Dr Shubhaprada S Gothe
Abstract :
Endometriosis is one of the commonest cause of recurring pelvic pain in women. It is mainly a gynecological problem of the reproductive age group, yet it is not uncommon in women after menopause. In the recent times, 1 in 10 women are affected by endometriosis, which often demands medical attention. When it comes to managing endometriosis, we are faced with an array of choices, from analgesics, hormone therapies to surgeries, it can be painful and even lead to infertility. Homoeopathy with its holistic approach, seeks to address the underlying imbalances and thus alleviate symptoms and prevent further progress of the disease so that pregnancy could be achieved. This article focuses on the Integrated approach of Homoeopathy and lifestyle changes, which is indeed the need of the hour.
Keywords : Endometriosis, Homoeopathy, Lifestyle changes
Introduction
The presence of functioning endometrium in sites other than uterine mucosa is called endometriosis. It is not a neoplastic condition, although malignant transformation is possible.
During the last couple of decades, the prevalence of endometriosis has been increasing both in terms of real and apparent. The real one is due to delayed marriage, postponement of first conception and adoption of small family norm.
The apparent one is due to increased use of diagnostic laparoscopy as well as hightened awareness of this disease complex amongst the gynecologists. The prevalence is about 10 percent. However, prevalence is high amongst the infertile women (30–40%) as based on diagnostic laparoscopy and laparotomy.
In normal conditions, the endometrium within the uterus is shed periodically during the menstrual cycle, whereas in endometriosis, the endometrium situated elsewhere in the body, is unable to exit the body. Nevertheless, it proliferates and cyclically, the bleeding also occurs but into the body cavity wherein it is situated.
Sites include 1. Abdominal: It can occur at any site but is usually confined to the abdominal structures below the level of umbilicus which includes
- Ovaries • Pelvic peritoneum • Pouch of Douglas • Uterosacral ligaments • Rectovaginal septum • Sigmoid colon • Appendix • Pelvic lymph nodes • Fallopian tube
- Extra-abdominal : The common sites are abdominal scar of hysterotomy, cesarean section, tubectomy and myomectomy, umbilicus, episiotomy scar, vagina and cervix
- Remote : Lungs , Pleura , Ureter ,Kidney , Arms ,Legs and Nasal mucosa
In each menstrual cycle the area of ectopic endometrium bleeds. Depending on where the endometriosis is, this bleeding can either cause
(i)local irritation and pain or
(ii) can collect as a cyst called as chocolate cyst or endometrioma
(iii) it can cause the development of fibrotic scar tissue that itself can become painful.
Therefore superficial endometriotic spots tend to cause dysmenorrhoea alone, whereas deep infiltrating endometriosis which causes, endometriomas, adhesions with infiltration of the large bowel—can cause dyspareunia, backache, dyschezia, tenesmus and cyclical changes in bowel habit .The scarring secondary to endometriosis has a detrimental effect on fertility, and a relatively asymptomatic patient may not discover the diagnosis until they seek help in conceiving.
Pathogenesis: still remains unclear and is full of theories.
Retrograde menstruation, Direct Implantation being the proposed theories, according to the theory, the endometrial or decidual tissues start to grow in susceptible individual when implanted in the new sites. but retrograde menstruation per se is unlikely to produce endometriosis. Probably, a genetic factor or favorable hormonal milieu is necessary for successful implantation and growth of the fragments of endometrium.
Pathology The endometrium (glands and stroma) in the ectopic sites has got the potentiality to undergo changes under the action of ovarian hormones. Cyclic growth and shedding continue till menopause. The periodically shed blood may remain encysted or else, the cyst becomes tense and ruptures.
Pelvic endometriosis: Typically, there are small black dots, the so called ‘powder burns’ seen on the uterosacral ligaments and pouch of Douglas
Clinical features of pelvic endometriosis
Patient Profile
The patient’s age is between 30–45yrs and are mostly nulliparous or have had one or two children long years prior to appearance of symptoms.
Infertility, voluntary postponement of first conception until at a late age and higher social status are often related. Thus, it is more common in private than hospital patients.
