Can Aromatase Inhibitors and/or Surgery Relieve Endometriosis in Women?

Feature Image of artistic depiction of female pelvic area in pain due to endometriosis sourced from:

Dear Pain Matters readers,


Hearing about women like Jessica Hirst inspired me to write this blog post today:

Jessica Hirst (28), a mother of a baby boy, has endured severe pelvic pain due to aggressive endometriosis since she was 11 when her periods started.


Jessica and her family


Quoting Jessica:

‘It feels like someone is stabbing me repeatedly in the abdomen.  I get a constant burning pain.  There’s an aching that starts in my lower back and comes right down through my legs … it feels like there’s a bowling ball in my uterus.’

Unable to work due to pain, Jessica relies on her husband as her full-time carer.  Despite her excruciating pelvic pain, Jessica finds joy and happiness in their 18-month old baby boy.  Jess is urgently in need of treatment.

Source:  ‘It’s like someone’s stabbing me in the abdomen.’ – Jessica has been in pain since she was 11 (by Gemma Bath, 18 April 2019).


Endometriosis is a painful disorder that affects up to 10% of all women of child-bearing age.  This includes approximately 1.5 million women in the UK and 176 million women worldwide.

Furthermore, 71% to 87% of all women with chronic pelvic pain plus 38% of all infertile women have endometriosis.

Endometriosis occurs when the tissue similar to the lining inside the uterus (i.e. endometrium) grows outside of the uterus.  This tissue may be found on the ovaries, fallopian tubes, tissue lining the pelvis (i.e. pelvic peritoneum), ureter, bladder, bowel and recto-vaginal septum.  It has even been found in the lungs and diaphragm in rare instances.

Endometriosis can cause severe pelvic pain during periods, ovulation and/or sex.  Heavy and/or irregular menstrual cycles, infertility, low energy levels, poor sleep and fatigue result.  Symptoms vary depending on where the rogue endometrium grows.  This can affect the women’s overall health and well-being (Amsterdam et al, 2005).



Women often suffer years of pain before they are finally diagnosed with endometriosis.  It takes 7.5 years on average before endometriosis is diagnosed.  This is because the pain and other symptoms are all-too-often dismissed as ‘normal’ and ‘not serious’.

Endometriosis is diagnosed via biopsy obtained during diagnostic laparoscopy.  This involves keyhole surgery under general anaesthetic.

Treatment Options

Endometriosis is said to be incurable (Howarth, 2019) …

… but is this always true??  Read on…

Several treatments exist that may offer relief from pelvic pain due to endometriosis:

  • Oral contraceptives;*
  • Aromatase inhibitors (e.g. letrozole, anastrazole); and
  • Surgery (excision) to remove endometrial tissue that grows outside of the uterus.

Whilst excision of endometriosis may offer pain relief in some women, multiple surgeries may be required.  Furthermore, there is a risk of recurrence.  Finally, surgery is more invasive than treatment involving aromatase inhibitors.

Studies suggest that aromatase inhibitors (e.g. letrozole; anastrazole) may reduce masses hence leading to relief from pelvic pain due to endometriosis.

Aromatase inhibitors have been used to treat postmenopausal breast cancer patients for over 10 years.


(1) An American Study (N=10) Involving Aromatase Inhibitors (Letrozole)

An American study found that aromatase inhibitors (letrozole) significantly reduced pelvic pain due to endometriosis in 9 of 10 patients.

Ten (10) premenopausal patients with endometriosis who had undergone surgical and medical treatment were selected for this study.

Endometriosis was confirmed via biopsy obtained during diagnostic laparoscopy.

Oral treatment of letrozole, together with norethindrone acetate, calcium citrate (to minimize bone loss) and vitamin D (to strengthen bones), was offered daily for 6 months.

Second-look laparoscopy was done following letrozole treatment for 6 months.

The good news:

This 2nd biopsy showed nil endometriosis in all 10 patients.  Nada!  

Furthermore, pelvic pain due to endometriosis was significantly reduced in 9 out of 10 patients following letrozole treatment for 6 months.  Bone density appeared unaffected.

In conclusion, letrozole may offer effective treatment for endometriosis (Ailawadi et al, 2004).

(2) A 2nd American Study (N=15) Involving Aromatase Inhibitors (Anastrazole)

A 2nd American study led by the same doctor revealed that another aromatase inhibitor called anastrazole also decreased pelvic pain due to endometriosis.

Fifteen (15) premenopausal patients with endometriosis and pelvic pain were selected for this study.   

Oral treatment of anastrazole and oral contraceptive was offered daily for 6 months.  Anastrazole treatment led to suppression of estradiol levels.

The good news:

Fourteen of 15 endometriosis patients obtained significant pain relief following 6 months of anastrazole treatment.  Specifically, median pain levels were reduced by 55% while mean pain scores were decreased by 40%.

In conclusion, anastrazole may offer effective treatment for endometriosis (Amsterdam et al, 2005).


(3) A Young Italian Woman with Endometriosis Finally Found Relief from Severe Pelvic Pain Thanks to Letrozole (After Ovariectomy Failed to Offer Pain Relief)

A young Italian woman named ‘Maria’ (not her real name) with aggressive endometriosis finally found relief from severe pelvic pain thanks to daily oral aromatase inhibitor (letrozole) treatment for 9 months.

Maria had initially undergone a subtotal hysterectomy as well as removal of both ovaries in an unsuccessful bid to reduce pelvic pain.

Following 3 months of daily oral letrozole treatment, Maria’s pelvic pain including pain during sex was significantly reduced.  Her pelvic ultrasound showed nil endometrial tissue in the pelvis.  Maria’s bone density remained unchanged thanks to daily calcium and Vitamin D supplements.

