Endometriosis:
Often dismissed as ‘women’s troubles’, endometriosis affects
one woman in 10 of reproductive age, yet a lack of research and funding means
sufferers can live in severe pain, unable to work or socialise
The hidden toll and extraordinary
neglect of a disease that affects an estimated 176 million women around the
globe, causing many to suffer a life of pain and debilitation and sometimes
infertility, is revealed by the Guardian.
One woman in 10 of reproductive age has
endometriosis, it is estimated, and yet often their primary care doctors do not
know what it is and the specialists to whom they are sent are ill-informed.
Vast numbers of women are under-treated
or badly treated. It can take years to get a diagnosis and during that time
women may suffer severe pain and are unable to work, socialise or maintain a
sexual relationship.
The disease does not always have
symptoms and may be the cause of half of all unexplained infertility.
Endometriosis has existed in the
twilight for centuries because of society’s reluctance to discuss what was
euphemistically known for so long as “women’s troubles”.
It occurs when tissue similar to the
lining of the womb is found elsewhere – most commonly in the abdomen, ovaries,
in the recto-vaginal septum, bladder and bowel. That tissue behaves like the
lining of the womb, bleeding every month, and can cause cause severe and
chronic pain . Women tell of such acute
pain that they pass out.
The lack of research and funding for a
disease that affects so many women is “a major scandal”, said Lone Hummelshoj,
who heads the World Endometriosis Research
Foundation and
the World Endometriosis Society.
“Endometriosis affects women in the
prime of their life. It is not a lifestyle disease. It is not a disease you get
later in life. It attacks teens, young women when they should be out being
active, working, having children, having sex – 50% of them are struggling with
sex because it is too painful,” she said.
It has exacted a massive social cost in
broken marriages and depression as well as being a huge economic burden, partly
because of the large number of women who have to drop out of the workforce.
In the US, with 7.6 million women
affected, the estimate was €70.9bn (£52.1bn, $80.4bn) a year; in the UK, which
has 1.6 million sufferers, the cost was estimated in 2012 at €14.4bn (£10.6bn).
In Australia, there may be 550,000 women affected, costing the economy A$6bn
(£2.75bn).
The numbers are comparable to diabetes
– and yet there is only a fraction of the awareness of the condition and help
for those afflicted.
Far too many women are turned away by
their doctors and told they must put up with the pain or even that they are
imagining it. A Guardian online call-out to women for their stories got 600
responses in one day. A recurring theme was: “The doctors thought it was all in
my head”.
Niki Dally, 33, in Wales, UK, has been
suffering from endometriosis from the age of 11. She said even her mother
thought she was making it up. “My mother thought I was a hypochondriac,” she
said.
“One doctor said ‘it’s in your head, girl. You have got to deal with it.’” She
was prescribed medication for her nausea and vomiting and told it was irritable
bowel syndrome, cysts, a UTI, eating disorders and depression.
“Aged 14, the doctors thought it might
be appendicitis and admitted her to hospital. It took 10 years to get the right
diagnosis, but she now lives on a cocktail of strong painkillers and is still
struggling to get the right treatment”.
In the US, Heather C Guidone who works
at the Center for Endometriosis Care, Atlanta, Georgia, and has herself been
through 22 operations for severe endometriosis, said women are still told
periods are supposed to hurt and that it’s a woman’s lot in life to suffer.
“All of those cliches that have surrounded menstruation since the dawn of time.
[A woman tells the doctor] ‘I have this horrible life-altering pain, and these
symptoms’, then the doctor will kind of pat her on the head and say take this
pill. Then you’ve got this vicious cycle, and ultimately she stops telling
people.”
“Every, every possible misdiagnosis is
brought on some of these women before the correct diagnosis is made. And the
traumatic assertions that you’re having pelvic pain because you have an STD –
the whole thing is bizarre.
Endometriosis can be mild or so severe
that it takes over a woman’s life. Former Spice Girl Emma Bunton, Dolly Parton
and Anna Friel all have endometriosis. So does Booker Prize-winning author
Hilary Mantel and actors Susan Sarandon and Whoopi Goldberg. Marilyn Monroe is
thought to have become addicted to the painkillers she took for endometriosis,
which resulted in her death.
Experts say the disease is little known. “The people we have
polled have never heard of it,” said Jane Hudson Jones, chief executive of the
charity Endometriosis UK. “I have never come across anybody in the general
public who knows about it. Yet it can be absolutely devastating.” Surveys of
their own membership showed that 25% had felt suicidal because of it. “It can
affect pretty much every area of your life – your work, career, income,
relationships and fertility. And many are constantly in pain.”
Carol Pearson, 43, had
to give up the successful career she loved because she was too ill too often.
“I hated losing my career,” she said. “I worked my socks off to get to
university and become a chartered accountant. I was in a management position
for many years and paying taxes. I worked for my company for 13 years and they
did everything they could to keep me at work.” But after extensive surgeries to
the bowel and bladder, which did not heal well, resulting in emergency trips to
hospital in an ambulance on more than one occasion, everybody realised her
career and her condition were incompatible.
Pearson
had bad period pains from the age of 11 but adopted the stoicism of her feisty
mother in the north-east of England and suffered in silence. It took 20 years
to get a diagnosis. Studying English at Oxford University was tough. “I got
together with my ex-husband at university and when we started to have sex, it
was incredibly painful. I thought it was all in my head. I thought I need to
get over this. I should have gone to get help but I was too embarrassed to see
a GP,” she said. She did not go until she started to bleed a lot in her late
20s, by which time she had advanced disease.
