The other day, AG, a 28-year-old accountant, came to see me about her menstrual cramps.
She has been suffering from it since puberty.
'I had my first period at 12. The pain wasn't too bad, and it was relieved after a hot shower. But by my late teens, it was getting more severe and I had to take Panadol regularly,' she recalled.
When she was in university, Panadol and other pain killers were not effective anymore. Her family physician suggested oral contraceptive pills.
'My Mum was not convinced so she took me to her gynaecologist. I was just 20. I remember the gynae saying that I had primary dysmenorrhoea and that it would disappear after I had given birth,' she continued.
'Do you have the pain on the first day or throughout your period,' I interrupted, as primary dysmenorrhoea refers to menstrual cramps which occur only on the first day and usually last for a few hours.
'I cannot recall,' she replied.
'Anyway, I was prescribed oral pills. I took them for a few months but stopped because of the side effects. The cramps became worse and I was completely incapacitated. On one occasion, I almost passed out.'
'Any investigation done?' I asked.
'Yes. An ultrasound scan and the result was normal. The gynae then suggested an operation where a telescope was inserted through my belly button to check my womb (laparoscopy). I reluctantly agreed as the pain was getting unbearable.'
'What were the findings?' I asked.
'My gynae found small chocolate-coloured spots of menstrual blood at the back of the uterus and ovaries which she removed during the operation. My pain went away and I was symptom-free for the next few years until recently when I experienced pain during sexual intercourse. The backache and menstrual pain returned and I had pain when I passed motion during menses.'
When I examined AG, her uterus was tender to the touch and relatively immobile. An ultrasound scan showed an ovarian cyst about the size of a tennis ball on her left side. It was subsequently removed through key-hole surgery and was confirmed to be an endometriotic cyst or 'blood cyst'.
Endometriosis is a common and troublesome disease affecting about one in 10 women of reproductive age. In women with fertility problems, the number may be as high as 50 per cent.
It is also a progressive disease, as is the case for AG. The lining of the womb (endometrial tissues) is spilled into other parts of the reproductive organs including the fallopian tubes, ovaries and the back of the womb.
These abnormal and wayward tissues bleed every month during menstruation. The surrounding areas become inflamed and form scars which pull on the nerve endings and cause pain. But some women will have little or no pain despite having extensive disease while others may have severe pain with only a few small affected areas.
The endometrial tissues trapped in the ovary will bleed and lead to the formation of the dark, thick and chocolate-coloured cyst known as 'chocolate cyst' or 'blood cyst'.
It may leak and form adhesions (abnormal tissues that bind organs together). The adhesions can block the fallopian tube and interfere with ovulation, causing infertility.
The exact cause of endometriosis is not well understood. A familial association exists as it can affect many siblings in a family. Past pelvic infection can also be a cause.
Common symptoms of endometriosis include menstrual cramps, backache and pain during sexual intercourse. Menstruation may be irregular, with staining before or after menstruation. There may also be clots in the menses.
An ultrasound scan may be misleading in the diagnosis of endometriosis. It is usually normal if there is no cyst formation as in the case of AG when she consulted the first gynaecologist. The diagnosis is based on clinical suspicion and confirmed by laparoscopy.
A blood tumour marker test (CA125) is also not very helpful as the level may be normal or raised.
When a cyst is present, surgical removal and microscopic examination is the only way to confirm the diagnosis as in AG's case.
The recurrence of endometriosis is very common. It will only dry up after menopause when the lesion is no more stimulated by ovarian hormones.
Pregnancy has a beneficial effect on endometriosis. Hormonal changes cause the diseased areas to become inactive. As infertility may be a consequence of endometriosis, I discussed with AG and her husband the possibility of their conceiving a baby . They heeded my advice and AG is now pregnant.
Dr Peter Chew is a senior consultant gynaecologist and obstetrician at Gleneagles Medical Centre. He is the founder chairman of aLife (www.alife.org.sg), a charitable organisation with a mission to nurture and promote healthy family life.
This article was first published in Mind Your Body, The Straits Times on May 28, 2008.