Given these encouraging results, treatment was continued for another 6 months.

In summary, daily oral aromatase inhibitor (letrozole) treatment may relieve severe pain in young women with endometriosis (Razzi et al, 2004).

(4) The First Woman to be Successfully Treated for Endometriosis via an Aromatase Inhibitor (Anastrozole)

An American woman (57) named ‘Jane’ (not her real name) with aggressive postmenopausal endometriosis finally found relief from severe pelvic pain thanks to daily oral aromatase inhibitor (anastrozole) treatment for 9 months.

Jane had previously undergone a hysterectomy as well as removal of her ovaries and fallopian tubes.

Guess what happened next?

Jane’s pelvic pain completely vanished after 2 months of daily oral anastrozole treatment!

Furthermore, a large 30mm X 30mm X 20mm bright red vaginal lesion had reduced to a mere 3mm gray tissue after 9-month anastrozole treatment.

Bone density was however decreased by 6.2% following 9 months of aromatase inhibitor treatment.

Aromatase inhibitors may offer benefits including pain relief and substantial eradication of endometrial tissue (Takayama et al, 1998). 

(5) Two Sisters Successfully Treated for Severe Endometriosis via an Aromatase Inhibitor (Anastrozole)

Two sisters, aged 24 and 26, had undergone several minimally invasive surgeries (i.e. laparoscopies) that, unfortunately, failed to alleviate severe pelvic pain due to aggressive endometriosis.

Both women received oral aromatase inhibitors (anastrozole), oral contraceptives (for birth control), calcitriol (to minimise bone loss) and rofecoxib (for pain control) on a daily basis for 21 days followed by 7 days off (i.e. a cycle).  Six cycles were offered over 6 months.

Within only 3 months, pelvic pain and other symptoms of endometriosis were eliminated in both sisters.  These positive effects lasted over a year, post-treatment.  

There was nil evidence of endometriosis disease in one of the 2 sisters, as confirmed via laparoscopy done 15 months after treatment.

Bone densities remained normal in both sisters after treatment (Shippen & West, 2004).

(6) A Woman (55) Successfully Treated for Endometriosis via an Aromatase Inhibitor (Letrozole)

‘Joan’ (55) in Belgium (not her real name) underwent a total abdominal hysterectomy 10 years earlier.

Recently, Joan had right-sided sciatic pain that radiated down her right leg due to recurring endometriosis.  

A pelvic ultrasound confirmed an endometrial mass that compressed against her lumbo-sacral plexus.  This mass was 4cm X 8cm in size.   

A daily oral aromatase inhibitor (letrozole) was offered to treat this large mass.

After 12 months of letrozole treatment, Joan no longer had sciatic pain. Following 18 months of treatment, Joan’s mass had shrunk to only 1cm in size.  

Due to a successful outcome, oral letrozole was stopped after 21 months.

Recurring endometriosis may successfully be treated via an aromatase inhibitor (letrozole).  This is a less invasive treatment option than surgery (Fatemi, 2005).


An enzyme called aromatase is important in oestrogen production.  This enzyme is absent in normal endometrium in the uterus.

However, this enzyme is aggressively produced in endometriosis, an oestrogen-dependent disease.  Increased aromatase activity leads to high estradiol levels in endometriosis.

Being potent oestrogen blockers, aromatase inhibitors ‘starve’ endometrial tissue of oestrogen.  This leads to shrinkage, and in some cases, complete elimination of endometriosis.

Thus, in the presence of aromatase inhibitors (that block oestrogen production), endometriosis may shrink, and even vanish altogether, during daily letrozole or anastrazole treatment for a certain period of time.

Aromatase inhibitors exert their anti-oestrogen effects on ovaries and on endometrial tissue growing outside of the uterus (Bulun et al, 2001; Ailawadi et al, 2004; Bulun et al, 2004; Amsterdam et al, 2005; Fatemi, 2005).


In addition to oral contraceptives* and excision, aromatase inhibitors (e.g. letrozole, anastrazole) may offer effective treatment for endometriosis (Ailawadi et al, 2004; Amsterdam et al, 2005; Hofmann-Werther)

Isn’t this exciting?

If you know someone with endometriosis, please forward this blog post to her.


Wishing all pain patients inspiration, hope and empowerment,

Sabina Walker

PS From a patient’s perspective, Gabrielle Jackson’ book called Pain and Prejudice offers enormous insight into endometriosis (Jackson, 2019).



Sabina Walker, Masters Appl. Science (Neuroscience)

Blogger of Pain Matters (in WordPress)


Author of soon-to-be published book called Pain Matters 





(1) Howarth, Angus. Lack of cash hinders research into condition affecting 10% of women. The Scotsman (8 April 2019).

(2) Facts about endometriosis.

(3) Bulun, Serdar & Wood, Ros. Aromatase in endometriosis.

* (4) Endometriosis in adolescence. Women’s Health Queensland

(5) Hofmann-Werther, Amelie. Chronic pelvic pain and endometriosis. Middle East Medical.


(1) Jackson, Gabrielle. Pain and Prejudice – A Call to Arms for Women and their Bodies. Allen & Unwin (2019).

ISBN 978 1 76052 909 3


 (1a) Amsterdam et al. Anastrazole and oral contraceptives: a novel treatment for endometriosis. Fertility and Sterility (Aug 2005); 84(2), 300–304.


(1b) Ailawadi et al. Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate: a pilot study. Fertility and Sterility (Feb 2004); 81(2): 290–296.


(1c) Bulun et al. Aromatase and endometriosis. Semin Reprod Med (Feb 2004); 22(1): 45-50.