About 25 percent of patients with endometriosis have no symptom, being accidentally discovered either during laparoscopy or laparotomy.
1.Dysmenorrhea (70%)
Pain usually begins after few years pain-free menses, The pain starts a few days prior to menstruation; gets worsened during menstruation and takes time, even after cessation of period, to get relief of pain, (co-menstrual dysmenorrhea), Menorrhagia is the predominant abnormality.
2.Dyspareunia (20–40%) The dyspareunia is usually deep. It may be due to stretching of the structures of the pouch of Douglas or direct contact tenderness
3. Infertility (40–60%): Whether endometriosis causes infertility or infertility produces endometriosis is not clear. Endometriosis is found in 20–40 percent of infertile women, where as in about 40–50 percent patients with endometriosis suffer from infertility.
4.Chronic Pelvic Pain: The pain varies from pelvic discomfort, lower abdominal pain or backache.
5.The symptoms are related to the organ involved.
Urinary—frequency, dysuria, back pain or even hematuria
Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea, constipation, rectal bleeding or even melena
Chronic fatigue, perimenstrual symptoms (bowel, bladder)
Hemoptysis (rarely), catamenial chest pain
Surgical scars—cyclical pain and bleeding
Physical signs:
- Pelvic examination may be unremarkable in superficial or mild endometriosis. It may be possible to detect enlarged ovaries on clinical examination or there may be tender areas in the pelvis particularly when the uterosacral ligaments are stretched.
- The nodular thickening of the uterosacral ligaments can usually be palpated best with a bi-digital examination using an examination index finger in the vagina and the rectum simultaneously. This is often too painful to give an accurate assessment in the outpatient clinic but can be very useful at examination under anaesthetic.
Diagnosis:
Transvaginal ultrasound scans can detect endometriomas with characteristic features of the blood-filled cysts; however, superficial endometriosis cannot be clearly identified.
Deep infiltrating disease can also be seen with ultrasound but is particularly operator dependant. Involvement of the bowel serosa and mucosa is best assessed with MRI scans, especially if using a technique to distend the rectum during the scan.
Multidisciplinary feedback of operative and scan findings is essential in helping to interpret the subtle signs that are seen on MRI in these patients.
Sigmoidoscopy or colonoscopy is not a particularly useful investigation even if there is cyclical rectal bleeding as there is rarely macroscopic breaching of the rectal mucosa.
For a definitive diagnosis of endometriosis, visual inspection of the pelvis at laparoscopy is the gold standard investigation.
1 . A negative laparoscopy misses histologically proven endome-triosis in around 0.7% of cases,
2. although many of us believe that this is only the case if the laparoscopy is accurately performed by an experienced operator.
There are a number of classification systems to score the severity of the disease. Each system has its advantages and disadvantages and no perfect system has yet been devised that correlates accurately with the severity of symptoms.
The commonest used is that suggested by the American Fertility Society .
The American Fertility Society (AFS) proposed a unique approach, the AFS score, in 1979 .
The stage of endometriosis was derived from a cumulative score. The weighted value system was scored and summed according to the size of the endometriotic lesions in the ovaries, peritoneum, and fallopian tubes, and the severity of adhesion at each of the aforementioned sites. The staging system was divided into four stages: I (1 to 5 points, mild), II (6 to 15 points, moderate), III (16 to 30 points, severe), and IV (31 to 54 points, extensive).
The size of deep ovarian endometriosis >3 cm scored 20 points, and dense ovarian adhesion and dense tubal blockage were adjusted upward to 16 points.
Endometriosis has been described in virtually every part of the body. Case reports of cyclical haemoptysis or cyclical pneumothorax because of lung endometriosis are described and it is not uncommon to find endometriosis seeding in a scar especially in the umbilicus after laparoscopy or in the abdominal wound after Caesarian section.
Homoeopathic point of view of the disease:
Considering Hahnemann’s classification of disease, Endometriosis falls under true chronic miasmatic disease
In Homoeopathy, there are no specific medicines , but medicine is personalized for the person suffering with endometriosis based on the individual totality of symptoms.
Here are few indicated homoeopathic remedies which can be prescribed after detailed case study.
