Need-Based Holistic Treatments for Endometriosis in Women

Background

In Endometriosis: A Natural Approach, Jo Mears explains that the Greek-derived word “endometriosis” means an abnormality inside the womb. The disease manifests when the tissue that normally sheds during the menstrual period is “ectopic,” or growing outside of uterus [2,3]. Thus, the lining of the uterus is essentially growing inside out and it does not properly shed. As such, blood collects in certain areas of the lining. These collections of blood can be referred to as patches or implants [4]. Further, these collections of blood can cause inflammation and, eventually, scarring.

According to the Obstetrics and Gynecology manual by Tamara Callahan and Aaron Caughey (2013), the pathogenesis of the disease originates in the endometrial tissue which “can be found anywhere in the body, but the most common sites are the ovary and the pelvic peritoneum... Endometriosis in the ovary appears as a cystic collection known as an endometrioma”. Though endometrial tissue is primarily found in the fallopian tubes and uterus, this tissue can also be found in the breasts, brain, ears and lungs. Naturally, the question may arise as to what causes this pathogenesis. As Mears further describes in her book, there is no definitive cause of endometriosis although several theories do exist. These explanations include retrograde menstruation when the menstrual blood flows backwards, autoimmune issues, abnormal hematology, and abnormal embryonic cells and ovum development [2].

Currently, the prevalence of this disease among women is “estimated to be between 10% and 15% [3,5].” Endometriosis may “affect up to 50% of teen girls experiencing typical symptoms [6].” Rush et al. (2019) estimate that 1 in 10 women of reproductive age experience endometriosis [7]. These values can only be estimated because endometriosis is not easily diagnosed, and some women often miscategorize the pain as the normal course of menstruation. Some symptoms that can indicate an endometriosis diagnosis include pelvic pain that starts one or more weeks prior to the first day of her period, and continues throughout the period “week,” painful urination, heavy periods including the potential for hemorrhage-volume blood loss, inconsistent and abnormal bleeding, back pain, and depression. Although women suffering from endometriosis would likely not categorize their disease as mild, the disease is further described based on the severity of abnormalities found in diagnostics. While “typical” endometriosis refers to the least severe form of the disease, “subtle, deep, and cystic” endometriosis can be used to describe the more severe forms of the disease [8]. The symptoms may also lessen in severity throughout a woman’s life especially after events such as childbirth and hysterectomy. Beyond that, there are also variations of the disease such as the size of the abnormal tissue area(s), level of pain described by women, and different means of treatment. Due to the many variations of this disease, it can take many doctor visits over a range of years for women to receive a proper diagnosis and an effective treatment plan [3,9].

Difficulty in Diagnosis

Although the word “endometriosis” may be used loosely or interchangeably to describe a wider range of women’s chronic menstrual pain including polycystic ovary syndrome (PCOS), hostile uterus, or severe menstrual pain, a diagnosis of the disease known as endometriosis requires an invasive surgical examination. Typically, a laparoscopic or laparotomic procedure is performed, so that there is a “direct visualization” of the affected areas. This is the only way for physicians to be able to see that there is indeed abnormal tissue growth, as well as any present scarring [5]. Even with laparoscopic or other exploratory surgery, it is still very difficult to diagnose endometriosis. One reason is that there is some disagreement among physicians as to what constitutes endometriosis, what is normal growing tissue and that which is abnormal. For example, some physicians consider some excess tissue around the peritoneum to be typical [8]. As a result, many women are often disappointed after undergoing exploratory surgeries because they receive inconclusive diagnoses even though their symptoms mirror those of endometriosis. Another finding also suggests that although endometriosis may not be found in women whose doctors believe there is a potential for the disease and thus recommend laparoscopic surgery, there are more women whose endometriosis is found during surgical exploration or treatments for other reasons, such chronic pelvic inflammation or post-partum or pre-menopausal complications.

The difficulty of diagnosing endometriosis is also reflective of hardships that women face in medicine. As is explored later in this paper and as is echoed in feminist works of Judith Butler (2004) and others who define persistent lack of power, it is the feeling of being unheard, uncounted, marginalized, and invisible [10]. The constant under diagnosis or misdiagnosis of a prevalent disease in women can make them feel powerless. This may lead women to avoid surgical diagnostic altogether for fear of being “invalidated.” This potential for clear diagnosis is additionally problematic for women lacking access to modern medical procedures, particularly in gynecology, from both a socioeconomic perspective to access to healthcare. This is further impeded when women are unable to effectively describe their symptoms or whose descriptions are dismissed as, again, “normal” menstrual pain.