(1d) Takayama, K, Zeitoun, K, Gunby, RT, Sasano, H, Carr, BR, Bulun, SE. Treatment of severe postmenopausal endometriosis with an aromatase inhibitor. Fertil Steril (1998); 69: 709713.

(1e) Bulun et al. Role of aromatase in endometrial disease. J Steroid Biochem Mol Biol (Dec 2001); 79(1-5): 19-25.

(2) Razzi et al. Treatment of severe recurrent endometriosis with an aromatase inhibitor in a young ovariectomised woman. BJOG (Feb 2004); 111(2): 182-184.

(3) Shippen & West. Successful treatment of severe endometriosis in two premenopausal women with an aromatase inhibitor. Fertil Steril (May 2004); 81(5): 1395-8.

(4) Fatemi, Human Mousavi. Successful treatment of an aggressive recurrent post-menopausal endometriosis with an aromatase inhibitor. RBM Online (2005); 11(4): 455-457.


There are many support groups including:

(1A) Endometriosis – Perth Sisterhood of Support.

Above support group is run by endometriosis sufferers, Joanne McCormick and Monique Alva (see below story).

(1B) Hedley, Kate. ‘The bad days are shocking’: Fresh hope for endometriosis sufferers. WA Today (15 Dec 2017).




A Doctor and a Nurse who can Literally Feel Pain in Other People

Feature Image of Dr Joel Salinas sourced from:

Dear Pain Matters readers,


Most doctors and nurses have great empathy and compassion for their pain patients.

Dr Joel Salinas and Megan Pohlmann, a nurse, take empathy to a new level.  They literally feel pain, physical sensations and emotions in patients.  They have heightened empathy for others that may also be viewed as ’empathy on steroids’, ’empathy in overdrive’ or ‘ultimate empathy’.

Dr Joel Salinas and Megan Pohlmann have mirror touch synesthesia.  This is when a person can perceive someone else’s pain or tactile sensation.

For some mirror touch synesthetes, this can be a curse rather than a blessing.  These people may require long periods alone after being exposed to other people’s pain and emotions.  They may even become recluses in their own homes for fear of ‘sensory overload’.

Others including Dr Joel Salinas and Megan Pohlmann embrace their mirror touch synesthesia as a special gift to help others.  These people apply their unique neurological trait in their work and personal life, when appropriate. 

Joel Salinas, Neurologist

Joel Salinas (34) is a neurologist, writer, researcher and Assistant Professor of Neurology at Harvard Medical School.  As stated, he can feel pain, physical touch and emotions in other people.  This ‘mirrored touch’ ability is automatically triggered by sight.  For example, when he sees someone’s right arm being touched, he feels a touch on his left hand, like in a mirror.  

In Dr Salinas’ words:

[Having mirror touch synesthesia] blurs this boundary between the self and the other’ (Kalter, 2017).

[Mirror touch synesthesia] is as close as I can get to literally putting myself ‘in the other person’s shoes” (Salinas, 2017).

‘… Like I’m the reflection … It’s really like I’m a reflection … Mirror touch is … like an automatic, very physical, super empathy …’ (quoted from video, below).

For more insights into Dr Salinas’ ‘super power’, see his TED Talk dated 18 May 2018:


Two interviews with Dr Salinas are also available:

  1. What It’s Like to Have Mirror Touch Synesthesia (a 4-minute interview dated 13 Dec 2018) (; and
  2. Mirror Touch: Rare condition means Dr Joel Salinas feels what others feel (a 7-minute interview by Boston 25 News dated 25 May 2017) (

Finally, Dr Salinas is the author of a fascinating book called Mirror Touch: Notes from a Doctor Who Can Feel Your Pain. 

Megan Pohlmann, Nurse

As noted, Megan Pohlmann is a paediatric nurse who has mirror touch synesthesia.  This trait often enables her to feel other people’s emotions, pain and other sensations as her own. In her words,

‘If someone’s hurting, for instance, if they have a cut on their arm … when I visualise the injury, I’ll get a feeling on my spine that’s kind of similar to being on a roller coaster.  It’s that gut-dropping feeling … the electricity … shoots up my spine and out my arms and my extremities.’

See 7-minute interview called ‘Meet the nurse who feels other people’s pain – literally’.

Please note that Dr Salinas is also featured in this interview, together with Megan Pohlmann.

The Science of Mirror Touch Synesthesia

A study revealed that 45 of 2,351 (2%) psychology students had mirror touch synesthesia (Medina & DePasquale, 2017; University of Delaware, 2017).

Mirror neurons are said to underlie mirror touch synesthesia (Linkovski et al, 2017).

Prof Ramachandran, a respected neuroscientist, nicknamed these mirror neurons ‘Gandhi neurons’or ’empathy neurons’.  In his words:

‘… You are, in fact, connected not just via Facebook and Internet.  You’re actually quite literally connected by your neurons.  And there [are] whole chains of neurons around this room, talking to each other.  And there is no real distinctiveness of your consciousness from somebody else’s consciousness.’ 

See TEDIndia by Prof Ramachandran called The neurons that shaped civilization (2009; a 7-minute video):


A question:

As noted, Dr Salinas’ ‘mirrored touch’ ability is automatically triggered by sight.  For example, when he sees someone’s right arm being touched, he also feels a touch on his own left hand – just like in a mirror.

Could Dr Salina’s experience with mirror touch synesthesia offer certain insight into why mirror therapy may offer relief from phantom limb pain in many amputees? 

See my 4 blog posts for further details on mirror therapy including:

Mirror Therapy for Relief from Phantom Limb Pain Inspired By Professor Ramachandran


This world is lucky to have many doctors, nurses and other medical clinicians who show empathy and compassion for their patients.

