WHAT IS ENDOMETRIOSIS ?
The inner lining of the Uterus is made up of specific cells called endometrial cells. These cells are shed every month during menses. When these cells instead of complete evacuation attach to the tissue outside the uterus they are known as endometrial implants and lead to a debilitating condition called endometriosis characterized commonly by pain and uncontrolled and prolonged bleeding. Endometrial implants are commonly found on ovaries and the Fallopian tubes but can range from vagina, cervix, urinary bladder and can also rarely occur in liver, old injury scars, lungs and brain.
WHO IS AFFECTED ?
Endometriosis affects women in their reproductive years. While most cases of endometriosis are diagnosed in women aged around 25-35 years, endometriosis has been reported in girls as young as 11 years of age. Endometriosis is rare in postmenopausal women. Endometriosis is more commonly found in white women as compared with African American and Asian women. Studies further suggest that endometriosis is most common in taller, thin women with a low body mass index (BMI). Delaying pregnancy until an older age is also believed to increase the risk of developing endometriosis.
WHAT ARE THE CAUSES ?
Estrogens: High levels of estrogens [reproductive years] , low progesterone levels are considered prime causes.
Retrograde menstruation: It is proposed that during menses some amount of endometrial debris gets shed from fallopian tube apart from the uterus which causes a retrograde flow in some women.The immune system over time gets rid of this debris but in certain women the debris may implant itself during this retrograde menstruation and cause endometriosis.
Mullerianosis: This theory states that some of the potential endometrial cells which are laid down along the Mullerian [female reproductive] tract get dislocated as the uterus moves downwards during 8-10weeks of embryonic life and subsequently act as stem or seed cells for the pathology.
Coelomic Metaplasia: Endometrial cells are considerd derivaties of Coelomic epithelium and it is proposed that inflamation is triggered during transformation [metaplasia].
Genetics : Hereditary factors contribute.
Environment: Use of plastic containers, microwave, pesticides, hormone fortified supplements increase the risk.
Birth Defect: Hymen [a tissue covering the vagina] does not perforate [rare] after first menstrual cycle, the endometrial debris may get trapped. This can be solved by surgical incision.
WHAT ARE THE SYMPTOMS ?
Pelvic pain : Mild to severe cramping that occurs on both sides of the pelvis,
Chronic pelvic pain: Lower back and rectal area and even down the legs.
Dysmenorrhea: painful, menstrual cycles
Dyspareunia: painful sex
Dysuria: urinary urgency, frequency, and sometimes painful voiding
Infertility: Many women with infertility have endometriosis.
Heavy or long uncontrollable menstrual periods with small or large blood clots
Hypoglycemia (low blood sugar)
Gastrointestinal symptoms that mimic irritable bowel syndrome
Rupture an endometriotic cyst may present with an acute abdomen as a medical emergency.
Other symptoms : nausea, vomiting, fainting, dizzy spells, vertigo,chronic fatigue,mood swings, pain from adhesions, extreme pain with or without the presence of menses,mild to severe fever, headaches, depression, anxiety.
WHAT IS THE RISK OF CANCERS WITH ENDOMETRIOSIS ?
Current research has demonstrated an association between endometriosis and certain types of cancers, notably ovarian cancer, non-Hodgkin’s lymphoma and brain cancer.Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders. However Endometriosis bears no relationship to endometrial cancer.
DOES SMOKING MANIPULATE CANCER PROGRESSION IN ENDOMETRIOSIS ?
Endometriosis is often accompanied with ovarian cysts which indicate advanced stage of endometriosis. Smoking increases the risk of a cyst turning to ovarian cancer.This condition is associated with tobacco smoking in women.
DOES ENDOMETRIOSIS CAUSE INFERTILITY ?
Endometriosis produce scarring of the ovary and tubes so they cannot move freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows. Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages. Abdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and gather an ovulated follicle (egg).
HOW IS ENDOMETRIOSIS DIAGNOSED ?
Physical examination and history
Surgery, Lesion biposy, Laproscopy
Magnetic Resonance Imaging [MRI]
Micrograph an endometrioma. H&E stain.
Often the symptoms of ovarian cancer are identical to those of endometriosis. If a misdiagnosis of endometriosis occurs due to failure to confirm diagnosis through laparoscopy, early diagnosis of ovarian cancer, which is crucial for successful treatment, may have been missed.
Markers : Markers are substances made by or in response to endometriosis that health care providers can measure in the blood or urine. The antigen CA-125 is known to be elevated in many patients with endometriosis but is not specifically indicative of endometriosis.
WHAT IS ENDOMETRIOSIS STAGING ?
Surgically, endometriosis can be staged I–IV. The process is a complex point system that assesses lesions and adhesions in the pelvic organs, but it is important to note staging assesses physical disease only, not the level of pain or infertility. A patient with Stage I endometriosis may have little disease and severe pain, while a patient with Stage IV endometriosis may have severe disease and no pain or vice versa.