When women believe that their chronic pain has been dismissed, when there are barriers to access, from affordable healthcare to feeling that their pain is “significant,” they may often turn to self-treatment. Self-treatment or self-help is a common practice in other groups that feel stigma, from minority lesbian women experiencing gynecological problems to monogamous heterosexual women with HIV. The Internet has been both a powerful tool and a dangerous one, in terms of readily-available self-help literature and treatment information. However, both the level of education and the level of health literacy can play a significant role in whether the information being received is either understood or can be differentiated as credible or fallacy. In her text, The Makings of a Modern Epidemic: Endometriosis, Gender and Politics, Kate Seear (2016) says that endometriosis is one disease for which women flock to self-help literature [11]. Whether it is prior to exploratory surgery for a definitive diagnosis or feeling lost within medical treatments, Seears describes self-help as taking back one’s power. This is significant for women who suffer from this disease, as chronic pain can already lead to a feeling of being out of control of one’s own health. From learning about alternative treatments to reading and sharing in the lived experiences of like-women, those suffering from endometriosis can feel a sense of being understood and belonging when the disease can often manifest feelings of isolation and exclusion.

In Menstrual Disorders, Annette Scambler and Graham Scambler (1993) discuss the important “sociological perspective” which also factors into both the access to and limitations of appropriate and effective healthcare. The authors discuss the historical gender disproportions in medicine, particularly the male doctor versus the female patient. Not only does this play a part in the misunderstanding of women’s descriptions of pain from the perspective that male doctors have no practical experience in what menstrual pain “feels like,” lack of female gynecologists may mean there is no access for care if the patient’s culture or religion dictates that they must see a female practitioner. The Scambler historical accounts also mention common stereotypes in medicine, from women’s “hysteria” to “hypochondria,” which have all been common factors in the pain of women being treated for a mental health imbalance rather than physiological abnormality [12]. Thus, there may be a benefit to women when seeking holistic care, even if simply to feel a sense of empathetic and experiential support, as the balance of practitioners in these practices are typically on the female side, then creating a feminist argument for widening the scope of discipline.

The Argument for a Multidisciplinary Approach

From the potential of misdiagnosis and the stigma associated with women’s chronic pain to the lack of definitive non-invasive diagnostics and the absence of an equitable healthcare access, it is arguably impossible to expect the “typical” course of action in traditional medicine will help alleviate the symptoms of endometriosis. For instance, women who are unable to “accurately” describe their pain in both location and severity, as well as those whose pain is unresponsive to pharmaceutical treatments such as pain-relievers and birth control, may inevitably be considered to have imagined her pain and thus be referred to psychological interventions. As such, this interaction can lead women to feel guilty for complaining about the pain and to believe that they should “overcome” the pain on their own. This stigma then raises the issue of underreporting of the disease and the lack of acknowledgement of women’s chronic pain. It is for these reasons that Leonardi, Singh and Condous (2019) assert “the management of pelvic pain and endometriosis presents one of the greatest challenges for gynecologists worldwide” [13]. They further reiterate, just as is done in this paper, women suffering from endometriosis will need flexible and creative treatments that are designed from a multidisciplinary approach.

Conventional Treatment Methods

The treatment methods that are traditional for endometriosis fall into three categories, pharmaceutical, surgical, and psychiatric. It is important here to recall that there is not a known cure for endometriosis, so any intervention is to treat the symptoms.

Birth control is the preferred method of endometriosis treatment. Birth control is often used because it is thought that the mediation and control of the premenstrual and menstrual cycle will be beneficial in controlling some symptoms associated with the cycle, such as the pain associated with the inflammation of the tissue due to blood collecting and improper shedding. Even so, birth control is quite varied including the types of hormones such as estrogen and progesterone that are supplemented. Some contraceptive pills stop the cycle altogether, which may or may not also alleviate pain. Other brands aim to regulate the menstrual cycle, so that women can plan for upcoming symptoms and feel more in control of what is happening to their bodies at that time by understanding the timing and patterns of their pain. Nevertheless, taking birth control has some risk factors including contra indicators for drugs, increased risk of infertility, stroke, and depression as well as weight gain, and changes in skin [2]. Further, progestin-only contraceptives can have even more pronounced side effects including heavier periods, migraines, breakthrough bleeding, hair loss, and stomach problems. Pituitary-affecting drugs are also sometimes used, but they have been known to have serious side effects as early menopause and osteoporosis, as well as insomnia and migraines.