The fact that some doctors and nurses can literally feel their patients’ pain may be one of the highest levels of empathy.


Articles and Book 

Joel Salinas, Neurologist


(1A)  Love, Shayla. The Anatomy of Empathy. Vice (8 May 2019).

(1B) Salinas, Joel. I’m a doctor with a rare neurological condition: I can literally feel your pain. Quartz (30 April 2017).

(1C) Carlton, Lindsay. A doctor who can feel his patient’s pain. Fox News (26 Apr 2018).

This article includes a 7-minute interview with Dr Joel Salinas:

Mirror-touch synesthesia: A doctor who can feel his patient’s pain

(1D) Ridley, Jane. This doctor can really feel your pain. New York Post (18 April 2017).

(1E) Angley, Natalie. This doctor can feel your pain. CNN (16 June 2017).

(1F) Kalter, Lindsay: This doc can feel your pain. Boston Herald (3 May 2017).

(1G) Salinas, Joel & Lee, Samantha. What It’s Like to Have Mirror Touch Synesthesia. The Cut (13 Dec 2018).

(a 4-minute interview with Dr Joel Salinas dated 13 Dec 2018)

(1H) Mirror Touch: Rare condition means Dr Joel Salinas feels what others feel

(a 7-minute interview with Dr Joel Salinas by Boston 25 News dated 25 May 2017)

A Book by Dr Joel Salinas

(1I) Salinas, Joel. Mirror Touch: Notes from a Doctor Who Can Feel Your Pain. HarperOne (18 Apr 2017); 320 pages.

ISBN-10 0062458663

ISBN-13 978-0062458667

ISBN 0062458663

Megan Pohlmann, Nurse


(1A) Kelly, Megyn. Meet the nurse who feels other people’s pain – literally. Today (11 April 2018).

(1B) Seaberg, Maureen. Meet the Nurse Whose Superpower Is Feeling Your Pain—Literally. Glamour (1 Mar 2018).

(1C) Nuñez, Gabriella. People You Should Know: Megan Pohlmann and her world of many colors. krcgtv (14 May 2018).

Peer-Reviewed Papers

(1A) Linkovski et al.   2017). Mirror Neurons and Mirror-Touch Synesthesia. Neuroscientist (April 2017); 23(2): 103-108.

doi: 10.1177/1073858416652079

(2A) University of Delaware. ‘I feel for you: Some really do: Researchers examine unusual condition of mirror-touch synesthesia.’ ScienceDaily (6 Feb 2017).

(2B) Medina J & DePasquale C. Influence of the body schema on mirror-touch synesthesia. Cortex (2017);  88: 53.

doi: 10.1016/j.cortex.2016.12.013

The Gall of Gallstones to Cause Pain

Feature Image sourced from:

Dear Pain Matters readers,


You may have heard a friend or family member say that they have an intense pain in their chest, upper right or mid abdominal area, just below their breastbone.  Alternatively, they may feel pain in their back, right shoulder blade or in between their shoulder blades.  They may feel sweaty, nauseous and an urge to vomit.  They may have to lie down due to pain, especially after a rich and fatty meal.

Patients may not understand why this is happening to them.  Could it be back pain, indigestion, ulcers or irritable bowel syndrome (IBS)?  Or are they simply over-reacting to a spicy meal?

What they do know though is that their pain is severe and repetitive.  This pain may last anywhere from a few minutes to several hours.

Here’s a thought:

Could gallstones* be responsible for the pain?  If yes, then the severe pain attacks will likely persist until properly treated.  Imaging via ultrasound, CT and/or MRI is necessary to rule out the possibility of gallstones that may otherwise lead to a blockage in a duct or gallbladder inflammation (cholecystitis).

If present, gallstones (and gallstone pain attacks) usually do not go away on their own.  Surgery to remove the gallbladder may be necessary.  Alternatively, if only 2-3 gallstones are present, shock wave treatment plus medication may offer relief from pain (although there is a risk of recurring gallstones) (more later).


Denise Fernholz, Germany 

Denise Fernholz, an editor in Germany, had severe pain attacks for 4 long years. Despite exclusively seeing her family doctor for 4 years, her symptoms were never taken seriously nor was any ultrasound test ordered.  As such, Denise had no idea that excess gallstones were the cause of her excruciating pain.

Denise first felt an intense pain emanating from her breast area when she was 17.  She attributed this pain to her tight-fitting bra.  However, her pain only became worse after she removed her bra.  Panicking, she thought she was having a heart attack.  She felt better after laying down for an hour or so.

After her doctor ruled out any cardiac issues, it was thought that she may have done something to her back.  Unconvinced, Denise hoped for the best anyway.

However, the severe pain attacks kept returning.  Her pain attacks were so unbearable that they rendered her bedridden during these episodes.  Denise felt like she was going to die.  Her parents always wanted to call an ambulance but Denise resisted.  By now, Denise was convinced that she was ‘only suffering from back pain’.  She was worried about being ridiculed by paramedics for ‘calling an ambulance for back pain only’.

Instead, Denise continued to see her family doctor who regularly performed his manual adjustments.

One day, Denise had an MRI that, sadly, did not elucidate the cause of her pain.

As such, Denise was told that ‘her pain was likely psychosomatic’.  She was asked if she had a lot of stress in her life.  Alternatively, ‘did she do drugs?’  Her answer, ‘No.’  Denise was then asked, ‘Are you sure?’  Her answer, ‘Yes, damn it, I am sure!’  Denise added, ‘Can you please prescribe something stronger for my pain?’  

Denise thought that it seemed rather convenient to simply attribute pain as being psychological in origin if a doctor can not find anything wrong with a patient.

