November 27, 2024 • 23 mins
Endometriosis: What exactly is it? What are the symptoms? How do we treat it? In this intriguing episode, we will explore the history of endometriosis, how it is diagnosed, and discuss various risk factors associated with it. Tune in to learn more!
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Resources:
Endometriosis Foundation of America: https://www.endofound.org/
The Endometriosis Foundation (UK): https://www.theendometriosisfoundation.org/.
Endometriosis Australia: https://endometriosisaustralia.org/
References:
https://www.fertstert.org/article/s0015-0282(12)01955-3/fulltext
https://drseckin.com/history-of-endometriosis/
https://pmc.ncbi.nlm.nih.gov/articles/PMC3135985/
https://www.mayoclinic.org/diseases-conditions/endometriosis/symptoms-causes/syc-20354656
https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-20354661
https://www.everydayhealth.com/endometriosis/living-with/celebrities-who-speak-endometriosis/
https://my.clevelandclinic.org/health/diseases/10857-endometriosis
https://www.hopkinsmedicine.org/health/conditions-and-diseases/endometriosis
https://www.who.int/news-room/fact-sheets/detail/endometriosis
https://www.healthdirect.gov.au/endometriosis
https://www.jeanhailes.org.au/health-a-z/endometriosis
https://pmc.ncbi.nlm.nih.gov/articles/PMC10410658/
https://www.health.com/condition/menstruation/period-facts
https://www.cancer.gov/publications/dictionaries/cancer-terms/def/peritoneal
*This podcast is for entertainment purposes only. If you suspect you have a medical condition, please seek out an opinion of a medical professional.*
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Lately, you have been experiencing severe stomach cramping that feels so intense that
(00:04):
you have to stop whatever you're doing whenever it comes on, desperately wanting to curl up
in a ball and clutch your stomach.
This agony has made it difficult for you to sleep, leaving you feeling utterly exhausted.
You have been struggling to eat due to being incredibly nauseous.
Despite this, you have been feeling incredibly bloated.
In a desperate bid for relief, you head to the bathroom, but the pain only worsens.
(00:24):
You look down and scream for your mum.
She comes running in.
After she takes one look at you and all of the blood, she calls the doctor.
(00:46):
Hello and Welcome to Anatomy Of Illness.
Today's episode is about endometriosis.
Before we get into the condition, we are going to start with the history.
So why do we know endometriosis exists?
Buckle up, this is about to get interesting.
We begin in Ancient Egypt around 1835 BC.
This is when the concept of the animalistic womb would first start being used.
(01:07):
Initially it would be used metaphorically.
This concept represented the idea that the uterus was like its own entity, not just a
regular organ.
This is why they described it as hungry for motherhood.
However, with the interpretations of this by the Ancient Greeks, this was taken more
literally and became the basis for several diseases.
Hippocrates, a Greek physician from around the 4th century BC, would describe a condition
(01:30):
called the wandering womb.
The symptoms of this have been considered to be similar or the same as endometriosis,
depending on the translation.
Similar due to the fact that during the time of Hippocrates and the Hippocratic Corpus,
they believed that the uterus could move around the body, especially when it felt dissatisfied.
These Hippocratic texts believed the condition to be a career woman's disease, and that
(01:50):
by delaying motherhood, you could trigger a number of conditions in the uterus.
Women with dysmenorrhea, which are menstrual cramps, at the time were urged to marry as
soon as possible, and have children quickly.
One of the authors of the Hippocratic Corpus stated that,
“If they have never been pregnant, the deranged state of menstruation is more common and more
dangerous than when they have borne children.
(02:11):
She will be released from this disease when she is pregnant.”
In another chapter of the Hippocratic Corpus, titled Aphorisms, this chapter explained how
heavy periods or menorrhagia was a potential cause for the disease.
The texts claimed that, “when the menses are excessive, disease takes place.”
The texts also observed that some women's floodings, yes that was an old term for menstruation
(02:33):
or periods, were accompanied by “grumulous clots, accompanied with pain, inflammation
of the uterus, and hysteric paroxysms.”
There was another chapter of this in the Hippocratic Corpus, this was the chapter called Diseases
of Young Girls.
These texts claimed that “the menses sometimes suddenly appear abundantly, at the end of
three months.
In clots of black blood, resembling flesh.
(02:55):
Sometimes ulcers of the uterus ensue, requiring much attention.”
“When in a diseased state, the menses are of a bilious character, they have a black and
shining appearance, and are accompanied with an erratic fever, chills, nausea, and heartburn.”
This potentially alludes to endometriosis being present in the lungs and the bowels.
This is also evident in another comment in this Hippocratic Corpus chapter.
(03:18):
“Sometimes the menses are vicariously discharged by vomiting or stool.
More commonly in the case of virgins than with married women.”
These texts were written at a time when it was seen as a woman's purpose to really
just be a wife and have children.
Which is why a lot of blame is placed on being unmarried or a career woman.
(03:39):
Being married or unmarried, working or not working will not affect if you have endometriosis.
Interestingly enough, the Hippocratics were familiar with uterine adhesions.
This is where the scar tissue between the uterus and another organ caused them to stick
together.
During the time, they used a variety of options in an attempt to treat the condition.
These include ingestible concoctions, fumigants, which are inhaled chemicals, and suppositories.
(04:03):
These suppositories often contained various substances such as the urine of men or bulls,
tar water, castor oil, chase tree, pomegranates, or cantharides, which is a material derived
from dried beetles.
Sometimes cantharides is known as the aphrodisiac Spanish fly.
It is not a fly, it is a beetle.
Tar water is a pine resin derived material that women were told if they ingested it would
(04:27):
cause them to be barren forever, so they would never be able to get pregnant or give birth.