Women
who are lucky enough to have a primary care doctor who recognises the symptoms
are referred to a gynaecologist. The only way to diagnose the disease is
through a laparoscopy – keyhole surgery that allows the clinician to view the
endometriosis.
But most gynaecologists
do not have the specialist training to remove the tissue they see, which in
severe cases is often very difficult to access. It often involves the bowel or
bladder, which are not parts of the body gynaecologists usually deal with.
Organs can be fused together. Women tell of having hysterectomies and the
wholesale removal of ovaries and parts of the bowel and bladder, and yet some
diseased tissue remains stuck to nerves and the pain continues.
Yet
even the most severe cases can do really well with specialist care, said
Hummelshoj, who also runs a
global information forum. “Some of them do very well with very good surgery,
but unfortunately that surgery is as specialised as cancer surgery.” In fact,
she said, cancer surgeons had told her it was more difficult. Women need access
to specialist care, not just to a general gynaecologist. “We need to train
these doctors to deal with endometriosis,” she said.
Geoff
Reid in Australia, one of the leading experts, believes the disease may be
getting more aggressive. “I have been dealing with endometriosis for 25 years.
I just don’t believe that 20 to 25 years ago we were missing the sort of people
that we see today,” he said. “I see young women in their early 20s with
dreadful colorectal endometriosis and I can’t believe we were missing that. We
may have to some extent, but it is my observation over the years that the
disease is becoming worse. You see some of the most pitiful people with this
disease – it’s awful. People who specialise in endometriosis certainly share
that view.”
IVF has meant that women with endometriosis who want children
have a good chance of having them. “When we were young we all had relatives who
were childless and I’m sure that a lot of them actually had
endometriosis-related infertility. Generally speaking we’ve overcome that these
days,” said Reid.
But a study in 2008 by the Belgian
gynaecologist Thomas D’Hooghesuggested that endometriosis may be a huge factor
in infertility. D’Hooghe’s team carried out laparoscopies on 221 infertile
women who had no obvious symptoms. “These were women who regarded their period pain
as being normal and 47% of them had endometriosis and 40% of those had stage
three and four disease,” said Reid.
“I
find that extraordinary. You can have women with really quite bad endometriosis
who are essentially asymptomatic, which means putting a handle on the
prevalence of endometriosis very difficult. 10% is the figure that is bandied
around. What the true incidence is is really difficult to tell.”
Reid
says it is really important that women facing surgery for endometriosis on
their ovaries are warned of the danger it could affect their fertility, because
it can cause their levels of a critical hormone called AMH to fall by between
50% and 70%. “Perhaps they should consider freezing some embryos or eggs,” he
said. If asked, he said, “women almost universally want to do that.”
The
care women can get varies massively around the world and within countries, and
is often dependent on what they can afford. In the US, insurance companies pay
the same amount for any endometriosis surgery, regardless of the method or
extent of the disease or the specialisation of the doctor.
“You
could spend 30 minutes in the operation just burning and zapping and get paid
the same amount if you did nine hours doing a meticulous surgery,” said
Guidone. “Insurance is not the patient’s friend in this regard.”
That
means insurance companies are likely to pay only for a local gynaecologist, who
may be unable to unwilling to carry out extensive surgery. Nearly every
specialist surgeon the Guardian spoke with had stopped accepting private
insurance because of low reimbursement rates.
In
the UK, a group of doctors who have become highly skilled in advanced keyhole
surgical techniques have set up an accreditation process for hospitals where
gynaecologists are treating endometriosis. So far, 45 centres have been accredited by the
British Society for Gynaecological Endoscopy.
But
patients and some doctors don’t know that high-quality keyhole surgery is
available. “If you went up and down the country, you would find a very large
number of women who aren’t getting access to this sort of surgery,” said
Dominic Byrne, chair of the BSGE’s endometriosis centres and a consultant at
the Royal Cornwall Hospitals NHS Trust. “They are told they need an open
hysterectomy and their ovaries removed to solve their pain. That would be the
most common gynaecological answer to severe endometriosis.”
Sometimes
women have had their healthy tubes and ovaries removed, only for the
gynaecologist to reach the cervix and find the endometriosis is too complex for
them to deal with, so the diseased tissue is left behind. “That in my opinion
is the worst of all worlds. Those patients are quite hard to treat,” said
Byrne.
n the developing world,
women may get no help at all. “There are a lot of countries that don’t even
recognise its existence, especially the Middle Eastern countries,” said Reid.
At the University of
Oxford in the UK, researchers are investigating
the entire human genome of women with the disease, comparing their genetic makeup with
others who do not have it. It is known that about 50% of endometriosis is
inherited.
“We need very large
numbers of cases and controls, larger than we or any other centre could collect
alone,” said Krina Zondervan, professor of reproductive and genomic
epidemiology. That will have to involve collaboration. The Oxford team, led by
Zondervan and consultant gynaecologist Prof Christian Becker, have been
involved in putting together a global standardisation initiative, to ensure
researchers around the world now collect compatible data.
But funding is short.
Even in the US, less than $1 a year is spent in research per woman who suffers
from the disease. In contrast to diabetes, which receives more than $1bn in
funding each year from the National Institutes of Health, endometriosis research
receives just $7m from the NIH each year. And that is down from $14m in 2011.
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