Nothing was offered other than Ibuprofen.  Denise felt that no one was taking her pain seriously.  Her doctors simply did not believe her.  

By now, Denise was in her early 20’s.

Denise’s pain attacks would often occur on special days such as birthdays or while away with her girlfriends.  After pizza, Denise would have to lie down in pain.  Then she’d go to the toilet to vomit.  Her concerned friends were tempted to call an ambulance.  However, by now, Denise had become accustomed to her pain attacks.  

Because she’d been told countless times that ‘her pain was due to back tension’, that she was otherwise healthy, that she was ‘merely imagining her pain’ and that ‘her brain was simply fabricating pain to avoid having fun’, Denise even started believing these so-called ‘reasons’ for her pain.

It was much later when Denise finally made a connection between pizza and pain.  

Until then, Denise’s doctor had prescribed gymnastics and sent her to an orthopedist.  Denise was urged to do more sport and given new insoles for her shoes.  She even bought a new mattress for her bed.

Guess what??  None of this helped with her pain attacks!  

Four (4) years went by.

At times, Denise was pain free for a month.  At other times, her pain attacks would occur several times in a week.  However, not once did Denise call an ambulance.

One day, Denise moved to another country to study.  She regularly returned home to visit her parents.  While home, she always returned to her trusted doctor for ongoing pain treatment.  Denise did not want to seek an alternative opinion from a new doctor or hospital for ostensibly back pain in a foreign country where she studied. After all, Denise had no reason to doubt her doctor’s opinion that she had back pain.

The turning point:

Despite being sceptical of alternative medicine, Denise was finally convinced by her friends to see an osteopath.  She felt strange when the osteopath placed his hands on her body.

Denise noted however that the osteopath was the first person to take time to do a proper medical history.  Denise told him about her pain, the vomiting and her doctor’s ‘diagnosis’.

Thereafter, the osteopath was quick to conclude that Denise’s pain did not come from her back, but rather, from her organs.     

During her next visit to her doctor, Denise insisted that he check her organs.

Then came the moment of truth!  An ultrasound clearly showed that Denise’s gallbladder was chockablock full of very small gallstones!  

Diagnosis:  Biliary colic, aka gallbladder attack or gallstone attack.

Because her gallbladder was full of very small gallstones, Denise would feel excruciating pain every time a gallstone would exit her gallbladder and force its way through the bile duct.*  Generally, this would occur after a fatty meal (e.g. pizza).  

Denise’s doctor thought that her newly-revised diagnosis was rather strange given that she was young and not overweight.

Denise, on the other hand, was ecstatic to have finally received a proper diagnosis after 4 long years of suffering due to pain attacks!  FINALLY, A CORRECT DIAGNOSIS!  YIPPEE!

Treatment:  Gallbladder removal surgery

While in hospital during her gallbladder removal operation, everyone was surprised by her gallstone story.  After all, even young, slim women and children routinely presented with gallstones these days.  Furthermore, gallstones were usually easy to diagnose via ultrasonography.

Denise was merely grateful that her gallstones were finally being removed forever.

The good news:

After 4 long years of sporadic and intense pain for ostensibly back pain, Denise finally received a correct diagnosis.  Shortly after, she underwent effective treatment involving surgical removal of her gallbladder.  This led to complete relief from pain (Fernholz, 2018).

Fiona Tapp, a British Freelance Writer and Educator based in the US 

Fiona Trapp first became aware of an intense pain in her breastbone after ordering a huge amount of Chinese food one day.  Thinking that her pain was due to eating too much, she went to lie down in the hopes that her pain would pass.  Instead, her pain got worse as it spread from her chest into her stomach and back.  Fiona felt as if an iron bar had impaled her from the front of her ribs and straight through her back.  Her then-boyfriend (now-husband) tried his best to help by massaging her in between her shoulder blade area.

While enduring excruciating pain for a few hours, Fiona thought that she was having a heart attack.  Fiona’s pain finally went away after vomiting and she fell into a deep slumber.

Sadly, this was not the last of her pain attacks.  Instead, these pain attacks arose at least once every 2 weeks over the next 5 years.  Her severe pain attacks in her chest, stomach and back would wake her up in the middle of the night.  As she cried out in pain, her partner would also be awakened.

Tragically, Fiona went from one misdiagnosis to another.

Fiona’s general practitioner (GP) first suggested that she keep a food diary to help identify any food allergies.  However, her pain attacks would persist regardless whether she drank water or indulged in junk food.

When her friends and family suggested that she might have an ulcer, Fiona returned to her GP.  However, after saying it was ‘just indigestion’, he prescribed antacids (which, of course, did nothing for her pain).

Fiona decided to get a second, and even a third, opinion.  Her third doctor prescribed esomeprazole pills daily for stomach acid.  Of course, these pills also did nothing for her pain attacks.

Upon returning to her GP, Fiona discovered that a new doctor was available to see her instead.  This doctor was energetic, empathetic and cheerful.  Moreover, after reviewing her history and doing some checks, he suggested that there may be more going on than ‘just indigestion’.  He then arranged for Fiona to do some blood tests and an ultrasound.

Guess what happened next?  You guessed it!  Finally, Fiona received a proper diagnosis after 5 long years of pain attacks and vomiting!  Whew!  

Fiona was finally diagnosed with ‘a lot of gallstones’ in her gallbladder, an organ next to her liver that holds bile until it is released to help digest food.*  These gallstones were blocking her bile duct as well as causing pain attacks and vomiting episodes.

Gallbladder removal surgery was recommended.

After awakening from surgery to remove her gallbladder, her surgeon said that her gallbladder was FULL of gallstones.  He had never seen so many gallstones in his entire life!  He also added that he was sympathetic for all the pain that she had endured over 5 years.

