Longevity asks Dr. Nedic about integrative treatment of Endometriosis…
Our health is governed by our hormones, and throughout our lives, ages and stages, these fluctuate and change. We look at some of the main women’s health concerns and what you can do. Being a woman can be challenging at times – the very thing that gives you the capability of producing life can sometimes impact on your own. This organ, your uterus, is the size of a pear or an avocado, yet is capable of expanding to contain a fully developed baby. For over 40 years, every 28 days, you experience bleeding from the uterine lining – shedding this lining up to 500 times during your lifetime. The British Medical Association reveals that the resultant strains and stresses on your uterus and supporting structures (the ovaries and cervix), during pregnancy and the repeated shedding and regrowing of the uterine lining, can lead to problems such as prolapse or heavy bleeding. Your hormones also play a role, as oestrogen is the main hormone produced by your ovaries and is responsible for the thickening of the uterine lining during the menstrual cycle (among other things). Progesterone is produced after the egg is released at ovulation, and acts on the uterine lining, thickening it in preparation of pregnancy. If you don’t conceive, your hormone levels drop, and your period starts.
PCOS is a common hormonal disorder among women of reproductive age. It is not just one thing, but rather a set of symptoms that can affect your cycle, hormones, blood vessels, heart and fertility, explains Dr Maureen Allem, founder and medical director of Skin Body & Health Renewal. Dr Sly Nedic, an aesthetic and anti-aging practitioner with an interest in integrative medicine, adds that this endocrine disorder is a hormonal unbalance with high testosterone levels. Often these patients exhibit oestrogen dominance and low progesterone levels, elevated insulin levels, high cortisol with metabolic problems (tending towards being overweight or obese), and hypertension.
CAUSES: There is scientific proof, says Nedic, that there is a gene that triggers higher than normal levels of androgen or insulin. “Supportive literature shows that insulin resistance and stress-related cortisol unbalance with low-grade inflammation are hugely responsible.” Currently one in 10 women experiences PCOS. Allem adds that other factors include not enough physical exercise and family history.
SIGNS AND SYMPTOMS:
- Irregular or absent menstrual
- Infertility / recurrent miscarriage;
- Excessive facial hair;
- Oily skin / acne;
- Male pattern baldness;
- Obstructive sleep apnoea;
- Cysts on the ovaries;
- Weight gain; and
- Pain in the pelvic area.
HORMONES AT PLAY AND WHEN TO WORRY: The key issue here is high testosterone, says Allem. However, the high testosterone is a side-effect, rather than the cause. In PCOS, the real underlying issue is insulin resistance and leptin resistance. Improper signalling from these metabolic hormones inhibits ovulation and causes the ovaries to produce testosterone. As this can affect the metabolic hormones, this is the main cause of weight gain. Nedic adds that if you are experiencing any irregular or absent periods, along with facial hair, acne or baldness, you need to seek medical advice. This is of particular importance if there is an increase in belly fat.
TREATMENT OPTIONS: This is a complex disorder with multihormonal unbalances, and needs an integrative approach of looking at all of the facets, including lowering insulin resistance, losing weight, treating vitamin D deficiencies, balancing the hormones and seeking advice on a healthier lifestyle, which may include omega-3 supplementation, a low-carbohydrate diet and exercise.
Uterine fibroids are non-cancerous growths of the uterus that often appear during childbearing years. These aren’t associated with an increase of uterine cancer and almost never develop into cancer. Dr Paul Rischbieter of Fibroid Care (www.fibroidcare.co.za) is the lead author studying the management and treatment of uterine fibroids. He explains that uterine fibroids often go unreported, with African women having a higher incidence than women from other parts of the world.
CAUSES: Uterine fibroids develop from the smooth muscular tissue of the uterus. A cell divides repeatedly, eventually creating a firm, rubbery mass distinct from nearby tissue. They may grow slowly or rapidly, or remain the same size. They range in size from undetectable by the human eye to bulky masses; they can be single or multiple. Rischbieter comments that as many as three out of four women have uterine fibroids at some time in their lives, but most are unaware of them, as they often have no symptoms. “Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.”
SIGNS AND SYMPTOMS: In many cases, these are asymptomatic and do not require treatment. However,
symptoms can include:
- Heavy menstrual bleeding;
- Prolonged menstrual periods;
- Pelvic pressure or pain;
- Frequent urination;
- Difficulty emptying your bladder;
- Constipation; and
- Backache or leg pains.
