Share review of Mr Robert Richardson

Endometriosis is a complex disease as is pelvic pain. Assessment of it includes careful history taking, accurate image interpretation and of course laparoscopy, and on occasion hysteroscopy and cystoscopy. Within the pelvis the bladder and bowel as well as the womb, its ligaments the ovaries and tubes can all become diseased and give troublesome symptoms. It is not always just endometriosis though in your case it seems that this was the case. New symptoms after laparoscopic excisional surgery for endometriosis has relieved them can be due to persistent disease as excision was incomplete or new disease that has activated since surgery. Return of symptoms at less than 6 months can be due to a persistent disease or reflect that the endometriosis was not the cause of the symptoms and that surgery has not helped . In the event of a return of symptoms the strategy is either medical or surgical depending on the assessment and the wish of the patient as medical and surgical treatment can be equally successful in reducing symptoms. By HRT I would expect that you used the Mirena IUS in combination with estradiol patches. This combination aims to achieve a state where the ovaries do not ovulate. Very much like taking the combined oral contraceptive pill continually the hormone levels are stable and endometriosis may regress. The Mirena IUS does not guarantee no ovulation – many patient continue to menstruate and endometriosis is not suppressed. By adding in the estradiol patches the idea is to suppress ovarian stimulation and stop ovulation and help the endometriosis regress not stimulate it. With interstitial cystitis treatment can be difficult and not always successful. The mechanism of how it gives pain is complex and type of and length of treatment varied. Antibiotics, usually low dose, orally for a number of months as a trial of treatment is often tried, sometimes without prior cystoscopy and biopsy. I am sad that the diagnosis in your case took over 9 years: this is common, though with awareness campaigns this will hopefully decrease. I apologise that the medical treatment strategy you embarked upon after your surgery was unsuccessful though for many with aggressive active or persistent disease medical treatment after surgery is successful. Medical and surgical treatment are equally successful in reducing symptoms, though medical treatment has a higher recurrence rate. With regard interstitial cystitis I usually offer cystoscopy and biopsy or a trial of treatment and for many the antibiotic treatment without further surgery is their first choice. With regards hypervigilance hypersensitivity syndrome this may or may not be a medical entity though certainly hypervigilance may bring about a state of increased anxiety which can cause exhaustion. Things, including pain and discomfort, are noticed more readily, and can be increasingly distracting. Coping techniques such as Yoga, mindfulness and, more medicalised ,cognitive behavioural therapy are helpful; drugs and laparoscopy are less so. Hypersensitivity is when the stimulus and effect are mismatched – with pelvic pain, for instance, there can be very little or no inflammation but the pelvis screams pain. Pain killers often work poorly and drugs such as amitriptyline and Gabapentin to modulate and reduce the pain can be tried. Knowledge that such conditions may be at play in giving patients disabling symptoms is important for both GP’s and patients to consider. If you don’t have such a condition then I am glad and again apologise if you felt I was labelling you with something you don’t have and attacking your character. As the pain felt is real, whatever the cause, I was, as an Endometriosis centre lead, exploring all the avenues with my team to help your suffering. I am also glad that you have now found relief again and hope these paragraphs explain to you and others how difficult it can be to manage this difficult disease.