One of the most common complaints that doctors receive in their daily practice is severe menstrual pain. Most of the time, we may mistake the pain as normal menstrual pain and often endometriosis might be overlooked. Many studies have shown that the diagnosis of endometriosis can be delayed up to 10 to 12 years. The delay in diagnosis of endometriosis could severely affect the fertility of many women while some women develop complications such heavy menstrual bleeding, low blood levels (anaemia), having painful enlarged uterus (adenomyosis) or ovarian endometriotic cysts. At present, there is no objective test to diagnose this disease. Doctors depend on patient’s signs and symptoms to make a clinical diagnosis.

What is endometriosis?
Endometriosis is derived from the word “endometrium,” which is the tissue that lines the womb (uterus). Patients with endometriosis have endometrial type of tissue which grows outside of the uterus particularly in the surrounding organs such as bladder, bowels and sometimes, even in the distant parts of the body such as the umbilicus, lungs and the brain. 

The endometriotic lesion is influenced by the female hormones. It undergoes proliferation, break downs and bleeds during each menstrual cycle. Its characteristics resemble a normal endometrial tissue which is found inside the womb. With each menses, endometriosis will cause chronic inflammation and the formation of scar tissues inside the pelvis, which can distort the anatomy of the surrounding organs and interfere with their functions.

What causes endometriosis?
Doctors and researchers have not identified the cause of endometriosis. One of the most popular and widely believed theory is Sampson’s Theory of Retrograde Menstruation, postulated by Dr. John Sampson in the 1920’s. According to the theory, during each menstrual cycle, a certain amount of menstrual fluid in the uterus is forced into the pelvic cavity via the fallopian tubes. The body usually responds to this kind of spilling by reabsorbing the menstrual fluid back into the circulatory system. However, in some women, due to immune system dysfunction, the fluid is not reabsorbed but instead implants itself and grows on the pelvic and abdominal organs. 

We also realise that endometriosis tends to run in families. If your mother or sister has endometriosis, you’re more likely to get it. Research shows that it tends to get worse from one generation to the next.

What are the symptoms and signs of endometriosis?

1. Pelvic pain 
Most women with endometriosis experience severe pelvic pain, lower back pain and cramps before and during menstruation. The medical term for such severe pain is called dysmenorrhea. Other common complaints include dyspareunia (pain during intercourse), dyschezia (painful defecation) and dysuria (painful urination). 

2. Heavy or irregular vaginal bleeding 
Women with endometriosis may experience excessive menstrual bleeding or bleeding between periods.

3. Infertility 
Some women with endometriosis may experience little or no pain at all but are unable to conceive and are usually first diagnosed with endometriosis while seeking treatment for infertility. These are usually cases where the formation of scar tissue (adhesions) due to endometriosis, has somehow distorted the reproductive organs and therefore results in inability to conceive.

4. Painful bowel movements 
Some women may experience bowel pain followed by abdominal bloating, constipation, or diarrhoea. The pain may intensify during menstruation.

Diagnosis 
There are no specific tests to assess whether a woman has endometriosis. Exploring a patient’s medical history may give the doctor some clue to the presence of this disease, and it is usually accompanied by a pelvic examination. 

The pelvic examination may reveal irregular painful swellings in the Pouch of Douglas and an enlarged uterus. The pelvic ultrasound may reveal ovarian cysts that appear in the form “kissing cysts” (picture below). Sometimes, the doctor may order a blood test called CA-125 and if it is elevated, it is suggestive of endometriosis.

In some cases, it is possible to be mistaken endometriosis for other gynaecological conditions that have similar symptoms and vice versa. The only reliable way to confirm and verify the suspected diagnosis of endometriosis is through laparoscopy.

