Women’s
Health Issues - See
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Wm.
LeRoy Heinrichs, MD, PhD.
Women’s
Healthcare Consultant
Professor(Emeritus) and Past Chair of
the
Department of Gynecology and Obstetrics
Stanford University School of Medicine
Endometriosis;
Effect on Fertility;
This
clinical condition affects about 10-20% of the women of reproductive
age (15-45yrs). The typical symptoms are severe menstrual cramping,
pain during and after sex, and relative infertility, but the severity
of these symptoms do not predict the amount of disease seen at
laparoscopy. And the types of the lesions do not always correlate
with the symptoms.
Newer
understanding of this confusing situation indicates that women
with endometriosis have known elevated levels of prostaglandins
in and around the pelvic organs, stimulating the contractions
of the uterus, causing the cramping. At last Fall’s meeting
of the American Society of Reproductive Medicine, a new understanding
was described.
The
opening of the tubes near the ovaries, the tubal ostea, also contract
and may close, or even be physically sealed together by this substance
produced in excessive amounts by the macrophage cells in the peritoneal
cavity of women with endometriosis. And contractions of the tubes,
called spasms, may also be seen during x-ray studies of the uterus
and tubes, also resulting from prostaglandins. What is new is
the confirmation that laparoscopic surgery for all stages of endometriosis,
even early disease, is better treated by surgical destruction
of the visible lesions, in women who seek to be pregnant.
This
can be accomplished by one of several means, such as laser vaporization,
electrosurgery, or ultrasound excision. New data indicate that
medical treatments are less effective than surgery when treatment
of infertility is the objective.
Advances
in Medical Treatment of Endometriosis
Still
without a known cause for over a century since the first pathological
description, endometriosis has been associated with several immunologic
alterations, and some of the symptoms are temporarily corrected
by medical treatments. The first line of medical treatment for
pain symptoms is the use of NSAIDS, the anti-inflammatory drugs
that reduce the production of prostaglandins.
Next,
many physicians prescribe cyclic oral contraceptives in an effort
to block ovulation and reduce menstrual bleeding. Symptoms of
endometriosis are particularly related to menses, and if these
are reduced in amount, or even stopped, symptoms of pain subside
by a significant amount. This observation has been confirmed by
several types of medical treatments, including continuous oral
contraceptives, danacrine, and GnRH-agonists. In research, new
approaches with GnRH-antagonists are progressing in attempts to
improve efficacy, and reduce the duration of treatment and the
side effects associated with the current group of medical agents.
Crinone(R)
, a New Progesterone Delivery System;
At
last Falls’ meeting of the American Society of Reproductive
Medicine, new reports indicated that old oral and intra-muscular
methods of giving progesterone treatment can be replaced by vaginal
administration. Why would a switch to this new gel preparation
be of interest? Oral progesterone is not absorbed reliably or
well, and because intra-muscular injections are painful, inconvenient,
and expensive; both cause systemic side effects. And because the
vaginal route produces the desired effects in the uterus nearby,
without getting into the circulation, at least in significant
amounts.
A
seven-fold greater amount was found in the endometrium after vaginal
administration, compared to the amount from an IM dose, even though
the peripheral blood levels were one-fourth as high. This means
that many women who experience the adverse effects of systemic
treatment with oral or intra-muscular methods, such as headache,
bloating, drowsiness, decreased libido, and depression, won’t
have to put up with these side effects for the 12-14 days per
month, or longer. Crinone(R) is the woman’s natural progesterone
added into an emulsion of neutral carbophil that sticks to the
cells for hours, with a slow release rate, and it migrates directly
into the uterus.
It
is available in a 4%, and an 8% gel for individual dosing, How
does the drug move from the vagina to the uterus? In research
using radioactive drug preparations, progesterone was found to
be absorbed by the vagina, and diffusing into the uterine arteries,
suggesting a special type of circulation in this part of the body,
a newly discovered portal circulation. This same diffusion process
may also be part of the explanation of how prostaglandins in semen
prompt uterine contractions after coitus.
This
type of portal circulation is known to exist between the hypothalamus
and pituitary gland in the brain, and within the liver, and now,
the utero-vaginal circulation can be added.
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