Mariska came to see him soon after discovering a lump in a small abdominal scar above her pubic bone. The lump wasn’t causing bet any pain, she said, although she’d been feeling uncharacteristically tired early in the day, and her menstrual cramps were getting worse. When Dr Obama took her medical history, he was surprised to hear that she had defected from Czechoslovakia with a friend five years before. She had been living in America for most of the time since defecting.

Mariska had been an idealistic nineteen-year-old Olympic ski-team hopeful when she was soundly blamed for “getting herself pregnant,” then telling no one until she was three months along. The facts were a lot kinder than the wrath of her parents, her coach, and the team doctor; for she had no idea that she was going to have a baby.

Mariska, a strong downhill skier, had been training intensively since she was twelve years old. “I was physically at my peak of strength and flexibility,” she said, “and I was told not to worry if my periods came irregularly.” This is a common occurrence among many women in dance and sports. One side effect of the committed athlete is lowered estrogen levels, which can stop menstruation or significantly lighten menstrual flow. For Mariska these hormonal changes were brought on by a low-fat diet, supplemented with a plentiful dosage of what she was told were “muscle-enhancing amino acids,” along with a strenuous daily exercise regime. That she missed four consecutive periods therefore didn’t alarm her even though she had been having a sexual relationship for the first time. What she did find worrisome was the sudden bloating. That prompted her visit to the team doctor, who told her his findings.

Although she was against abortion for herself, Mariska was told to terminate the pregnancy. If she chose to keep the baby, all her training would be in vain—pregnant downhill skiers do not compete—and she’d upset team morale. Believing in the “infallibility of those who cared for me,” Mariska agreed to a hysterotomy, following surgery, she recovered quickly and competed in the Olympic Games.

Dr Obama examined her six years after these events. He strongly suspected endometriosis, and this was doubly confirmed by laparoscope. The disease had sprayed from the point of incision on her uterus to the scar on her abdomen. The endometriosis had also wrapped itself thickly around the fallopian tubes—not a good indicator for any woman who still wants children. He recommended treatment with Danocrine for six months and did exploratory surgery to remove as much endometriosis as was visible. It remains to be seen whether Mariska will be able to conceive.

Abortion by hysterotomy is rare now; doctors prefer other techniques that do not require uterine surgery.

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Look for relevant books in the library.

Go to a good bookshop that specialises in health topics.

Contact your nearest Endometriosis Association. They will have heaps of pamphlets you can read and will give you advice if required.

Avoid feeling isolated

Talk to your doctor about any concerns that you have.

Don’t push your parents away — give them the information to read and tell them how you feel.

Explain your disease to your friends.

You may even want your teachers to know about endometriosis.

Talk to other young people who have endometriosis so you can gain mutual support by contacting your nearest Endometriosis Association.

Don’t bottle up your feelings

If you are angry get it out of your system — it’s OK to shut yourself in a room and yell or hit a punching bag. Try not to let the pain overpower you

Don’t take too many painkillers.

Try blotting out the pain by imagining yourself enjoying life without pain.

Resist making endometriosis an excuse for something you do not want to do. But if you are genuinely not well, don’t hesitate to explain why you cannot do it.

When you are feeling well — go for it — enjoy life!

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Following a course of hormonal treatment

Continued infertility following surgery

Recurrence of symptoms

Persistence of symptoms following an apparently normal laparoscopy.

Following hormonal treatment

A repeat laparoscopy at the end of a course of hormonal treatment enables your gynaecologist to see exactly how effectively the treatment has eradicated your endometriosis. The location and size of your implants and cysts can be charted and compared to the chart that was made during the laparoscopy performed before your hormonal treatment began.

If the repeat laparoscopy showed that the treatment had eradicated your endometriosis then nothing further needs to be done for the time being. If it showed that the treatment had only been partially effective then it might be worthwhile considering a continuation of the same treatment. If it showed that the treatment had been ineffective you will need to consider some other form of treatment.

Infertility

If you have had surgery in order to improve your chances of conceiving, a repeat laparoscopy may be recommended if you have not conceived within six to twelve months of the surgery. In thus situation the laparoscopy will be performed to determine whether or not any adhesions have developed that may be reducing your chances of pregnancy.