HORMONES AT PLAY AND WHEN TO WORRY: Oestrogen can stimulate the growth of fibroids. Fibroids should be monitored to ensure that they do not pose a risk. You need to see your doctor if you have pelvic pain that doesn’t go away; overly heavy or painful periods; spotting or bleeding between periods; pain consistently with intercourse; enlarged uterus and abdomen; or difficulty in emptying your bladder. “Seek prompt medical care if you have severe vaginal bleeding or sharp pelvic pain that comes on suddenly,” warns Rischbieter.
TREATMENT OPTIONS: According to Rischbieter, there is no single best approach to uterine fibroid treatments and many different options exist. If you have symptoms, it is recommended that you speak to your doctor about your options. More often than not, fibroids don’t require treatment unless they are causing problems. After menopause, these tend to shrink.
However, if a treatment option is required, these include:
Medication to control symptoms or shrink fibroids: This includes non-steroidal and anti-inflammatory drugs, oral contraceptive pills, intrauterine devices, hormonal and other medications. Your gynae will be able to advise you.
Uterine fibroid embolisation or uterine artery embolisation: Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to the fibroids, resulting in them shrinking and dying. This is an effective procedure, although complications might arise if the blood supply to your ovaries and other organs is compromised. Rischbieter adds that uterine artery embolisation is a relatively new procedure in mainstream South African medicine. This has led to a national research body being formed with the aim of promoting and studying the management of symptomatic fibroids in South African women. It recently launched the South African Fibroid Registry, designed to be an anonymous database of all patients managed through uterine artery embolisation.
MRI-guided ultrasound ablation: This noninvasive procedure preserves the uterus and can be done on an outpatient basis. This is performed inside an MRI scanner and uses sound waves to heat and destroy small areas of fibroid tissue. As this is a relatively new technique, it is not widely available. Research, while limited, does show this to be an effective method.
Radiofrequency ablation: Again, this is a relatively new, minimally invasive treatment. The fibroid is shrunk by inserting a needle-like device into the fibroid through the abdomen and heating it with radiofrequency electrical energy to cause the death of fibroid cells. This may be an option for women who have had their children already but want to avoid a hysterectomy.
Endometrial ablation: This technique, which destroys the endometrial lining of the uterus, can be used if the fibroids are within the uterus and are relatively small. There has been a high failure and recurrence rate noted on large or intramural fibroids.
Myomectomy: This is surgery to remove one or more fibroids, and is usually recommended when other, more conservative options fail for women who are looking for fertility-preserving surgery or want to keep their uterus. There are three types of myomectomy: hysteroscopic, where the fibroid is removed through the vagina and cervix; laparoscopic, which is performed through an incision near the navel; and laparotomy, which is considered the most invasive, as an incision is made through the abdomen. Unfortunately, myomectomies are associated with a recurrence rate.
Hysterectomy: This has long been the preferred method of treating fibroids, and while it is now recommended only as a last option, fibroids still remain a leading cause of hysterectomies.
Endometriosis is when the tissue from the uterine lining that normally grows inside of the uterus instead grows outside in the bowel, ovaries, tubes, peritoneum and even the vaginal wall and skin, leading to chronic pelvic pain and infertility.
CAUSES: There are many theories. First, genetics, as there is a six-fold increase incidence in women who have an affected first-degree relative. Environmental toxicity and xenoestrogens mimic oestrogen activity. “Recent Italian research showed that women with the highest consumption of meat and dairy products (preservatives) increased their risk of endometriosis by 80% to 100%, while those who ate a diet rich in green vegetables and fresh fruit reduced their risk by 40%,” says Nedic. Allem adds that retrograde menstruation can also be a problem, as menstrual blood, containing endometrial cells, flows back through the fallopian tubes into the pelvic cavity. Surgery, such as caesarean sections, can also result in endometriosis, as can immune system problems. Stress, says Nedic, is also a concern, as this is linked to increased cortisol or adrenal fatigue, and can also result in endometriosis.
