Funny Places for Endometriosis

The July edition of The Journal of Minimally Invasive Gynaecology (JMIG) presents 2 case reports of endometriosis occurring in abnormal places. In the first case, the patient had nose bleed and pain and was found to have growths there. The second case presented with gastric-like abdominal pain and was found to have a growth in the pancreas on scanning. Both cases were confirmed as endometriosis after surgical removal. Of note was that these patients had positive correlation with cyclical symptoms as well as previous suggestion of endometriosis. So, endometriosis in the nose and in the pancreas. Who would have thought it?

Tapak Aneh Penyakit Endometriosis 

Dalam isu bulan Julai The Journal of Minimally Invasive Gynaecology (JMIG), terpapar 2 kes penyakit endometriosis yang ditemui di kedudukan yang aneh. Pesakit kes pertama melapor pendarahan dan perasaan sakit di hidungnya serta ternampak ketumbuhan. Pesakit kes kedua pula mempunyai perasaan sakit ala gastrik dan ternampak ketumbuhan di kelenjar pankreasnya melalui imbasan. Kedua-dua kes ini dipastikan mengidap penaykit endometriosis selepas pembedahan untuk mengeluarkan ketumbuhan-ketumbuhan tersebut. Yang penting dalam kes-kes ini ialah sejarah perubatan yang mengaitkan penimbulan simptom-simptom tersebut dengan kitaran haid serta sejarah lama penyakit endometriosis. Jadi, endometriosis di hidung dan pankreas, sungguh aneh!

August Case - Twin Fibroids

Sorry, I have been meaning to write but have been swamped with other things. This was a 51 year old lady who had never conceived in 30 years and presented with abnormal and heavy menstrual bleeding. There was a mass felt in the abdomen, about 6 months pregnancy size. Ultrasound scan showed multiple uterine masses suggestive of fibroids. This was the view on laparoscopy - twin, large fibroids. I had counselled hysterectomy, but it was difficult due to the restricted view. I had to remove the fibroids from the uterus first (myomectomy) before proceeding to hysterectomy. As usual, everything was done laparoscopically. 

Fibroid Kembar

Maaf atas kelewatan menulis. Kes ini adalah seorang wanita berumur 51 tahun yang tidak pernah mengandung walaupun kahwin selama 30 tahun. Beliau mengalami pendarahan haid yang berpanjangan dan lebat, dan setelah diperiksa, didapati mempunyai ketulan di perut sebesar kandungan berusia 6 bulan. Imbasan ultrasound telah menampakkan banyak ketumbuhan di rahim yang berciri fibroid. Gambaran ini dilihat melalui laparoskop - fibroid-fibroid besar dan berkembar. Pembuangan rahim menjadi rumit apabila penglihatan terhad kerana ketumbuhan-ketumbuhan tersebut. Akhirnya, fibroid-fibroid ini dipisahkan dahulu dari rahim sebelum histerektomi dilaksanakan. Saperti biasa, semua prosedur dilakukan dengan melalui pembedahan laparoskopi.

Facts About Menopausal Hormonal Therapy

10 years after the seminal publication of the Women’s Health Initiative trials data¹, certain facts and data have emerged that can help guide us in this so controversial an issue of Menopausal Hormonal Therapy (MHT). The following is a summary of a review published lately in the journal Menopause².

It has always been a truth that MHT is an acceptable option for treating severe early menopausal symptoms. As is the wont of these symptoms, they disappear within 10 years of menopause, thus this treatment is prudent and applicable within this time frame. Such therapy must of course be precluded in the presence of medical problems, foremost of which are blood clots, heart disease, stroke and cancer.

Estrogen replacement alone suffices for a woman who has lost her uterus, whereas progesterone therapy needs to be added for the sole purpose of prevention of endometrial cancer in those who retain theirs. If the symptoms are limited to the vulva, vagina and the bladder, topical estrogen therapy to the affected parts might be enough to soothe the symptoms.

So much is so true, and we must keep in mind that the whole controversy arose not because of questionable beneficial effects, rather, the serious consequences of MHT. Foremost in the mind of most women is the occurrence of breast cancer. The WHI trials demonstrated an increased risk of breast cancer with more than 5 years continued use of the estrogen-progesterone combination therapy. This increased risk was not present in users of estrogen-only preparations, thus suggesting a causal link of breast cancer with progesterone. The data shows that the risk is not that great and decreases after discontinuation of said replacement therapy. Estrogen, whether given alone or together with progesterone, increases the risk of thromboembolic events (TE) such as deep vein thrombosis, pulmonary embolism and stroke, but these occurrences are rare before the age of 59 years.

Thus we have come to accept that combination estrogen-progesterone MHT is proven effective in the management of early menopausal symptoms only (and not for other indications) but should be used for the shortest duration and with the lowest possible dosage. More flexibility is accorded to estrogen only therapy but similar caveats should apply whenever possible.

Fakta Berkenaan Rawatan Hormon Menopause

10 tahun selepas maklumat daripada kajian unggul berkenaan rawatan menopause diketengahkan¹, situasi berkenaan rawatan ini semakin jelas, saperti dipaparkan dalam jurnal Menopause baru-baru ini². Berikut adalah ringkasan tajuk utama.

Terapi hormon untuk menopause (MHT) sungguh berkesan mengatasi gejala awal menopause dan boleh diteruskan selama 10 tahun, iaitu, sehingga simptom-simptom keadaan ini hilang. Rawatan ini tidak boleh digunakan jikalau seseorang wanita mengalami beberapa masalah perubatan, terutama sekali ketulan dalam saluran darah, serangan angina ahmar, sakit jantung dan kanser.

Rawatan ini boleh dibahagikan kepada 3 – hormon estrogen sahaja untuk wanita yang tidak mempunyai rahim, kombinasi hormon estrogen-progesteron bagi mereka yang ada rahim dan krim estrogen setempat jikalau gangguan terhad kepada kemaluan, faraj atau pundi kencing.

Risiko penggunaan MHT ialah kejadian saperti kanser payudara dan kejadian tromboembolik (TE) saperti angina ahmar, ketulan darah dan embolasi paru-paru. Tidak dinafikan yang MHT meningkatkan risiko mengalami kanser payudara, tetapi jumlah kejadian ini kecil dan risiko tersebut hilang selepas rawatan diberhentikan. Lagipun, risiko berlakunya kanser payudara hanya meningkat jika digunakan terapi kombinasi estrogen-progesteron dan bukan estrogen bersendirian. Kejadian TE lebih berkemungkinan berlaku dengan kesemua jenis rawatan oral tetapi jarang dialami sebelum umur 59 tahun.

Dengan ini, MHT didapati sesuai untuk rawatan simptom-simptom awal menopause sahaja tetapi perlu digunakan dalam dos yang paling rendah dan dalam jangkamasa yang paling pendek. Pengawasan untuk gejala kanser payudara dan kejadian TE mesti berterusan.

1. Risks and Benefits of Estrogen Plus Progestin in Healthy Postmenopausal Women. Principal Results From the Women's Health Initiative Randomized Controlled Trial. JAMA 2002;288(3):321-333.

2. Stuenkel CA, Gass MLS, Manson J et al. A Decade After the Women’s Health    Initiative – The Experts Do Agree. Menopause 2012;19(8):846-847.