Pain management is also one of the typical treatment options even though the true effectiveness of these drugs is debatable. Women with endometriosis often report that over-the-counter (OTC) medications are not strong enough or quickly lose their efficacy due to build tolerance. NSAIDs and other pain relievers can also, in large quantities, cause gastric issues or even ulcers. Certain prescription painkillers can be effective, but opioids and codeine can lead to dependency. Tranquilizers and antidepressants, as well as anti-anxiety drugs may also be used, but they offer only a Band-Aid approach and often feel like a temporary fix to a complex issue. There are other pharmaceuticals that are not used as often, such as nerve blockers and anti-inflammatory biological [2]. Again, the dilemma of using this short-term remedy for a chronic illness is the lack of attention given to the disease and that “all women” with the disease cannot do “all the things.” Teen girls suffering from endometriosis, for example, should not rely on birth control long-term, considering the potential for either infertility or stroke, or both, and biologicals are not appropriate in certain environmental conditions. Similarly, strong painkillers may lead to additional drug, often non-pharma, dependency. The net must have a wider catch.

As mentioned before, whether considered to be a byproduct of complaining about chronic pain and not experiencing relief from painkillers or using anti-anxiety or antidepressants as a form of remediation, psychology and chronic pain suffering is often treated simultaneously. As such, acknowledging both of these factors can be a positive asset to a treatment plan.

The most invasive medical approach is the post-diagnostic surgical intervention, and they range from conservative to radical. The former is the laparoscopic “excision of any visible endometrial implants,” removing as much of the effected tissue as possible, with the latter being a total hysterectomy and removal of all affected tissue [5]. Again, the logic of such a radical approach must be considered especially its implications for women whose religious beliefs may not permit such actions and teenagers who are typically only at the beginning of reproductive planning. The risk factors for lower health literacy, poor or inadequate support or counseling, education level, language or other cultural barriers to understanding risk factors of these surgeries are also reminiscent of the same reasons why women inadvertently agree to forced sterilization procedures when only trying to treat incontinence or other bladder issues. Surgery is a last resort.

Unconventional Treatment Methods

Broaching the topic of the unconventional can already make for a difficult conversation with one’s medical practitioner. The limitations of seeking only medical advice versus researching other potential interventions is numerous, as has been stated above, in that long¬term use of birth control and pain medications may not work, or they may work temporarily, and then the next tier approaches may include psychology or surgery. There must be a middle ground that is not being considered. Part of this lack of consideration by medical professionals is lack of knowledge, lack of training, lack of insurance coverage, lack of resources, and, honestly, lack of sustainable partnerships, acknowledging that another intervention just might be better than theirs.

Looking into self-help literature can be a powerful tool for women, particularly if the research leads to deeper conversations with trusted professionals that can continue to weigh the pros and cons of each treatment method. Most of these alternative approaches are also low-risk and are often prescribed or recommended for a wide range of diseases and illness, such as diet and exercise [14]. Other interventions, such as acupuncture and homeopathy, may be lesser known or believed as a treatment. Even so, they should be considered as they are low risk.

As with other diseases that attack the body in the form of inflammation, avoiding foods that can cause inflammation can be one key to feeling less pain. An anti-inflammatory diet includes staying away from foods such as gluten, dairy, and refined sugar and increasing the intake of healthy fats, protein, fiber, and vibrant vegetables, high in vitamins. Though being conscious about one’s diet should be intuitive, associating diet with pain can be powerful knowledge when trying to feel in control.