TREATMENT OPTIONS: There is no cure for endometriosis, but the treatment options can alleviate the symptoms and the problems it causes, Allem says. Hormonal birth control is usually the first step (if you are not trying to fall pregnant). If you are trying to fall pregnant, your doctor may prescribe a gonadotropin-releasing hormone (GnRH) agonist. This medicine stops the body from making the hormones responsible for ovulation, the menstrual cycle, and the growth of endometriosis. urgery is an option for severe symptoms, when hormones are not providing relief or if you are having fertility problems. During surgery, the surgeon can locate and remove the endometriosis patches. After surgery, hormone treatment is offered, unless you are trying to conceive. Nedic notes that the integrative medical approach looks at holistically addressing a problem: rebalancing the hormone ratio (bioidentical progesterone), decreasing oestrogen dominance and xenoestrogen influence (supporting liver detoxification, decreasing aromatase activity and adding nutritional support), restoring healthy immune response and adrenal function, threating yeast overgrowth, etc. “Once the contributing factors are eliminated, conventional or surgical intervention might be considered,” says Nedic.
SIGNS AND SYMPTOMS:
- Painful periods;
- Pain during sexual intercourse;
- Painful bowel movements and urination during periods;
- Excessive bleeding;
- Chronic pelvic and back pain;
- Throbbing and dragging pain;
- Shooting rectal pain; and
- Predisposition for cancers, such as ovarian, non-Hodgkin lymphoma and brain tumours.
HORMONES AT PLAY AND WHEN TO WORRY: “It appears that oestrogen dominance plays an important role in endometriosis, so the mainstream of an integrative medical approach is to counteract oestrogen dominance, eliminate sources of xenoestrogens, and rebalance the oestrogen and progesterone ratio,” says Nedic. Allem adds that there is research currently under way to investigate whether endometriosis is a problem with the body’s hormonal system. Seek medical advice if you develop repeated painful cramps during menstruation, as well as any of the other symptoms described. However, it is important to note that 25% of endometriosis sufferers don’t have any symptoms, other than infertility.
Perimenopause, or “around menopause”, refers to that time when your body makes its natural transition towards menopause. It starts several years before menopause (usually four to six, but anything from a few months to 10 years is considered normal). “It usually starts in a woman’s 40s, but can start in her 30s, or even earlier,” says Nedic. Allem adds that your oestrogen levels rise and fall
unevenly during this transitional phase, leading to an irregular menstruation cycle.
SIGNS AND SYMPTOMS:
- Menstrual irregularity is the first sign – the length between your periods may be longer or shorter, your flow may be light to heavy, and you may skip some periods;
- Mood swings;
- Hot flushes;
- Low sex drive;
- Discomfort during sex; and
- Breast tenderness.
Perimenopause effectively ends when you have gone 12 months without having your period.
HORMONES AT PLAY AND WHEN TO WORRY: Nedic warns that perimenopausal menstrual irregularities can be mistaken for other menstrual irregularities, which in turn can be signs of cancer, pregnancy, hormone unbalance not related to natural perimenopause, etc. As such, these should always be checked out with your doctor. “Menstrual irregularities with heavy bleeding and clots can be signs of oestrogen dominance and low progesterone, and usually lead to unnecessary hysterectomies. These can be treated with additional bioidentical progesterone,” adds Nedic.
TREATMENT OPTIONS: A simple blood or saliva test to check hormone levels may be helpful. Once perimenopause is established, you can start bioidentical hormone replacement to make this transition period easier, says Nedic. Along with hormone replacement (bioidentical is preferred), says Allem, you can also look at black cohosh or phytoestrogens (plant-derived xenoestrogens), eat healthily and exercise regularly.
You are born with a finite number of eggs in the ovaries that make the oestrogen and progesterone hormones that control the processes of menstruation and ovulation. Menopause happens when your ovaries no longer release an egg every month. You are considered to be in menopause when you haven’t had a period in 12 months; this usually occurs anytime from the age of 45 to 55. You are considered to be in premature menopause if this happens prior to the age of 40. Nedic explains that this natural process results in the cessation of feedback from the ovaries (without eggs and follicles) and the part of the brain (pituitary gland) responsible for stimulating the ovaries via FSH and LH hormones.
SIGNS AND SYMPTOMS:
- Hot flushes;
- Night sweats;
- Vaginal dryness;
- Mood swings;
- Loss of sexual interest;
- Hair growth on face;
- Painful intercourse;
- Panic attacks;
- Urinary tract infections;
- Lower-back pain;
- Aching joints;
- Hair loss;
- Sore breasts;
- Memory loss;
- Weight gain; and
- Sagging skin and sarcopenia.
