In evaluating my own work on the subject as well as the research of others, my scientific conclusion is this; endometriosis—as a consequence of abortion—is not an absolute biological inevitability. In fact, cases of abortion causing the disease are rare. When they do occur, it could directly involve an abortion technique, now out of favor, called hysterotomy.

Perhaps the best way to understand hysterotomy is to think of it as a mini-cesarean section. In this type of abortion, a small incision is made in the abdomen; then an internal incision is made in the womb and its contents arc removed. Surgeons make a transverse (horizontal) or classical (vertical) incision in the lower portion or lower flap of the uterus—the same choice of incisions used for full-term deliveries by cesarean section. It is this type of surgical procedure, made during the late first trimester or early second trimester of pregnancy, that could be most responsible for the onset of endometriosis.

Why is this so? In the early months of pregnancy, there are still living endometrioric cells lining the uterus that have the potential to implant themselves on abdominal organs, and on the scar, given the chance. We know that pregnancy halts menstruation, which is the usual time of transport of these cells from the uterus. Therefore, another avenue into the abdominal cavity is required before any invasive endometriotic cells can run wild. Hysterotomy supplies the route. (Full-term cesarean deliveries differ entirely. At term, the placenta is fully formed and no endometriotic tissue remains in the uterus. Therefore, there is no way for random tissue to implant itself, or spread to an abdominal incision and implant itself there.)

immediately following hysterotomy, surgeons wilt routinely cleanse the internal abdominal area of cells and blood clots with saline solution. However, in some cases, the cleansing is not effective enough; random cells that have been sprayed outward when the incision was made find a host organ. If the patient has a tendency toward endometriosis, the disease could take hold. (It is also possible that she already had endometriosis before the abortion, and the operation released other live cells.)

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She would experience dull pain for about for one week before her period was due. This dull pain would then develop into a sharp, stabbing pain one day before her period and would continue throughout the whole time she was bleeding.

Her periods were irregular — this means that the bleeding could come every two or three weeks and last up to ten days. As well as experiencing pain and heavy bleeding Anna-Maree started to vomit, suffered from constipation and developed low backache.

Numerous visits to her GP over the next few months resulted in her being examined by specialist doctors for her backache and constipation. She was told that she suffered from an irritable bowel (spastic colon). The suggestion to take Panadol and eat a high fibre diet did not relieve her pain and other problems.

At this ti me the pain was so bad that she had to take two to three days off school each time she had a period. She was always worried about the pain and hated missing out on being with her friends.

Her family and friends were becoming increasingly concerned about her.

After two years of going back and forth to her GP she was finally sent to a gynaecologist who suggested that she take Ponstan. The gynaecologist said that if the Ponstan did not decrease the pain she would have to live with it.

Unfortunately, the Ponstan did not relieve the pain and so once more she turned to her GP for help. He suggested that she take the Pill for four months. She felt much better on the Pill but as soon as she stopped taking it the pain and heavy bleeding returned.

She continued to try and live with the pain and over the next year she read many medical books trying to find the answer to her problem.

At 15, just before she was about to set off on a school camp Anna-Maree again had extreme pain with her period. Her GP told her to keep taking Ponstan and to see him again if necessary.

After returning from the camp her period had finished but the severe pain persisted. After seeing her GP yet again, he suggested Anna-Maree have an ultrasound which was eventually performed five days later. The ultrasound revealed an ovarian cyst and possible pelvic inflammatory disease (an infection of the reproductive system). She was given antibiotic tablets to take.

The night after her ultrasound Anna-Maree’s pain became unbearable. She was admitted to hospital and was operated on the following day. She had endometriosis.

Anna-Maree cannot remember the details of her gynaecologist’s visit after the operation as she was still too sleepy to understand what he was saying. However, the gynaecologist spoke at length to her parents.

After reading about the Endometriosis Association in the local paper, her mother contacted the Association and had many of her questions answered. They recommended a book about endometriosis that would be helpful for Anna-Maree to read. Her family also read the book and at last they had some understanding of what she had been going through over the past three years.

Anna-Maree understood most of the medical terms in the book because she had received a good grounding in sex education at school.

After the operation, Anna-Marie was told to take Duphaston (a hormonal tablet used for treating endometriosis) for six months. The Endometriosis Association was able to give her information about the drug. She took two tablets a day but she started vomiting and suffered from dizziness. Her doctor suggested that she only take one tablet a day for two or three weeks.

This helped to reduce the side effects and she has not had any other side effects since, even though she has increased her dosage to two tablets a day again. She continued to have periods while on Duphaston.

At her check-up six weeks after the laparoscopy, Anna-Maree found her doctor understanding and happy to answer her questions. Unfortunately, she then was not given another appointment to see him for the six months while she was taking Duphaston. Anna-Maree feels that she would have liked the opportunity to have seen him during that time for support and further information.

