision for an operation is always a balance between the severity of the symptoms, the other treatment options available and the effort, the risks and the possible consequences of an operation.
The endometrial foci are removed during an operation. The tissue samples taken are always examined in terms of tissue detail, whereby the stage of the disease is also determined. Endometrial foci and cysts can be removed by cutting out or destroyed by targeted heat exposure using special electrical instruments or lasers. Particularly in the case of deeply infiltrating endometriosis, these can be lengthy and very difficult operations. The aim of an operation should always be the complete removal or destruction of all endometrial foci. The aim is not to remove any organs or parts of organs, which unfortunately is not always possible. If a laparoscopy is not sufficient as an access route, opening the abdomen by means of an abdominal incision is a further option.
How well an operation succeeds, i.e. how completely all endometrial foci are removed and the organs preserved, depends very much on the surgeon's experience. Therefore, an operation should be carefully planned and only performed by surgeons who are experienced in this area.
How to operate in the event of a chronic disease course depends on the individual situation and must be decided by the patient together with an experienced surgeon. The severity of the symptoms, the other treatment options available and the risks and consequences of an operation all play a role. These include, for example, wound healing disorders and severe blood loss, but also other adhesions and internal scars up to loss, injuries and functional restrictions of organs.
During an operation, however, only the visible endometrial foci can be removed, but not microscopic foci and also not the “predisposition” of a woman, which causes new foci to arise again and again.
Since many manifestations of endometriosis are estrogen-dependent, they can be influenced therapeutically by regulating the effect or production of estrogen. Adhesions and internal scars that can arise from the endometriosis are unfortunately not hormone-dependent, so they cannot be treated with hormones.
The stimulating effect of estrogen on the lining of the uterus and on the hormone-sensitive endometrial foci can be counteracted by administering luteal hormones - the "gestagens". Gestagens are given for months or even years and dry out the endometrial foci and uterine lining for as long as they are given. During this time there is no regular menstrual period. They also stop the egg cells from maturing and thereby reduce the production of estrogen. They cannot improve fertility, and they have no effect on endometriosis cysts. In fact, it is not usually possible to become pregnant while taking them. Side effects that may occur include bleeding disorders, weight gain, mood swings, depressive moods and disorders of the lipid metabolism.
An effect comparable to that of progestins can also be achieved with the administration of contraceptive pills, which consist of a constant and progestogen-based combination of progestins and an estrogen. The pill should ideally be taken continuously, i.e. without the usual one-week break. The aim of these two medications is to completely switch off the cycle and thus the cyclical production of estrogen. In addition to the side effects of progestins, there are also water retention, headache and chest pain and the risks of thrombosis or an increase in blood pressure. Nevertheless, the tolerance and the efficiency of cycle suppression are better with the contraceptive pill than with the progestins.
The pituitary gland controls, among other things, the production of estrogens and corpus luteum hormones in the ovaries. With a targeted drug-based blockade of this control through the administration of so-called "GnRH agonists", it is possible to completely switch off the cyclic hormone production in the ovaries and the cycle as long as these drugs are administered. During this time, side effects can include hot flashes, vaginal dryness, sleep disorders, loss of libido, depressive moods and a decrease in bone strength. However, you can largely reduce these side effects if you give the body a small amount of estrogen and luteal hormone using the so-called "add-back" method. With or without add-back, the endometriosis dries up even more than with progestin therapy or taking the contraceptive pill, but therapy with GnRH agonists is usually only carried out for three to six months.
You can then switch to long-term treatment with progestins or the contraceptive pill. The extent to which long-term treatment is necessary or even possible in the case of a desire to have children can only be decided individually. Even drug therapy cannot cure endometriosis in its aspect as a predisposition to possibly recur.
Pain therapy is used when surgical therapy or hormone therapy are out of the question or are not successful enough. Ibuprofen or naproxen are particularly recommended as effective medicinal pain relievers. Sometimes herbal pain relievers, which can be taken as tea or as a ready-made preparation in the form of drops, are sufficient. For example, goose-fingerweed, butterbur, willow bark, feverfew, frankincense and devil's claw have a pain-relieving effect. Other finished preparations are Khella and Phytodolor drops.