In her plan, Katie Edmonds, treats endometriosis as a systemic issue, asserting that the relationship between food and hormones, inflammation, immunity, digestive issues, and malnutrition, is key to living with the disease. As with the previous points, this would be true for a variety of diseases that are affected by both environmental and physical triggers. For acute and chronic diseases, most physicians will suggest cleaner eating and a nutritional diet, as part of any wellness plan. Edmonds remarks that lipopolysaccharide bacteria in the gut can increase the inflammation that encourages lesion growth, and that women with endometriosis are often deficient in vitamins A, C, D, and E, as well as omega-3s [15]. Diet change is suggested here in addition to other therapies, but the effects of meaningful probiotic and anti-inflammatory eating can be a powerful tool. A serious limitation of the nutrition component is for women who are unable to afford more nutritious foods, particularly the organic meats and vegetables that are commonly suggested, to reduce the potential contamination and additional inflammation caused by added chemicals and hormones that are often found in these products. Women who are experiencing food insecurity due to lack of food choices can also be at a disadvantage. Eating raw, fresh foods and maintaining a steady level of hydration are suggested as guidelines for women who may not be able to follow exact recipes or food lists [4].

Targeted exercise and physical therapies can also be beneficial. Although conflicting research exists suggesting some pelvic exercises may be uncomfortable for women experiencing endometriosis, increasing movement can have both physical and mental health benefits. Anti-gravitational exercise such as using inversion machines or participating in hot water interventions may also be beneficial when symptoms also pair with joint pain or pressure when standing. These may have the added benefits associated with coping strategies for chronic pain, as will be discussed, as well as the endorphin-release associated with exercise. One such reason that exercise may serve as a remedy for chronic pain is osteopathy acknowledges that the buildup of toxins and inadequate circulation, as well as physical limitations of a body to flex, reflex, and move properly, can cause additional pain. Further, reducing nerve and muscular pain can help women with endometriosis visualize and verbalize their centers of pain. In turn, this can relieve discomfort associated with other conditions, so that they can more effectively pinpoint that associated only with their disease [16].

Further, exercise focusing on abdominal muscles and the pelvic floor have also had a positive impact for some women suffering from endometriosis. This includes strengthening the core through modified sit-ups and leg lifts while laying on the side, as well as fortifying the vaginal muscles through Kegels and other pelvic work. This is important for women who also experience painful sex, as learning to control these muscles can be an important part of gaining some comfort back during these activities. Yoga is often recommended because it offers controlled stretching and accompanying meditation as part of both a mind-body approach. Swimming is also helpful for those who may not be able to engage in any weight-bearing exercises. The relationship between exercise, endorphins, and refocus is also important, as this refocus is also the target of hypnosis. If exercise that alleviates pain enables a woman to feel stronger and more in control of her body, she may adopt exercise as part of her overall health regimen, which may have additional positive effects such as weight loss. The association between exercise and weight loss also has an impact on the prevalence of chronic diseases, such as hypertension, coronary heart disease, and diabetes. Thus, exercising can also help to diminish symptoms associated with these diseases such as edema, inflammation, respiratory distress, and high blood pressure. Further, weight loss can be beneficial when combating endometriosis because excess abdominal weight may cause inflammatory triggers of the disease. It is also important to note that some exercises such as pounding exercises like running are not recommended, as it can trigger spasms and lead to inflammation in the hips, which can cause increased pelvic pain.

In addition to exercise, abdominal massage, acupuncture, acupressure, and pelvic floor massage are also techniques for alleviating the pain and pressure associated with endometriosis. Abdominal massage can help to alleviate spasms associated with endometriosis flare-ups, as well as break up scar tissue masses that are close to the skin. It is important to find therapist familiar with endometriosis or other gynecological abnormalities in women, so that the massage is a targeted and positive experience. It should not cause additional pain. Acupuncture works by activating certain pressure points to Rebalance the body by activating energy channels that may be blocked, asserting that this imbalance can “be a cause of illness” and pain [4]. Much like exercise, acupuncture is associated with the release of endorphins [2]. From Arvigo Mayo abdominal massage to health therapy, these techniques increase “proper blood flow to the abdominal cavity,” increasing circulation that can decrease inflammation hot spots [15].

Holistic practices such as the use of Traditional Chinese Medicine (TCM), Ayurvedic detoxification, cleansing, and both topical and ingested essential oils are all discussed as alternative treatments to pharmaceutical intervention [15]. There can be negative assumptions and perceptions regarding the use of homeopathy. These perceptions tend to stem from the belief that early practitioners were white witches and often resulted in fear from those with little understanding of the practice of using herbal medicine to treat ailments and disease. The same lack of understanding and association is true of spiritual healers, which are common in some other parts of the world. Practitioners of traditional or old medicine may have underlying mistrust of modern medicine and vice versa. There is also the “[assumption among doctors] that biomedicine is the most advanced and correct way to heal,” disregarding important, relevant, and effective practices that may be tradition in certain societies [17]. As such, there is a strong connection between distrust of public health, lack of reporting, and lack of care, that needs to be addressed, particularly among populations that may want a more collaborative intersection between familiar and new, natural or pharmaceutical, or ethno medicine and biomedicine.