Treatment Options 
There is no cure for endometriosis now and this condition can be difficult to treat. The aim of treatment is to relieve pain, to remove endometriotic tissues to improve fertility and to prevent disease recurrence. Treatment modalities can be divided into 3 categories:
a) Pain killers 
b) Surgery 
c) Hormonal therapy

a) Pain killers 
Non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are widely used to relieve pain, help to reduce inflammation, and bring down a fever; for example, ibuprofen and mefenamic acid. They can be used together in combination with paracetamol for more severe pain. These painkillers are available in pharmacies.

b) Surgery 
Surgery is the main treatment option for women with endometriosis. Laparoscopic surgery (key hole) is the preferred surgery but sometimes we may need to perform open laparotomy for very complicated cases. The aim of surgery is to diagnose endometriosis as well as to remove as much of the diseased areas as possible.

c) Hormonal therapy 
Endometriosis is influenced by the hormone oestrogen. Whenever there is menstruation, the endometriotic lesion will grow, causing pain and forming adhesions in the pelvis. By giving hormonal therapy, menstruation is reduced or suppressed and therefore prevents the growth of endometriosis and relieve its symptoms. Hormonal therapies can be given before and essentially after laparoscopic surgery to suppress any remaining tissues. Some of the therapies include:

i. Gonadotropin-releasing hormone (GnRH) agonist 
ii. Combined oral contraceptive pills 
iii. Progestogens pills
iv. Mirena® (intrauterine device coated with hormone)

Can endometriosis recur after surgery? 
Endometriosis can recur after surgery and medical treatment. The chance of recurrence is higher if endometriotic lesions are not excised completely. If the patient is not contemplating pregnancy immediately after the surgery, continuing medical therapy after surgery to suppress any endometriotic lesion that has not been excised. 

Complimentary Therapies
Although there is only limited evidence for their effectiveness, some women may find the following therapies helpful to reduce pain and improve their quality of life:
• reflexology
• transcutaneous electrical nerve stimulation (TENS) 
• acupuncture 
• vitamin B1 and magnesium supplements 
• traditional Chinese medicine 
• herbal treatments 
• homeopathy

Is endometriosis associated with ovarian cancer?
Studies have shown that patients with ovarian endometriosis have 2-3-fold increased risk of ovarian cancer.

Should pregnancy be recommended as a treatment for endometriosis? 
Pregnancy might help to reduce endometriosis symptoms only temporarily, but it is not a cure. There are also risks involved, as women with endometriosis are more likely to have pre-term births, increased rates of caesarean sections and an increased risk of miscarriages.

Are there ways to prevent endometriosis?
Endometriosis is an idiopathic condition, meaning there is no known cause. There are also no specific ways to prevent endometriosis. However, being aware of the symptoms and whether you could be at higher risk can help you know when to discuss it with a doctor.

Summary
Women with endometriosis constantly battle with monthly pelvic pain, and it affects their fertility. Being pregnant with endometriosis may also increase your risk of serious pregnancy complications. Therefore, women should seek consultation with their gynaecologists for an early diagnosis. With early intervention, it may improve their quality of life and reduce severe complications.

Dr. Chua Shih Keat received his medical degree from Universiti Putra Malaysia and obtained the membership of Royal College of Obstetricians and Gynaecologists (MRCOG), United Kingdom.

Dr. Chua specializes in the care of women during pregnancy and childbirth and in the diagnosis and treatment of diseases of the female reproductive organs. He has been managing women’s health issues for the past 16 years in various health facilities.

What is lymphoma? 
Lymphoma is a cancer of the lymphatic system, which is part of the body’s immune system. The lymphatic system consists of lymph nodes, tonsils, spleen, thymus gland and bone marrow. Lymph fluid contains white blood cells which defend the body against invasion by bacteria, viruses, parasites and other foreign substances. Lymphoma develops when white blood cells called lymphocytes grow out of control. 

What are types of lymphoma? 
There are two major types of lymphomas: Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), which differ in the way they develop and spread, as well as in the way they are treated. The World Health Organization (WHO) divides HL into two main groups: classical HL (cHL) and nodular lymphocyte-predominant HL (NLPHL). Most patients with HL are diagnosed between 15 and 30 years of age, followed by another peak in adults aged 55 years or older. For NHL, it is a heterogenous group of blood disorder arises from B-lymphocytes, T-lymphocytes, or natural killer (NK) cells. There are more than eighty subtypes of NHL, which can be simplified into two major categories, namely B-cell and T/NK-cell NHL. 