Other possibilities come from physiotherapy: heat pads and plasters, special massages and transcutaneous electrical nerve stimulation (TENS). With TENS, small devices for domestic use generate electrical impulses that are transmitted through the skin to the nervous system and superimpose the perception of pain.
In addition, local anesthetics can be used specifically in neural therapy to treat pain. In addition, pain can be relieved with traditional Chinese medicine and homeopathy. And finally, all procedures can be recommended that can relieve pain through forms of deep relaxation. These include autogenic training, progressive muscle relaxation, mindfulness-based stress reduction, yoga and others.
Mental and psychological relationships
When pain occurs in the body, it is not always perceived to the same extent, regardless of its cause. Pain is generally perceived more strongly when it has an alarm function, when a person is not feeling well or when fear, worry and other negative emotions are associated with it. Since this is also the case with endometriosis, the mental and emotional connections are at least given via the modulation of pain perception.
Another connection is that a chronically painful course of the disease or difficulties with fertility affect the mental and emotional well-being over time. This can range from impaired joy in life to depressive moods. This can cause problems in the partnership - e.g.through loss of libido due to pain during sexual intercourse - as well as in professional life, which in turn affect the mental and emotional state.
In the past, various scientific investigations were carried out to find out whether endometriosis patients have common features in the intellectual or emotional area that are causally related to the disease. Such connections could not be scientifically proven. Nevertheless, in my opinion it can be worthwhile to look for yourself - alone or with support - for experiences or influences that disturb inner harmony and freedom. In my holistic understanding of the human being, the mind, soul and body are inextricably linked and influence one another. I think it is possible that disharmonies in this triad of spirit-soul-body, lack of freedom and negative experiences that one had to “put away” lead to physical reactions that point to these inner disharmonies and become perceptible as “diseases”.
Connection with diet
Pain is aggravated when on the one hand too few fruits and vegetables and on the other hand too many animal products and empty carbohydrates (sugar) are eaten. The saturated fats in sausage, meat, milk and cheese promote inflammation and pain processes. In addition to fruit and vegetables, two fish meals a week and the use of vegetable oils, such as olive, linseed, rapeseed and walnut oil, are recommended.
Estrogens are also an increasing problem in the food chain; think of their use in meat production and their occurrence in wastewater. Estrogen-like substances are also found in some fragrances, plasticizers and many plastic materials.
Course of the disease
Endometriosis can be a chronic condition with a high risk of recurring. This often depends on the stage of the disease. Endometriosis is divided into four stages according to the American Fertility Society (rAFS score). In a study from 1993, after surgical treatment in patients with minimal and mild endometriosis, stages I and II, the disease recurred in 37 percent within five years. With moderate and severe endometriosis, stages III and IV, this was the case in 74 percent of the patients. The disease-free interval can be extended through hormonal therapy.
Relapses, i.e. relapses, can occur on the one hand because surgical therapy can remove the visible endometrial foci, but not the microscopic ones. Without further treatment, these can continue to grow over time and cause symptoms again. On the other hand, the predisposition to the disease or the impulse that triggered the disease cannot be treated with the therapies available up to now. What ultimately triggers the disease and the symptoms associated with the disease remains unclear.
So far the favorable course of the disease cannot be explained in this way. It is unclear why 63 percent of patients in stages I and II and 26 percent of patients in stages III and IV did not recur within 5 years and why the disease impulse apparently died out spontaneously. Often the disease no longer occurs after pregnancy. It is believed that the hormonal constellation dries up the endometrial foci during pregnancy.
Alternative and naturopathic procedures
In addition to the established conventional medical treatment methods, other therapy options can also be used as a supplement to conventional medicine and sometimes as an alternative to it.
Herbal medicines can be administered to combat pain, to stop and bleed blood, to treat wound healing disorders, to regulate hormones, to inhibit inflammation, to inhibit growth and to remove harmful substances.
Osteopathy, reflexology on the foot, neural therapy and special massage techniques from physiotherapy can be used both to treat pain and to harmonize various body processes.
Homeopathy and Traditional Chinese Medicine are independent and very complex medical systems that can often produce good treatment results for women with endometriosis. They are used both to alleviate individual symptoms and in their original holistic understanding.