Fiona was simply grateful that a correct diagnosis was finally made and that gallbladder removal surgery was done.  Finally, her severe pain attacks ended after 5 long years! 

Please see Fiona Tapp’s inspiring story for more details and advice:

(Tapp, 2017; Stinton & Shaffer, 2012).    



Gallstones are not rare.  They can affect both young and healthy people as well as the young-at-heart.  Between 10% to 15% of adults in developed societies have, or will have, gallstones including 25 million Americans.

Despite being common, gallstones are sometimes mistaken for back pain, food allergies, ulcers, indigestion, excess stomach acid and even irritable bowel syndrome (IBS).


Ultrasonography is done to diagnose gallstones.  Other imaging techniques (e.g. CT, MRI) may also be useful.

Two Treatment Options

(1) Gallbladder Removal Surgery (Cholecystectomy)

Treatment usually involves gallbladder removal surgery (cholecystectomy).

Risk of Ongoing Pain Despite Surgery in Some Patients

After gallbladder removal surgery, some patients may still suffer from ongoing pain.  As such, the risk of a poor outcome following surgery needs to be discussed with patients prior to surgery (Dijk et al, 2019; Guest & Søreide, 2019; Rapaport, 2019).

(2) Extracorporeal Shock Wave Lithotripsy (ESWL)

Alternatively, extracorporeal shock wave lithotripsy (ESWL) may be offered if there are only a few gallstones (i.e. no more than 3).  This treatment involves generating sound waves (shock waves) from outside of the body.  Produced by a machine called a lithotripter, these shock waves are aimed directly at the gallstones until they shatter.  Medication is usually necessary to dissolve the remaining shattered fragments.

While shock waves shatter gallstones, they are not harmful to muscle, bone or skin.

Risk of Recurrent Gallstones

Despite ESWL being less invasive than gallbladder removal surgery, there is a risk of recurrent gallstones (mydr; Barhum, 2018).


What lessons can be learned here?

According to Denise Fernolz, if a diagnosis and treatment(s) are not effective, please urgently seek a second medical opinion.  Importantly, always trust your own instincts and feelings (Fernholz, 2018).

According to Fiona Tapp, if your gut feeling tells you that there is something wrong with your body, please persist in trying to get to the bottom of this. Please don’t ever give up.  

Most doctors do want to help their patients get better.  However, sometimes it is up to the patients to also insist on getting further tests done right from the start.   

Patients have to learn to become better advocates for their own health.  They have to learn to become more assertive and take responsibility for their well-being.  After all, they know their own bodies better than anyone else does.   

Patients should never feel as if they are wasting their doctors’ time.  After all, that is what the doctors are there for – to help diagnose medical problems.

Patients and doctors need to work together as a team to properly diagnose medical problems including the cause(s) for any pain.  A patient-doctor team approach will lead to more effective and timely treatments as well as better results and outcomes.

If necessary, patients may need to pursue a 2nd, 3rd or even 4th medical opinion (as Fiona did).  

I hope these 2 stories inspire.


* Gallstones (aka cholelithiasis) are solid masses, or crystals, of cholesterol or pigment that sometimes form in the gallbladder.  Gallstones may be as small as a grain of sand or as big as a golf ball.  While gallstones are asymptomatic in some people, they may cause excruciating pain in others.

Bile is a yellow-green digestive fluid made in the liver and stored in the gallbladder.  During digestion, bile is released into the bile duct and upper part of the small intestine to help break down the fat in food.




(1) Tapp, Fiona. I Lived in Hell for 5 Years Due to a Misdiagnosis. Healthline (9 June 2017). 

(2) Gallstones: Treatment.

(3) KevinMD (15 March 2005).

(4) Rapaport, Lisa. Gallbladders may be removed too often. Reuters (10 May 2019).

MEDIA (In German)

(1) Fernholz, Denise. Vier Jahre Schmerzen – Weil ich meinem Arzt vertraute. Protokoll einer Fehldiagnose – Angeblich nur Rückenprobleme. Stern (20 April 2018).–vier-jahre-schmerzen–weil-ich-meinem-arzt-vertraute-7950602.html


(1) Gallstones. Mayo Clinic.

(2) Fletcher, Jenna. What are the most common gallbladder problems? Medical News Today (16 Nov 2018).

(3) Stinton & Shaffer. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver (2012); 6(2): 172–187.


(4) Barhum, Lana. Lithotripsy for stones: What to expect. Medical News Today (3 July 2018).

(5) AIHW. Gallstone lithotripsy. Australian Institute of Health and Welfare (1 Dec 1988).

(6A) Dijk et al. Restrictive strategy versus usual care for cholecystectomy in patients with gallstones and abdominal pain (SECURE): a multicentre, randomised, parallel-arm, non-inferiority trial. The Lancet (26 Apr 2019).

(6B) Guest & Søreide. Pain after cholecystectomy for symptomatic gallstones. The Lancet (26 Apr 2019).

Inserting A ‘Mini Cushion’ and/or Other Implants in the Spine to Reduce Back Pain

Feature Image sourced from:

Dear Pain Matters readers,


Degenerative Cervical Myelopathy

The most common cause of spinal cord dysfunction and pain in adults is degenerative cervical myelopathy.  Myelopathy is spinal cord damage caused by disc degeneration (disc bulges), bone spurs (osteophytes) and other inflammatory triggers.

If not effectively treated, back pain, limb sensory loss and abnormal sensations (paraesthesia)* may result.  Gait and hand dexterity may be compromised.

See Anne’s story (below) that highlights degenerative cervical myelopathy including the importance of timely diagnosis and effective treatment

Degenerative Disc Disease   

Countless people suffer from severe back pain due to degenerative disc disease.  

