Experts warn of increasing cases of rare reproductive disease
By Tabitha Gathurai and Aghan Daniel


Nairobi, September 4, 2007 - Medical experts fear that endometriosis, a leading cause of infertility and chronic pelvic pain among the women, could be rearing its ugly head in Kenya.

According to Dr Rafique Parkar and Dr William Obwaka, both gyaenecologists based in Nairobi, the disease could be on the prowl in the country. They say that they have lately been encountering the disease among many patients.

Worse still, the experts are worried because few trained doctors can determine the presence of lesions (determine the presence of lesions on what part of the body?). The medical experts further say that the inadequacy in numbers of personnel and equipment in the country’s public health facilities?could be stifling proper diagnosis for women with endometriosis.

“Endometriosis is a condition caused by excess oestrogen created each month in the female body,” says Prof Thomas Dhooghe, a researcher at the National Museums of Kenya’s Institute of Primate Research (IPR). “When this happens, the inner lining of the uterus called endometrium, grows abnormally outside the cavity of the uterus or in other areas of the body,” he adds.

Oestrogen (a hormone produced from the ovary that regulates the menstrual cycle and is also responsible for the development of changes that occur in the female at puberty) levels tend to go up when a women is under pressure, has worries, too anxious, tensed or tired.

Normally, the endometrium is shed each month during the menstrual cycle; however, in endometriosis, the misplaced endometrium is usually unable to exit the body. The condition largely refers to the presence of endometrial tissue outside the uterine cavity.

“Several theories explain this, “ says Dr Sikolia Wanyonyi of the Aga Khan University Hospital, "the most widely accepted is that there is retrograde flow of menstrual blood through the tubes into the pelvic cavity. That is instead of the blood flowing entirely outside through the cervix some of it flows backwards and the tissues within it grows and thrives outside its usual location.”

Other theories include defects in the immune system and also imbalances in hormones responsible for reproduction. Although restricted to the reproductive age group, few cases have been reported in teenagers and postmenopausal women.

Prof Dhooghe, who conducts basic research in drug and vaccine development against endometriosis at IPR, adds that changing lifestyles that have seen the modern African woman assume new roles and challenging responsibilities previously a reserve for men could be the major cause in accelerating the prevalence of endometriosis.

“Changes in lifestyle actually mean smoking, excess alcohol intake, obesity, lack of exercise, delay in child bearing, exposure to harmful insecticides; use of oral contraceptives, early age of onset of menstrual flow and fewer pregnancies,” explains Dr Wanyonyi.

Current estimates place the number of women with endometriosis at between 5 per cent and 50 per cent.

"It is advisable for women with severe pain during menses, sex and heavy menstrual flow, especially if not responding to simple medication to seek the advise of a gynecologist. The condition could be frustrating if diagnosis is delayed, " adds Dr Wanyonyi.

This is especially given that the condition could exist without any symptoms and only discovered coincidentally during procedures like tubal ligation.

The incidence of the disease in women undergoing laparoscopic tubal ligation is as high as 7%. Yet the incidence in women with primary infertility is 9-50%, while in women presenting with pain alone is 5-21%.

The subject of debate is whether the disease occurs among Africans. It has been widely believed to be rare among Africans but this is no longer the case as more and more cases are being reported.

The only sure way to confirm an endometriosis diagnosis is by laparoscopy ( this is a form of surgery where a patient is not opened up, instead a camera is used to spot growth otherwise indiscernible by the naked human eye). The diagnosis is based on the characteristic appearance of the disease. Laparoscopy is very useful not only to diagnose endometriosis, but to treat it. It allows for surgical treatment of endometriosis. Surgery is important in that it removes the endometriosis lesions while preserving the womb as much as possible, says Prof Dhooghe.

For Dr Parkar, also a specialist in laparoscopic and hysteroscopy surgery, medical treatment may also be given. Generally, endometriosis-directed drug therapy (other than the oral contraceptive pill) is utilized after a confirmed surgical diagnosis of endometriosis.


“We use progesterone only pills for hormonal suppression,” Dr. Parkar says. On the contrary, hormonal suppression is a temporary measure. “If you stop the medical treatment the disease will recur,” adds Prof Dhooghe. He says the drug therapy, hormonal treatment, is meant to suppress the lesions only.

According to Dr Wanyonyi laparoscopy remains the gold standard in diagnosing the disease. At the moment there are many on going studies to determine whether a number of blood tests can also be used. The use of ultrasound is minimal though it can also be useful in detecting endometriosis of the ovary that causes endometrioma. “Even though the exact prevalence is hard to tell due to technicalities in designing proper epidemiological studies and lack of proper case definition, we have confirmed many cases among the black African population,” he says.

Dr Wanyonyi observed that data is scanty locally on the condition because there has been a misconception among medics that the disease does not occur among women of African ancestry. This is bound to change as laparoscopy becomes widely accepted among the clinicians.

“Data is hard to come by but isolated case reports have been observed - the condition was previously misdiagnosed as pelvic inflammatory disease (PID) among the blacks. It was thought to be rare in blacks as they tended to give birth early, used no hormonal contraceptives and gave birth to many children which is seen as a protection against endometriosis,” he said.

Even among infertile women the condition was rarely seen due to tubal blockage occurring as a result of PID. This prevents the menstrual blood from flowing backwards. " He explained that the advent of laparoscopy and the changing lifestyles in the African woman have now seen the detection of the disease more frequently.

Dr Wanyonyi noted that they have recently concluded a study on the condition whose findings will be published soon. The study aimed to characterize the clinical characteristics and severity of the condition in an African set up in comparison to other populations. A total of 89 cases with a confirmed diagnosis of endometriosis over a six-year period were studied.

It is also emerging that the disease is closely linked with cancer. Women with the painful disease endometriosis are prone to certain cancers, mounting evidence suggests according to reports from a fertility conference in Kyon in July. French researchers told the conference how risk of ovarian, kidney and thyroid cancers rises by over a third with the condition.

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