Dear Dr Mitchell,

I have had endometriosis for the last 10 years. I have been on the contraceptive pill non-stop to stop the periods but I am worried about side effects. Is there a point where it becomes unsafe to use the pill for this? I have heard of Mirena but it is a five-year treatment and I may want to try to get pregnant in the next three years. Would Mirena affect that? Should I be taking calcium when using the pill? What is the most effective and reversible treatment for endometriosis?

Endometriosis is a condition in which tissue resembling that in the lining of the uterus is present outside of its usual site in the cavity of the uterus. Common sites include the muscles of the uterus, the ovaries, the lining of the inside of the abdomen (peritoneal surfaces) and fallopian tubes. In some rare instances it is present in sites such as the lungs, bladder, vagina and brain. When there is a menstrual period these deposits will bleed and shed in a similar manner to the lining of the uterus. The common problems that endometriosis cause include severe, chronic, pelvic pain and infertility.

Some women with endometriosis have no symptoms at all. In rare sites such as the brain, bladder and lungs, it will present with brain haemorrhage, blood in the urine, the coughing up of blood or even collapse of a lung.

Treatment of endometriosis usually involves medication to stop the menstrual period to prevent the deposits from bleeding. The use of the oral contraceptive pill continuously for six to nine months is a safe option in women where the use of oestrogen is not contraindicated. The contraceptive injection, Depo Provera, is another commonly used method to control pain and bleeding. This does not contain oestrogen and so can be used in all patients.

Other forms of treatment include drugs that cause a pseudo menopausal state. These drugs temporarily shut down ovarian function and allow the endometriosis and symptoms to resolve. These include Zoladex and Leucrin. These drugs can only be used for a short term -- up to six to nine months because of the severe low levels of oestrogen that they cause and the associated effect on the heart and bones, increasing the risk for heart disease and osteoporosis.

The Mirena works well in suppressing symptoms due to endometriosis since it suppresses ovulation. It contains levonongestrel which gives the device this additional benefit. The Mirena lasts for five years but the effect can be easily reversed once pregnancy is desired. Once it is removed from the uterus, the effect is readily reversed.

The oral contraceptive pill is safe to use for long-term control of symptoms due to endometriosis. The effect of the pill is readily reversed once the pill is discontinued.

You can take calcium tablets ontheir own if you do desire or take it in your usual multivitamin supplementation. This is important if you are on the Depo Provera long-term or using Leucrin or Zoladex. If you have no other problems then a well-balanced diet with calcium rich food is usually adequate.

The preparations used for endometriosis work equally well in most cases. The use of the Depo Provera injection usually is associated with a longer period of time in return of the menstrual period to normal and hence ovulation can be somewhat delayed on discontinuation of the method for several months. The other methods are readily reversed on discontinuation of the medication.

Endometriosis can sometimes cause significant scarring of the fallopian tubes and ovaries resulting in an inability to conceive despise the use of medical treatment. In this case surgery has to be done to help to improve fertility. If no conception occurs after trying for one year then you will need proper evaluation by your gynaecologist.

In vitro fertilisation can be done in women who have severe scarring from endometriosis. There is a well-equipped invitro fertilisation unit at the University Hospital of the West Indies. The outcome is very good and comparable to first world countries. Consult with your doctor who will make the appropriate referral to one of the doctors in the unit who will advise you further and determine if you will need this form of treatment. This works well when the fallopian tubes are damaged. The egg is fertilised with the sperm and then put inside the uterus thus bypassing the fallopian tubes.

You should consider taking folic acid supplementation to prevent birth defects once you plan to try for pregnancy.

Best wishes.

Dr Sharmaine Mitchell is an obstetrician and gynaecologist. Send questions via e-mail to allwoman@ jamaicaobserver.com; write to All Woman, 40-42 1/2 Beechwood Ave, Kingston 5; or fax to 968-2025.

DISCLAIMER:

The contents of this article are for informational purposes only and must not be relied upon as an alternative to medical advice or treatment from your own doctor or other professional health care provider.