Thinking outside the box

When you look back at the history of science, you'll notice that it is heavily punctuated by radical ideas to solve complex problems. Some of these radical ideas have lead to changes that shaped and changed the world, others not so much. For example, American doctor Jonas Salk saved the lives of millions and practically eradicated the disease polio in the 1950s by injecting people (including himself and his own family) with ‘inactive’ versions of the polio virus; a hefty risk that paid off. Other medical cures haven’t proved quite so successful. For example, there is the sad case of Alan Turing, a brilliant British scientist without whom you would not have the computer you are reading this on now. Around the same time Salk was developing his polio vaccine Turing was convicted of being a homosexual (a custodial offence in the UK at the time) and rather than face prison he was forced to undergo estrogen injections to ‘cure’ his homosexual urges. The side effects were, of course, horrific and not long after he committed suicide by taking a bite from an apple laced with deadly cyanide (some people speculate the logo for Apple computers pays homage to Turing).

Obviously those are two very extreme examples, but they set the scene for the topic of this post, which is radical thinking in science, especially in relation to endometriosis.

Endometriosis is complicated, no matter what your views on the origin, treatment or mechanism of the disease; we can all agree it is complicated. In order to solve a complex problem, no matter what it is, people have come up with many different possible solutions and endometriosis is a shining example of that. There are so very many different types of treatment for the disease, from established treatments like the multitude of hormonal therapies and surgeries, through alternative medicine all the way to cutting edge technology like gene therapy.

But the field is always progressing, as scientists we are always researching and doing experiments to try and solve complex problems and sometimes the ideas that are borne of these experiments can seem a little different or unusual at first.

Take, for example, this piece of research by a group from Turkey. This group induced endometriosis in rats and then divided them into two groups. One group of rats were left to get on with their business without any interventions (a control group), whilst the other group was placed in hyperbaric oxygen therapy (HBO) for two hours a day over 6 weeks. So what is hyperbaric oxygen therapy? Basically it involves the subject being placed in a chamber which contains pure oxygen which they breathe for a period of time. This isn’t a new treatment either; it’s been used for a long time to treat all sorts of conditions, from sports injuries to carbon monoxide poisoning and even alleviate the side effects of radiotherapy, but never as a possible treatment for endometriosis (for more on HBO follow this link). Below is a picture of a HBO system used for humans.

Source: http://mdmedicine.wordpress.com/2011/04/10/what-is-hyperbaric-oxygen-therapy-hbot/

Anyway, back to our original study. The results of this study showed that endometriotic implants of rats receiving HBO had decreased in size compared to the implants from the control group. There was also a marked decrease in markers of inflammation in the HBO rats. Essentially endometriosis in the HBO rats had gone into remission. So why might his be the case and where do we go from here? Well, HBO is used for the purposes I mentioned above because it encourages wound healing and also helps boost the immune system, so it could be that the HBO therapy is helping the body destroy the endometriotic implants. Despite this being an animal based study (which means it may not work the same in humans) this is still an encouraging result as HBO therapy has no serious side effects and is overall very safe. Because of this, in the future it would be easy to test HBO therapy on human subjects with endometriosis to see if it could help recovery from surgery or reduce symptoms.

Whilst I’m not anticipating hyperbaric oxygen therapy will be a cure for endometriosis, the type of thinking that the authors of this study were doing will eventually lead to a cure. By that I mean in science it is important to step out of one’s comfort zone occasionally, take risks, think of the radical ideas no-one has thought of before but be prepared to be proved wrong and always be held accountable. It is only by embracing what is new and being fearless in our approach that means we will, one day, find a cure for endometriosis.

A Recurring Problem

One of the problems with a disease like endometriosis is that, because our understanding of the disease changes over time, the things that we hold as true today may turn out to be inaccurate, misunderstood, or just plain wrong in the future. For example, it used to be thought that endometriosis was a problem reserved almost exclusively for women in their 30’s, ‘career women’ as they used to say. There never seemed to be any rationale for this, no reason as to why women of this age appeared to be more at risk, it was just accepted, most likely because the shared experience of many people in the field led them to that conclusion.

However, this perception seems to be radically shifting, especially over the last five years or so. Nowadays it is becoming increasingly recognised that cases of endometriosis are rising higher and higher in younger and younger women, particularly girls in adolescence (case in point, there was a recent report of an 11 year old girl diagnosed with an endometrioma). If we look at the literature we can see that in the last 10 years there have been 526 articles published containing the keywords ‘endometriosis’ and ‘adolescent’. Compare that to the previous decade there were only 278 articles published.

