May Roundup

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. 

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.

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.

The problem is, I’m quite familiar with the work of the authors who wrote this paper and it’s usually enlightening and insightful. This is why I am somewhat dismayed to see this study where conclusions seem to have been drawn hastily and without much thought to alternative explanations.

April Roundup

2012 seems to be flying by - April is already drawing to a close and soon summer will be upon us. Of course here in England that just means the weather switching sporadically from raining so hard it feels like the ocean is trying to climb onto the land, to irradiating levels of sunshine so intense a hydrogen bomb would seem like an air conditioner. 

But I digress, on a more relevant note you’ll be glad to hear that, even though endometriosis awareness month has come and gone, research into the disease is still carrying on apace. There hasn’t really been any one big piece of news that has caught my attention this month, so instead I’ll do a rundown of all the little bits of endometriosis research, from diagnosis to treatment, that have been published recently.

To start with; getting diagnosis. In order to get diagnosed, you first have to go see your local doctor, an activity many women with endometriosis will know does not always go well. So firstly, a report from France about how much knowledge general practitioners have about endometriosis diagnosis and care. To test this, the study gave a 36 item questionnaire to 100 doctors from a region of upper Normandy. The survey found that 63% of respondents were “ill at ease in the diagnosis and follow up of women presenting with endometriosis”. I’m not entirely sure what they mean by “ill at ease” but it doesn’t sound like a good thing and certainly doesn’t seem representative of a professional attitude.

According to this survey half of the doctors surveyed couldn’t name three main symptoms of endometriossis and only 24% would refer the patient without delay. Unsurprisingly the authors found that general practitioners were much more likely to give better answers if they had attended advanced gynaecology courses or followed up more patients who had been diagnosed with endometriosis. It seems then that if these advanced gynaecology courses are available to general practitioners, they should be made mandatory.

So let’s say you do get referred to a specialist, the next step is getting your condition confirmed. Traditionally this is done laparoscopically, but an interesting report from the Netherlands on the development of a new type of diagnostic method for endometriosis may change that in the future. Whilst the good old fashioned laparoscopy can’t be beat for accuracy and precision (in the right hands), it would be nice to have a different method for detecting endometriosis that didn’t involve having to be knocked out and cut open. Step up then ‘gadofosveset-trisodium enhanced magnetic resonance imaging’, I’ll not go into the technical details because frankly I don’t know what they are.  Basically it is a modification of the MRI detection system which is a scanning method that allows us to see inside your body, much like x-rays but without the radiation. The gadofosveset-trisodium is a chemical that is injected into the body to help the MRI pick up blood vessels more easily. Importantly though this method makes it easier to distinguish between older blood vessels and newer blood vessels which the endometriotic implants would grow to survive. The authors of this study testing the technique on mice that had been induced to have endometriosis and found that the newer blood vessels from the endometriotic implants did show up clearly on the MRI scan, meaning this technique could one day be used for the non-invasive detection of endometriosis in humans.

Onto medical treatment now, which is usually the first line approach to endo treatment. The drugs we have for the treatment of endometriosis are many and varied, some are quite good, others not so much. But if you’re trying to develop a new drug, where do you start? In the past scientists would turn to Mother Nature for inspiration and, although synthetic drugs are fairly dominant today, we still haven’t lost sight of the old ways.  This is highlighted by two studies which have looked at the potential of compounds extracted from plants as possible treatments for endometriosis. The first of these studies found that compounds called Kaempferol and Apigenin, which were extracted from red clover, showed some positive effects on endometrial cells grown in the lab. The trouble with this is that endometrial cells grown in the lab are very different from the cells found in endometriosis, so whether or not these compounds will have any real benefit remains to be seen.

The second study looked at a compound you can extract from hops called Xanthohumol. This study was a bit more in-depth than the first because they induced mice to have endometriosis, gave some of them the Xanthohumol and then observed what happened. What they found was that the mice given Xanthohumol had smaller endometriotic implants and the blood supply feeding the implants was also reduced.  These studies are encouraging because it means people are actively seeking new and better therapies for endometriosis and another advantage of these compounds is that they are non-steroidal, so should have much fewer side-effects. 

Hops - Source: Wikipedia

Red Clover - Source: Wikipedia

Speaking of medical treatments, a study was published recently concerning the effectiveness of a relatively new endometriosis drug called dienogest (also marketed as Visanne™). Unlike other drugs which are more commonly used for other reasons (such as the birth control pill), dienogest was designed specifically as a treatment for endometriosis. To put dienogest to the test this study took 252 women with endometriosis and gave 124 of them dienogest and 128 of them leuprolide acetate (also known as Lupron™) over a course of 24 weeks. To assess the effectiveness of each treatment the authors questioned the women about their endometriosis symptoms and their health overall.