HORMONES AT PLAY AND WHEN TO WORRY: Your hormones are designed to work together. The cessation of ovarian function means oestrogen and progesterone are decreased. Menopause occurs when all of your hormones decrease, says Nedic. This includes testosterone, DHEA, growth hormones and thyroid. “If one hormone is altered or deficient, it will affect the others,” she says. “Oestrogen has 400 functions in the body; you can imagine what happens to your body when this is absent. Women approaching menopause must plan their strategy long before menopause sets in, as today’s women in their 50s and 60s still want the quality of life of a 40-year-old. Treatment options: It is estimated that half of all women quit taking their synthetic hormone replacement therapy (HRT) after a year, because they are unable to tolerate the side-effects, says Nedic. Another third will stop as soon as the hot flushes are gone. “In fact, scientific data showed that conventional HRT can increase the risk of breast cancer, thrombosis and heart attack.” Nedic recommends bioidentical hormone replacement therapy, where a compounded customised dose is prescribed in conjunction with other hormones that have declined, such as growth hormones, melatonin, DHEA and testosterone. “A combination of these hormones would be considered as long-term menopausal treatment, preventing age-related degenerative diseases and ensuring quality of life, rather than temporarily relieving symptoms of menopause.” Nedic believes that to make an informed decision that is best for you, you should get information and advice, from both conventional and integrative medical doctors, on the pros and cons of the two different forms of HRT (synthetic or bioidentical). Furthermore, there is a lot of scientific data available on the Internet, and since menopause is a phase of life, you must decide with certainty what approach you wish to take.” She adds that she personally advocates bioidentical hormones, according to research which ensures their safety if
prescribed correctly. Allem advises that, at Health Renewal, they have various treatment options available, from applying bioidentical hormone replacement creams to having bioidentical implants or pellets inserted. Sexual discomfort and libido disorders associated with menopause can be addressed through prescription medications and carboxy sexual rejuvenation treatments.
HORMONE REPLACEMENT THERAPY
Many people think you need to balance your hormones only when menopause kicks in and your menstrual cycle stops. However, warns Allem, this is too late. Oestrogen dominance is common about 10 to 15 years preceding menopause. This is due to progesterone production dropping more rapidly than oestrogen as women age, causing an imbalance. This can lead to unnecessary problems such as heavy periods, uterine fibroids and ovarian cysts. Patients with a history of active or past breast cancer, blood clots, liver disease, pregnancy or hormonal (endometrial) cancer should always consult a physician before using any over-the-counter or prescription therapy. There are two main types of traditional HRT. The first is oestrogen replacement, and the second a combination of oestrogen and progesterone hormones, referred to as HRT combination therapy. Nedic suggests that the decision on the use of hormones is a personal one, although in the case of surgical or premature menopause, it would be advisable to take hormones to
prevent osteoporosis, cognition decline and cardiovascular risk. “Integrative medical practitioners opt to use bioidentical hormones for further prevention of problems associated with aging (anti-aging), rather than treating the symptoms of menopause, but, as in any situation, the decision is made with a patient with the patient, weighing risks vs benefits.” Bioidentical hormone therapy (BHRT) refers to the use of
hormones that are chemically identical to those produced in the body, in a pharmaceutical compounding customised dose that is adjusted to a particular woman’s hormone levels. “This is far from using a ‘one size fits all’ approach, which is always the case with conventional HRT.” A recent scientific study on using a combination of bioidentical oestrogen and progesterone showed superior safety compared to oestrogen use only. It demonstrated that BHRT was associated with a lower risk of breast cancer and cardiovascular disease, and had more efficacy than its synthetic and animal-derived counterparts, which are found in conventional HRT. BHRT is also used mostly as a topical gel, overriding detoxification pathways in the liver, which are important for oestrogen metabolism, and possible production of dangerous metabolites involved in breast cancer pathology. “BHRT can be obtained from compounding pharmacies and at any integrative medicine doctor who is trained in using BHRT. A consent form with detailed information should be given to the patient about the superiority of BHRT prior to treatment,” adds Nedic. Conventional HRT is often given as a short-term relief from menopausal symptoms, mainly hot flushes and night sweats. Allem adds that the synthetic hormones commonly used in HRT are not usually individualised and can produce intolerable side-effects. HRT is not focused on balancing hormones in the female body and mostly consists of oestrogen and progesterone. There is no attention given to testosterone. Attitudes towards conventional HRT changed in 2002, following a report that the Women’s Health Initiative Study found that women who received equine conjugated oestrogen and progestin (classic HRT combination) had a larger incidence of breast cancer, heart attack and pulmonary embolism. More recent forms of conventional HRT are skin patches, sub-dermal implants, and gels rather than pills or injections in a lower dose that allows a safer use. Professor Alan Alperstein, a Cape-based gynaecologist, says that in SA, conventional HRT products require mandatory regulation and registration by the Medicines Control Council. This involves regular testing for purity, efficacy and safety.