Another interesting treatment that was used in an attempt to help to treat the condition
at the time was what was known as succession.
This was considered to be a mechanical procedure for repositioning the uterus, as at the time
they thought the uterus would move around the body when dissatisfied.
In the practice of succession they would tie a patient to a ladder, turn them upside
(04:50):
down and shake them until the uterus returned to its proper place.
This was most likely used in the case of a prolapsed uterus, so when the uterus is coming
out rather than sitting in its normal place.
Interestingly enough, Plato, the philosopher in 375 BC, had his own comments about gynecological
conditions.
He was actually the first to mention the extreme pain that women felt resulting from the condition,
(05:13):
called the suffocation of the womb.
He claimed that the condition occurs when “the womb remains barren too long after puberty,
is distressed and sorely disturbed, and straying about the body cutting off the passages of
breath.
It impedes respiration and brings the sufferer into the extremest anguish and provokes all
manner of illnesses besides.”
The Roman scholar Pliny the Elder, who lived between 23 to 79 AD, would also report on
(05:38):
the suffocation of the womb.
Observations would add a new symptom to the condition.
This new symptom of the condition would lead to women experiencing a semi-conscious state
for several days, lying “as if dead for several days”.
Soranus about 100 years later would suggest something that was actually causing these
symptoms – the violent contractions occurring in the uterus.
He explained it could happen either chronically or acutely.
(06:00):
He also suggested a potential explanation for the suffocation of the womb, this being
inflammation in the uterus, as an origin for the condition.
This was a radical new theory.
Moving on to Celsus.
He reported women suffering from a violent illness like epilepsy, however it originated
from the womb.
The women with this condition would fall down but, “rather than exhibiting the normal signs
(06:21):
associated with that disorder, such as foaming or the eyes rolling back, instead they lie
down as if asleep”.
He also reported “some women suffer from this their entire life”.
My guy reported period cramps, however this is considered to be one of the potential origins
for hysteric fits.
The women were experiencing a severe unexpected cramp and ending up in a fetal position because
(06:41):
they couldn't just take a quick ibuprofen from the pharmacy as no pharmacies existed
back then.
So, hysteria was used as an explanation for this.
Moving on to Dioscorides around the year 77 AD.
This is about the time he published his book De Materia Medica.
In this text he called the condition the strangulation of the uterus.
With this condition he had similar descriptions to previous accounts.
(07:02):
He suggested that the condition caused women to fall down and caused either a quasi-conscious
state or caused them to be unable to stand.
He prescribed shellfish shells as he believed that it would help to “rayse up such women
as are troubled with strangulatus uteri and such as have ye falling sicknesse.”
His words, not mine.
He also had some other interesting treatments for the condition including bed bugs, brains,
(07:27):
human urine and several other concoctions.
What I feel like is an almost monthly occurrence on this podcast.
Please do not go drinking urine.
If something comes out of you, it should not go back into you.
These treatments are almost 2000 years old.
If they did not work back then, they will not work now.
One of his concoctions for dysmenorrhea was described as “the Horne of an hart being burnt
(07:48):
and washt.
If it be dranck the quantity of twoe spoonfuls, it is good also for women troubled with the
flux of ye womb, being given with somme liquor fitting for that grief.”
Makes me feel like a pirate talking like that.
Dioscorides also recommended medications to suppress menstruation as he recognised
menorrhagia as a pathological condition and saw it as something in need of medical intervention.
(08:11):
He recommended the brain of a hare “being dranck after three days after ye menstrual courses.”
Very pirate.
As it was believed to cause sterility so it stops the “flux of ye womb and the belly.”
Now we move to between 129 to 216 with Claudius Galen.
He suggested that the condition affected the ligaments that held the uterus in place.
(08:31):
He suggested that they became swollen and inflamed due to the adhesions.
He also suggested that it was also related to psychological symptoms.
He was the first to associate the condition with mental illness, suggesting that young
widows could be “driven to madness as a result of their loss of sexual fulfilment.”
An indication of the shift that was about to occur, Orobacius who lived between 325
(08:53):
to 397 AD suggested shouting therapy to be used on those who had passed out from suffocation
of the womb.
Essentially, have you tried yelling at someone who has fainted from pain?
Reminds me of that scene from Finding Nemo where she's shaking the bag and is like
fishy why are you sleeping?
It's about as useful as that.
And now we move into the Dark Ages, also known as the Middle Ages, because this is where
(09:13):
all progress is stalled.
This is evident with Paul of Aegina's views, who lived between 625 to 690 AD.
He suggested that the suffocation of the uterus occurred in lascivious women or “those
who used drugs to prevent conception”.
At least with Aetius of Amida, who lived between 502 to 575 AD, he suggested that the symptoms
(09:35):
were actually triggered by menstruation.
This was like with Galen's suggestions of violent contractions causing symptoms.
Aetius suggested it was caused by a cooling of the uterus.
Sadly, the Middle Ages would get worse.
As it progressed, choking therapy was suggested.
Yes, they believed strangling women around the neck would encourage the uterus to go
back to its rightful place and to stop the suffocation of the womb.
(09:58):
As you could have guessed, strangling people is not a cure for anything unless you consider
a cure for life because this would have killed a lot of people.
Please leave this therapy in the Middle Ages, where it belongs.
Moving on to the 12th century in Salerno, Italy.
We're in the High Middle Ages.
This is where the era's best known gynecological text would be published, by a female physician
(10:18):
by the name of Trotula.
The descriptions of uterine suffocation would be almost identical to Hippocrates.
This text has a treatment for suffocation of the womb.
It required “a powder to be made of the testicles of a fox or a kid and that this be injected
by means of a tampon.”
And now we come into the Renaissance, where medicine starts to be less saints and demons
and more actually medical.