The results of this study showed that dienogest and leuprolide acetate performed equally as well at reducing the symptoms of endometriosis; most of the women noticed a dramatic decrease in pelvic pain, dyspareunia and dysmenorrhoea.  However, it was when comparing overall health that the differences really start to show. The patients who took dienogest had much, much greater levels of improvement in overall physical and mental health, indicating that dienogest is much better tolerated and has far fewer negative side effects.  The authors of the study put this down to the fact that, unlike leuprolide acetate, dienogest doesn’t cause a huge decrease in estrogen levels which leads to some of the nasty side effects you can get with leuprolide acetate.

From medical treatment to surgical treatment. Some of you may have heard about the Da Vinci Robot system that can be used by surgeons to aid them in performing delicate operations. For those that haven’t heard about ‘the robot’, it’s basically a remote operated series of robotic arms (see picture below) that, according to the marketing on their website, makes minimally invasive surgery quicker, simpler and increases recovery rates. The trouble is there haven’t been many studies concerning how safe the robot is in real world use; although that is most likely because the robot hasn’t been in use for very long so large, long term studies concerning its safety probably won’t be coming out anytime soon. Nevertheless, a study was published recently from Taiwan where 60 patients underwent robot-assisted surgery for a number of different gynaecological conditions (including two resections of deep pelvic endometriosis). What the surgeons found was that robotic surgery “is feasible and safe for patients with complicated gynecologic diseases” and “surgeries were performed smoothly without ureteral, bladder or bowel injury” which is encouraging. The only problem is these surgeries were performed by specialists surgeons with a great deal of experience, it would be good to know how less experienced doctors fair with the robot before coming to any conclusions about its overall safety. 

The Da Vinci Robot System - Source: davincisurgery.com

Lastly, it turns out endometriosis is not a uniquely human condition. I’ve wrote here before about endo occurring in non-human primates, but a report from Japan was the first to find endometriosis developing spontaneously in a female Mandrill.

This is the happiest picture of a Mandrill I could find - Source: Los Angeles Zoo

Now on Twitter!

Well I've finally decided to get with the times and join twitter, if you want to follow this blog to get regular updates on endometriosis research you can @EndoUpdateBlog

Endometriosis Awareness Month: Part 6

This will be the final part of my endometriosis awareness month posting marathon; over the last few weeks I’ve noticed I’ve gained a lot more followers, which is great, so a ‘welcome’ and ‘thank you’ is deserved to new and old followers alike. I hope that I’ve managed to impart some useful knowledge over the last month because I’ve learned so much from women with endo over the years.

For the last post of this month I’m going to do a quick rundown of some of the top endo-related research highlights I haven’t had a chance to cover in full.

A study from Italy examined the incidence of endometriosis in the area of Piedmont and found that women from the South and Central provinces were at, in some cases, a 30% increase in risk of endometriosis than those women in the South-West. The authors of this study suggested that heavier pollution in these regions could be a contributing factor; however it is also possible that different populations in the different provinces may carry certain genetic mutations that make them more susceptible to endometriosis.

Another study from Italy found that women with endometriosis were more likely to be right handed and less likely to be left or mixed handed. Apparently handedness is determined whilst you are still in the womb and due to exposure to certain hormones, so there may be something to that. This study also found that there was no association with birth order, their mother’s age, smoking habits, weight gain or morning sickness. There was also no association between endo and having a low birth weight, being premature or whether or not you were breast fed.

Some good news for a change in the findings from a study in Denmark. This study looked at medical records for women diagnosed with endometriosis and registered to the Danish Hospital Discharge Register from 1977-2007, encompassing a grand total of 37,661 women, and checked to see what other medical conditions they presented with. This, rather large, analysis concluded that women with endometriosis were not at an increased risk of multiple sclerosis, systemic lupus, erythematosus, or Sjogren syndrome, yay!

Urinary tract endometriosis (UTE) was the subject for this article from France, which found that of the 221 women selected to undergo laparoscopic surgery for severe endometriosis, almost a fifth had some involvement of endometriosis on the urinary tract. Unsurprisingly the most common symptoms of women with UTE were dysuria (painful urination), blood in the urine and frequent need for urination. Fortunately, the authors noted that surgical treatment was very effective and diagnosing UTE can even be done with a non-invasive MRI scan.

To California now and a report of endometriosis found in the para-aortic lymph node (which is in the centre of your body, on roughly the same level as the kidneys) in a pregnant woman with a previous history of ovarian endometriosis. The authors state that this could be evidence that endometriosis can spread via the lymphatic system, however as this was the first ever reported case of endometriosis in this location, drawing such conclusions may be premature.