Damaged discs in the spine may lead to reduced shock absorption while walking, jogging or pursuing other activities.  Shortened discs due to injury, disease or prior surgery may cause vertebrae to come into direct contact with one another.  This may result in bone-on-bone pain, sciatica and other complications.

Tingling and/or numbness in the buttocks or legs may occur due to herniated (i.e. bulging, collapsed or slipped) discs.  This may render walking difficult for some patients.

Once injured or arthritic, discs are usually unable to heal due to their avascular nature.  

Sadly, back pain may become a constant companion.

Novel Treatment for Back Pain Resulting from Damaged Discs: An Implant Called a Device for Intervertebral Assisted Motion (DIAM Implant)

Traditionally, the only surgical option for back pain caused by degenerated discs involved fusing the spinal bones together (aka spinal fusion).

A new implant called a Device for Intervertebral Assisted Motion (DIAM implant) is now available that may offer relief from back pain due to diseased or injured discs.

The DIAM implant is as a polyester-covered silicone interspinous shock absorber that works like a ‘bumper’.  Being small and H-shaped, this implant is designed to shift the weight away from the anterior column.  This helps restore the functional integrity of the posterior column of the spine.

Like a small cushion inserted between injured or diseased vertebrae in the spine, this implant may prevent vertebrae from coming into contact, hence preventing further damage to the vertebrae.  By acting as a shock absorber by reducing stress on damaged vertebrae, a DIAM implant may lead to reduced or eliminated back pain.

During surgery, a small surgical incision is made along the spine and a low amount of bone, interspinous ligament, muscle and/or other soft tissue is removed.  The DIAM implant is then inserted into the space between the spinous processes.**  This implant is subsequently attached to nearby vertebrae.

Other Interspinous Spacers Including Aperius Devices

Degenerative spinal disease may also be treated via alternative interspinous spacers including Aperius PercLID system (Fabrizi et al, 2011).


Wear and tear and/or rejection by the immune system of DIAM implants and other interspinous spacers may occur in some patients.  This may lead to pain and inflammation as well as the removal of affected implants (Seo et al, 2016).

‘Anne’, a 62-Year Old Woman, has Discectomy and Implants for Severe and Painful Cervical Myelopathy

‘Anne’ (not her real name) (62) suffered from severe degenerative cervical myelopathy since she was 59 (although this diagnosis was not confirmed until 3 years later).  As a result, Anne was hospitalised 11 times in the emergency room (ER) in 3 years.

Anne endured pain and abnormal sensations (paraesthesia) from her neck down including in her hands, groins, trunk and legs.  She had a ongoing feeling of water retention throughout her body.

Anne had many strange sensations including:

  • ‘A wet gel-like substance’ had invaded the skin of her face, limbs and trunk; and
  • ‘Something [was] stuck on her skin’ and ‘her hair was stuck down’.

Anne thought that these odd feelings were caused by her olive oil moisturising cream.  (This was because her severe degenerative cervical myelopathy was not diagnosed until 3 years later.)  

During her 11 visits to ER, doctors dismissed Anne ‘for being delusional’ (despite her not taking any psychiatric medication).

While doctors urged her to undergo a psychiatric assessment and a mental health review, Anne resisted.

Anne had back and neck pain as well as numbness and tingling in her arms.  Her legs were stiff and she had difficulty walking.  Anne’s right leg often gave way resulting in numerous falls.   Her coordination and manual dexterity were severely compromised.  Anne had difficulty urinating as well as urinary and faecal incontinence.

Three years later, Anne was finally referred for MRI imaging of her spine.

Following MRI imaging, Anne was diagnosed with severe cervical myelopathy due to degenerative changes in her cervical spine NOT delusions!  Specifically, there was 2 bone spur protusions, one that compressed her spinal cord at C3/4 and another one that led to a narrowing near C5/6.

Surgery for decompression via anterior cervical discectomy at C3/4 was expedited as well as spinal implants.

Following recovery from spinal surgery, Anne’s pain levels decreased while her other symptoms improved.

In summary, despite having been seen by many doctors during 11 visits to ER, Anne was not diagnosed with severe cervical myelopathy until 3 years later.  As a consequence, Anne suffered from intense neck and back pain, abnormal sensations and other symptoms of severe cervical myelopathy for 3 long years.

The good news is that once a correct diagnosis was finally made, and successful spinal surgery was done, many of Anne’s symptoms either decreased or disappeared (Mowforth et al, 2019; Berres, 2019).

A Back Pain Patient Named Rebecca Who Had DIAM Implant Surgery

Having suffered severe low back pain for several years that worsened after becoming a mom of two, Rebecca Morgan of Bristol, UK, said:

‘I started to find everyday activities difficult — even sitting down for any length of time was painful.  The thought of having to lift my son in and out of the bath would sometimes drive me to tears.’

An X-Ray and MRI revealed a collapsed disc as well as changes in the adjacent joints.  Due to the disc’s shortened height, (quoting Rebecca) ‘the nearby joints were inflamed and rubbing together.’ 

In her spinal surgeon’s words:

‘A standing X-Ray showed that one of [her joints in her back] slipped backwards every time she moved or stood up.’

A DIAM implant was inserted between the inflamed joints via minimally invasive surgery.

Rebecca continued with her story (quoting):

‘… my disc was so unsupported and unstable that [the specialist] could move it every which way during the operation.’

No wonder Rebecca had severe back pain prior to her DIAM implant!!

Following successful surgery involving DIAM implant, Rebecca stated (quoting):

‘I was up and walking within a couple of hours after the operation, and within a few weeks I was back to normal. I went on a long-haul flight to Australia, to take the children to visit relatives, just seven weeks after the operation. Now, I’m looking forward to starting pilates classes.’