Essential oils can be a powerful tool in creating an environment conducive to relaxing and promoting positive energy and mental health. The use of certain herbs and essential oils in homeopathic medicine such as bergamot, cypress, fennel, clary sage, and geranium, are attributed to improving the well-being of women suffering from menstrual pain. These oils are used in a diffuser or topically with a carrier oil, but they are not ingested. It is important to understand the dosages and toxicity of each of these oils to better understand any side effects and drug interactions, and to understand when it may be harmful to use them like during pregnancy.

Like anyone who learns how to cope with chronic pain, women who suffer from endometriosis can benefit from counseling. Along with talking to mental health professionals and others experiencing the same disease, calming techniques, such as deep breathing, meditation, relaxation, trigger avoidance, pain disassociation, and refocusing, can be powerful tools to reducing some feelings of negativity, isolation, and sadness associated with having persistent pain and a lifelong disease. Psychiatric help may be especially helpful for women who suffer from clinical depression from endometriosis. The acknowledgement that their emotions and depression are real can also be an important tool for living with the disease [4]. Further, hypnosis may be also been an effective tool when combating endometriosis. Hypnosis aims at reducing pain and creating disassociation by using cognitive transfer and visualization to cope with situations in which pain may be more prevalent such as during sexual intercourse. Sex can be a painful symptom of endometriosis, as well as a source of tension in relationships. Through hypnosis, women learn to transfer the discomfort of pain, as well as the potential fear of engaging in activity that can cause pain, to constructive thought and “reframing of pain situations” [18].

Sociological and Psychological Importance of Support

The psychology of the invisible, misunderstood, and misdiagnosed disorders of women is both a psychological and theoretical barrier to good health, and it can lead to adverse mental health conditions.

As described previously, the barriers to women being understood and being believed are manifold, including lack of empathy and representation in healthcare, as well as the inability or limitations in the conveyance of pain. The ability to describe and measure pain is an indicator of health literacy. Thus, the use of pain charts and diagrams can be helpful tools for women because it provides women with a way to describe pain as “shooting, stabbing, sharp, to tender, blinding, intense.” Additionally, drawings can help women visualize and convey from where their pain is radiating [4].

The believability and validation of women experiencing endometriosis pain can have a powerful effect on their mental well-being. In a societal environment that values strength and powering through pain, many women suffering from this disease may feel alienated, avoided, and treated with impatience, when their symptoms prevent them from being able to engage in and enjoy normal, daily activities.

Aside from the theoretical assertion that society may, over time, have become desensitized to the pain of others, personality characteristics of women are often stereotyped, asserting that those suffering from chronic pain are exaggerating or that it is normal to experience some level of menstrual pain.

When women already feel medical bias and discrimination in medicine, stigma can contribute to the physical and psychological pain of endometriosis. Women have reported difficulty in describing symptoms of female reproductive discomfort and pain, from premenstrual syndrome to the intensity of labor in childbirth. Naturally, these descriptions vary between individuals, in both scope and variety. This variation alone can cause professionals to discriminate between women, potentially asserting that one woman is being too emotional or hysterical, while deciding that the woman whom is able to more effectively articulate her pain, as well as describe it with reasonable tolerance, and is the baseline norm. It does not help when many medical journals assert that “women’s illness are assumed psychosomatic until proven otherwise” and the consistent reporting of chronic pain and other symptoms, even related to the same underlying disease, is often construed as hypochondria [19].

Furthermore, women have faced stigma and stereotyping worldwide regarding their reproductive health, including the shame of having diseases that either affect their ability to engage in or enjoy sex, their ability to have children, the perception of their monogamy or health, and other reproductive diseases. For example, HIV in married, monogamous, heterosexual Latina women carries the stigma of infidelity, when it is their husbands who infect them after unprotected sex with prostitutes during periods of migratory work. The same stigma is true of women in Haiti, thus leading women to live with the disease in secrecy, silence, and shame. Theorists from Freud to Butler (2008) to Foucault assert that women’s power is closely associated with her ability to “assume [a maternal body]” which also devalues women who suffer from endometriosis and other gynecological diseases that may lead to infertility [20].