And finally, the award for the most self-explanatory article title goes to this paper.

Wishing you all well and see you again in April!

Endometriosis Awareness Month: Part 5

Hot on the heels of a previous report comes another study examining the burden of endometriosis on the individual and society as a whole. This one is a bit more in depth though, taking information from 909 women from 10 different countries including: Belgium, Denmark, Germany, Hungary, Italy, Netherlands, Switzerland, UK and USA. The women who took part in this study were given specially designed questionnaires that would assess the impact of endometriosis on their lives and included questions on a number of subjects from health care costs to work loss and quality of life. What makes this study different then from all the previous studies that have examined the costs of endometriosis? Well, this study is the only one I know of that has taken women from multiple countries, also other studies have usually only focussed on one aspect, such as health care or work productivity, never both.

But enough of the details, what did this study actually discover? The main finding from this study was a number, €9,579, equivalent to $12,635 or £7,990; this was the average cost of endometriosis per woman, per year. This breaks down to an average €6298 lost in work productivity and an average €3113 for health care costs (which is similar to health care costs of diabetes, Crohn’s disease and rheumatoid arthritis). So with those numbers in mind let’s do some maths. If the average total cost of endometriosis per woman is £7,990 (I’ll work in British pounds because that’s what I’ve got in my pocket) and the UK has approximately two million endo sufferers, this means endometriosis costs the UK economy around £15,980,000,000 per year (The authors of the study reported it as £8.3billion, but they estimated the prevalence at only 7%). That is what we technically call, in the scientific community, a shitload of money. Feel free to re-do the calculation for your own country and sit back and be shocked by how much money is being lost by governments who ignore endometriosis.

Endometriosis Awareness Month: Part 4

Brains are funny things, all grey and squishy. Inside the roughly 3lbs of brain you have is held all your accumulated memories, dreams, fears, loves and just about everything that makes you, you. But for all its complexity and sophistication the human brain is far from a perfect construct. Whilst it is the source of all our joy, it is also the reason we feel pain, and this is especially not good if you’re in pain for a significant portion of your waking life, for example if you happen to suffer from a chronic condition like endometriosis.

What then, is the effect of pain on the brain? If you have suffered from pain for any length of time then you’ll know that the relentless assault of pain, and all the limitations it puts on your body, can have a deleterious effect on you mental condition. It will probably come as little surprise to you to learn that studies have shown that women with endometriosis present with a very high levels of depressive symptoms. The study in the link above found that 86.5% of women with endo presented with depressive symptoms (22.1% mild, 31.7% moderate, 32.7% severe) and 87.5% presented anxiety (24% minor, 63.5% major).

Does this mean that the brains of women with endometriosis function in a unique way? Is there such a thing as an ‘endo brain’, a specific psychological profile, which is created by suffering long-term with the condition? According to one study, no there isn’t. This study took women suffering from chronic pelvic pain (CPP) either due to endometriosis (30 women), myofascial abdominal/pelvic pain (70 women) or pelvic adhesions (38 women). The authors then asked the women to complete a number of ‘inventories’ (basically questionnaires) asking them about factors such as demographic status, pain experience and symptoms, disability caused by pain, depressive symptoms, level of affective distress, satisfaction with pain treatment and satisfaction with their relationships. So overall it was a pretty comprehensive, and what they found was that the emotional, social and psychological distress caused by endometriosis was not significantly different to that caused by other chronic pain conditions.

This is actually a good thing to know, because it’s a way to shut up any of the idiots who think endometriosis is the result of psychological disturbance. If we can show that the suffering experienced by women with endometriosis is so similar to that of women with other chronic conditions, then it is impossible to say it is ‘all in your head’. Because if that were the case, then the suffering experienced by all those people with other chronic pain conditions must be ‘all in their head’ too.

Is this finding at odds then, with another recent study which found that a greater proportion of women with endometriosis presented with bipolar disorder? Perhaps, but there are a lot of factors to consider; for example, we need to examine what bipolar disorder is. There are good websites giving descriptions of bipolar disorder here and here which basically describe it as rapid, extreme swings of mood from feeling very high to feeling very low. Now we need to consider whether there is some neurological alteration in women with endometriosis that makes them more susceptible to bipolar disorder, or could it be that there is something about living with endometriosis that causes these extreme mood swings? It is know that the steroidal, in particular hormonal, medications used to treat endometriosis can lead to extreme mood swings and living with a chronic pain condition is bound to affect the suffers mental state (as we have seen from the studies I’ve mentioned previously, and just through plain old common sense really).

