It’s an
increasingly busy time for endometriosis research at the moment. In the last 31
days there have been 111 articles published on endometriosis, which means an
average of just over 3 articles every day. That’s also pretty impressive when
you consider that, in the same period of time ten years ago, there were only 33
articles published! So the march of progress rolls ever onward and it’s nice to
know endometriosis isn’t being left behind; however this means it’s becoming
harder for me to keep up with the research!
I shouldn’t complain really, so instead I’ll get on with a roundup of
this month’s top endo research highlights.
I’ll start
off with what, at first glance, would appear to be a report from the Twilight
Zone. It’s another report
of endometriosis occurring in a man. I say ‘another’ as if it happens all the
time, but this is only the fifth or so record of endo in a man, ever. I’ve
reported on endometriosis in males before and it is a very unusual thing to
find for several, probably quite obvious reasons. However, previously reported
cases have been in elderly men undergoing estrogen therapy for prostate cancer.
The thought behind this was that the estrogen somehow caused certain cells in
the male body to transform into endometrial cells. This new report throws a bit
of a spanner into the works. If you click on the above link you should be able
to read the full article, but basically a man was admitted to hospital with an
inguinal hernia (a hernia located just above the testicles, in line with the
bladder). Upon surgical inspection a cyst was discovered that was found to have
endometriosis within in it. The really puzzling part here is that the man was
undergoing anti-estrogen therapy for
infertility, so how could the endometriosis possibly have developed? It makes
no sense.
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| Seriously, this picture makes more sense |
The authors
of the paper point out that there are three main theories about how
endometriosis develops; transplantation
(aka retrograde menstruation), metaplasia
and embryonic rest. Transplantation can
be discounted straight away; metaplasia could make some sense as it relies on
the transformation of tissue under the influence of inflammation or hormones,
but the man was taking anti-estrogen medication so that doesn’t quite hold.
That leaves embryonic rest theory. This basically states that, during
development, microscopic pieces of the tubes which go on to form the
reproductive organs end up getting misplaced around the body. These tiny pieces
can then go on to develop into what we see as endometriosis. If this was to
happen in a man, we would expect to see endometriosis developing along the ejaculatory
and diferent ducts, which is exactly what the authors found, so it looks
like we have a winner for embryonic rest theory.
Next up is study on the effects of
different causes of infertility on the outcome of IVF/ICSI. Many women with
endometriosis also present with subfertility or infertility, therefore a higher
number of women with endo are likely to employ assisted reproduction
technologies (ART) if they cannot conceive naturally. This may lead some women
to wonder if all the problems endo causes will have any impact on the health of
their baby. This study aims to answer those questions by taking patient records
from 255 Finnish women (29 of whom were diagnosed with endometriosis) that had
undergone successful assisted reproduction of some variety and comparing them
to women who conceived naturally.
What they
found was that women with endometriosis who underwent ART were at the highest
risk of pre-term birth and thus, were more likely to have babies of low birth
weight. However, though this may sound scary, the authors also found that these
babies required an amount of neonatal care similar to that of all the other
subgroups of women, indicating that though the babies were small, they were
also healthy. Interestingly, although this was a relatively small study, it
found that women with endo who conceived with ART were less likely to have a previous miscarriage, a chronically ill baby
or foetal demise than healthy women who conceived naturally. So if you do have
endometriosis and are considering IVF or another type of ART, hopefully this
study will put your mind at rest a bit. If you would like to read the full
article, you can by following this
link.
Moving on now
to a couple of studies from our Teutonic cousins; the first of which looks at
the age distribution of women with endometriosis. This study took information from
42,079 women who were diagnosed with endometriosis in Germany between 2005 and
2006 and divided them into three age groups; premenopausal (0-45 years),
perimenopausal (45-55 years) and postmenopausal (55-95 years). What they found
was that the majority of women with endo were in the premenopausal group
(33,814 or 80.36%). That doesn’t come as much of a surprise as it’s the largest
age group and the one we most commonly find women with endo in. What was quite
surprising was the finding that 7,191 (17.09%) women with endo were in the
perimenopausal group and 1,074 (2.55%) were in the postmenopausal group; which
means nearly 1 in 20 women diagnosed with endo were over 45. This shows that
endometriosis does not discriminate by age and that it is important for medical
professionals to know that just because your periods have stopped, it doesn’t necessarily
mean your endo has.
The second study from
Germany examined the cost of endometriosis in terms of in-patient treatment in
2006. Coincidentally this follows on nicely from the previously study which was
looking at number of women diagnosed and this one looks at the cost of treating
those women. These authors found that a total of 20,835 women were admitted to
hospital for endo treatment in 2006 at an average cost of 3,056.21€ each. In
total this brings the cost of treating all those endo patients to
40,708,716.26€. That’s just in-patients treatment as well, it doesn’t take into
consideration the addition cost of lost work productivity, out-patient costs,
or other economic factors that endo impacts on. It wasn’t long ago that I posted
about a study that examined the total cost of endo, and if 40 million Euros
sounds like a large amount of money, the true cost is likely to be 10 fold.
The final
study for this month seems a little controversial to me. Not because there is
anything particularly offensive or contentious said, but the conclusions that
are drawn are tenuous to my eye. You can read the summary here and make up your
own mind, but I’ll tell you what I think. To summarise, the authors of this
study conclude that endometriosis is rare in rural, isolated communities such
as those in Northern Uganda, because the women there have a high number of
children, have more teen pregnancies and a longer duration of breast feeding.
An interesting conclusion but I can see several flaws in it. Firstly, I’m not
sure I agree wholeheartedly with the opening statement “Women in Western nations are exposed to an "unnatural" high
number of menstrual cycles”. Maybe it’s just the way it’s worded, but I
don’t like that sentence. I can see where they are coming from; women in
Western countries start their periods earlier and have fewer children than
those in developing countries. But how is this ‘unnatural’? What is a 'natural'
amount of menstrual cycles? Is there such a thing?
Also it
doesn’t seem to take into account that women in developed countries have a far
greater use of the contraceptive pill, which means fewer, lighter periods. For
example, in the UK in 2008, 84% of women of reproductive age were taking the
contraceptive pill; compare this to only 15% of women of the same age group in
Nigeria (Source: Worldbank,
I couldn’t find the stats for Uganda). So surely this indicates that saying
women in the Western world have an ‘unnaturally’ high number of menstrual
cycles, isn’t necessarily correct.
Another
thing that’s bugging me is that, out of the 528 gynaecological consultancies
performed over a year at the Ugandan Aber district hospital, only 1 woman was
diagnosed with endometriosis thus, the authors conclude, it is rare in this
part of the world. However, even in wealthy western countries, there is a very
high rate of misdiagnosis and endometriosis specialists who can accurately and
thoroughly diagnose the disease are in short supply; so how can you expect the
same level of diagnostic accuracy in small rural hospital in a developing
nation with no specialist training? It is very likely endometriosis is far more
common than reported here, but inadequate facilities and ‘masking’ of the
disease by high pregnancy rates leads to under-reporting of endometriosis in
this part of the world.
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| Pictured: The developing and developed world; sadly the one on the right is only marginally better at diagnosing endo than the one on the left |
One last
thing is that it’s assumed that number of menstrual cycles (and hence
menstruation itself) is important for the development of endometriosis. Whilst
there is still some debate about this, consider the fact I have reported (in
this post and previously)
on cases of male endometriosis, endometriosis in unborn
foetuses, endometriosis in women
who can’t menstruate and even endometriosis in animals
that can’t menstruate. So I’ll leave you to think about how relevant
menstruation may be in the development of endometriosis.