HOW IS ENDOMETRIOSIS TREATED ?
Treatment is done with medicines and surgery. Treatment depends whether the patient wishes to conceive or not.
(Treatments and drugs used in modern medicine are constantly updated with research and are subject to change. Please consult your physician/medical advisor to upgrade over the data published in this article).
OKAY I DO NOT WISH TO CONCEIVE, WHAT ARE MY OPTIONS ?
Progesterone which counteracts estrogen and inhibits the growth of the endometrium which over a period would reduce or eliminate menstruation in a controlled and reversible fashion. Progestins[for example, medroxyprogesterone acetate (Provera, Cycrin, Amen), norethindrone acetate, norgestrel acetate (Ovrette)] are chemical variants of natural progesterone.
Avoiding products with xenoestrogens, which have a similar effect to naturally produced estrogen and can increase growth of the endometrium.
Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis.[Seasonale] Continuous hormonal contraception consists of the use of combined oral contraceptive pills without the use of placebo pills without the break week which eliminates monthly bleeding episodes.
Danazol (Danocrine) and gestrinone are suppressive steroids with some androgenic activity. Both agents inhibit the growth of endometriosis but their use remains limited as they may cause hirsutism and voice changes.
Gonadotropin Releasing Hormone (GnRH) agonist: These agents work by increasing the levels of GnRH which induce profound hypoestrogenism. Over a period the therapy leads to osteoporosis and sometimes estrogen is added to balance. These drugs can only be used for six months at a time. [Lupron depo]
Aromatase inhibitors: These medications block the formation of estrogen.[Anastrozole (Arimidex) and letrozole (Femara)].
HOW ABOUT PAIN MANAGEMENT ?
MST Morphine sulphate tablets and other opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called “endorphins”.
Diclofenac in suppository or pill form. Taken to reduce inflammation and as an analgesic reducing pain.
ARE THERE ANY SIDE EFFECTS WITH THESE MEDICINES ?
Since management involves Hormone intake and painkillers over a prolonged period many side effects are seen with respect to drugs used.Weight gain, edema, decreased breast size,acne, oily skin, hirsutism (male pattern hair growth), deepening of the voice, headache, hot flashes, changes in libido, mood changes, vaginal dryness.
I WISH TO BECOME PREGNANT , WHAT ARE MY OPTIONS ?
Treatment of infertility associated with endometriosis
Use of fertility medication that stimulates ovulation (clomiphene citrate, gonadotropins) combined with intrauterine insemination (IUI) enhances fertility in these patients.
In-vitro fertilization (IVF) procedures are effective in improving fertility in many women with endometriosis.
HOW IS ENDOMETRIOSIS MANAGED WITH SURGERY ?
Surgery procedures are classified as
- Conservative when reproductive organs are retained,
- Semi-conservative when ovarian function is allowed to continue.
- Radical when the uterus and ovaries are removed.
I HAVE HEARD OF DIETARY MANAGEMENT OF ENDOMETRIOSIS , EXPLAIN ?
Endometriosis is considered as an auto-immune condition by certain medical fraternity. It is suggested that abstaining from certain foods which compromise the immunity may prove therapeutic. Common intolerances in people with endometriosis are wheat, sugar, meat and dairy.
Eating foods high in indole-3-carbinol, such as cruciferous vegetables appears to be helpful in balancing hormones and managing pain,as do omega 3 fatty acids, particularly EPA. Avoiding foods high in hormones and inflammatory fats proves beneficial in endometriosis pain management.
DOES IT AFFECT MALES ?
Endometriosis has been described in men receiving a very high estrogen medication (TACE) as part of treatment for prostatic cancer.
WHAT IS THE AYURVEDA PERSPECTIVE TO ENDOMETRIOSIS ?
Ayurveda considers each disorder as an imbalance of Dosha at macro and micro level. The process of creation, transformation and elimination is prevalant in harmony at healthy levels and disrupted at diseased state. Taking a brief look at the above explanation about Endometriosis , it may become clear that the process of tissue formation at the uterus, its stability before and after periods and elimination of waste products to stimulate fresh tissue gets compromised. This compromise happens due to various factors that cause the concerned Dosha imbalance. This factors may range from lifestyle , food to congenital and acquired defects in terms of immunity and organ weakness.
HOW DOES AYURVEDA PROPOSES TO TREAT ENDOMETRIOSIS ?
Ayurveda treatment as apparent focusses on setting the balance right o achieve healthy menstrual cycles. Ayurveda in treatment of women emphasis strongly on a healthy menstrual cycle and gives few tests to check its nature. The tests are as follows
- Menstrual flow should be devoid of pain however a mild heaviness at the lower back region is expected
- The flow should be dark and subtle during first day, improve on the second turning crimson in color. On the third day it should be at its peak and slowly diminish towards the 4th day with a orange color.
