The etiquette of endometriosis: stigmatisation, menstrual concealment and the diagnostic delay

Endometriosis is a chronic gynaecological condition of uncertain aetiology characterised by menstrual irregularities. Several studies have previously identified a lengthy delay experienced by patients between the first onset of symptoms and eventual diagnosis. Various explanations have been advanced for the diagnostic delay, with both doctors and women being implicated. Such explanations include that doctors normalise women's menstrual pain and that women might delay in seeking medical advice because they have difficulty distinguishing between 'normal' and 'abnormal' menstruation. It has been suggested that the diagnostic delay could be reduced if women were trained in how to distinguish between 'normal' and 'abnormal' menstrual cycles. In this paper I argue that whilst these may be factors in the diagnostic delay, women's reluctance to disclose problems associated with their menstrual cycle may be a more significant and hitherto neglected factor. I argue women are reluctant to disclose menstrual irregularities because menstruation is a 'discrediting attribute' (Goffman, 1963) and disclosure renders women vulnerable to stigmatisation. Women actively conceal their menstrual irregularities through practices of the 'menstrual etiquette' (Laws, 1990) which involves the strategic concealment of menstrual problems. This argument is supported through an analysis of the experiences of 20 Australian women diagnosed with endometriosis. The ramifications of this analysis for chronic pain conditions more generally and for practical strategies designed to address the endometriosis diagnostic delay are considered.

The effect of surgery for symptomatic endometriosis: the other side of the story

BACKGROUND

Surgery is often considered the best treatment option in women with symptomatic endometriosis. However, extent and duration of the therapeutic benefit are still poorly defined.

METHODS

The best available evidence on surgery for endometriosis-associated pain has been reviewed to estimate the effect size of interventions in the most frequently encountered clinical conditions.

RESULTS

Methodological drawbacks limit considerably the validity of observational, non-comparative studies on the effect of laparoscopy for stage I-IV disease. As indicated by the results of three RCTs, the absolute benefit increase of destruction of lesions compared with diagnostic only operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods. The effect size tended to decrease with time and the re-operation rate, based on long-term follow-up studies, was as high as 50%. In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by approximately 70-80% of the subjects who continued the study. However, at 1 year follow-up, approximately 50% of the women needed analgesics or hormonal treatments. Major complications were observed in 3-10% of the patients. Medium-term recurrence of lesions was observed in approximately 20% of the cases, and around 25% of the women underwent repetitive surgery.

CONCLUSIONS

Pain recurrence and re-operation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated. Clinicians and patients should be aware that the expected benefit is operator-dependent.

What's the delay? A qualitative study of women's experiences of reaching a diagnosis of endometriosis

OBJECTIVE

To investigate the reasons women experience delays in the diagnosis of endometriosis and the impact of this.

DESIGN

A qualitative interview-based study of 32 women, 28 of whom were subsequently diagnosed with endometriosis.

SETTING

Southeast England.

PATIENT(S)

Women attending a pelvic pain clinic.

INTERVENTION(S)

Semistructured interviews.

MAIN OUTCOME MEASURE(S)

Women's reported experiences of being diagnosed with endometriosis.

RESULT(S)

Delays in the diagnosis of endometriosis occur at an individual patient level and a medical level, as both women and family doctors normalize symptoms, symptoms are suppressed through hormones, and nondiscriminatory investigations are relied upon. Women benefited from a diagnosis, because it provided a language in which to discuss their condition, offered possible management strategies to control symptoms, and provided reassurance that symptoms were not due to cancer. Diagnosis also sanctioned women's access to social support and legitimized absences from social and work obligations.

CONCLUSION(S)

Although recent guidelines for the management of chronic pelvic pain suggest that diagnostic laparoscopy may be considered a secondary investigation after the failure of therapeutic interventions, the present study highlights the importance of an early diagnosis for women who suffer at physical, emotional, and social levels when they remain undiagnosed.

Pain, quality of life and complications following the radical resection of rectovaginal endometriosis

OBJECTIVE

To determine the long term response, quality of life and levels of pain following the radical excision of rectovaginal endometriosis.

DESIGN

A cohort study.

SETTING

A tertiary referral centre for the management of advanced endometriosis.

SAMPLE

All patients who had undergone radical resection.

METHODS

Case note review and patient questionnaire.

MAIN OUTCOME MEASURES

Surgical complications. Overall improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic pain were measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire.

RESULTS

Twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population.

CONCLUSIONS

Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.