THE HYSTERECTOMY CHOICE
According to the British Medical Association, hysterectomy (the surgical removal of the uterus) is one of the most common operations performed in Western countries. Statistics reveal that by the age of 55, around one in five UK women would have undergone a partial or full hysterectomy. In some countries, such as Australia and the US, these numbers are considerably higher.
REASONS FOR HYSTERECTOMIES:
- Endometriosis: 5,4%;
- Cancer: 5,6%;
- Prolapse: 6,5%;
- Menstrual problems: 35,3%;
- Fibroids: 38,5%; and
- Other: 8,7%.
Hysterectomy is considered to be different from other major operations in that it can often involve the removal of healthy or non-diseased organs, and, for some women, it’s a lifechanging decision – particularly if you are still considering having children. A study entitled The Effect of Hysterectomy on Sexuality and Psychological Changes, published in the US National Library of Medicine National Institutes of Health, reveals that hysterectomy is a procedure that often does not need to be performed as a matter of urgency, except in the case of cancer. Choosing to undergo a hysterectomy takes an informed decision – as problems or reactions may arise if the operation has been done for the wrong reasons. It is imperative that you have a good relationship with your gynae and that you discuss all of your options prior to making your choice. According to research, the decision whether to have a hysterectomy or not can be a very difficult and emotional process, and has been linked to depression, including severe and prolonged feelings of sadness and hopelessness; diminished interest in activities; significant weight loss or gain; insomnia; and fatigue. Ultimately, the researchers say, each woman will react differently, and the emotions are a combination of emotional and physical responses. Professor Alan Alperstein, a Cape-based gynaecologist, explains that a hysterectomy is performed when “uterine pathology impacts or threatens a woman’s health”. Most often this is due to growths (tumours), cancers or precancers. “In these women, there is no doubt that hysterectomy is appropriate. Uterine prolapse and pelvic pain are other indications.” He adds that many women have hysterectomies due to excessive bleeding. “However, many of these bleeding related conditions can be managed without hysterectomy. Once pathology is excluded, these excessive bleeders can have hormonal therapy, medical therapy, an intrauterine device with progesterone inserted, or have an ablation of their lining of the uterus.” Alperstein says this could prevent up to 40% of the hysterectomies performed.
There are a number of options with a hysterectomy: they can be done via the abdomen (open surgery), vaginally or laparoscopically. Total hysterectomies involve the removal of the uterus and cervix, and can be done with or without ovarian removal. This is considered to be the most common form of hysterectomy. The advantage of removing the cervix is that it protects against the risk of abnormal cellular changes, which can in turn lead to cancer. Having a total hysterectomy means you no longer have to go for your annual pap smear, provided, of course, that your uterus was healthy and free of any abnormalities at the time of your hysterectomy. A subtotal hysterectomy is one that involves removing the uterus, but not the cervix. “This means that the upper part of the uterus (which causes most of the problems) is removed,” states Alperstein. This form of hysterectomy is a shorter and simpler operation, as the removal of the cervix is considered the most difficult part of the operation. However, the disadvantage is that you may still be at risk of abnormal cellular changes, so you will need to continue going for your annual pap smear. The good news is that research reveals that, even if you go for a total hysterectomy, you will not experience a deterioration in your sex life. “The decision of the technique to be performed is made by the surgeon, in discussion with you. It will depend on the pathology and skills/experience of the surgeon,” Alperstein notes. In general, the duration of your stay in hospital will be between one and four days. On average, you can expect to take two weeks of rest, with no physical activity, followed by two weeks of slowly getting back to normal activities. “Assuming no complications, most women feel better by four weeks. Often ‘tiredness’ is the biggest problem. By six weeks, a full
recovery is expected,” he says