What is the incidence of lymphoma? 
NHL is more common than HL. Most NHL (85-90%) are from B cells and less than 15% develop from T cells. Classical and nodular lymphocyte predominant HL account for 95% and 5% of all HL respectively. According to Malaysia National Cancer Registry Report 2012-2016, lymphoma is the fourth most common form of cancer overall in Malaysia after breast, colorectal and lung malignancies (table 1). 

What causes lymphoma? 
The causes of lymphoma are not understood. However, people with certain risk factors have a slightly higher chance of developing lymphoma compared with people without these risk factors. Known risk factors for lymphoma include: 
1. Immunodeficiency: HIV infection, transplantation, Wiskott-Aldrich syndrome. 
2. Infection: human T-cell lymphotropic virus type 1, Epstein-Barr virus, helicobacter pylori. 
3. Autoimmune: Crohn’s disease, systemic lupus erythematosus, Sjogren syndrome. 
4. Environmental toxins: pesticides, herbicides, certain drugs used to treat cancer. 

While siblings and children of patients with lymphoma have a slightly increased risk of developing this disease compared with the general population, there are no clearly identifiable genetic or hereditary factors that can predict this slightly increased risk. Therefore, routine screening for lymphoma among the immediate family members of patients with lymphoma is not recommended. 

What are the symptoms? 
Some patients with lymphoma do not have any obvious signs or symptoms of the disease. The clinical features at presentation reflect a spectrum from low grade to high grade lymphoma. Low grade (also called indolent) lymphomas usually grow slowly, exhibit few symptoms, typically present with widespread disseminated disease at diagnosis and are generally not curable. Patients can live a long time with indolent lymphomas because they tend to respond well to treatment and can remain in remission for many years or even decades. However, over time, some indolent lymphomas may transform into high grade lymphomas. 

High grade lymphomas (aggressive lymphomas) grow and spread more quickly than low grade lymphomas. Destructive growth pattern of the deep lymph nodes within the chest or abdomen may press against various internal organs, causing difficult breathing, cough, poor appetite, weight loss, abdominal pain and distension, constipation, fever and legs swelling. Many patients with aggressive lymphomas can be cured by chemotherapy that kill rapidly dividing tumour cells. 

Anyone who has an enlarged lymph node that does not return to normal size within few weeks and/or persistent symptoms should see a doctor immediately to make sure that lymphoma or another serious condition is not present. 

How is the diagnosis made? 
An accurate pathologic diagnosis is the most important first step in the management of lymphomas. An incisional or excisional lymph node biopsy in combination with immunohistochemistry (IHC) is recommended to establish the diagnosis of lymphoma. IHC is essential for the differentiation of various subtypes. Fine needle aspiration (FNA) is inadequate for reliable diagnosis and grading. Other special test includes cytogenetic analysis, which involves examination of chromosomes from lymphoma cells under a microscope to check for any abnormalities in number or structure. The result of cytogenetic analysis often helps doctors to determine which type of lymphoma a patient has.  

What is the workup for lymphoma? 
Essential workup procedures include: 
1. Physical examination 
2. Laboratory: blood count, lactate dehydrogenase, metabolic panels, hepatitis viruses, HIV
3. Bone marrow aspiration, trephine biopsy +/- immunophenotyping (for staging purpose). 
4. Imaging: chest X-ray, CT neck, chest, abdomen, pelvis (for staging purpose) 
5. Electrocardiograph (ECG) and echocardiogram
6. Optional: PET CT scan, lumbar puncture, brain MRI (depending on subtype & site) 

What are the treatment options available? 
Treatment results for lymphomas have improved dramatically over the past four decades. The advent of more effective treatment options has improved the 5-year survival rates.  Treatment for lymphoma varies widely based on the subtype. Treatment options include: 
1. Watchful waiting (for low grade lymphomas) 
2. Chemotherapy +/- immunotherapy (monoclonal antibody) 
3. Radiotherapy 
4. Stem cell transplantation (autologous, allogeneic) 
5. Chimeric antigen receptor (CAR) T-cell therapy 
6. Novel agents 
7. Clinical trials 

What is the prognosis? 
The prognosis is based on the stage at which the disease is diagnosed and determined by the lymphoma subtype, in addition to other factors such as performance status, age and other medical issues. Treatment for HL is highly effective and most patients are eventually cured. The survival rate for HL is generally higher than that of NHL. The American Cancer Society reports 5-year overall survival rate of 80% for HL and 72% for NHL. Various prognostic indices have been developed for different forms of lymphoma. The International Prognostic Index (IPI) was developed for aggressive NHL and validated in all clinical grades of NHL as a predictor of response to therapy, relapse and survival. The IPI is based on five factors: age, performance status, lactate dehydrogenase level, number of extra-nodal sites and stage of the disease.