Endometriosis with Neuralgic pains : Specific remedy for Endometriosis
Xanthoxyllum fraxineum – Its specific action is on the nervous system and mucous membranes. Sluggish capillary circulation. –Menses too early and painful. Ovarian neuralgia, with pain in loins and lower abdomen; worse, left side, extending down the thigh, along genito-crural nerves. Neuralgic dysmenorrhœa, with neuralgic headaches; pain in back and down legs. Menses thick, almost black. After-pains ,Leucorrhœa at time of menses. Neurasthenic patients who are thin, emaciated; poor assimilation with insomnia and occipital headache.
Endometriosis at the site of scar : ( Scar Endometriosis):
Thiosinaminum:
Thios. has been used externally and internally in cases of lupus, chronic glandular tumours, and for dissolving scar tissue; and internally for resolving tumours of the uterine appendages.
Used for dissolving scar tissue, tumors, enlarged glands; lupus, strictures, adhesions.
Endometriosis with menstrual abnormalities:
Ustilago maydis: Flabby condition of uterus. Hemorrhage. Congestion to various parts, especially at climacteric. Vicarious menstruation. Ovaries burn, pain, swell. Profuse menses after miscarriage; discharge of blood from slightest provocation; bright red; partly clotted. Menorrhagia at climaxis. Oozing of dark blood, clotted, forming long black strings. Uterus hypertrophied. Cervix bleed easily. Postpartum hemorrhage. Profuse lochia.
Cimicifuga ( Actea racemosa)
Has a wide action upon the cerebrospinal and muscular system, as well as upon the uterus and ovaries. Especially useful in rheumatic, nervous subjects with ovarian irritation, uterine cramps and heavy limbs. Its muscular and crampy pains, primarily of neurotic origin, occurring in nearly every part of the body, are characteristic.
Pain in ovarian region; shoots upward and down anterior surface of thighs. Pain immediately before menses. Menses profuse, dark, coagulated, offensive with backache, nervousness; always irregular. Ovarian neuralgia. Pain across pelvis, from hip to hip. After-pains, with great sensitiveness and intolerance to pain. Infra-mammary pains worse, left side.
Sabina Has a special action on the uterus; also upon serous and fibrous membranes; Pain from sacrum to the pubis and from below upwards shooting up the vagina. Hæmorrhages, where blood is fluid and clots together. Tendency to miscarriage, especially at third month. Violent pulsations; wants windows open. Menses profuse, bright. Uterine pains extend into thighs. Threatened miscarriage. Sexual desire increased. Leucorrhœa after menses, corrosive, offensive. Discharge of blood between periods, with sexual excitement . Retained placenta; intense after-pains. Menorrhagia in women who aborted readily. Inflammation of ovaries and uterus after abortion. Promotes expulsion of moles from uterus. . Hæmorrhage; partly clotted; worse from least motion. Atony of uterus.
Viburnum opulus – A general remedy for cramps. Colicky pains in pelvic organs. Superconscious of internal sexual organs. Female symptoms most important. Often prevents miscarriage. False labor-pains. Spasmodic and congestive affections, dependent upon ovarian or uterine origin. Menses too late, scanty, lasting a few hours, offensive in odor, with crampy pains, cramps extend down thighs . Bearing-down pains before. Ovarian region feels heavy and congested. Aching in sacrum and pubes, with pain in anterior muscles of thighs ; spasmodic and membranous dysmenorrhea. Leucorrhea, excoriating. Smarting and itching of genitals. Faint on attempting to sit up. Frequent and very early miscarriage, causing seeming sterility. Pains from back to loins and womb worse early morning.
Borax : Leucorrhœa like white of eggs, with sensation as if warm water was flowing. Menses too soon, profuse, with griping, nausea and pain in stomach extending into small of back. Membranous dysmenorrhœa. Sterility. Favors easy conception. Sensation of distention in clitoris with sticking. Pruritus of vulva and eczema.
