Endometriosis: A Hysterical History

Endometriosis: A Hysterical History

It's anything but funny.
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Leeches: so common a tool in medical history that for part of the 1800's, France was importing about 33 million leeches annually. With so many to keep track of, one journal advised doctors to count their leeches before and after a bloodletting for gynecological conditions — because a leech lost in a woman's uterus would cause not only extreme physical pain but also undue mental stress.

Yes, you read that correctly. Internal bloodletting. Leeches up the vagina. Aren't you glad to live in the 21st century?

By now, modern medicine understands that endometriosis is an extremely painful gynecological condition where cells from the endometrium — that is, the innermost layer of the uterus — show up elsewhere in the body. These growths of endometrial cells, also called ectopic lesions, cause infertility in affected women as well as inflammation and scar tissue wherever they grow. That scar tissue can turn into adhesions, sticking abdominal organs together (ow). This condition affects about one in ten women, which means a conservative estimate would be over 15 million people suffering from endometriosis in the United States alone. The only sure diagnosis is through laparoscopic surgery (inserting a camera to get a clear view of the lesions), and the only current treatment of the root cause (the lesions) is through surgery (deep tissue excision or total hysterectomy, which doesn't always help). Symptoms can be treated with painkillers and hormone therapy, but that's the same broad treatment for most gynecological conditions. Even with so many women affected, progress in understanding this disease has been slow.

A basic description of endometriosis was first given around the fifth century B.C.

The writers of the Hippocratic Corpus, of the fourth and fifth centuries B.C., narrowed down the symptoms of a gynecological disease to four main factors: pain, infertility, menstrual dysfunction and temporary relief with pregnancy. Although there was some suggestion that social class may influence the condition (that it was somehow only a condition of the upper class), these four symptoms would form a common thread connecting various seemingly distinct conditions with various names that wouldn't be connected in the medical field for thousands of years. Though we now refer to the condition as endometriosis, its most popular name for centuries was "suffocation of the womb" first coined by the Greek philosopher Plato (375 B.C.). According to him, this suffocation occurs because a uterus left too long without pregnancy starts to wander around the young woman's body, hungry for motherhood. If it wanders too far, the tubes get tangled and it is unable to breathe. Women so afflicted in ancient Greece would be treated with succession, the practice of tying the patient upside down on a ladder and shaking them until the womb returns to its proper location. The best prevention method they could come up with was to have girls get married and pregnant as soon as possible after puberty so as to satisfy this hungry and animalistic organ. This method of thinking about gynecological conditions likely contributed to the culture of early marriage for women throughout history and is actually still used in some parts of the world.

After about 500 years of descriptions of extreme pelvic pain causing convulsive fits, persistent infertility, organ adhesions and ligaments infiltrated with endometrial tissue, in the second century A.D., Galen of Pergamon concluded that on one hand, suffocation of the womb might be caused by menstrual blood flowing backwards and becoming anchored in the wrong organs (a theory still used today, called retrograde menstruation theory), and on the other hand, the condition is also likely psychological in nature because young widows simply must go mad after "their loss of sexual fulfillment."

Given centuries of medical research on this kind of pain... Meh, it's all in her head.

This was the first time that gynepathology was authoritatively linked with psychology (though the Hippocratic Corpus also vaguely suggested a link), and it was far from the last. From this seed of thought, the idea that women in chronic, invisible pain are just crazy would persist for millennia. Women would be labeled hysterical, blamed for their conditions, locked in madhouses that civilians visited for entertainment, and treated with shock therapy.

But that's up to the 19th century — let's not get ahead of ourselves. We wouldn't want to miss witchcraft and demonic possession, right?

She's a witch, and she's a witch, and she's a witch...

During the Middle Ages — or the Dark Ages of Europe — the supernatural found its way into the scientific scene. Whether a convulsive fit of pain was blamed on the woman herself being possessed, who was then exorcised, or was blamed on the neighbor across the street, who was then sent to the pillory or executed on charges of witchcraft, women got the worst of this new companionship between the mystic and the medical. Despite new observations on the anatomy of suffocation of the womb, such as an association with ulcers, treatments developed during the Middle Ages included those such as "shouting therapy" and other painful or torturous prescriptions with the idea that a malady like invisible pelvic pain is caused somehow by the woman's bad behavior, so the treatment must be karmic in response. We have to look elsewhere in the world for a bit of level-headedness. For example, it was Avicenna, the Persian polymath, who finally determined that pain was solely biologic and had zero medical benefits. Yet, with no cause of the chronic pelvic pain in sight, ideas of demons and magic as a cause of suffocation of the womb persisted through the Middle Ages and into the Renaissance. Occasionally, a physician would be called in as a witness during witchcraft trials, and it's known that Dutch physician Johannes Weyer and English physician Edward Jorden defended the women accused of witchcraft, insisting that the allegedly supernatural symptoms were in fact entirely natural conditions of the uterus.

