Evidence of meeting #92 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was surgery.
A video is available from Parliament.
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
That's also a very good question, because everybody feels pain differently. Depending on where the endometriosis occurs, if it affects the nerves; then it can cause different pain as well.
What I can say is that, when somebody doesn't respond to anti-inflammatories such as Advil plus Tylenol, the first line is birth control. With both of those, if they continue to have debilitating pain, that is when they need to be investigated further with imaging and see a specialist.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
Thank you so much.
Dr. Jolly, I want to move over to you because I want to talk about menopause and the early menopause that endometriosis can cause.
Menopause is usually in that 50 age range. When would you start seeing women who have endometriosis start going into an early menopause? Are we talking about 35 or 40? What's the age group?
Professor Emeritus, Department of Obstetrics and Gynecology, University of Ottawa, As an Individual
Premature menopause is defined as menopause that occurs before age 40. We know that. Ages 40 to 50 is the perimenopausal range. Most of the patients with endometriosis who enter into menopause have to have ablation surgery, which means having a hysterectomy and their ovaries out. If they are lucky, any endometriosis is completely removed. That is not so difficult to treat, because you can put this patient on low-dose estrogen to prevent the ravages that can occur that I talked about with regard to cardiovascular disease, stroke, osteoporosis, etc.
When somebody is in menopause because they've had severe endometriosis and have had surgery, which is a surgical menopause, that can occur any time. These wonderful surgeons can tell you that once in a while they have to do it between ages 20 and 30—hopefully not very often, because we're getting better and better. Certainly, in the olden days, it was more common, so we are making ground on that.
Let me just say, listening to all of this, that you must understand that endometriosis is a condition that is stimulated by estrogen. Women produce estrogen every month. At ovulation, they produce progesterone, which can temper it.
If you control this estrogen, it is important to realize that it's a lifelong treatment. You diagnose endometriosis as an adolescent. You treat it appropriately because you suppress the estrogen. You can make it so that the patient doesn't have any periods at all, which is quite wonderful. Not everybody believes that is holistically good, but that's a different thing.
Conservative
Karen Vecchio Conservative Elgin—Middlesex—London, ON
Dr. Jolly, I want to ask a few more questions specifically on this.
We talked about bowels being affected by this. You just mentioned early menopause. A lot of other things can happen to a woman.
What are some of the other impacts or effects if a diagnosis of endometriosis is delayed? What are some of those other impacts to women's systems that you see?
Liberal
Professor Emeritus, Department of Obstetrics and Gynecology, University of Ottawa, As an Individual
Okay, I'll try.
There are issues regarding cognitive function—fear, depression, anxiety, living with the fear of the pain every month and the sequelae of that. It's gritting your teeth when you have sexual intercourse and not having the ability to have a comfortable bowel movement. These pains are very difficult. When imprinted on that woman, they can do a huge amount of damage so that you need your psychologist, you need counsellors, and you need help from the holistic point of view. If untreated, it can result in losing your uterus and your ovaries.
Liberal
November 29th, 2023 / 9:15 p.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you, Chair.
Thank you to all of the witnesses for your insightful testimony.
I want to build on Ms. Vecchio's questions. According to a study published in the National Library of Medicine, anxiety disorders and depression are more frequent among women with endometriosis than in the general population.
Can you please talk about the importance of an approach with psychotherapy or counselling?
Dr. Jolly, you can start, then, Dr. Nguyen, you can add on.
Professor Emeritus, Department of Obstetrics and Gynecology, University of Ottawa, As an Individual
It must be nipped in the bud so that you have, with the early diagnosis, that support system from an empathetic, kind physician, who understands and doesn't normalize it and say, “There, there, that's what women have to have. Go and get pregnant and that will take care of everything.” That is not the answer.
You need support in the home. You need the parents and the significant other to be part of this whole treatment, with timely referral to an appropriate counsellor, psychologist or possibly even a psychiatrist, because we certainly have seen women have severe effects and take their life. There's data to support this.
You bring up something that's very important, and it's the whole approach. Because that woman isn't going to be going right now to the big centre; she needs her family doctor to support her, the specialist to support her, and she needs to be able to reach out to the other community members to know they are all looking after her.
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
Yes, thank you for bringing up mental health as one of the big concerns, because it is. It is under-represented and undertreated.