Recurrence

A repeat laparoscopy is advisable if you have a recurrence of your symptoms following a period of remission, particularly if you are contemplating any treatment. You really need to know that the symptoms are due to endometriosis and not some other condition. In addition, it is advisable not to undertake any hormonal treatment unless you know that you definitely have endometriosis.

Normal laparoscopy

A repeat laparoscopy may be advisable if you have had a persistence or worsening of symptoms that may be due to endometriosis, despite the fact that you have previously had an apparently normal diagnostic laparoscopy. It is now recognised that, in the past, a proportion of women with endometriosis were incorrectly diagnosed as not having endometriosis because their gynaecologists did not recognise their atypical implants or because they had microscopic endometriosis.

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Calculating Your Body Mass Index (BMI)

Being the right weight for your height is very important. The easiest way to measure this is by means of the Body Mass Index (BMI) which identifies the percentage of body tissue which is actually fat. The amount of fat is important for fertility because we produce oestrogen from fat cells.

Your BMI is the ratio of your height to your weight and is calculated as follows: BMI = your weight in kg divided by the square of your height in meters. For example, if my weight is 63.5kg (10 stone) and my height is 1.68m (5ft 6in), my BMI is 63.5 – 1.68 X 1.68 = 22.5.

What does your BMI mean?

Under 20: underweight

20—25: normal

25—30: overweight

30-40: obese

Over 40: dangerously obese

A BMI of 30 would indicate a person around 16kg (2 1/2 stone) overweight.

What is Underweight?

Anything under a BMI of 20 is considered underweight and could make it difficult for you to conceive. This is one of nature’s protective mechanisms. The theory is that if we do not have enough fat stores our bodies think we are starving. Since it is not appropriate to become pregnant when food is short, ovulation or menstruation stop. (This is why women of the Bushmen tribes only ovulate at a certain time of year when food is plentiful.) When our weight gets back to normal (because we have stopped dieting and/or reduced the amount of exercise we take) we start ovulating and menstruating again. Our bodies assume that food is now plentiful and we become fertile again.

And even short-term dieting can have an effect. For example, healthy women who were put on a diet of 1,000 calories a day for just six weeks showed hormonal disruption in that short time. Progesterone, the important hormone which maintains pregnancy, dropped significantly and so did their oestrogen levels.

The good news is that getting back to the right weight really does boost your fertility. One study showed that nearly three-quarters of women with unexplained infertility managed to conceive naturally once they stopped dieting and returned to a normal weight.

If you get your weight back up to normal quickly it is still advisable to wait at least four months before trying to conceive. You will almost certainly have some vitamin and mineral deficiencies because you have been restricting your food intake. The four-month wait before getting pregnant is vital because otherwise, if you have been undernourished, you are more likely to have a low birth weight baby.

As we have seen, the current popularity of no-fat or low-fat foods and diets has some serious implications for fertility. Dieting in this way may deprive you of the nutrients that are essential for the proper functioning of your reproductive system. Just how serious an effect this can have was demonstrated by one study which showed that only 27 per cent of the women on a fat-restricted diet were actually ovulating.

To improve your fertility you should aim for a BMI within the normal range of 20-25, the optimum being 24.

Food should be eaten regularly and you should never skip meals. Apart from ensuring that you are well-nourished, regular meals are important to maintain your hormonal balance.

What is Overweight?

A BMI of over 25 is considered overweight and it can reduce your fertility. However, just losing a small amount of weight, say 10 per cent, can be enough to improve your hormone profiles, make your periods more regular, stimulate ovulation and increase your chances of pregnancy.

In fact it has been suggested that changing a woman’s diet should be the first move if she is overweight and failing to conceive. And research shows that even women with normal ovaries gain positive improvements in their hormone balance as they lose weight.

However, once you are pregnant, dieting is positively harmful. This is because, when you diet, your body gets rid of toxins and waste products. This is usually a good thing but if you are pregnant then the toxins can go straight into the developing baby.

For this reason, you must aim to lose any excess weight before you get pregnant. If you are already pregnant, then it is fine to change the quality of your food (by buying healthier foods such as organic vegetables, changing to organic free-range eggs, eliminating sugar, etc) but you still need to eat a good variety of food and not skip meals.

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