(10:39):
Ambroise Paré suggested that it was an abundance of menstrual vapors causing the symptoms.
Interestingly enough, this condition potentially shows up during the English witch trials.
Dutch physician Johannes Weyer, who lived between 1515 and 1588, defended women who
had been accused of witchcraft when their condition was more likely to have been endometriosis.
(11:00):
He claimed that it was hysteria and that it was a “bodily disease like all other conditions.”
He also encouraged the court to end the torturing and killing of women.
As Weyer stated, “don't you know that these poor women have suffered enough?
Can you think of a misery anywhere in the world that is worse than theirs?
If they do seem to merit punishment, I assure you their illness alone is enough.”
(11:21):
Moving on to 1642, there is a reference to the condition in artwork, specifically an
engraving done by Hendrick Hondius.
This is known as the pilgrimage of the epileptics to the church of Molenbeek.
This engraving is thought to be of women suffering from hysteria associated epileptic-like symptoms
that were traveling to the shrine of Saint Vitus for their annual visit.
(11:42):
This is because it was said that if one was to jump over the bridge leading to the shrine
one would be illness free for a year.
Moving on to Thomas Sydenham who lived between 1624 to 1689.
He described the cyclical pattern of endometriosis, the vomiting and the diarrhea, what he called
hysteric lumps and also the back pain.
He called the condition hysteria of the stomach.
(12:03):
He recommended the use of a hysterical pill, which was actually mostly opium.
Nowadays, opium is illegal and highly addictive.
Don't use it for endometriosis.
In 1690, a German physician by the name of Daniel Schroen would publish his thesis on
ulcers in the uterus.
Schroen describes the ulceration of the glandular layer.
“The anatomists also describe a glandulous layer, or if you prefer, a layer full of little gland-like
(12:28):
corpuscles.”
“When their action is disturbed, they become the agents of many kinds of fermentation.”
This was how he described the beginning of ulcers forming.
He differentiated these from other common lesions at the time like scabies, smallpox,
and also syphilis.
In 1776, Scottish physician Lewis Brotherson discussed the pain that women experiencing
the worst stages of the condition went through.
(12:50):
Also in the 18th century, post-mortem examinations of endometrial lesions would increase.
Scottish physician William Broughton and English physician Robert Taliford would describe structures
that would later be known as polyp-like.
In 1882, a Canadian surgeon by the name of Thomas Cullen would present his findings of
adenomyosis and endometriosis.
Cullen had collected 90 uteruses with adenomyosis, which is the growth of endometrial tissue
(13:15):
into the muscle wall of the uterus.
He showed that these lesions were endometrial tissues, but he was ultimately ignored and
rejected by his peers.
In 1899, Russell W.W. would describe what would later become known as chocolate cysts
due to their appearance.
These were found in a woman who had undergone surgery for a cystic adenocarcinoma on her
ovary.
Chocolate cysts were a prototype of the uterine glands and inter-glandular connective tissue.
(13:40):
By 1922, Dr. John A. Sampson would publish 37 cases of these chocolate cysts.
The cysts would give rise for several theories behind endometriosis spread into the peritoneal
cavity.
The peritoneum is the tissue that lines the abdominal cavity, this being peritoneal endometriosis.
Sampson would suggest a ruptured cyst.
Others would suggest lesions arriving from the lymphatic system into the ovary or outer
(14:03):
lesions invading the ovary.
Sampson would also suggest retrograde menstruation.
Retrograde is backwards movement.
So retrograde menstruation is when the menstrual blood goes out of the fallopian tubes.
So out the wrong way.
In 1927, Sampson would publish an article titled, “Peritoneal Endometriosis Due to Menstrual
Dissemination of Endometrial Tissue into the Peritoneal Cavity.”
(14:25):
And thus the term endometriosis was coined.
With the 1930s and 1940s, endometriosis tissues began being found in many areas, including
the lungs, bowels, bladder, lymph nodes, rectum, and cervix.
In 1946, Dr. J. Fallon discovered the condition in teenagers.
In 1955 and 1958, Drs. Raoul Palmer and Hans Fragenheim began to have successes in the field
(14:47):
of color live laparoscopy, which essentially means surgery using small incisions and cameras.
They were able to do surgeries for endometriosis with camera assistance.
In 1989, the first laparoscopic hysterectomy would be performed by Dr. Harry Reich.
But what actually causes endometriosis?
We currently don't know what causes the condition, but there are several theories
that could contribute to the development of the condition.
(15:09):
Some of these theories include retrograde menstruation.
So this is when menstrual blood flows backwards through the fallopian tubes and into the abdominal
cavity.
This blood has endometrial cells.
These attach to various organs and start to grow.
Embryonic cell changes.
This is when hormones like estrogen change embryonic cells into endometrial-like cell
growths during puberty.
(15:30):
Endometrial cell transport.
The blood vessels or tissue fluid may transport the endometrial cells to different parts of
the body.
These are just some of the theories behind endometriosis.
It may be one of these, it may be a combination of these, or it may be none of these that
cause endometriosis and its symptoms.
What are the risk factors for developing endometriosis?
There are several risk factors that increase the chance of developing endometriosis.
(15:50):
These include starting your period at a young age, having close family members with the
condition.
So if your mother, sister, or aunt have the condition, you are more likely to develop
the condition.
Having shorter menstrual cycles.
So if your cycle lasts less than 27 days, you are at a higher risk for developing the
condition.
Having menstrual periods that last for longer than 7 days.
Having a higher level of oestrogen in your body or being exposed to high levels of oestrogen.
(16:13):
Having a low body mass index.
Never giving birth.
Having conditions that prevent the blood from flowing out of the body during your period.
Going through menopause at a later age.
How do we test for endometriosis?
To test for endometriosis and diagnose endometriosis, several tests will be done.