In our centre, we try to have physiotherapists come on board with us as well. We had several back-and-forth discussions because they were all very interested in the subject and wanted to help. The first question they asked us was, do you have funding? For us, we managed to get funding through generous patient donations and the foundation. Through those we were able to fund a nurse navigator role for us. Then in the next steps we have several things that we have under the budget, but a psychotherapist was definitely one of them.
In Quebec, and I think in most of Canada, psychotherapy is not covered, so you need to be privately funded. It would be approximately $150 to $200 per session.
While I don't think this is an elective thing, I really do think it's mandatory and essential. Again, it comes down to the fact we're now able to recognize this and know that it is important, but how do we get the funding to people to help these women to get the help for their mental health?
Liberal
The Chair Liberal Sean Casey
Ms. Sidhu, I think Ms. Wahl wants in on this discussion.
Ms. Wahl, please. You're on mute.
Executive Director, EndoAct Canada
We couldn't go one meeting without someone being on mute.
I just want to say quickly that I think when you speak with people who have endometriosis, a lot of the mental health concerns they experience come from being disbelieved by their health care providers, by their families, by their friends, by their communities. A lot of the burden comes from that.
I think in addressing some of the delayed diagnosis issues, we'll also have an opportunity to mitigate the effects on mental health—not completely but certainly, I think, in a significant proportion.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you.
My next question is about ovarian cancer and public awareness. There are several types of ovarian cancer, which account for 140,000 deaths each year, making it the fourth-largest cause of cancer death in women. How can we enhance public awareness about endometriosis to ensure early recognition of the symptoms so that we can save lives? Then we heard about the $2.5 billion cost, which is a lot of burden on the health care system.
Dr. Nguyen can start.
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
Ovarian cancer is increasing in women with endometriosis. It is anywhere between one-and-a-half times to twice the relative risk of having cancer. It comes down again to the importance of imaging and being able to recognize it, because the first signs are typically seen on imaging, and being able to have the resources to follow these patients over time to make sure that cancer doesn't develop.
Liberal
The Chair Liberal Sean Casey
Thank you, Ms. Sidhu.
Next, we'll go to Ms. Roberts, please, for five minutes.
Conservative
Anna Roberts Conservative King—Vaughan, ON
Thank you, Mr. Chair.
I have a question and I'm not sure if anyone has the answer for it. How many pelvic floor physiotherapists are there and, if so, how well trained are they?
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
I'm not sure of the number.
Go ahead, please.
Obstetrician-Gynecologist, As an Individual
In Calgary, we have about 40, and to my knowledge, there isn't a qualifying certificate to call yourself a pelvic floor physiotherapist, but we do have a large number here.
Co-Chair, EndoAct Canada
In British Columbia, I think we're probably unique in Canada in having probably the most pelvic physiotherapists. Our physiotherapist told us there was a certificate she had to do to get that designation, although some may choose to call themselves that without the designation and without the certificate, because there's no governance of that, I believe. But there certainly are some extra courses they can do to have that expertise.
Conservative
Anna Roberts Conservative King—Vaughan, ON
I have another question, but I am not sure who can answer it.
Has endometriosis been related to cancer of the bowels?
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
It has not that I'm aware of. It's mostly ovarian or peritoneal cancer, which is sort of the lining that's near the bowels or the uterus.
Conservative
Anna Roberts Conservative King—Vaughan, ON
Okay. So would you say that if caught early enough, it would avoid the issue with the bowels?
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
It would most likely. As Dr. Nguyen said earlier, we don't really know the full natural history of endometriosis and the rate of change, and often we catch things late because of all the problems we've talked about for two hours. Definitely catching things early and intervening early can make an impact, which is why it is important to look at this.
Co-Director, Endometriosis Centre for the Advancement of Research and Surgery, McGill University Health Centre
For instance, some bowel lesions are small. Then they can be excised with a technique that spare the back of the bowel, versus once the lesion has gotten to be very large, then we have to do a larger resection of the complete bowel. So there are two different techniques. One is associated with half the risk of complication that you can see after. So, if you're able to pick it up when the lesion is still small, the patient can undergo a surgery that is less risky to the patient.
Conservative
Anna Roberts Conservative King—Vaughan, ON
I have another question.
I think, Dr. Jolly, you mentioned that 40% of people in Canada have endometriosis.