Before laparoscopy, culdoscopy had a reputation as being a good diagnostic aid for women who were suffering from endometriosis or infertility- Laparoscopy has gained favor as the better tool for two reasons: the use of carbon dioxide allows a dearer view of abdominal organs (culdoscopy uses no gas), and a greater number of other techniques are possible during the procedure. Culdoscopy has a few shortcomings, but is an accepted diagnostic procedure and may still be used from time to time by practitioners who are, it is hoped, experienced at it.

Culdoscopy can be a somewhat tricky procedure, requiring experience and skill. A small incision is made in the vaginal wall into the abdominal cavity and a pcriscopelike instrument if inserted through it, offering a view of the uterus, ovaries, and the fallopian tubes. To make ‘hat incision, a woman must remain in a slightly awkward position that requires some other conscious control and cooperation. Because of this positioning, she is not put under general anesthesia.

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Many women feel isolated and confused when they have been diagnosed as suffering from endometriosis. Who do you turn to when your family and friends do not understand? They may find it difficult to understand your feelings and are not always able to provide the support and help you need.

A support group such as the Endometriosis Association ends that feeling of being alone. You can meet and talk to other women suffering from the same condition as you.

It is a time of sharing and learning and provides an opportunity to express your thoughts when your family and friends are tired of listening. On a very practical level, joining a support group offers a chance for you to hear how other women have coped with pain, to discuss difficulties in getting a diagnosis and to learn about choices of treatment, side-effects and outcomes. Support groups can help to overcome confusion by providing easily understood information and access to relevant material which can help you to make decisions about your treatment.

Your questions are answered and your feelings of being overwhelmed are lessened. Receiving current and accurate information about endometriosis makes it easier to talk to your doctor and gives you the confidence to ask questions without feeling intimidated by the medical profession.

In a time of crisis, you can discuss your problem with other women who have been through similar experiences.

But belonging to a support group does not mean dwelling on the negatives — it is an opportunity to share the good and to provide mutual support. It is a give and take situation where women can share their own experiences with others which, in turn, helps to eliminate the myths and fears about endometriosis and its treatment.

Partners and friends are also encouraged to attend discussion sessions so they too can learn about this chronic illness.

Through a support group, you can look for ways of producing positive action to help make doctors aware of the suffering and debilitating effects this disease can cause.

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The Pill, often known as the oral contraceptive pill or the birth control pill, is not just one drug but rather a group of many drugs first developed for use as a contraceptive in the late 1950s. Initially, they were made up of a combination of synthetic oestrogen and progestogen (synthetic progesterone) but since the 1970s various synthetic progestogen-only drugs have also been used.

The Pill was first used as a treatment for endometriosis in the late 1950s and for many years it was the main form of treatment. It has now been superseded by Danazol and the progestogen-only drugs such as Duphaston and Provera.

Nowadays, many gynaecologists believe that there is no place for the Pill in the treatment of endometriosis because they feel it does not effectively eradicate the condition. However, many gynaecologists believe that it still has a role in the long-term management of endometriosis because they feel that although it does not eradicate the disease it may slow down or halt its progression. Therefore it is sometimes recommended for women with mild or minimal endometriosis in an attempt to stop the progression of their disease.

How the Pill works

It is thought that the Pill works by mimicking the hormonal condition of pregnancy because it leads to high levels of oestrogen and progesterone in the body. The high levels of oestrogen and progesterone suppress ovulation and lead to changes in the endometrial implants which eventually cause them to waste away.

Sometimes the Pill causes an initial enlargement and softening of the endometrial implants and cysts in the first few weeks or months of treatment, which may result in a worsening of symptoms and may occasionally cause endometriomas to rupture.

Dosages of the Pill generally used

There are many different varieties of the Pill available but not all of them are used for endometriosis. Initially, various high dose combinations were used but nowadays most gynaecologists would recommend a combination with a low dose of oestrogen and a relatively high dose of progesterone. The progesterone-only

Mini-Pills are not suitable.

Regardless of the combination used, most gynaecologists recommend that the Pill be taken continuously — every day without a break, for six to twelve months. You will usually be advised to begin with one tablet per day and to increase the dosage by one tablet per day if any vaginal bleeding occurs. The final dosage will usually be the lowest dosage on which you have no vaginal bleeding and this may be three or four tablets per day.

Side effects of the Pill

Side effects when using the Pill for endometriosis are common. Many women experience a greater number of side effects and they are often more severe than those experienced when using the Pill as a contraceptive, because the dosages used for endometriosis are usually much greater.