The women were found guilty.

Women like them were found to be witches while, at the same time, physicians searched for a medically treatable cause of their ailment. There were two paths of research happening in parallel — some physicians, such as Thomas Sydenham, began to flesh out theories of a psychological cause of "hysteria," while others, like William Harvey and Johannes Vesling, looked to autopsies for a physical source of suffocation of the womb. Both of these paths would develop into the 20th century, and it appears that the treatment a woman got depended on whether she was recommended to a physician or a psychologist for her symptoms.

Physicians and psychologists gave wildly different treatments, but both would appear to have hundreds of years of research backing up their conclusions.

Women diagnosed with hysteria were held in the worst of mental institutions, including the infamous St. Bethlehem Hospital (commonly known as Bedlam), where they were physically restrained with chains and straitjackets. In France, many were held at Salpêtrière outside of Paris. The "hystero-epileptic" ward was entirely comprised of young women, the vast majority complaining of ovarian pain, yet even when the famous French psychiatrist Jean-Martin Charcot visited and made note of this common thread that should have pointed to a gynapathological condition, he concluded that the condition was psychiatric in nature. There was no reason, it seemed, to stop sending these "hysterical" women to the worst of prisons: mental institutions of the 19th century.

Meanwhile, physical signs of endometriosis were noticed most clearly in 1852 by Edward Tilt and in 1858 by Armand Trousseau, who identified the lesions on a macroscopic scale, and named the disease "catamenial hematoceles." It was finally in 1860 that Karl von Rokitansky discovered microscopic signs of endometriosis. Looking at strange tissue growths and uterine polyps, he noticed striking similarities between the growths and the characteristics of endometrial tissue, specifically the presence of glands that should only be present on the tissue inside of the uterus. These findings would be confirmed (or re-discovered) in 1921 by John Sampson, who would then coin the term "endometriosis" in 1927. Importantly, in 1887, Franz Wickel was the first to realize that it was women with very small endometriotic lesions who were most likely to be diagnosed with hysteria and sent to mental institutions, as the lesions were virtually undetectable.

20th century progress (mostly).

In the 1900's, a woman with pelvic pain but no clear cause could still be referred to psychiatrists, but progress in treatment and public awareness was rapidly increasing. Hysterectomy and specific nodule removal surgeries became more advanced with the introduction of non-video laparoscopy in the 1940's. In the 1950's, pelvic exams, previously considered a vulgar suggestion in the United States, became a common procedure with the rising awareness of cervical cancer and the introduction of the Pap smear. It was also in the 1950's that, with the vision of Margaret Sanger, the funding of Katharine McCormick, and the science of George Pinkus that the hormonal contraceptive pill was first introduced, and women with endometriosis were some of its earliest recipients. Unfortunately, the pill at that time used such high doses of estrogen that its side effects included cancers. Research didn't always move forward, though. In 1949, an investigator brought back theories from ancient Greece when he asked, "Is endometriosis principally a disease of the higher social and economic levels of society?"

Video-assisted laparoscopy was developed in the 1970's, and over time the cameras became smaller and the surgeries more precise. While surgical precision and awareness of rampant misdiagnosis have increased in the last few decades, there is still much confusion over the best treatment options for endometriosis. With only laparoscopy as a diagnostic, there is an average of seven years between the onset of symptoms and a diagnosis of the condition. Treatments now include full hysterectomy, deep tissue excision and hormone treatments — none of which tend to work on the first try. This leads women to get multiple surgeries in attempts to treat their chronic pain. Even as recently as 1995, reports have shown that over 50 percent of women complaining of chronic pelvic pain were told there was no "organic" basis for their complaints, thus leaving them forever untreated, or labeling them mentally unstable, or they're even recommended pregnancy as a treatment — the same archaic conclusion as thousands of years ago.

After thousands of years of ambiguity and belittling, it's clear that more information is needed about endometriosis.

Frustratingly, some recent researchers purport to quantify the relative attractiveness of women with endometriosis, or characterize personality traits of women with pelvic pain.

However, many researchers are taking steps in useful, foundational research, working out the molecular markers of the condition, some of which might be treatable with prescription drugs or be useful as a diagnostic red flag as an alternative to laparoscopy.

Cover Image Credit: Medarus

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To The Teacher Who Was So Much More

Thank you for everything
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I think it's fair to say that most people remember at least one teacher who had a lasting impact on them. I have been incredibly lucky to have several teachers who I will never forget, but one individual takes the cake. So here's to you: thank you for all you have done.