None of her friends at school had heard of endometriosis. They wanted to know about the disease and how it would affect her. They wondered if the tablets would get rid of the endometriosis and if she would be able to have children later in life. Anna-Maree was very open with her friends and tried to answer all their questions.

Anna-Maree’s mother also contacted the school nurse who gave Anna-Maree’s teachers information leaflets so that they too could understand her problem.

Now 16, Anna-Maree has finished taking the Duphaston tablets and is waiting to have another laparoscopy to make sure that her endometriosis has been cleaned up.

What were Anna-Maree’s feelings

Anna-Maree was asked what her feelings had been during the last four years. Before she was diagnosed as having endometriosis she was confused. As a 12 year old she found it difficult to understand why she could not cope with the pain at the time of her period. None of her friends had to take time off from school. Was the pain really as bad as she believed it to be?

She was frustrated that a cause for her problems could not be found. Her mother gave her support and continued to seek doctors’ opinions. She felt that her elder brother was tired of her being sick so often and her father did not accept that she was unwell and thought that she was ‘playing on it’ to get out of doing her school work and chores around the house.

Anna-Maree felt intimidated by her doctors. They talked down to her and did not seem to understand how she felt.

Once Anna-Maree had been diagnosed she experienced different feelings. At first she was relieved to know that all her problems were not in her head — she was not making them up — they were real — she had endometriosis. She was frightened that endometriosis was a form of cancer and that she might die. She was quickly reassured that this was incorrect.

She then became angry. Why me? What have I done to deserve this? She was angry with her doctors. She felt that her GP had taken too long to send her to a gynaecologist. She was angry that he had not taken her symptoms seriously. She was angry at her gynaecologist who told her parents about the disease and not her — the one who was suffering. She wished that the gynaecologist had told her in private about the disease with plenty of opportunity for her to ask questions. She was angry with her mother. Was it hereditary? Was it her mother’s fault that she had the disease?

Anna-Maree also felt guilty that she had developed this disease. She questioned herself whether there was anything that she had done as a child to cause the endometriosis to develop.

At times Anna-Maree feels isolated because she does not know any other teenagers who have the disease. She would like to meet and talk with others of her own age. She feels that she now has the full support of her parents, brother, friends and teachers but she still wants to find out how other teenagers feel and cope with the disease and its implications.

Anna-Maree has found a great comfort in her dog. She can talk to her dog about her concerns and feelings and know that it will not answer her back!

She feels that she has accepted her condition but still has concerns for the future.

Anna-Maree knows that endometriosis can be treated but that it may recur. She realises that it may be an ongoing problem and that in the future she may have difficulty in becoming pregnant.

As a teenager she is concerned that she will not have control over her decisions. She wants to be able to listen to her doctor’s opinions, read as much information as possible and talk over her options with her family and others and then make a decision herself — a decision that she is happy with.

She is concerned that she may continue to have to take time off school each month, and that this may jeopardise her studies in the future.

Anna-Maree is not concerned about future relationships with boyfriends. She feels that she will be able to talk openly about endometriosis when the time comes.

She says that she is not going to dwell on these concerns but will take life as it comes.

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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 centimetre 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 gynaecologists 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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Since September 1998, manufacturers have been obliged to label products containing genetically modified DNA. However, this labeling only applies to genetically modified soya and maize (corn) products and only where protein or DNA can be detected in the final product by laboratory screening. Foods containing soya oil, refined starches, and additives (such as emulsifiers and lecithins) are excluded. Greenpeace estimate this means that 90 per cent of foods containing genetically modified products are unlabelled. Since the latter part of 1999, because of public opposition to GM foods, supermarkets have been claiming that they have less than 1 per cent GM foods on their shelves and they are trying to go lower than that.

Genetic engineering involves manipulating the basic DNA of a plant or animal. This happens naturally in evolution of course, but with nature in charge the process normally takes hundreds if not thousands of years. It is this process which ensures that the fittest of the species survive. But the gene manipulation that humans are now tinkering with bypasses evolution, and we don’t know as yet what the price will be. In order to smuggle these new genes across the species barrier, scientists use infectious agents (viruses and bacteria).Then the antibiotic-resistant genes are used as genetic markers to allow the scientists to track the movements of these new genes. In one instance a nut gene was inserted into a soya bean and people with allergies to nuts became allergic to the soya milk. This would have posed a very serious risk for anyone with a nut allergy who would have had no idea that the soya milk contained a nut gene.

Even the scientists disagree violently as to the value and dangers of genetically modified foods. So the only sensible thing to do is to try to avoid them when you shop for food.

The Vegetarian Society has announced that, from August 1999, all foods bearing the ‘V symbol will have to be free from genetically modified products. Provamel, the market leader for soya products in the UK, have stated that their foods are free from genetically modified material and have implemented a system to trace the soya from seed to final production. Also, at the moment, if a food is labeled organic it is not genetically modified. My advice is to avoid genetically modified foods where possible by buying organic and reading the labels. If we as consumers consciously do not buy these foods then eventually there may not be a market for them.

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