The immune system has an awesome task, employing a force of “agents1* co keep it operating at its peak. These agents fight disease and remember the type of invading microorganism so they can prevent reinfection. The system’s guard consists of interferon, complex fighter cells that attack bacteria and viruses by destroying their ability to reproduce in the human body. Interferon responds first in fighting infection, slowing down the potency of invaders so the body can summon other defenses. Laboratory studies reveal that only four hours after infection the body begins its charge with interferon.

The suppport system has varied responsibility, but it operates as a strategic team. Phagocytes engulf and consume invaders, or antigens, and can prevent disease from spreading. Antibodies recognize intruding bodies, clamp on to them, and destroy them. T cell lymphocytes, which are derived from the thymus gland, and B cell lymphocytes, derived from bone marrow, also work in tandem. T cells will control and regulate antibodies; B cells perform the important function of binding with antigens (the enemies) to render them harmless.

When bodily tissue is invaded, substances are released into the blood that marshal white blood cells of a different nature: neutrophils and macrophages. Neutrophils can consume about twenty-five invaders, and macrophages can “cat” four times that amount before expiring from the toxins they’ve ingested. Macrophages also clean up blood and keep it healthier by consuming diseased or ineffective red blood cells. (In terms, of endometriosis, macrophage count, for example, has been found to be double the normal amount in the cul-de-sacs of women with the disease.) Memory cells function after disease is fought of C recognizing invaders and acting quickly to prevent reinfection.

Individual immune systems, like any army—no matter how sweeping—on suffer losses or serious setbacks in defense efforts through stress, alcohol consumption, smoking (cigarettes or marijuana), drugs (recreational or medicinal), and even diets that arc high in fat, sugar, and. recent srtidie have found, deity products. An extreme form of immune system devastation is AIDS (acquired immune deficiency syndrome). Traced to a virus that begins a chain of destruction among these infection-fighting cells, victims of AIDS don’t die from AIDS itself, but from diseases the body’s immune system is powerless to fight-Doctors have long speculated that there may be an altered cellular immune response among women who develop endometriosis. This alteration, they propose, might explain why the implants adhere and grow. Among the many studies done in chit field. Investigators sought to explore an Immune system deficiency that may occur along with another factor, (or example, excessive menstrual flow or malfunction of the fallopian tubes. Answers to many of these studies were inconclusive. It was found that there might be an immune system breakdown or physiological problems in a victim of endometriosis, or an immune system deficiency and another factor. Therefore, conditions explaining the cause of the disease might exist as mutually exclusive factors or they might in fact be interconnected, la other words, there is, so far, no conclusive answer.

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Establishing infertility

Usually the first thing is to try to conceive for a year without using contraception. A Melbourne IVF specialist says that approximately 10% to 15% of couples will not conceive in that time. ‘At that stage we feel that it is time to start investigations and try to pinpoint any problem’, he said.

The first step is to get a referral to a gynaecologist. Most women with endometriosis will already be under a specialist who may also manage their infertility investigation but they may be referred to an infertility specialist.

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testing a specimen of your urine

taking your blood pressure

examining your breasts

examining your abdomen

a pelvic examination (sometimes also known as an internal or a vaginal examination).

The purpose of the pelvic examination is to try to determine whether there are any indications that you may have some endometrial implants or cysts present. Sometimes, the pelvic examination will suggest the presence of endometriosis but often nothing abnormal will be found, especially in the early stages of the disease.

Knowing what is involved in a pelvic examination will help to relieve any anxiety that you may have and help you to relax and therefore make the examination more comfortable for you and easier for the doctor. Ask your doctor to explain the procedure to you before she or he begins.

It is best if you empty your bladder just before the examination as a full bladder will make it difficult for the doctor to perform the examination satisfactorily.

During the pelvic examination you will usually be asked to lie on your back with your legs spread apart, knees bent and feet together.

While the doctor is examining you it will help if you tell him or her when you can feel any pain or discomfort. A pelvic examination may cause a little discomfort but it should not be painful. If the examination does cause pain ask your doctor to stop for a moment to allow the pain to subside while you relax again. After the examination has been completed ask the doctor to describe what he or she felt.

The doctor will begin by examining the external genitalia, which includes the vulva, clitoris and labia, for any signs of inflammation, irritation or infection.

The doctor will then insert an instrument, known as a speculum, that holds the sides of the vagina apart to examine the vagina and the cervix. The doctor may also take a Pap smear or a sample of any unusual discharge using a cotton swab or a wooden spatula. Once a thorough examination has been made the doctor will remove the speculum and perform a bimanual pelvic examination.

In the bimanual examination the doctor inserts two gloved fingers into your vagina and places the fingers of the other hand on your lower abdomen in order to feel the outline, shape, size and location of the pelvic organs between his or her hands. The doctor will also feel for any nodules, lumps, growths, enlargements or areas of tenderness.

During the examination the doctor may be able to feel nodules of endometriosis in the Pouch of Douglas, on the utero-sacral ligaments or in the recto-vaginal septum. It may also be possible to feel if the ovaries are enlarged, which may indicate cysts on the ovaries. The doctor will also be able to feel if the uterus is lying in the normal position or if it is stuck in a retroverted position.