‘[The DIAM implant] has changed my life … As a result, I have finally said goodbye to all the prescription drugs I used to take, and gone back to the gym.’

In her surgeon’s words:

‘[The DIAM implant] acts as a firm cushion and a stabiliser, and is unique in that it is not made out of metal and isn’t stiff. Rebecca had instant relief and needed only a short stay in hospital’

(Dobson, 2010).

What a heart-warming and inspiring story!

Four Studies Involving Interspinous Spacers (e.g. DIAM Implants, Aperius Devices) for Degenerative Spinal Disease

1. A DIAM Implant Study

A study involving back pain patients (N=68; aged 23 to 75) showed that all patients enjoyed benefits including 92% who had good to excellent improvements, post-DIAM implant.  

Best of all, implant patients enjoyed pain reductions of 71% and enhanced movements by 64% (on average) (Dobson, 2010).

2. A Taiwanese DIAM Implant Study

Back pain patients (N=34) who underwent DIAM implant surgery were followed up for a minimum of 3 years.

All 34 patients enjoyed relief from symptoms.

Specifically, 31 patients (91%) remained symptom free and enjoyed excellent/good results throughout the study, post-DIAM implant. 

However, back pain not due to DIAM surgery nor degenerated discs returned in 3 patients (9%) (Lu et al, 2016).

3. An Italian Review Involving Interspinous Spacers (i.e. DIAM and Aperius Devices) for Degenerative Lumbar Spinal Disease

An Italian review was done of low back pain patients (N=1575) who underwent interspinous device (DIAM or Aperius) insertion for the treatment of degenerative spinal disease.  This included patients with degenerative disc disease (N=478), canal and/or foraminal stenosis (N=347), disc herniation (N=283), black disc and facet syndrome (N=143) and topping-off (N=64).

The average operating time for a DIAM implant was 35 minutes and for an Aperius device was 7 minutes.

Complications arose due to infections (N=10) and fractures of the posterior spinous processes (N=10).  Forty patients required spinal fusion (N=30) or total disc replacement (N=10).

The review reported that symptoms were resolved or improved in 1505 patients (95%) after interspinous device insertion.

This included 924 patients who enjoyed excellent results including nil back pain and complete restoration of mobility after implant surgery.  All 924 patients were able to return to normal work and pursue normal activities.

Another 483 patients had good results including relief of symptoms albeit with some nonradicular pain.  All 483 patients were able to return to modified work.

A further 98 patients had fair results with some improvement in function.  However, these patients could not return to work and/or remained disabled.

Sadly, the remaining 70 patients had a poor outcome following interspinous device insertion.  Their symptoms remained unchanged and they required further surgical intervention.

Having said that, interspinous implant is reversible in failed back syndrome.  More importantly, the vast majority of patients enjoyed partial or complete relief from back pain after interspinous device insertion (Fabrizi et al, 2011).

4. A French DIAM Implant Study

A French study involving back pain patients (N=104) showed that 88.5% enjoyed improvements, 9.6% had no change and 1.9% were indeterminable.

Pain medication intake was decreased in 63.1% of the patients, increased in 12.3% and unaltered in 24.6% (Taylor et al, 2007).


I hope that the stories about Rebecca and Anne as well as the 4 studies may offer hope to some patients with severe back pain due to degenerative spinal disease.

Sabina Walker, Blogger of Pain Matters (in WordPress).


* Paraesthesia is abnormal sensation.  This may include tingling or pricking (i.e. pins and needles).  This may be due to pressure or damage to peripheral nerves.

** Spinous processes are the vertebrae that stick out in the back of your spine.  These can be felt as bumps on your back.   


(1) Dobson, Roger. Tiny cushion that sits in your spine to cure back pain. Daily Mail Australia (

Peer-Reviewed Paper

(2) Lu et al. Clinical outcome following DIAM implantation for symptomatic lumbar internal disk disruption: a 3-year retrospective analysis. J Pain Res (31 Oct 2016); 2016: 917—924.

(3) Taylor et al. Device for intervertebral assisted motion: technique and initial results. Neurosurg Focus (15 Jan 2007); 22(1): E6.

(4) Seo et al. Foreign Body Reaction after Implantation of a Device for Intervertebral Assisted Motion. J Korean Neurosurg Soc (Nov 2016); 59(6): 647–649.

(5) Fabrizi et al. Interspinous spacers in the treatment of degenerative lumbar spinal disease: our experience with DIAM and aperius devices. Eur Spine J (2011); 20(Suppl 1): S20–S26.

doi: 10.1007/s00586-011-1753-2

(6) Mowforth et al. “I am not delusional!” Sensory dysaesthesia secondary to degenerative cervical myelopathy.

Peer-Reviewed Papers Not Discussed Above

(7A) Pintauro et al. Interspinous implants: are the new implants better than the last generation? A review. Curr Rev Musculoskelet Med (2017); 10(2): 189–198.


(7B) Buric and Pulidori. Long-term reduction in pain and disability after surgery with the interspinous device for intervertebral assisted motion (DIAM) spinal stabilization system in patients with low back pain: 4-year follow-up from a longitudinal prospective case series. Eur Spine J (2011); 20(8): 1304–1311.

doi: 10.1007/s00586-011-1697-6

(7C) Gazzeri et al. Failure rates and complications of interspinous process decompression devices: a European multicenter study. Neurosurg Focus (2015); 39(4): E14.

doi: 10.3171/2015.7.FOCUS15244

Media (in German)

(8) Berres, Irene. Eine rätselhafte PatientinDie ist doch verrückt. Spiegel (5 May 2019).