After discussing your symptoms with your doctor, a doctor most likely will start with an exam.
This will be done in an attempt to feel for any abnormalities, painful spots, irregular
(16:36):
growths known as nodules, or scar tissue.
After this, other tests are likely to be performed if endometriosis is suspected.
These include ultrasounds.
An ultrasound cannot diagnose endometriosis outright, but they can be used to spot cysts
that can indicate endometriosis.
They can also indicate other conditions.
These cysts linked to endometriosis are known as endometriomas.
MRI.
(16:57):
An MRI cannot diagnose, but it can be done to help with surgical planning.
It can help to locate endometriosis growths.
Laparoscopy.
This is a surgery that is done through small incisions.
This surgery takes a small biopsy of the abnormal tissue, which can be used to diagnose the
tissue.
And if the surgery is well planned, they can remove endometriosis tissue, ruling out the
need for another surgery.
(17:17):
A biopsy of diseased tissue is needed for an endometriosis diagnosis.
So a laparoscopy must be done at some point to diagnose the condition.
We will get right into the symptoms and presentation right after this little break.
If you have enjoyed this episode so far, you can check out our notes on Buy Me A Coffee.
(17:45):
What symptoms might you have if you had endometriosis?
Symptoms can vary between person to person.
Some of the more common symptoms include painful periods.
This is normally pelvic pain that may start before your period actually does and may last
throughout your period.
It can also cause lower back pain and stomach pain.
Painful periods are also known as dysmenorrhea.
Pain during intercourse.
Pain during or after sex is common in those with endometriosis.
(18:07):
You may also have pain during urination or bowel movements.
This is more likely to happen close to a period or during a period.
Excessive periods.
So this is heavy bleeding during menstruation and also bleeding between periods.
Having issues with infertility.
Endometriosis can also cause many other symptoms including fatigue, diarrhoea, constipation,
bloating, nausea.
These symptoms will be more common right before and during your period.
(18:29):
What are some complications that a doctor should be aware of when it comes to endometriosis?
Some complications a doctor should be aware of when their patient has endometriosis are
infertility.
Endometriosis tissue can affect the ability to get pregnant as the endometriosis tissue
can block the fallopian tubes.
It can also indirectly affect the egg.
Cancer.
Endometriosis raises the risk of ovarian cancer.
There is also a rare cancer that endometriosis has been associated with.
(18:52):
This is called endometriosis associated adenocarcinoma.
This is a rare cancer that can occur later in life with those who have endometriosis.
A doctor should also be aware that one in 10 women will experience endometriosis in
their lifetime.
So it is not a rare condition.
If symptoms are brought up, then this is a condition that should be considered.
How do we treat endometriosis?
Endometriosis treatment is normally approached from a medication approach first and if that
(19:15):
does not work, surgeries are then used.
Medications that are used to treat endometriosis are hormonal contraceptives.
So this is birth control pills, patches, injections, and rings.
These medications help to control the hormones that stimulate the growth of endometriosis
tissue.
These medications may help to ease symptoms.
Gonadotropin releasing hormone agonists and antagonists.
These medications are used to block the menstrual cycle and lower oestrogen levels.
(19:38):
They essentially create an artificial menopause while taking the medications.
Progestin therapy.
These medications are a synthetic version of a hormone that is part of the menstrual
cycle and pregnancy.
These can stop the menstrual cycle and the growth of endometrial tissue.
These can be done through an IUD, which is an intrauterine device, an implant which goes
in the arm, an injection, or a pill.
There are also aromatase inhibitors.
(20:00):
These medications lower the amount of oestrogen in the body.
These may be given alongside progestin therapy.
There are also surgical options in the treatment of endometriosis.
There are two main forms.
These are the conservative laparoscopic treatment.
This is treatment that is done to remove the endometriosis tissue that is on the organs
and on the abdominal walls.
This surgery is done in an attempt to preserve the uterus and the ovaries.
(20:21):
There is also a hysterectomy with the removal of ovaries, which is an oophorectomy.
This is normally considered a last resort as it can help some, but if there is remaining
endometriosis tissue, this will continue to cause pain.
This treatment is not considered curative.
Who are some famous people that have or have had endometriosis?
There is Lena Dunham.
She is the creator and star of Girls.
Dunham in early 2018 announced in Vogue that she underwent a hysterectomy at the age of
(20:46):
31 due to the condition, after living with it for 10 years and going through various
surgeries in an attempt to help treat it.
There is also Padma Lakshmi.
She is an Emmy nominated actress and the host of Top Chef.
She had symptoms of endometriosis from early adolescence.
However, even with good insurance and access to the best doctors, it would take her more
than 20 years to get a diagnosis.
(21:07):
Because of this experience, she teamed up with her diagnosing doctor to co-found the
Endometriosis Foundation of America in 2009 because she didn't want the next generations
of women to experience the delays she had to go through to receive a diagnosis and treatment.
If you would like to check out a movie, there is the short film Chronic.
This film was inspired by one of the director's friends who lives with endometriosis.
(21:28):
The short film is based around two characters who are sisters.
One of them has endometriosis and has just had a surgery.
The other is there to help her deal with recovery.
This goes through their relationship, friendship and jealousy between them as one feels like
they aren't progressing in life due to the condition.
If you would like to check out a foundation, there is, for those in the US, the Endometriosis
Foundation of America.
They aim to increase recognition of endometriosis, assist in expert surgical training and fund
(21:52):
research into endometriosis.
There is for those in the UK, the Endometriosis Foundation.
They strive to raise awareness for endometriosis, provide education and support for those experiencing
the condition.
For those in Australia, there is Endometriosis Australia.
This foundation aims to raise awareness for the condition and fund research.