Thank you for teaching me lessons not just in the textbook.

Although you taught a great lecture, class was never just limited to the contents of the course. Debates and somewhat heated conversations would arise between classmates over politics and course material, and you always encouraged open discussion. You embraced the idea of always having an opinion, and always making it be heard, because why waste your voice? You taught me to fight for things I believed in, and to hold my ground in an argument. You taught me to always think of others before doing and speaking. You showed me the power of kindness. Thank you for all the important lessons that may not have been included in the curriculum.

Thank you for believing in me.

Especially in my senior year, you believed in me when other teachers didn't. You showed me just what I could accomplish with a positive and strong attitude. Your unwavering support kept me going, especially when I melted into a puddle of tears weekly in your office. You listened to my stupid complaints, understood my overwhelming stress-induced breakdowns, and told me it was going to be okay. Thank you for always being there for me.

Thank you for inspiring me.

You are the epitome of a role model. Not only are you intelligent and respected, but you have a heart of gold and emit beautiful light where ever you go. You showed me that service to others should not be looked at as a chore, but something to enjoy and find yourself in. And I have found myself in giving back to people, thanks to your spark. Thank you for showing me, and so many students, just how incredible one person can be.

Thank you for changing my life.

Without you, I truly would not be where I am today. As cliche as it sounds, you had such a remarkable impact on me and my outlook on life. Just about a year has passed since my graduation, and I'm grateful to still keep in touch. I hope you understand the impact you have made on me, and on so many other students. You are amazing, and I thank you for all you have done.

Cover Image Credit: Amy Aroune

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10 Things Economics Majors Want You To Know

For the MOST part, it isn't that bad.

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I decided to become an economics major the day I started college — I know, it wasn't easy for me to decide. Well, technically the real reason why I even chose the major to begin with was that I was undecided when applying for colleges. I was, and still am, an indecisive person.

When I saw economics as one of the majors at Stony Brook, I thought it was something I was interested in. After all, it was the "study of markets and the behaviors of people in that same market." Besides psychology and philosophy (the two majors my parents didn't want me to study), I then chose econ. While it wasn't a piece of cake, it wasn't too challenging either. Here are a couple things we all want so desperately to say.

1. It's not all math, don't worry

While so many people tend to think that economics is all math and no fun, I beg to differ. As I mentioned above, it is the "study of the behavior of people in the market," so while it is equations and statistics, it is also observing how people treat prices and products.

2. It's not difficult to understand

I don't understand why parents think that if you're majoring in econ, you're pretty much signing up to fail all your courses. If they actually took the course, they would understand that it isn't the economic theory you need to understand, but how people react to changes in the stock market.

3. Majoring in econ isn't the same thing as majoring in business

When I tell people I'm an econ major, they immediately say, "Oh, business?" And then I squeeze the urge to yell in their face that I said "ECON, ECON, NOT BUSINESS." Then they continue to say they know someone that majors in business, and then ask if I know the person. The annoyances then continue. Econ is the study of markets. Business is the study of being an entrepreneur. Totally two different things. Yes, they are co-dependent, but they are not the SAME thing.

4. Please don't rely on me to do your taxes or calculate tips at a restaurant

I hate it when everyone just stares at me when the check comes. I regret telling people I'm an econ major at that point. Because I don't know how to tell them I don't learn how to do taxes or calculate tips in class, that's what finance majors do. AGAIN, not the same thing.

5. I know most of us are Asian, but don't be racist

Don't come up to me, ask me what my major is, and automatically assume that I'm an international student. It really sucks. I have to then correct them and say I'm not, and then have them walk away.

6. One of the prime motives is because we want to learn game theory

How we play games is vital to econ majors, and it does involve heavy readings of game theory books.

7. We mostly won't do econ during grad school

Because grad school is a time where we want to actually exercise our skills, it isn't a time to dawdle and major in the same things as we did in undergrad. We're actually adults by then, and we most likely will resort to marketing, sales, or advertising agencies. At least I want to work at Instagram HQ someday.

8. Our classes never have curves

Finals season is always tough on us because it just means we gotta put in three times as much work to memorize formulas, theories, and math terms. Have mercy on our souls. Most professors aren't even nice enough to bring up our grades or give us extra credit.

9. The TAs are too busy with work to help us

Even they understand econ isn't a breeze, and as TAs, they can't really explain stuff to us that they don't understand either. In fact, most of the stuff we learn in class are self-taught, usually late nights with Starbucks coffee.

10.  We actually hate business majors

Because they have it easy. And they don't need math. Everything they do is easy peasy lemon squeezy.

Not gonna lie, I love being an econ major. But some cons can be too much and it does teach me not to do econ in grad. One thing is for certain though, I love what I do and I don't regret choosing it.

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