The more common side effects include vaginal bleeding, fluid retention, abdominal bloating, weight gain, increased appetite, nausea, headaches, breast tenderness, acne, depression, changed libido and vaginal thrush.

You will usually begin to ovulate and menstruate again within four to eight weeks of ceasing treatment and any side effects usually disappear within a few weeks.

How effective is the Pill

As previously mentioned, most gynaecologists these days do not believe that the Pill is an effective treatment for endometriosis. The research suggests that only a small proportion of women obtain relief from their symptoms and that the likelihood of becoming pregnant following treatment is low. In addition, the likelihood of developing a recurrence of the disease soon after treatment is high.

The Pill, pregnancy and breastfeeding

The Pill should not be used during pregnancy as progestogens can cause abnormalities in the developing foetus.

The use of the brands of the Pill containing both synthetic oestrogen and progesterone while breastfeeding is not recommended. The progestogen-only Mini-Pills may be safely used while breastfeeding.

Interaction with other drugs

The Pill interacts with a number of drugs therefore you should tell your gynaecologist if you are taking any other medication.

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Provera is one of the hormonal drugs that is used to treat women with endometriosis. In the past, Provera was used infrequently in Australia for the treatment of endometriosis but its use has increased markedly over the last four or five years. It has also been used for over 25 years to treat a number of other conditions including endometrial cancer (cancer of the uterus), abnormal uterine bleeding, amenorrhea (absence of periods) and menopausal symptoms in some women.

Provera is a strong progestogen (a synthetic progesterone) which is sometimes also known by its chemical name, medroxyprogesterone acetate.

Provera tablets, manufactured by Upjohn, come in several strengths. Those most commonly used in the treatment of endometriosis are small, white 10 milligram tablets.

Provera should not be confused with its controversial close relative Depo-Provera. Although both have the same chemical composition, Provera is in the form of a short-acting tablet whereas Depo-Provera is in the form of a long-acting injection. The long-term side effects that may be associated with the use of Depo-Provera do not occur with the use of Provera. If side effects occur when using Provera they can be rapidly reversed by stopping the treatment because the drug does not remain in the body for a significant length of time. The delay in the return of ovulation that sometimes occurs following the use of Depo-Provera is not a problem with Provera.

How Provera works

It is not known precisely how Provera eradicates endometrial implants but it probably works by suppressing ovulation and inhibiting the growth of the misplaced endometrial cells in some way, causing them to gradually waste away.

At the dosages usually recommended for endometriosis most women will stop ovulating and menstruating.

Dosages of Provera generally used

Most gynecologists recommend dosages of Provera in the range of 20 to 60 milligrams a day (two to six 10 milligram tablets a day). Generally, gynecologists recommend that Provera be taken daily for three to nine months.

Although the usual length of treatment is three to nine months there is no evidence that prolonged or repeated courses of Provera cause long-term side effects.

You should visit your gynecologist about six to eight weeks after starting your course of Provera so that you can discuss how me treatment is progressing. Thereafter, you should visit every two to three months for the remainder of your course of treatment.

Side effects of Provera

Most women using Provera will experience one or more side effects which are usually mild to moderate in severity and generally quite manageable. A few women will find them intolerable.

The more common side effects are weight gain, bloating, spotting, irregular vaginal bleeding, decreased libido, lethargy and tiredness, depression, headaches, acne, nausea and tender breasts.

The amount of weight gain on Provera varies widely and although most women will gain only one or two kilograms some women will experience greater gains.

Vaginal bleeding is a significant problem for some women on Provera. Usually it can be controlled by increasing the dosage but some women will continue to suffer vaginal bleeding even if they take relatively high dosages in the order of 60 to 80 milligrams per day.

Ovulation and menstruation usually occur within four to six weeks of completing therapy.

The side effects of Provera are reversible and they usually disappear within a few weeks of completing treatment.

There are no known long-term side effects of Provera.

How effective is Provera

Although very little research has been carried out into the effectiveness of Provera the results so far indicate that it is as effective as Danazol.

Studies have shown that about 60% to 80% of women had partial or complete relief from their symptoms and that about 50% of the women who wished to conceive became pregnant following treatment. There is no information available on how frequently endometriosis recurs following treatment.

Provera, pregnancy and breastfeeding

The manufacturers of Provera state that it should not be used during pregnancy as progestogens may cause abnormalities in the developing foetus.

The use of Provera while breastfeeding is also not recommended by the manufacturers. Small amounts of progestogens have been found in the milk of mothers taking them and the effect on the child is not known. However, some gynecologists believe that Provera can be safely used during pregnancy and breastfeeding.

Interaction with other drugs, alcohol or foods

There are no known interactions of Provera with any foods, alcohol or other drugs.

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