So it’s more likely that for the majority of women with endometriosis who present with symptoms indicative of bipolar disorder, the moods swings they feel are due to the conditions of living with the disease (of course, there are women with endo who have the symptoms of bipolar disorder for other reasons).The only way to tell for sure would be to do a follow-up study, where women who have been successfully treated for endometriosis are tested again to see if the signs of bipolar disorder remain after symptoms have abated.

In conclusion then; you’re not mad, it’s not all in your head and if you live with a chronic pain condition you may get depressed (well there’s a shocking revelation).

Endometriosis Awareness Month: Part 3

At what age did the symptoms of your endometriosis appear? A lot of women I’ve spoken to have told me that their symptoms appeared not long after they started their periods, and certainly, a great deal of women with endo find their symptoms were in full force by the end of adolescence. Of course, no matter when the symptoms began, the most universal challenge women with endometriosis face, is getting those symptoms taken seriously so a diagnosis can be made. Therefore, wouldn’t it be great if there were a set of guidelines regarding pelvic pain that doctors could use to flag up potential cases of endometriosis in young girls to speed up the whole diagnostic process.

Hopefully that is a reality not far off. Several studies published over the last few years have tried to formulate a procedure that will increase accurate diagnoses of pelvic pathology in young girls. It goes something like this; if girl complains of excessively painful menses, first off give her non-steroidal anti-inflammatory painkillers (NSAIDs) for three months. If these fail to work give the patient oral contraceptives and suggest referral to a gynaecological specialist for further assessment. That’s about it really, pretty simple. Of course it’s not that simple, because we must educate the patient (and doctors) about the different kinds of pain girls can present with.

For example, the most common pain symptom in women with endometriosis is dysmenorrhoea, or excessively painful periods. But what classes as excessively painful? Yes, pain is subjective, but if the pain is becoming debilitating (i.e. it is forcing you to take time off from school/work on a regular basis) then this is excessive and needs to be taken seriously and investigated further.

Then there is also chronic pelvic pain (CPP). This is pain that occurs in your pelvic area, either with or without your period, that lasts for over 6 months. If a girl is presenting with both CPP and dysmenorrhoea, this should raise a red flag with any doctor worth his salt.

Then we come to the ‘dys’s’, these are other pain symptoms frequently associated with endometriosis, such as dyspareunia (painful sex), dyschezia (painful bowel movements) and dysuria (painful urination). Any of these pain symptoms, especially if they occur more frequently during menses, are all indicators for doctors to be aware of it they are to get a rapid diagnosis and prevent undue suffering.

But why might some doctors be reluctant to refer girls to specialists? There is the age old “I know better, just get on with it” ignorant attitude that many women have to deal with, but doctors are also being put under pressure, especially these days, not to refer girls to specialists because of the cost implications, but let’s think about it logically for a second. If a girl is presenting with pain symptoms indicative of endometriosis at a young age, surely it would be better to send her to a specialist as soon as possible to get the problem treated whilst she is still young, rather than waiting until she is older and more likely to need multiple surgeries/treatments.

Getting endometriosis treated quickly not only makes more sense from a patient centred approach, it also makes sense from an economic approach, especially when you consider the impact endometriosis in adult women has. Let’s put it in political (i.e. monetary) terms. A study from Canada estimated the cost of endometriosis to be $5,200 per patient, per year for surgically confirmed cases of endometriosis. This adds up to a hefty $1.8 billion annually in Canada just for surgically confirmed cases of endometriosis. Where are these costs being incurred though? Obviously there are the medical costs, but endometriosis is incapacitating, so it affects all aspects of a woman’s life. A study from Puerto Rico amply demonstrates this by assessing the quality of life and work productivity of women with endometriosis. What they found was that women with endometriosis presenting with quality of life scores “denoting statistically significant disability in the physical and mental health components”. I should probably point out that when they say significant disability in the mental health component, they are referring to mental aspects of the disease such as stress and depression, they’re not suggesting you’re all mentally handicapped!

The study goes on to say women with endometriosis lose, on average, one day a week in work time due to the disease symptoms. Lose 13% of work time, lose 64% of work productivity, have a 65% impairment of work and a 60% impairment of daily activities.

All those billions of dollars lost, all those hours of life spend needlessly suffering, all that time lost, all those lives ruined; where does all this lead back to? To the diagnostic and treatment delays in endometriosis. If the disease is diagnosed and treated early and effectively we can begin to eradicate the negative impact it has. So, to all those people, doctors, nurses, family, partners, anyone, who dismisses and marginalises the suffering women with endometriosis must endure, you are not only catastrophically harming the life of an individual, you are damaging society as a whole.