In the holistic view of people and their diseases, not only the internal relationships and mutual influences of mind, soul and body are taken into account, but also the influence of people on the one hand by their social environment - partners, family, friends, colleagues - and on the other hand by environmental influences from the fields of nature, technology and chemistry - think, for example, of additives in food, clothing, cleaning products or electrosmog in the house, electromagnetic waves from transmitter masts in the vicinity. Very different treatment paths are followed here, always with an individual approach.
While osteopathy and physiotherapy require special professional training, the other therapeutic methods can be carried out by both alternative practitioners and doctors. The practitioners in both professional groups should have completed intensive training, usually several years, in the respective therapy methods and have extensive experience with the disease endometriosis. Because endometriosis is a very complex disease that requires a high degree of creativity, sensitivity, responsibility and experience, both from the operative as well as from the alternative therapists.
Chances of recovery
Unfortunately, one can only speculate about the chances of recovery. The established current conventional medicine does not know the actual cause of the disease. She defines the illness on the basis of her physical findings, without being able to say anything about the disposition of the illness or the impulse that could have triggered the illness. Accordingly, the treatment options are geared towards the findings and symptoms, such as pain or infertility. Established conventional medicine cannot cure endometriosis.
Homeopathy and Traditional Chinese Medicine are medical systems that have a holistic approach and therefore differ significantly from the findings-oriented approach of conventional medicine and some naturopathic procedures. They try to grasp people both in their entirety and in their individuality, which sometimes works well and sometimes not. Therefore, the therapeutic success of these procedures, which try to restore inner harmony and to strengthen the vitality of a person as a whole, are not uniform or reliable. However, I believe that cure is possible with these methods, although there is hardly any scientific research into it.
Incidentally, I attach great importance to the unity of body-soul-spirit and their internal mutual influence. I think healing comes from within rather than from without. Healing has to do with being whole, with overcoming divisions and splits that have arisen in the course of life. Separations and splits from the wholeness of one's own loving and lovable being.
Endometriosis and fertility
Particularly when it comes to fertility issues, it makes sense to classify the severity of endometriosis according to the American Fertility Society into stages I, II, III and IV (rAFS score): minimal, mild, moderate and severe. This classification does not necessarily correlate with the painfulness of the disease, but definitely with the fertility of endometriosis patients. As the severity of the endometriosis increases, fertility decreases. However, the data from the scientific studies on this are not uniform and often cannot be compared with one another.
If you summarize all the severity of endometriosis, 30 to 50 percent of all women with endometriosis have reduced fertility. But up to 30 percent of all endometriosis patients get pregnant without any problems.
The monthly pregnancy rate in women with untreated endometriosis was 2 to 10 percent in a study from 2004, while it was given as 15 to 20 percent in healthy couples.
In a 2002 publication, mild and minimal endometriosis the probability of becoming pregnant within a period of six months is given as 28 percent.
For patients with moderate and severe endometriosis it is much more difficult to get pregnant without treatment; the pregnancy rate is 5 to 10 percent within a year.
Endometriosis leads to local inflammatory changes in the organs and structures in the pelvis with the formation of adhesions. As a result, the patency or mobility of the fallopian tubes can be restricted or impaired, so that the egg-uptake mechanism necessary for fertilization is disturbed. Changes in the ovaries caused by endometriosis can disrupt hormone production and egg maturation. Endometriosis leads to inflammatory and immunological changes in the abdominal cavity fluid and the cells in it, so that an environment that is unfavorable for the sperm is created and these are increasingly taken up by phagocytes. Adenomyosis, in which the muscle layer of the uterus is affected by endometriosis, can disrupt the directed transport of sperm through the uterus and the fallopian tubes. In addition, the implantation of the embryo is disturbed by the adenomyosis and changes in the uterine lining.
The chances of getting pregnant can also be reduced if intercourse is very painful and as a result, it takes place less or less.
The treatment of women with an unfulfilled desire to have children and endometriosis depends on the one hand on the severity of the disease (rAFS stage), the age of the patient, the duration of the unfulfilled desire to have children and the pain. Other very important factors for the couple's decision are the urgency of the desire to have children, other causes of sterility in the couple, the willingness for possible treatment measures - for example an operation or artificial insemination and the associated physical and mental-emotional stress - and last but not least the financial possibilities. The decision can therefore only be made on a case-by-case basis.