Another psychological and sociological aspect of endometriosis is the perception of inequity in the power between provider and patient, as well as the role health literacy plays in a woman’s understanding of both the disease and the treatment plan. Often, women feel inadequate and unable to advocate for themselves in these situations. Feminist theory asserts that lack of power can be derived from a sense of invisibility, and that women, in particular, can feel “too often not listened to and that we are misunderstood and treated callously, without regard for the social context of our actual lives,” with the latter also denoting a failure in medicine to address social determinants of health, namely access to effective treatments regardless of socioeconomic status and healthcare [21]. Women who carry additional responsibilities of family, work, and home may also experience feelings of inadequacy and guilt, and a higher loyalty to care of others than themselves, especially when it comes to time and money. Lack of both equity and agency of women and for women is an overall failure of certain healthcare and support systems, from medical to social.

Consequently, women may not always admit to a lack of understanding of the information or feel their questions are appropriate, particularly when questioning a treatment plan. In Coping with Endometriosis, Breitkopf, Bakoulis and Ballweg (1988) offer interactive conversation suggestions between doctor and patient to remedy this problem [22]. They assert that one may be too afraid to absorb information at that time and the provider should follow up the visit by phone, once the patient has had a chance to review or think about the information, as well as question if a procedure or pharmaceutical treatment is necessary and what other options may be available. They suggest that patients take notes during their interactions with professionals, as an effective tool for being the manager of their health. Power inequities also exist between patients of traditional and ethno medicine and medical doctors. This is because there is an assumption that the commonly prescribed or commonly practiced biomedical approach is the right one, and it can be treated as the only solution [17]. As such, both Farmer (2009) and Bastien (1992) assert the need for cultural sensitivity training for medical doctors to better understand the social determinants of health, gender roles, and health equity that are relevant when treating diseases such as endometriosis [23].

The intersection of both physical and mental health is complex, particularly when coping mediation asserts a mind over body approach, which can feel like a dismissal of pain symptoms to women. Finding a practitioner or multidisciplinary support plan that can effectively marry the relationship between physiological and psychogenic pathologies of the psychological manifestations of pain can feel like validation, which is paramount to many women suffering from chronic disease [18].

Conclusion

The key assertion here is that endometriosis is still not only a widely misdiagnosed and under diagnosed disease, with limited long¬term, non-invasive treatment options which carries the isolation and depression of the under treated pain in women, but also that pharmaceuticals and surgical interventions are not universally effective or ideal for all women. Whether it stems from important intersections of social determinants of health or women who want to blend both traditional and holistic treatments for a more well-rounded approach to the disease, a multidisciplinary approach should not feel like a threat to a medical professional and become part of the conversation between provider and patient. As with other sources of chronic pain in women, we don’t know what we don’t know in terms of the most effective treatment methods, and some may resonate more with some women than others. In fact, there is no definitive research that suggests that any medical intervention works better than other treatment methods. Women of different cultural and spiritual backgrounds may feel that a treatment plan that resonates more closely with their belief systems may intuitively find that meaningful body and mind combination that alleviates some psychological barriers to wellness. Women concerned with the side effects of increased medications and chemicals, the potential for dependency on pain medication, or the long-term infertility or stroke potential of birth control, may want a clean slate approach to understand the baseline symptoms of pain without those interventions. They may then choose to strategies that modify their diet to exercise until these symptoms begin to decrease. Women who feel unheard or unsupported in their disease may benefit from counseling and support that may make them feel more empowered to self-advocate, whether it be to vocalize their needs within their families and friends or to assert themselves with their practitioners.

The call for a multidisciplinary approach is not unique to endometriosis. Further, the lack thereof is a consistent failure of healthcare to acknowledge not only the symbiosis of varied treatments, when used in a purposeful, intentional, and meaningful way, but also that the one size engendered medical approach does not work for everyone. The intention of holistic medicine is not to sell snake oil. Rather, it is to admit to the lack of research in the field of holistic treatments, especially within United States healthcare, and the potential for treatment success for those offered a varied, interactive approach. Women who feel that medication and surgery was thrust upon or done to them, particularly in cases of total hysterectomy, versus mediation that they in full understanding or complicity, can be left with further feelings of powerlessness and inadequacy [24-38].

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