Cyclamen – Menses profuse, black, membranous, clotted, too early, with labor-like pains from back to pubes. Flow less when moving about. Menstrual irregularities with megrim and blindness, or fiery spots before eyes. Hiccough during pregnancy. Post-partum hæmorrhage, with colicky bearing-down pains, with relief after gush of blood. After menses, swelling of breasts, with milky secretion.
Helonias : Sensation of weakness, dragging and weight in the sacrum and pelvis, with great languor and prostration, are excellent indications for this remedy. There is a sensitiveness expressed as a consciousness of a womb. Tired, backache sfemales. The weakness shows itself also in a tendency to prolapse and other malposition of the womb. The menses are often suppressed and the kidneys congested. It seems as if the monthly congestion, instead of venting itself as it should through the uterine vessels, had extended to the kidneys. With it all, there is a profound melancholia. Patient must be doing something to engage the mind. Remember it, for women with prolapsus from atony, enervated by indolence and luxury (better when attention is engaged. Dragging in sacral region, with prolapse, especially after a miscarriage. Pruritus vulva. Backache after miscarriage . Weight and soreness in womb; conscious of womb. Menses too frequent, too profuse. Leucorrhea. Breasts swollen, nipples painful and tender. Parts hot, red, swollen; burn and itch terribly. Albuminuria during pregnancy. Debility attending the menopause.
Belladonna :Sensitive forcing downwards, as if all the viscera would protrude at genitals. Dryness and heat of vagina. Dragging around loins. Pain in sacrum. Menses increased; bright red, too early, too profuse. Hæmorrhage hot. Cutting pain from hip to hip. Menses and lochia very offensive and hot. Labor-pains come and go suddenly. Mastitis pain, throbbing, redness, streaks radiate from nipple. Breasts feel heavy; are hard and red. Tumors of breast, pain worse lying down. Badly smelling hæmorrhages, hot gushes of blood. Diminished lochia.
Crocus sativus
Threatened abortion, especially when hćmorrhage is dark and stringy. Urging of blood to genitals. Menses dark, viscid, too frequent and copious, black and slimy. Uterine hćmorrhage; clots with long strings; worse from least movement. Jerking pain in interior of left breast, as if drawn toward back by means of thread (Crot tig). A bounding feeling, as if something alive in right breast.
Role of Nutrition and Lifestyle changes in managing endometriosis:
Nutrition and Lifestyle changes play a major role in managing Endometriosis and thus improving the quality of life.
Research says the possible explanations for the implications of dysbiosis in endometriosis include the Bacterial Contamination hypothesis and immune activation, cytokine-impaired gut function, altered estrogen metabolism and signaling. And also reducing inflammation in such patients helps to managing the symptoms and achieving overall wellness in them.
Foods habits:
- Dairy products, fried foods, must be consumed in a limited manner, if possible can avoid them.
- Consume probiotic foods, like buttermilk, bananas, to maintain alkaline internal environment
- Increase consumption of fresh food and reduce packaged foods
- Consume more seasonal vegetables, fruits, green leafy vegetables.
- Increase fibre rich foods , which reduces constipation thus reducing estrogen dominance .
- Keeping yourself hydrated.
- Nutritional deficiencies must be addressed, to reduce inflammation, like omega 3 fatty acids, Vitamin B 12, Vitamin D.
Exercise:
- Exercise , yoga practices which calms down the nervous system can incorporated into daily routine .
- Managing stress by practicing meditation, yoga can be a additional advantage over alleviating symptoms.
Early detection and diagnosis can prevent long term complications and managing the symptoms through Homoeopathy and lifestyle changes ,thus helping the patient to live symptom free life.
References:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737931/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787892/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9986482/#:~:text=Possible%20explanations%20for%20the%20implications,altered%20estrogen%20metabolism%20and%20signaling.
- D C Dutta textbook of Gynecology,9/e
- Shaw’s Textbook of Gynaecology,16/e
- Pocket Manual of Homoeopathic Materia Medica & Repertory: William Boericke
Dr Shubhaprada S Gothe
MD part I Materia medica
Government Homoeoepathic medical college and Hospital, Bengaluru
Under the guidance of Dr Renuka S Patil
HOD and Professor, Dept of Materia medica GHMC, Bengalur
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