Hi again,
I don't know why but I felt the need to address one significant problem women with endo and pelvic pain have - relationship issues, but as I started to write I realized there is much I don't know about this aspect of the disease. So, I'll start, and you guys can send me your comments so that we can have a discussion about this and we'll all be better for it.
To start with, there are a couple of obvious issues for women with endo and their partners. The 800 lb gorilla is the sexual component, and how pain affects intimacy. We see a lot of couples with these problems, but since we're not "Dr. Ruth", we don't really delve into the emotional aspect very much (because hopefully these issues will be solved postoperatively). Yet I sense that these are very serious challenges that can either strengthen or ruin relationships. Some of the men are frustrated because they aren't as active as they'd like, yet at the same time they feel guilty when they do try intercourse and cause their wives/partners pain. Most of the women by the time we see them could care less about sex, all they want is their pain relieved, but underneath the immediate need for pain relief are the suppressed desires for a normal life and normal relations. Some couples can find other ways to share intimacy, replacing actual intercourse with other aspects of physical intimacy, or having deeper conversations to sustain the emotional intimacy. These are usually the ones that can get through these difficult times, sustaining each other when pain turns to depression and hopelessness. Other couples have difficulty and end up separating, probably for lots of different reasons - some sexual, some emotional, and some because they've lost their "normal life" that they used to have.
Another big issue is the husband/partner as caretaker thing. Some guys do this exceptionally well and are incredibly patient, doting, caring, and just great nurses. Other guys pull back into their shells when their wives/girlfriends are suffering, mainly because they don't know what to say or what to do. Here's a story for you - the first baby I ever delivered (back in 1988) was to a couple where the wife was pushing, screaming, and miserable, and her husband sat with his head on the back of the chair, looking at the wall. I thought he was such a jerk until I realized he was probably scared stiff and didnt' know how to help. I think there are quite a few guys like him - they want to do the right thing, but really don't know what to do. For men who are good caretakers, the issues change some when their wives have their surgery, then start to feel better. They have gotten so used to the "nurse" role, that it takes some adjusting to get things back to normal.
You can probably tell that I'm not a real expert in this particular area, but I think it deserves some discussion and consideration. I'm sure that all you ladies who are suffering and living with endo think about this all the time, and have a lot to contribute about your own insights and things you've learned over the years. I'd love to hear from you, because the more I know about what people are going through, the better I can counsel my patients and the more I can empathize with them.
Take care, and have a great week. I look forward to hearing from you!
Dr. Mos
Tuesday, June 12, 2007
Wednesday, June 06, 2007
Answers to you questions.....
I've received some questions from readers on various subjects, so I thought I'd answer them individually.
First, a number of questions about back and leg pain with endo. All of the nerves in the pelvis eventually run into the spine before connecting with the spinal cord. Endo tends to frequently involve the uterosacral ligaments, which as the name suggests, run from the uterus to the sacrum (the base of the spine that forms the back of the pelvic girdle). Pain from the uterus as well as endo on the uterosacrals can cause pain that is perceived in the low back, although touching the skin over the area where the pain is felt doesn't usually increase the pain. This is known as "referred pain", and it is caused when internal organs are painful, but the pain is felt where the somatic nerves (from the skin or muscles) from the same nerve root as the visceral nerves (from internal organs) from the source of pain. In other words, the lumbar nerves go to the uterus as well as the low back and buttock. When the uterus hurts, your brain can't localize all of the pain to the inside of the pelvis, so it is felt in the back where the other nerves from the same spinal segment come from. This is the same reason that appendicitis initially causes pain around the umbilicus (when only the appendix is irritated), then as the inflammation involves the abdominal wall, the pain localizes to the right lower quadrant. The nerves from the intestine are felt as generalized belly pain rather than an isolated discreet spot. Likewise, some pelvic areas don't send pain impulses that are perceived as coming from the pelvis, but they're felt in the back. The uterus can also generate pain referred to the legs, most commonly the anterior and medial thigh. Referred pain is usually a deep pain that aches and throbs, sometimes it can feel hot or burning, usually it doesn't increase by pushing or rubbing the place where it is felt.