Occasionally, the doctor may feel that it is necessary to perform a recto-vaginal examination if you are complaining of symptoms involving the bowel. This examination is similar to a bimanual pelvic examination but the index finger is inserted into the vagina and the middle finger into the rectum. The fingers of the doctors other hand are placed over the lower abdomen to help outline the organs and feel for any enlargements or growths.

If a pelvic examination does not indicate anything abnormal and if it was not performed near the time of your period it may be worthwhile having another examination just before, or during, your period when the endometriosis is most active thus making the implants more tender, larger and easier to feel.

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Because of the progressive and recurrent nature of endometriosis it is important that an accurate chart of your endometriosis be made at the time of your diagnostic laparoscopy. The chart will provide a record of the initial extent of your endometriosis that can be compared at a later date with the charts made during any subsequent laparoscopics so that an accurate assessment can be made of the progress of your condition.

The information gained from the laparoscopy and the chart is then used to rate the extent and severity of your condition. There are several formal classification systems which have been developed, the most widely known being a system developed by the American Fertility Society. These classification systems generally allocate a certain number of points to each implant or cyst depending on its nature, size and location and the total number of points is then used to classify the severity of the condition.

For example, according to the American Fertility Society’s classification scheme, a woman with a four centimeter endometrioma on one ovary, some adhesions on both ovaries and implants in the Pouch of Douglas would score a total of 30 points (20 + 2 + 2 + 6) which would be defined as moderate endometriosis (16-40 points).

However it appears that few gynecologists in Australia use any of the formal classification systems. Their classification of the disease is usually based on their visual impression gained from the laparoscopy.

The four categories most commonly used to classify endometriosis are minimal, mild, moderate and severe. The terms stage I, stage II, stage III and stage IV are also used occasionally. A brief description and diagram of a typical example of each category is shown in Fig.9 on p.56.

It is important to remember that the classification system only rates the extent and severity of your endometriosis and your classification does not necessarily bear any relationship to the severity of your symptoms. Minimal or mild endometriosis can cause severe symptoms while severe endometriosis can sometimes cause no symptoms.

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Electrocardiogram (ECG)

This test can detect some disorders of heart function before they cause any symptoms.

Blood tests

These can be taken to discover any disorders of blood-cell formation, or any abnormalities in the chemistry of the serum that could be the result of disturbed liver, kidney or thyroid function. If sugar is found in the urine, further blood-sugar tests will be advised.

Chest X-ray

This can be taken particularly if anything picked up on physical examination suggests chest problems.

Cancer-screening tests

These may be advised. Mammography and bowel-cancer screening tests (by examining the faeces for hidden blood) are the most common.

Eye-pressure tests

These are performed by an optometrist or an eye doctor. The aim is to detect early any increase of pressure within the eye. Raised pressure within the eye causes glaucoma, a nasty condition that can destroy sight. It usually develops very slowly and gradually, and often causes irreparable damage to sight before it causes symptoms. Glaucoma is one of the most important causes of blindness in older people. It is rare before the age of 40; after that the incidence increases to more than 1 in 20 at 75 years of age.

I don’t think the importance of testing for early glaucoma has been given enough publicity. It is done routinely when new spectacles are prescribed, but most of us who wear glasses don’t need to change our specs after about the age of 60, so we don’t visit the optometrist or eye doctor unless eye symptoms develop. This may be too late to prevent damage from glaucoma.

Because glaucoma is common and because early control (with eye drops) can prevent loss of sight, I would advise everyone over the age of 40 to speak to an optometrist or eye doctor about how frequently testing is advisable. It should be more frequent if there is any family history of glaucoma.

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PID has had a lot of publicity during the past decade because of the increasing number of reports of women with ’silent’ PID from chlamydia infection. Public health authorities have put much effort into making women aware of this possibility and encouraging them to have checkups if there has ever been a risk.

Why are we only aware of this epidemic happening now if chlamydia has been around forever? The explanation may be that with the increased sexual freedom of the 1960s and 70s (before we knew how to detect chlamydia), many people were infected with both gonorrhoea and chlamydia at the same time. They were treated with penicillin, which cleared up the gonorrhoea but left the chlamydia to spread to the tubes and be passed on to others.

For those who do have symptoms, hormonal treatment usually brings relief, though you may need to try several types before you find the right one. Sometimes Vitamin B6 or evening primrose oil helps. A mammogram is always advised to rule out any suspicion of breast cancer.

Pain in one breast only may be caused by inflammation, a tense cyst or an abscess, but may be due to nearby muscle or bone problems. Uncommonly, one-sided breast pain is due to cancer, therefore mammography is always recommended. Treatment is directed to the cause, when it is known.

Breast infection (mastitis) can occur at any stage after puberty and is common during the early stages of breast-feeding. Treatment is by antibiotics and occasionally, if an abscess forms, by surgical drainage.

