Endometriosis and kidney involvement

Endometriosis is a very common condition which may start early in life. It is thought to be an autoimmune disease but nobody really knows what the cause is. I had a 30 year old patient who started having painful and irregular periods from her teenage years. She had seen many gynaecologists over the years all of whom told her that she will grow out of the pains treating her with hormonal therapy. Unfortunately she did not 'grow out of her pains' but instead the painful periods worsened. She also started getting pain in her back where her right kidney was. When I saw this young lady she was also concerned that although she had been trying for a pregnancy for the last two years, nothing was happening and her in-laws were getting anxious. Mdm FKL had an ultrasound scan which then showed that she had ovarian cysts on both ovaries and they appeared to be stuck to back of the womb. As I suspected that she had endometriosis. I proceeded to do the full endometriosis work-up for her including an MRI of her pelvis and a hormonal profile. The MRI confirmed the endometriotic cysts and the adhesions. In addition there was a suggestion that the right kidney and urinary tract may be involved. MRI is now an important tool in the assessment of endometriosis as it will give the gynaecologist an indication of the extensiveness of the endometriosis. In this way he is not taken by surprise during surgery, and instead will have a well thought out plan to deal with the endometriosis prior to operation. Mdm FKL was referred to a urologist to assess the extent of the urinary tract involvement. The urologist was also there to insert stents into the ureters so as to aid in the operation. I then performed a laparoscopic key hole removal of the cysts and extensive freeing of all the adhesions so that the tissues were returned as best as possible to their original state. I am happy to say that Mdm FKL is now free of her pain and is now 6 weeks pregnant!
Extensive work-up prior to surgery is vitally important so as to get the best results. Planned well executed surgery is better than a haphazard approach and perhaps incomplete surgery which may result in the patient having to have further surgeries in the future.

  

Recommendations for individuals who are BRCA1/2 +ve

It is a well known fact that breast cancer may be due to a genetic mutation of the BRCA1 and 2 gene. Women who have a family history of persons having breast cancer at a relatively young age should have the gene mutation tested to see if they are at risk of breast cancer. It is also known that the risk of ovarian cancer is high with a positive BRCA1/2 mutations. The link between ovarian and breast cancer is well established.

Women with BRCA1 or 2 mutations should have clinical breast examinations every 6 to 12 months and annual breast MRI screening from the age of 25 or earlier depending on family history. At 30, mammograms should be added and alternated with MRIs every 6 months until 75 years. Prophylactic bilateral mastectomy should be discussed as it decreases the incidence by more than 90%.

Twice yearly screening for ovarian cancer by ultrasound and CA125 should begin at 30 years or earlier, and if completed family, removal of both tubes and ovaries is indicated at 35 years of age to prevent ovarian cancer.

Irregular vaginal bleeding due to endometrial hyperplasia

Irregular vaginal bleeding or intermenstrual spotting is a very common problem. It is very often the result of a hormonal imbalance where there is excessive amounts of oestrogen, and will need to be investigated. In postmenopausal women there is the possibility that this is due to a cancer of the lining of the womb and should be investigated urgently. My latest patient was a peri-menopausal lady with heavy irregular bleeding for several months. An ultrasound scan showed that the lining of the womb was thickened to more than 15 mm. In addition there was an ovarian cyst measuring 4 cms in diameter. In view of the unusual thickening of the lining, I advised a minor procedure. Using a hysteroscope (fine telescope), I examined the lining and took a sample for examination. The histology turned out to be simple endometrial hyperplasia.
Endometrial hyperplasia can be simple, complex, with or without atypia. The risk of cancer developing is highest in complex endometrial hyperplasia with atypia and lowest in simple endometrial hyperplasia without atypia.
My patient had the best prognosis. However I advised her to have treatment in the form of low dose progesterone and regular follow-up. The risk of progression to a cancer is less than 5% for her. The risk of progression in simple or complex with atypia is around 30%.
The take home message is that all abnormal bleeding needs to be investigated without delay particularly when it is around the time of menopause.