The following recommendation can be given as a general guide, but may not be appropriate in individual cases:
Usually endometriosis is diagnosed with a laparoscopy. This laparoscopy should determine the stage of the disease and eliminate all visible foci. Patients with minimal or mild endometriosis (rAFS stage I or II) who are younger than 35 years can try to make the most of them during the next six to twelve cycles to get pregnant. If necessary, competent cycle monitoring and hormonal cycle regulation are useful. If you really want to have children, it doesn't make sense to just wait and see.
In patients older than 35 years of age, regardless of the severity of their disease, and in younger women with moderate or severe endometriosis (rAFS stage III or IV), artificial insemination should be considered at an early stage. How early depends on the findings. If the fallopian tubes are blocked, waiting is in vain. If the conditions are favorable, you can try to get the most out of the next three to six cycles.
According to a study from 2002, the pregnancy rates per cycle with artificial insemination were 21 percent in stages I to II and 14 percent in stages III to IV. As a side note: the pregnancy rates with artificial insemination are not to be equated with the birth of a child. The pregnancy rates for all in-vitro fertilization, i.e. fertilization in the test tube, not only performed on endometriosis patients, were 27.2 percent in 2007. The birth rate was only 11.6 percent.
Regardless of these medical-technical considerations, I agree with the recommendations of the psychologist Tewes Wischmann, who advises women with endometriosis and wanting to have children the following:
- Realistically assess the chances of success of artificial insemination methods
- Consider “Plan B” right from the start
- insist on effective pain management
- clearly reject a psychopathologization
- prepare for and accept emotional crises
- Do not let yourself be dominated by the desire to have children
- are not afraid of psychosocial counseling
- Seeing fulfilled sexuality not only in the performance of coitus
- learn a relaxation procedure
- respect different experiences of childlessness
After egg retrieval, artificial insemination and cultivation of the embryos in the test tube, fewer embryos survive the time to embryo transfer in women with endometriosis than in women without endometriosis.
There are contradicting research results on the question of whether women with endometriosis are more likely to have miscarriages after artificial insemination and successful embryo transfer (i.e. after pregnancy has been established). A 1998 study showed a higher rate for stages III and IV (47% versus 14%). However, some other studies could not find an increased rate of miscarriages.
Studies of egg donations, which are banned in Germany, have shown that the conditions under which the egg ripens is more important than the environment in which it is implanted. If endometriosis was not found in either the donor or the recipient, the implantation rate was 20.1% and the resulting pregnancy rate was 61.4%. If only the recipient had endometriosis, these rates were only slightly changed (20.8% and 60.0%, respectively). However, if only the donor was sick (the recipient was not), the implantation rate was only 6.8% and the pregnancy rate 28.6%.
If pregnancy has occurred, endometriosis patients do not have a higher risk of pregnancy complications in the course of the pregnancy, e.g. B. Gestational diabetes, pregnancy-related increase in blood pressure or reduced child growth. There is no higher risk of premature or death births. And the condition of the child during childbirth is also not affected by endometriosis.
Of all couples who want to have children, around 80 percent become pregnant within the first six cycles. In 20 percent of all couples, at least slightly reduced fertility must be assumed after six unsuccessful cycles. After 12 cycles, around 10 percent of women have not become pregnant. It must be assumed that their fertility is significantly reduced. Only after 48 unsuccessful cycles are a few considered sterile. This is only the case for five percent of couples. When the time comes for diagnostic or therapeutic measures depends on various factors - one of the most important is the woman's age.
Since 30 to 50 percent of all involuntarily childless women suffer from endometriosis, a gradual clarification of the causes responsible for this makes sense. This also includes a laparoscopy after cycle monitoring, hormonal diagnostics and the examination of the sperm. The patency of the fallopian tubes and pathological changes in the genital organs, such as endometriosis, can be determined. This enables surgical treatment that can improve fertility. As far as we know today, endometriosis does not seem to be causally involved if pregnancies come about without any problems, but repeatedly end in miscarriages. An examination for endometriosis is not one of the usual examination steps.
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