Due to their work educating the public and medical practitioners, the average time to
(22:12):
diagnosis in Australia went from between 7 to 12 years to 6 and a half years.
Which again is still a long time but it is better.
They also advocate for better access to healthcare for those with endometriosis.
If you want to check out the sources, social media links or any other links, you can head
to anatomyofillness.com.
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our latest episodes.
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(22:35):
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The links to all of these can be found on our website.
Otherwise stick around for the next episode.
Did you know during an average period, you normally lose only 3 to 6 tablespoons of blood.
(23:02):
However, if you do have endometriosis, more blood will be lost.
Oh, and there is also a rare form of endometriosis called Ocular Endometriosis.
This can cause you to have endometrial tissue in your eyes and therefore bleed from your
eyes during a period.
This however, is rare.
Lately, you have been experiencing severe stomach cramping that feels so intense that
(00:04):
you have to stop whatever you're doing whenever it comes on, desperately wanting to curl up
in a ball and clutch your stomach.
This agony has made it difficult for you to sleep, leaving you feeling utterly exhausted.
You have been struggling to eat due to being incredibly nauseous.
Despite this, you have been feeling incredibly bloated.
In a desperate bid for relief, you head to the bathroom, but the pain only worsens.
(00:24):
You look down and scream for your mum.
She comes running in.
After she takes one look at you and all of the blood, she calls the doctor.
(00:46):
Hello and Welcome to Anatomy Of Illness.
Today's episode is about endometriosis.
Before we get into the condition, we are going to start with the history.
So why do we know endometriosis exists?
Buckle up, this is about to get interesting.
We begin in Ancient Egypt around 1835 BC.
This is when the concept of the animalistic womb would first start being used.
(01:07):
Initially it would be used metaphorically.
This concept represented the idea that the uterus was like its own entity, not just a
regular organ.
This is why they described it as hungry for motherhood.
However, with the interpretations of this by the Ancient Greeks, this was taken more
literally and became the basis for several diseases.
Hippocrates, a Greek physician from around the 4th century BC, would describe a condition
(01:30):
called the wandering womb.
The symptoms of this have been considered to be similar or the same as endometriosis,
depending on the translation.
Similar due to the fact that during the time of Hippocrates and the Hippocratic Corpus,
they believed that the uterus could move around the body, especially when it felt dissatisfied.
These Hippocratic texts believed the condition to be a career woman's disease, and that
(01:50):
by delaying motherhood, you could trigger a number of conditions in the uterus.
Women with dysmenorrhea, which are menstrual cramps, at the time were urged to marry as
soon as possible, and have children quickly.
One of the authors of the Hippocratic Corpus stated that,
“If they have never been pregnant, the deranged state of menstruation is more common and more
dangerous than when they have borne children.
(02:11):
She will be released from this disease when she is pregnant.”
In another chapter of the Hippocratic Corpus, titled Aphorisms, this chapter explained how
heavy periods or menorrhagia was a potential cause for the disease.
The texts claimed that, “when the menses are excessive, disease takes place.”
The texts also observed that some women's floodings, yes that was an old term for menstruation
(02:33):
or periods, were accompanied by “grumulous clots, accompanied with pain, inflammation
of the uterus, and hysteric paroxysms.”
There was another chapter of this in the Hippocratic Corpus, this was the chapter called Diseases
of Young Girls.
These texts claimed that “the menses sometimes suddenly appear abundantly, at the end of
three months.
In clots of black blood, resembling flesh.
(02:55):
Sometimes ulcers of the uterus ensue, requiring much attention.”
“When in a diseased state, the menses are of a bilious character, they have a black and
shining appearance, and are accompanied with an erratic fever, chills, nausea, and heartburn.”
This potentially alludes to endometriosis being present in the lungs and the bowels.
This is also evident in another comment in this Hippocratic Corpus chapter.
(03:18):
“Sometimes the menses are vicariously discharged by vomiting or stool.
More commonly in the case of virgins than with married women.”
These texts were written at a time when it was seen as a woman's purpose to really
just be a wife and have children.
Which is why a lot of blame is placed on being unmarried or a career woman.
(03:39):
Being married or unmarried, working or not working will not affect if you have endometriosis.
Interestingly enough, the Hippocratics were familiar with uterine adhesions.
This is where the scar tissue between the uterus and another organ caused them to stick
together.
During the time, they used a variety of options in an attempt to treat the condition.
These include ingestible concoctions, fumigants, which are inhaled chemicals, and suppositories.
(04:03):
These suppositories often contained various substances such as the urine of men or bulls,
tar water, castor oil, chase tree, pomegranates, or cantharides, which is a material derived
from dried beetles.
Sometimes cantharides is known as the aphrodisiac Spanish fly.
It is not a fly, it is a beetle.
Tar water is a pine resin derived material that women were told if they ingested it would
(04:27):
cause them to be barren forever, so they would never be able to get pregnant or give birth.
Another interesting treatment that was used in an attempt to help to treat the condition
at the time was what was known as succession.
This was considered to be a mechanical procedure for repositioning the uterus, as at the time
they thought the uterus would move around the body when dissatisfied.
In the practice of succession they would tie a patient to a ladder, turn them upside
(04:50):
down and shake them until the uterus returned to its proper place.
This was most likely used in the case of a prolapsed uterus, so when the uterus is coming
out rather than sitting in its normal place.
Interestingly enough, Plato, the philosopher in 375 BC, had his own comments about gynecological
conditions.
He was actually the first to mention the extreme pain that women felt resulting from the condition,
(05:13):
called the suffocation of the womb.
He claimed that the condition occurs when “the womb remains barren too long after puberty,
is distressed and sorely disturbed, and straying about the body cutting off the passages of
breath.
It impedes respiration and brings the sufferer into the extremest anguish and provokes all
manner of illnesses besides.”