Back pain in the context of pelvic pain can also be due to muscular issues. Pelvic pain can cause muscle spasm of the levator muscles, which can cause spasm of the piriformis and obturator muscles. These little bugger muscles are both on the inside and outside of the pelvis, and line the inside of the pelvic cavity. They externally rotate the hip, and when they are in spasm, they can alter the normal curvature of the lumbar spine by pulling down on the sacrum and flattening the lumbar curve. They can also cause the tailbone to hurt (coccodynia). Similarly, the hamstrings (muscles of the posterior thigh that flex the knee) originate on the iscial tuberosity, the bones we all sit on, the ones that get sore riding a bike. When people are inactive, many times the hamstrings will tighten up (try touching your toes with straight knees - if you can't, your hamstrings are tight). This also pulls down on the posterior pelvis and flattens the lumbar curve, causing back pain.
Then next subject is fatigue after surgery - this is incredibly common after any kind of surgery. One can think of postop fatigue as nature's way of making sure we rest enough to allow the body to heal itself. This is a simplistic explanation, but usually the fatigue resolves slowly as activity increases. One study looked at healthy students who were made to stay in bed for varying numbers of days. Their cardiovascular fitness was measured before and after their forced rest. It took an average of three days of activity for every day in bed to recover to their previous level of conditioning, and that was without any illness or surgery, so extrapolating that study to surgery, it would be normal to take a while after surgery to feel as energetic as beforehand. When the body is injured, whether by surgery, infection, or disease (like endo), our response consists of mobilizing white blood cells to swarm to the area that's injured. They release all sorts of factors that eventually help promote the healing process, but sometimes cause more inflammation than they should. These factors are things like histamine, leukotrienes, prostaglandins, and cytokines that act in an incredibly complex way to effect wound healing. Along the way, they can also cause fatigue, and more nerve stimulation that rarely can eventually lead to neurogenic pain. There is also a connection between inflammation and sleep disturbances, as well as a defined restorative effect of deep sleep enhancing immune functioning. Pain in and of itself can cause fatigue, and pain that results in lack of exercise also increases fatigue. To some extent as this postop inflammation resolves, the inflammatory mediators decrease, and fatigue lessens. However, in order to get back to preop or pre-disease levels of fitness, you have to work at conditioning by exercising daily, pushing yourself somewhat in order to recondition your muscles, heart, and lungs.
The last question was about estrogen and endometriosis. Yes, estrogen alone does stimulate endometriosis, but most birth control pills are progesterone dominant, which means that the progesterone in the pill is able to suppress endometrial cells more than the estrogen stimulates them. This is why most women have lighter menstrual flows while on the pill than when they're not taking it. To the extent that endometriosis can be suppressed (some superficial endo can be suppressed quite well, while the deep lesions really can't), the more progesterone dominant pills will be better. The best way to take OCPs with regards to endo is to take them continuously, so that you don't have a period. This is facilitated by slowly increasing the interval between periods - first putting 2 packs together, then 3, then 4, and so on, while skipping only 3-4 days between active pills rather than 7.
The last question was related to weight and endo. Most of our endo patients are thin, so although I'm not aware of a study of endo patients and weight, I'd have to weigh in (pun intended) to say that endo does not cause weight gain. Abdominal bloating around the menses is usually either gas-related, muscle laxity of the abdominal wall, or fluid retention, and isn't really fat deposition, so that doesn't count.
Well, I hope this helps your inquisitive minds. Please let me know if there are any other burning questions you have, and I'll do my best to give you the straight scoop. Also, if you think you have endo and want me to review your records to see if Dr. Redwine and I can help, please check our website for instructions on how to submit this information.
Thanks for reading, and have a great week.
Dr. Mos
First, a number of questions about back and leg pain with endo. All of the nerves in the pelvis eventually run into the spine before connecting with the spinal cord. Endo tends to frequently involve the uterosacral ligaments, which as the name suggests, run from the uterus to the sacrum (the base of the spine that forms the back of the pelvic girdle). Pain from the uterus as well as endo on the uterosacrals can cause pain that is perceived in the low back, although touching the skin over the area where the pain is felt doesn't usually increase the pain. This is known as "referred pain", and it is caused when internal organs are painful, but the pain is felt where the somatic nerves (from the skin or muscles) from the same nerve root as the visceral nerves (from internal organs) from the source of pain. In other words, the lumbar nerves go to the uterus as well as the low back and buttock. When the uterus hurts, your brain can't localize all of the pain to the inside of the pelvis, so it is felt in the back where the other nerves from the same spinal segment come from. This is the same reason that appendicitis initially causes pain around the umbilicus (when only the appendix is irritated), then as the inflammation involves the abdominal wall, the pain localizes to the right lower quadrant. The nerves from the intestine are felt as generalized belly pain rather than an isolated discreet spot. Likewise, some pelvic areas don't send pain impulses that are perceived as coming from the pelvis, but they're felt in the back. The uterus can also generate pain referred to the legs, most commonly the anterior and medial thigh. Referred pain is usually a deep pain that aches and throbs, sometimes it can feel hot or burning, usually it doesn't increase by pushing or rubbing the place where it is felt.
