By Gilman Welply FRCS FRCOG
Consultant Gynaecologist, St.Anthonys Hospital

Day-surgery using a YAG laser can offer a more acceptable solution than hysterectomy for younger women for relief of symptoms of endometriosis.

Endometriosis is a frequent cause of pelvic pain and distress in women of reproductive years. It is almost unknown before puberty but the incidence increases up to 10% in women between 15 and 45 years and declines again after the menopause. Endometriosis is a significant cause of pain and suffering in younger women and may also be associated with subfertility in 30% of couples. If a woman is sure that her family is complete and her symptoms warrant it, hysterectomy is a very effective way of treating severe disease. In other cases laparoscopy with laser offers a considerably less drastic solution.

Endometriosis is a condition where deposits of cells, like those that line the uterus, are found in the pelvis but outside the uterus. They are usually found behind the uterus on supporting ligaments (utero-sacral ligaments) and on the ovaries. The tissue can occur on other sites in the pelvis including the bladder and bowel and can be found in scar tissue (Caesarean or episiotomy) and rarely in other parts of the body. The origin of this tissue is uncertain but it is known that many women when they have a period will bleed back down the Fallopian tubes and this blood can carry cells from the uterus that then implant themselves in the pelvis and grow. There is sometimes a family history of endometriosis and so there may be a genetic component to the condition.

Symptoms
The endometriotic tissue behaves in the same way as the lining of the uterus and thus with each period it will swell, cause inflammation and bleeding which leads on to scarring and cyst formation. This produces pain in the pelvis which often starts at mid-cycle and increases reaching a peak with the onset of the period and then decreases. The period itself may be heavier with the passage of clots and more prolonged. There may be backache, often worse first thing in the morning and pain with bowel movements and bladder symptoms as well. Deep pelvic pain with and following intercourse is a frequent symptom and may contribute to the fertility problems associated with the condition. Another puzzle is the fact that the symptoms are not related to the extent of the disease and frequently, women with minimal change will have severe and distressing symptoms.

Fertility problems
It is uncertain how endometriosis causes problems with conception when there is only minimal or mild disease present. With severe disease, where there is disruption and distortionof the pelvic anatomy, infertility is more understandable. However, studies have shown that treating endometriosis improves the fertility rate.

Diagnosis
A diagnosis can often be made from a careful history and examination but laparoscopy is the most accurate way of assessing the situation. Laparoscopy is a day-case procedure performed under a light general anaesthetic in which a telescope is passed into the abdomen through a small incision under the navel. This allows the pelvic organs to be inspected and the extent of any endometriosis accurately recorded. Ultrasound scans can be helpful in diagnosis of severe disease but are of little help with minimal disease. The appearance of endometriosis at laparoscopy varies from small lesions that can be white, red or blue-black and are often associated with changes in the peritoneum and increased vascularity. The ovaries can also be a site of endometriosis with cysts (endometriomas) and adhesions. The disease is usually staged from minimal to mild, then moderate and severe. With the last two stages there is major scarring with cyst formation and distortion of the pelvic anatomy.

Treatment
Treatment will depend on symptoms and the extent of distress being experienced. It can range from explanation and reassurance, with simple analgesics for the pain, to hormone therapy or some form of surgery.

The hormones available include the pill and progesterones which may just mask symptoms and not actually treat the problems. There are specific treatments such as Danazol and Gestrinone, and then hormones which create a temporary menopause (Zoladex, Buseriline, Synarel). The use of these drugs should be discussed and the risks and benefits explained. They are usually taken for six months at a time and by stopping the period allow the endometriosis to heal. However, active endometriosis will often return in 1 2 years following treatment with hormones.

Surgery
For severe disease producing symptoms that interfere with life and where the woman does not want more children, hysterectomy may be the treatment of choice. This is of course a major procedure requiring 4 5 days in hospital and 3 4 weeks convalescence afterwards. In some but not all women, removal of both ovaries may be wise and in this instance hormone replacement therapy may be required.