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The main bacterium that overgrows is called Gardnerella vaginalis, but there is also overgrowth of an assortment of other bacteria including anaerobes (bacteria that can live and grow without oxygen). When other bacteria get a hold in the vagina, its normal main inhabitants – Döderlein’s bacilli – are vanquished and can’t maintain the normal, healthy acidity of the vagina. The vaginal environment becomes totally disturbed.

We don’t know why this happens, only that it’s more likely to affect women who are run down, so immunity must have something to do with it. But not all rundown women get bacterial vaginosis: perhaps some women are more susceptible to this manifestation of poor health.

Symptoms of bacterial vaginosis

The most common complaint is a bad smell from the vagina, often worse after intercourse. It’s often described as a sour, cheesy or fishy smell. There may also be a smelly discharge, which may be thick and gluey or thin and watery, sometimes frothy, scant or copious, and varies from

greyish to yellow in colour. Bacterial vaginosis rarely causes tenderness of the genitals, itch, or pain with sex.

How is bacterial vaginosis diagnosed?

The smell and appearance of the discharge in a non-inflamed vagina are suspicious; especially if the vagina is less acid than usual (this is tested by placing a strip of litmus paper against its wall). If on-the-spot examination of a drop of the discharge shows no Döderlein’s bacilli but very many other bacteria and ‘clue’ cells (cells of the vaginal lining with bacteria all over their surfaces), the diagnosis is pretty sure. If any doubt remains, a swab of the discharge can be sent to a laboratory for further tests.

Treatment

If bacterial vaginosis is causing symptoms, treatment is by oral tablets of metronidazole or tinidazole. For the first attack a single dose is usually effective. If the problem recurs a longer course generally gives better results. Very troublesome recurrences may be helped by using an intravaginal antibiotic cream as well as metronidazole by mouth.

Bacterial vaginosis isn’t sexually transmissible, so there is no need to treat your partner.

If Gardnerella is found by chance (in swabs or a Pap smear) and there are no symptoms, treatment is unnecessary: remember that it is a normal vaginal inhabitant.

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After a bimanual examination to ascertain the size, shape and position of the uterus and other pelvic organs, a speculum is inserted into the vagina to bring the cervix into view. The cervix is held steady with forceps while the depth of the uterine cavity is sounded. The cervical canal is dilated to 6-7 mm in diameter (its undilated diameter is 2-4 mm) by inserting through it metal rods of gradually increasing thickness. A curette is then passed into the uterus to remove the endometrium, which separates very easily.

Other methods can be used to obtain samples of endometrium. Suction aspiration can remove the entire endometrium in the same way as does curettage. Other instruments have been designed that don’t need dilatation of the cervix for insertion into the uterine cavity and can be used with local or no anaesthetic. These instruments generally remove small fragments of the endometrium rather than all of it, and can be used when it’s not important to examine the entire uterine lining. When the purpose of the procedure is to exclude the possibility of endometrial cancer, curettage is preferred.

Pain relief during labour and delivery

Contractions of the uterus in labour are painful. Some people have played down me force of labour pains and given the impression that if you know what to expect and are armed with the right attitude plus breathing and relaxation techniques that can help to distract you from the pain, you’ll be able to cope with them and shouldn’t need pain relief. This is called psychoprophylaxis (meaning ‘prevention by the mind’), and works wonderfully for some women, but not for all. It’s impossible to predict how much pain any woman will feel during labour: it can be different for the same woman from one deliver to the next.

Nine out of ten women having their list delivery need more than psycho-prophylaxis and minor pain relief. More women manage well without drug relief in subsequent deliveries. The drugs used today include self-administered nitrous oxide/oxygen gas anaesthesia (with which you can’t put yourself too far under because you drop the mask), pethidine (a synthetic narcotic) and epidural block, which anaesthetises the body from the waist down. Methods of pain relief will be explained to you in your antenatal classes and by your doctor. During labour you can ask for pain relief if you need it, and refuse if it’s offered to you and you don’t want it.

There has always been some concern about the effects of drugs on the foetus and on the course of labour, though when administered and monitored with care, all the above methods have proved safe. There has been controversy about the increasing use of epidural anaesthetic, especially in first deliveries (six out of ten in one study in New South Wales). A 1983 review by the NHMRC of potential benefits and hazards of epidural block in labour concluded that in experienced hands epidural is safe, but recommended that its possible effects on delivery (mainly that forceps delivery is more likely to be needed) should be discussed with the pregnant woman before the onset of labour.

Delivery sitting or lying down?

It’s only during the twentieth century that women have been encouraged to lie down during labour and delivery. It’s been suggested that the main reason for this position is that it is easier on the backs of the birth attendants!

Advocates for more active roles for women in childbirth encourage walking around and a variety of positions during the first stage of labour. You’ll learn about these in your antenatal classes. It’s been suggested that uterine contractions may be more effective when the mother’s body is upright, resulting in a shorter labour.

Delivery may be in whatever position you find easiest: sitting semi-reclined; crouching holding someone or something; squatting; kneeling; on ‘all fours’; lying on your back. Delivery-room staff say that the majority of women feel most comfortable lying on their backs, and this position is certainly easier for birth attendants. If you need some help with delivery (for example forceps), you may have to lie on your back so that procedures can be performed safely.

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