The Roman scholar Pliny the Elder, who lived between 23 to 79 AD, would also report on
(05:38):
the suffocation of the womb.
Observations would add a new symptom to the condition.
This new symptom of the condition would lead to women experiencing a semi-conscious state
for several days, lying “as if dead for several days”.
Soranus about 100 years later would suggest something that was actually causing these
symptoms – the violent contractions occurring in the uterus.
He explained it could happen either chronically or acutely.
(06:00):
He also suggested a potential explanation for the suffocation of the womb, this being
inflammation in the uterus, as an origin for the condition.
This was a radical new theory.
Moving on to Celsus.
He reported women suffering from a violent illness like epilepsy, however it originated
from the womb.
The women with this condition would fall down but, “rather than exhibiting the normal signs
(06:21):
associated with that disorder, such as foaming or the eyes rolling back, instead they lie
down as if asleep”.
He also reported “some women suffer from this their entire life”.
My guy reported period cramps, however this is considered to be one of the potential origins
for hysteric fits.
The women were experiencing a severe unexpected cramp and ending up in a fetal position because
(06:41):
they couldn't just take a quick ibuprofen from the pharmacy as no pharmacies existed
back then.
So, hysteria was used as an explanation for this.
Moving on to Dioscorides around the year 77 AD.
This is about the time he published his book De Materia Medica.
In this text he called the condition the strangulation of the uterus.
With this condition he had similar descriptions to previous accounts.
(07:02):
He suggested that the condition caused women to fall down and caused either a quasi-conscious
state or caused them to be unable to stand.
He prescribed shellfish shells as he believed that it would help to “rayse up such women
as are troubled with strangulatus uteri and such as have ye falling sicknesse.”
His words, not mine.
He also had some other interesting treatments for the condition including bed bugs, brains,
(07:27):
human urine and several other concoctions.
What I feel like is an almost monthly occurrence on this podcast.
Please do not go drinking urine.
If something comes out of you, it should not go back into you.
These treatments are almost 2000 years old.
If they did not work back then, they will not work now.
One of his concoctions for dysmenorrhea was described as “the Horne of an hart being burnt
(07:48):
and washt.
If it be dranck the quantity of twoe spoonfuls, it is good also for women troubled with the
flux of ye womb, being given with somme liquor fitting for that grief.”
Makes me feel like a pirate talking like that.
Dioscorides also recommended medications to suppress menstruation as he recognised
menorrhagia as a pathological condition and saw it as something in need of medical intervention.
(08:11):
He recommended the brain of a hare “being dranck after three days after ye menstrual courses.”
Very pirate.
As it was believed to cause sterility so it stops the “flux of ye womb and the belly.”
Now we move to between 129 to 216 with Claudius Galen.
He suggested that the condition affected the ligaments that held the uterus in place.
(08:31):
He suggested that they became swollen and inflamed due to the adhesions.
He also suggested that it was also related to psychological symptoms.
He was the first to associate the condition with mental illness, suggesting that young
widows could be “driven to madness as a result of their loss of sexual fulfilment.”
An indication of the shift that was about to occur, Orobacius who lived between 325
(08:53):
to 397 AD suggested shouting therapy to be used on those who had passed out from suffocation
of the womb.
Essentially, have you tried yelling at someone who has fainted from pain?
Reminds me of that scene from Finding Nemo where she's shaking the bag and is like
fishy why are you sleeping?
It's about as useful as that.
And now we move into the Dark Ages, also known as the Middle Ages, because this is where
(09:13):
all progress is stalled.
This is evident with Paul of Aegina's views, who lived between 625 to 690 AD.
He suggested that the suffocation of the uterus occurred in lascivious women or “those
who used drugs to prevent conception”.
At least with Aetius of Amida, who lived between 502 to 575 AD, he suggested that the symptoms
(09:35):
were actually triggered by menstruation.
This was like with Galen's suggestions of violent contractions causing symptoms.
Aetius suggested it was caused by a cooling of the uterus.
Sadly, the Middle Ages would get worse.
As it progressed, choking therapy was suggested.
Yes, they believed strangling women around the neck would encourage the uterus to go
back to its rightful place and to stop the suffocation of the womb.
(09:58):
As you could have guessed, strangling people is not a cure for anything unless you consider
a cure for life because this would have killed a lot of people.
Please leave this therapy in the Middle Ages, where it belongs.
Moving on to the 12th century in Salerno, Italy.
We're in the High Middle Ages.
This is where the era's best known gynecological text would be published, by a female physician
(10:18):
by the name of Trotula.
The descriptions of uterine suffocation would be almost identical to Hippocrates.
This text has a treatment for suffocation of the womb.
It required “a powder to be made of the testicles of a fox or a kid and that this be injected
by means of a tampon.”
And now we come into the Renaissance, where medicine starts to be less saints and demons
and more actually medical.
(10:39):
Ambroise Paré suggested that it was an abundance of menstrual vapors causing the symptoms.
Interestingly enough, this condition potentially shows up during the English witch trials.
Dutch physician Johannes Weyer, who lived between 1515 and 1588, defended women who
had been accused of witchcraft when their condition was more likely to have been endometriosis.
(11:00):
He claimed that it was hysteria and that it was a “bodily disease like all other conditions.”
He also encouraged the court to end the torturing and killing of women.
As Weyer stated, “don't you know that these poor women have suffered enough?
Can you think of a misery anywhere in the world that is worse than theirs?
If they do seem to merit punishment, I assure you their illness alone is enough.”
(11:21):
Moving on to 1642, there is a reference to the condition in artwork, specifically an
engraving done by Hendrick Hondius.
This is known as the pilgrimage of the epileptics to the church of Molenbeek.
This engraving is thought to be of women suffering from hysteria associated epileptic-like symptoms
that were traveling to the shrine of Saint Vitus for their annual visit.