In other circumstances, laser surgery, such as is available at St.Anthonys, offers the ability to diagnose and treat at the same time using the laparoscope and a contact laser (YAG) to burn out any lesions. Use of the laser does not seem to produce extra discomfort or prolong the hospital stay of a laparoscopy. For minimal and mild disease it produces a rapid resolution of the symptoms, but even for moderate to severe endometriosis much can often be done by simple conservative surgery. There is a relapse rate of about 10% per year and a repeat laparoscopy and laser may be more beneficial. Put another way, after laparoscopy and laser, 50% of women will be symptom free for at least five years and a significant number will be cured.

St.Anthonys is doing its bit for nurse training with clinical placements for pre-registration nursing students from Kingston University/St.Georges Hospital. The first group of five students arrived on 17th June for a 7 week training period. More groups are due to follow later in the year. St.Anthonys has always placed great emphasis on nurse education and for a number of years in the 1950s and early 60s ran its own Nurse School from which some of the graduates have only recently retired.

Following the visit to St.Anthonys by the Health Quality Service last year, the hospital has had its accreditation confirmed.

Starting in August, the kitchen in St Anthonys will undergo a complete renovation. The increase in patient and staff numbers in recent years and the establishment of St Raphaels Hospice and St Bedes Conference Centre has meant that the present kitchen, which has been in use for 27 years, is no longer adequate for preparing the volume of meals now required, sometimes up to 900 a day.

The plans include enlarging the total area by approximately one third, replacing the present, inadequate air conditioning, updating all the equipment and creating separate food preparation areas. This major project is expected to take approximately 3 months and will result in St Anthonys housing one of the most up to date kitchens in the Borough.

In the meantime, the kitchen will be relocated to a temporary building from which the staff will no doubt continue to produce the award-winning standard of catering for which they have become known.

The rolling programme to update all wards with the latest electric Hillron beds has now been completed.

PHYSIO FIX FOR VERTIGO

A BALANCING ACT

Small things can have large effects: for want of a nail, an empire was lost. Did you know that symptoms of vertigo, dizziness and nausea can be due to the arrangement of minute crystals of calcium carbonate within the inner canals of your ear? It is the displacement of these crystals, or their impact upon an inflamed ear membrane,that can lead to these most unpleasant symptoms. For some, they can be debilitating; in extreme cases patients are housebound, while others have to sleep sitting up.

The Physiotherapy department at St.Anthonys Hospital has now extended its service to help patients suffering from these conditions; there are three physiotherapists who have been trained in vestibular rehabilitation. Vestibular rehabilitation may sound like painting your hall, but it is the overall term used for treatment of patients suffering from vertigo, dizziness nausea, imbalance and other conditions such as Menieres Disease. While the Physios treat their patients over a period of 6 12 weeks in the Physio department, there is also a graduated home exercise programme (the Cawthorne Cooksey exercises) which patients have to follow in-between treatments.

Over a period of time, head exercises by the Physios in the department and by the patient at home, reduce and then dispel the symptoms, allowing the patient to move on to the next stage of exercises. Thus a patient who at the first appointment may be unable to stand on one leg, can end up standing and turning with eyes closed. Likewise, at the outset, the initial home exercise, often accompanied by feelings of nausea and dizziness, is simply to look up, then down, several times; but some weeks later the patient may be able to walk a tightrope (on the floor!) with eyes closed. The constant repetition of exercise has the effect of retraining or hoodwinking the brain so that the messages received by the positioning of the minute crystals of calcium carbonate are not passed on as symptoms of nausea and dizziness. No matter, therefore, where those crystals may end up, the treatment can immeasurably improve the quality of life for these patients.

QUESTIONNAIRE RESULTS

Once again, the responses to the in-patient questionnaires have been very positive with 98.99% of patients saying that they would recommend St. Anthony's Hospital. A total of 95.21% of answers rated the services as Excellent or Good, the highest percentage since the survey began in 1998.

There was praise for the Nursing staff and the level of service provided in general. 'It would be hard to improve on your current standards, which should sewrve as an axample of excellence for others to aim at' and'all hospitals should be based on St. Anthony's' were just two of the observations made. The inevitable difficulties with parking and insufficient ventilation in the bedrooms during the recent warm spell were the main problem areas identified.