Dr Teoh Ching Soon is the Clinical Haematologist & Physician in Loh Guan Lye Specialists Centre. He has a keen interest in the management of malignant haematological disorders such as leukaemia, lymphoma, multiple myeloma, myelodysplastic syndrome and myeloproliferative neoplasm. His clinical work also focuses on benign haematological diseases, red cell and platelet disorders, coagulation and haemostasis, consultative haematology and haematopoeitic stem cell transplantation.

Your child hardly speaks like other children their age do. Does that automatically mean that your child has autism? Not necessarily. Even though speech delays and language delays  often go hand in hand with autism, there are key differences between communication delays caused by autism and other types of speech-language disorders.

SPEECH DELAY VS LANGUAGE DELAY
While speech and language delays are often confused and used interchangeably, there are distinguishing characteristics.

Speech delay: A disorder which affects ‘how’ children verbalise, articulate and control the sounds that are used in words. The children may be following typical speech patterns, but at a slower rate than their peers. Three major types of speech disorder include articulation, fluency, and voice disorders.

Language delay: A disorder which affects ‘what’ the children say. In other words, they are able to pronounce words well, but fail to form them effectively for others to understand. In addition, a receptive language delay can affect how children process information, be it verbal, nonverbal or written.

Autism is not the only cause to speech and language delays. Other causes, including hearing loss, deprivation of time talking with adults, bilingual environment, and etc. could also lead to the delays.

AUTISM
Autism is also often called Autism Spectrum Disorder (ASD). It is a neurological and developmental disorder that causes significant social, communication and behavioural challenges. Children with ASD may have trouble understanding the world around them. Since autism is a spectrum disorder, the learning, thinking, and problem-solving abilities of children with ASD can range from highly skilled to severely challenged.

Concerning how ASD can be diagnosed, the leading medical reference is the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5). The core symptoms of autism are social communication challenges and restricted or repetitive behaviours. The severity of the symptoms varies among the affected children. Symptoms include avoidance of eye contact with people, not responding to name, not looking at objects when parents point. Children with ASD may not notice when other people around them appear sad or hurt. They show little interest, if any, to play with other children. Stimming, or repetitive unusual body movements or noises, is also one of the typical autistic children’s behaviours. They like to line up toys in a set order, or may get upset when there are minor changes. If parents notice any of these signs that worry them, it is advisable to seek medical attention.

Regardless of the complexity of ASD, following treatments can make a difference to the children and their families.
i. Speech and language therapy aims to help children with ASD to communicate and interact better.
ii. Occupational therapy provides assessment and intervention to maximise activities of daily living.
iii. Applied behaviour analysis encourages desired behaviours and discourages undesired behaviours in children with ASD.
iv. Parent education improves parent-child interaction and communication skills.
v. Cognitive behaviour therapy helps children to cope with anxiety and depression.

THE EARLIER, THE BETTER
Parents may spot the signs and symptoms at home, but they cannot diagnose the subject without an expert’s help. Early intervention programs are proven to be highly effective. If a child is not developing social and communication skills on par with the standards, do not hesitate to make an appointment with a professional. The journey of raising a child is tough enough, let alone a child with ASD, but who knows, you may find some extraordinary talent in them!

Dr Long Wai Lup is a Paediatrician in Loh Guan Lye Specialists Centre. He attained his medical degree in 2009. His special care and interest towards childcare fuelled his desire to specialise in Paediatrics subsequently. He graduated from the Royal College of Paediatrics and Child Health UK (MRCPCH) in 2019.
Dr Long has special interest in treating children with:
• Developmental delay such as delay in speech-language development, motor skill and others
• Skin illness in children including: Eczema, Infection, Allergy and others
• Feeding issues from newborn to childhood
• Growth issues in newborn to childhood