(11:42):
This is because it was said that if one was to jump over the bridge leading to the shrine
one would be illness free for a year.
Moving on to Thomas Sydenham who lived between 1624 to 1689.
He described the cyclical pattern of endometriosis, the vomiting and the diarrhea, what he called
hysteric lumps and also the back pain.
He called the condition hysteria of the stomach.
(12:03):
He recommended the use of a hysterical pill, which was actually mostly opium.
Nowadays, opium is illegal and highly addictive.
Don't use it for endometriosis.
In 1690, a German physician by the name of Daniel Schroen would publish his thesis on
ulcers in the uterus.
Schroen describes the ulceration of the glandular layer.
“The anatomists also describe a glandulous layer, or if you prefer, a layer full of little gland-like
(12:28):
corpuscles.”
“When their action is disturbed, they become the agents of many kinds of fermentation.”
This was how he described the beginning of ulcers forming.
He differentiated these from other common lesions at the time like scabies, smallpox,
and also syphilis.
In 1776, Scottish physician Lewis Brotherson discussed the pain that women experiencing
the worst stages of the condition went through.
(12:50):
Also in the 18th century, post-mortem examinations of endometrial lesions would increase.
Scottish physician William Broughton and English physician Robert Taliford would describe structures
that would later be known as polyp-like.
In 1882, a Canadian surgeon by the name of Thomas Cullen would present his findings of
adenomyosis and endometriosis.
Cullen had collected 90 uteruses with adenomyosis, which is the growth of endometrial tissue
(13:15):
into the muscle wall of the uterus.
He showed that these lesions were endometrial tissues, but he was ultimately ignored and
rejected by his peers.
In 1899, Russell W.W. would describe what would later become known as chocolate cysts
due to their appearance.
These were found in a woman who had undergone surgery for a cystic adenocarcinoma on her
ovary.
Chocolate cysts were a prototype of the uterine glands and inter-glandular connective tissue.
(13:40):
By 1922, Dr. John A. Sampson would publish 37 cases of these chocolate cysts.
The cysts would give rise for several theories behind endometriosis spread into the peritoneal
cavity.
The peritoneum is the tissue that lines the abdominal cavity, this being peritoneal endometriosis.
Sampson would suggest a ruptured cyst.
Others would suggest lesions arriving from the lymphatic system into the ovary or outer
(14:03):
lesions invading the ovary.
Sampson would also suggest retrograde menstruation.
Retrograde is backwards movement.
So retrograde menstruation is when the menstrual blood goes out of the fallopian tubes.
So out the wrong way.
In 1927, Sampson would publish an article titled, “Peritoneal Endometriosis Due to Menstrual
Dissemination of Endometrial Tissue into the Peritoneal Cavity.”
(14:25):
And thus the term endometriosis was coined.
With the 1930s and 1940s, endometriosis tissues began being found in many areas, including
the lungs, bowels, bladder, lymph nodes, rectum, and cervix.
In 1946, Dr. J. Fallon discovered the condition in teenagers.
In 1955 and 1958, Drs. Raoul Palmer and Hans Fragenheim began to have successes in the field
(14:47):
of color live laparoscopy, which essentially means surgery using small incisions and cameras.
They were able to do surgeries for endometriosis with camera assistance.
In 1989, the first laparoscopic hysterectomy would be performed by Dr. Harry Reich.
But what actually causes endometriosis?
We currently don't know what causes the condition, but there are several theories
that could contribute to the development of the condition.
(15:09):
Some of these theories include retrograde menstruation.
So this is when menstrual blood flows backwards through the fallopian tubes and into the abdominal
cavity.
This blood has endometrial cells.
These attach to various organs and start to grow.
Embryonic cell changes.
This is when hormones like estrogen change embryonic cells into endometrial-like cell
growths during puberty.
(15:30):
Endometrial cell transport.
The blood vessels or tissue fluid may transport the endometrial cells to different parts of
the body.
These are just some of the theories behind endometriosis.
It may be one of these, it may be a combination of these, or it may be none of these that
cause endometriosis and its symptoms.
What are the risk factors for developing endometriosis?
There are several risk factors that increase the chance of developing endometriosis.
(15:50):
These include starting your period at a young age, having close family members with the
condition.
So if your mother, sister, or aunt have the condition, you are more likely to develop
the condition.
Having shorter menstrual cycles.
So if your cycle lasts less than 27 days, you are at a higher risk for developing the
condition.
Having menstrual periods that last for longer than 7 days.
Having a higher level of oestrogen in your body or being exposed to high levels of oestrogen.
(16:13):
Having a low body mass index.
Never giving birth.
Having conditions that prevent the blood from flowing out of the body during your period.
Going through menopause at a later age.
How do we test for endometriosis?
To test for endometriosis and diagnose endometriosis, several tests will be done.
After discussing your symptoms with your doctor, a doctor most likely will start with an exam.
This will be done in an attempt to feel for any abnormalities, painful spots, irregular
(16:36):
growths known as nodules, or scar tissue.
After this, other tests are likely to be performed if endometriosis is suspected.
These include ultrasounds.
An ultrasound cannot diagnose endometriosis outright, but they can be used to spot cysts
that can indicate endometriosis.
They can also indicate other conditions.
These cysts linked to endometriosis are known as endometriomas.
MRI.
(16:57):
An MRI cannot diagnose, but it can be done to help with surgical planning.
It can help to locate endometriosis growths.
Laparoscopy.
This is a surgery that is done through small incisions.
This surgery takes a small biopsy of the abnormal tissue, which can be used to diagnose the
tissue.
And if the surgery is well planned, they can remove endometriosis tissue, ruling out the
need for another surgery.