So why might this be the case? Is there some evidence to suggest young women are becoming more susceptible to the disease? Or is it that increased awareness, both in the medical and public environment, leads to women getting their symptoms investigated seriously at a younger age? I know that the average time until diagnosis stands at a completed unacceptable 7-9 years (depending on who you talk to) and I also know that many, many women have to struggle to get their symptoms taking seriously in the first place, so the age at which a woman is diagnosed cannot be used as an indicator for when the disease first appeared. This is probably where the whole idea of endometriosis being a disease of women in their 30’s came from; because that was the age they were being diagnosed, not the age at which the disease/symptoms appeared.

Have you ever watched a horror film where the protagonist goes into a room, expecting to find a nasty surprise, only to find the room is empty? They feel a huge sense of relief, turn around to walk away and then a monster jumps out of the shadows, in the process lifting you several feet off your chair, well endometriosis is kind of like that monster. Because even if endometriosis is removed surgically, and we all breathe a collective sigh of relief, it can still be waiting in the shadows. This study from Italy exemplifies the recurrent potential of endometriosis with its finding that approximately 1 in 5 women undergoing laparoscopic surgery for endometriosis experienced recurrence of the disease. Further studies looking at a wide range of literature found that recurrence of endometriosis after surgery can be as high as 21.5% after 2 years and 40-50% after 5 years. At the moment we don’t have a good idea why recurrence should be this high. Certainly the skill of the surgeon and the quality of equipment used play a big part, but whether there are other factors that could influence the recurrence of endometriosis, such as lifestyle factors, medication or genetics, remains to be shown.

The reason I’ve been talking about endometriosis in younger women and the recurrence problem is that there has been a paper published recently combining those very subjects. This study, also from Italy, took 57 girls under 21 who had been diagnosed with endometriosis and followed their medical history over the next 5 years. Out of the 57 girls that enrolled in this study, 32 (56%) had a recurrent diagnosis of endometriosis. Of these 32 girls with a recurrence, 11 had further laparoscopic surgery to treat the disease. The authors of this study found that factors such as: symptoms, stage/site of disease, type of surgery, medical treatment did not influence who got a recurrence and who didn’t.

The recurrence rate of endometriosis in these young girls is very high, well over half of the girls treated experienced either a recurrence of the disease, or of their symptoms. But the million dollar question still remains, why?

I have no definitive answer, but I know that endometriosis can be an insidious disease. Tiny patches of endometriosis can evade the eye of even the most skilled surgeon and from these seeds, the vicious thorns of the disease can flourish. In the future better methods for visualising the disease may vastly increase the ability of a surgeon to remove all of the disease. Until that time though, for some people, endometriosis will be a recurring problem.

A free e-book on pelvic pain

This month seems to be the month for free online books. This time its an e-book on pelvic pain, which I know will be relevant to many of my readers, by Dr Susan Evans and Ms Deborah Bush.

Topics covered include:

• Period Pain
  


• Endometriosis
  


• Bowel and Bladder pain



• Painful Sex



• Fatigue and more
  

To download the book follow this lin

http://www.drsusanevans.com/e-booklet.html

and click on 'Click here to download'

Free online book on heavy menstrual bleeding

This may be of interest to some of my readers, but I noticed that the National Collaborating Centre for Women's and Children's Health and the National Institute for Health and National Institute for Health and Clinical Excellent have published their guidelines for the assessment and treatment of heavy menstrual bleeding (HMB), a problem that can affect women with endometriosis.

To read the guidelines in their entirety follow this link

http://www.ncbi.nlm.nih.gov/books/NBK56536/

and click on ‘PDF version of this title’ in the right hand margin

Although the guide is aimed more at clinicians, I think it contains a lot of relevant and interesting information for patients who suffer with heavy menstrual bleeding. The guide covers such topics as:

• How we define HMB

• The risk factors for HMB and its prevalence

• How doctors should assess and test for HMB

• Education for women about HMB

• Medical and surgical treatments for HMB

Although these guidelines have been drawn up for the use in the UK, the evidence upon which the guidelines have been based was taken from international studies and are applicable to women all over the world.