Back pain in the context of pelvic pain can also be due to muscular issues. Pelvic pain can cause muscle spasm of the levator muscles, which can cause spasm of the piriformis and obturator muscles. These little bugger muscles are both on the inside and outside of the pelvis, and line the inside of the pelvic cavity. They externally rotate the hip, and when they are in spasm, they can alter the normal curvature of the lumbar spine by pulling down on the sacrum and flattening the lumbar curve. They can also cause the tailbone to hurt (coccodynia). Similarly, the hamstrings (muscles of the posterior thigh that flex the knee) originate on the iscial tuberosity, the bones we all sit on, the ones that get sore riding a bike. When people are inactive, many times the hamstrings will tighten up (try touching your toes with straight knees - if you can't, your hamstrings are tight). This also pulls down on the posterior pelvis and flattens the lumbar curve, causing back pain.
Then next subject is fatigue after surgery - this is incredibly common after any kind of surgery. One can think of postop fatigue as nature's way of making sure we rest enough to allow the body to heal itself. This is a simplistic explanation, but usually the fatigue resolves slowly as activity increases. One study looked at healthy students who were made to stay in bed for varying numbers of days. Their cardiovascular fitness was measured before and after their forced rest. It took an average of three days of activity for every day in bed to recover to their previous level of conditioning, and that was without any illness or surgery, so extrapolating that study to surgery, it would be normal to take a while after surgery to feel as energetic as beforehand. When the body is injured, whether by surgery, infection, or disease (like endo), our response consists of mobilizing white blood cells to swarm to the area that's injured. They release all sorts of factors that eventually help promote the healing process, but sometimes cause more inflammation than they should. These factors are things like histamine, leukotrienes, prostaglandins, and cytokines that act in an incredibly complex way to effect wound healing. Along the way, they can also cause fatigue, and more nerve stimulation that rarely can eventually lead to neurogenic pain. There is also a connection between inflammation and sleep disturbances, as well as a defined restorative effect of deep sleep enhancing immune functioning. Pain in and of itself can cause fatigue, and pain that results in lack of exercise also increases fatigue. To some extent as this postop inflammation resolves, the inflammatory mediators decrease, and fatigue lessens. However, in order to get back to preop or pre-disease levels of fitness, you have to work at conditioning by exercising daily, pushing yourself somewhat in order to recondition your muscles, heart, and lungs.
The last question was about estrogen and endometriosis. Yes, estrogen alone does stimulate endometriosis, but most birth control pills are progesterone dominant, which means that the progesterone in the pill is able to suppress endometrial cells more than the estrogen stimulates them. This is why most women have lighter menstrual flows while on the pill than when they're not taking it. To the extent that endometriosis can be suppressed (some superficial endo can be suppressed quite well, while the deep lesions really can't), the more progesterone dominant pills will be better. The best way to take OCPs with regards to endo is to take them continuously, so that you don't have a period. This is facilitated by slowly increasing the interval between periods - first putting 2 packs together, then 3, then 4, and so on, while skipping only 3-4 days between active pills rather than 7.
The last question was related to weight and endo. Most of our endo patients are thin, so although I'm not aware of a study of endo patients and weight, I'd have to weigh in (pun intended) to say that endo does not cause weight gain. Abdominal bloating around the menses is usually either gas-related, muscle laxity of the abdominal wall, or fluid retention, and isn't really fat deposition, so that doesn't count.
Well, I hope this helps your inquisitive minds. Please let me know if there are any other burning questions you have, and I'll do my best to give you the straight scoop. Also, if you think you have endo and want me to review your records to see if Dr. Redwine and I can help, please check our website for instructions on how to submit this information.
Thanks for reading, and have a great week.
Dr. Mos
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