(17:17):
A biopsy of diseased tissue is needed for an endometriosis diagnosis.
So a laparoscopy must be done at some point to diagnose the condition.
We will get right into the symptoms and presentation right after this little break.
If you have enjoyed this episode so far, you can check out our notes on Buy Me A Coffee.
(17:45):
What symptoms might you have if you had endometriosis?
Symptoms can vary between person to person.
Some of the more common symptoms include painful periods.
This is normally pelvic pain that may start before your period actually does and may last
throughout your period.
It can also cause lower back pain and stomach pain.
Painful periods are also known as dysmenorrhea.
Pain during intercourse.
Pain during or after sex is common in those with endometriosis.
(18:07):
You may also have pain during urination or bowel movements.
This is more likely to happen close to a period or during a period.
Excessive periods.
So this is heavy bleeding during menstruation and also bleeding between periods.
Having issues with infertility.
Endometriosis can also cause many other symptoms including fatigue, diarrhoea, constipation,
bloating, nausea.
These symptoms will be more common right before and during your period.
(18:29):
What are some complications that a doctor should be aware of when it comes to endometriosis?
Some complications a doctor should be aware of when their patient has endometriosis are
infertility.
Endometriosis tissue can affect the ability to get pregnant as the endometriosis tissue
can block the fallopian tubes.
It can also indirectly affect the egg.
Cancer.
Endometriosis raises the risk of ovarian cancer.
There is also a rare cancer that endometriosis has been associated with.
(18:52):
This is called endometriosis associated adenocarcinoma.
This is a rare cancer that can occur later in life with those who have endometriosis.
A doctor should also be aware that one in 10 women will experience endometriosis in
their lifetime.
So it is not a rare condition.
If symptoms are brought up, then this is a condition that should be considered.
How do we treat endometriosis?
Endometriosis treatment is normally approached from a medication approach first and if that
(19:15):
does not work, surgeries are then used.
Medications that are used to treat endometriosis are hormonal contraceptives.
So this is birth control pills, patches, injections, and rings.
These medications help to control the hormones that stimulate the growth of endometriosis
tissue.
These medications may help to ease symptoms.
Gonadotropin releasing hormone agonists and antagonists.
These medications are used to block the menstrual cycle and lower oestrogen levels.
(19:38):
They essentially create an artificial menopause while taking the medications.
Progestin therapy.
These medications are a synthetic version of a hormone that is part of the menstrual
cycle and pregnancy.
These can stop the menstrual cycle and the growth of endometrial tissue.
These can be done through an IUD, which is an intrauterine device, an implant which goes
in the arm, an injection, or a pill.
There are also aromatase inhibitors.
(20:00):
These medications lower the amount of oestrogen in the body.
These may be given alongside progestin therapy.
There are also surgical options in the treatment of endometriosis.
There are two main forms.
These are the conservative laparoscopic treatment.
This is treatment that is done to remove the endometriosis tissue that is on the organs
and on the abdominal walls.
This surgery is done in an attempt to preserve the uterus and the ovaries.
(20:21):
There is also a hysterectomy with the removal of ovaries, which is an oophorectomy.
This is normally considered a last resort as it can help some, but if there is remaining
endometriosis tissue, this will continue to cause pain.
This treatment is not considered curative.
Who are some famous people that have or have had endometriosis?
There is Lena Dunham.
She is the creator and star of Girls.
Dunham in early 2018 announced in Vogue that she underwent a hysterectomy at the age of
(20:46):
31 due to the condition, after living with it for 10 years and going through various
surgeries in an attempt to help treat it.
There is also Padma Lakshmi.
She is an Emmy nominated actress and the host of Top Chef.
She had symptoms of endometriosis from early adolescence.
However, even with good insurance and access to the best doctors, it would take her more
than 20 years to get a diagnosis.
(21:07):
Because of this experience, she teamed up with her diagnosing doctor to co-found the
Endometriosis Foundation of America in 2009 because she didn't want the next generations
of women to experience the delays she had to go through to receive a diagnosis and treatment.
If you would like to check out a movie, there is the short film Chronic.
This film was inspired by one of the director's friends who lives with endometriosis.
(21:28):
The short film is based around two characters who are sisters.
One of them has endometriosis and has just had a surgery.
The other is there to help her deal with recovery.
This goes through their relationship, friendship and jealousy between them as one feels like
they aren't progressing in life due to the condition.
If you would like to check out a foundation, there is, for those in the US, the Endometriosis
Foundation of America.
They aim to increase recognition of endometriosis, assist in expert surgical training and fund
(21:52):
research into endometriosis.
There is for those in the UK, the Endometriosis Foundation.
They strive to raise awareness for endometriosis, provide education and support for those experiencing
the condition.
For those in Australia, there is Endometriosis Australia.
This foundation aims to raise awareness for the condition and fund research.
Due to their work educating the public and medical practitioners, the average time to
(22:12):
diagnosis in Australia went from between 7 to 12 years to 6 and a half years.
Which again is still a long time but it is better.
They also advocate for better access to healthcare for those with endometriosis.
If you want to check out the sources, social media links or any other links, you can head
to anatomyofillness.com.
If you enjoyed this episode and would like to hear more, subscribe to be notified about
our latest episodes.
If you would like to join our community, we would love to see you join us on Discord or
(22:35):
Instagram.
If you are interested in more great content, you can check us out on YouTube.
The links to all of these can be found on our website.
Otherwise stick around for the next episode.
Did you know during an average period, you normally lose only 3 to 6 tablespoons of blood.
(23:02):
However, if you do have endometriosis, more blood will be lost.
Oh, and there is also a rare form of endometriosis called Ocular Endometriosis.
This can cause you to have endometrial tissue in your eyes and therefore bleed from your
eyes during a period.
This however, is rare.
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