- The menstrual blood should not leave a stain on a cloth after washing
- The menstrual cycle at its healthy best must coincide with the lunar cycle of 28 days
These points were not mere hypothesis but arrived fter studying different women over a period of time. With modernization the work patterns and lifestyles have changed and its difficult to find many women who meet the above requirements in a urban society. The aim of Ayurveda treatments would be to achieve a closest standard to the above described features. the treatments include internal medications and external procedures as per the healers discretion and patients conditions. Endometriosis with its multiple manifestations is very difficult to treat. However it is also very easily curable if the patient is willing to put in a effort with regards to diet and medicines.
WHAT DIET AND LIFESTYLE CHANGES ONE NEEDS TO ACCOUNT FOR ?
- The patient should follow strict timings with respect to his meals, waking and sleeping.
- The patient should sleep early almost an hour before midnight and rise early as close to sunrise as possible
- Breakfast should consist of natural uterine cleansers and tonics like Pappaya at least till good control is achieved
- Lunch should comprise of food which is easy to digest. Use of bakery products, foods containing excessive salt, red meat etc must be avoided. Cruciferous vegetables, cereals must be preffered prepared with very minimal salt
- Sea food must be strictly avoided as I have observed it contains certain toxins that manipulate uterine activity.
- Dinner should comprise of light foods , lots of carrot and parsley. Salt again must be restricted if not using Himalayan Crystal salt
- Salt and Sugar plays a major role and the minimal usage the better. In my clinical practice I recommend the patient to go on a complete salt restriction for at least 10 days on commencement of treatment and then reintroduce.
- Avoid all forms of refined sugar. Even fruit juices which contain fructose. Have fruits like Papaya, Musk melon etc low on fructose. Reduce your insulin spikes. Do not eat after sunset. If you find cravings for sugar cut coconut rind [entire one with oil in it] and eat. It is highlybeneficial
- Stay away from Copper. Do not use any vessels of Copper.
- Check your fasting Insulin levels and do Iron studies. Your ferritin levels must be ideally between 40-70 [normal range 15-150] and S.iron must be above 80. If not your mineral imbalance may cause problems. Through Ayurveda Bhasma this is effectively corrected in very short time but supervision is required. Do not self medicate.
The lifestyle modifications are identical to ones I describe in my other articles regarding PCOS , Breast cancer and Hypo-Thyroid the reason being all these disorders have common metabolic anomalies and one must research in the diet to get good control of Estrogen. as these all disorders mostly happen due to Estrogen malfunctions.
CAN YOU DESCRIBE FEW EFFECTIVE MEDICINES ?
Medicines include usage of herbs that help strengthening the immune system which in turn helps the glands function properly and create an hormonal balance
1> 20gms of Daruharidra [Berberis aristrata] boil in 8cups of water [500ml] reduce to 1 cup[50ml]. Filter and drink evry morning empty stomach for 3 menstrual cycles. This tea can be taken 2 times a day. This strengthens the uetrus controls bleeding and also allievates pain. The following herbs can also be used instead of Daruharidhra; Lodhra [Symplocos racemosa], Arjun [Terminalia arjuna].
2> 5gms of Shatavari [Asparagus racemosus var. javanica], 5gms of Vidarikanda [Pueraria tuberosa], 3 gms of Arjun [T. arjuna]. Boil this herbs in 50ml of cow’s milk in an iron vessel and 150ml of water till milk remains. Filter and drink once a day. This is very effective tonic. This medicine must be used once the bleeding is controlled and menses become regular by medicine 1
3> Soak Anantmool root[Hemidesmus indicus] 10gms in a ceramic vessel in a cup of boiling water. Next morning filter and consume by adding 1tsp of cumin and 1tsp of sugar. repaet the procedure in evening and night. This medicine effectively controls bleeding and helps the quality of blood improve. It can be combined with medicine 1 if symptoms are severe.
4> Chandraprabha vati [with shilajit] is a generic Ayurveda preparation. 2 tablets [250mg each] two times a day with pomegranate juice/ cow’s milk must be taken. This strengthens the ovaries and helps prevent cysts.
5> Ashwagandhaaristha is a medicated wine which is an excellent medicine to strengthen the uterus. 5ml of the wine diluted with 10ml of warm water two times a day for 3 -4 months. The above tablets can be consumed with it for better results.
6>Use of a mild laxative is recommended to strengthen the intestine and prevent build up of toxins. A simple formulation is as follows.
Rose petals 20gms, Triphala powder 20gms, Senna leaves powder [Cassia senna] 10gms, Fennel seeds 10gms, Black salt 5gms. Mix this powders and store in a clean glass jar. 1tsp of the powder with warm water at bedtime does the job. If powders are difficult to intake, one can boil 5gms rose petals, 20gms of black raisins in 3 cups of water, reduce to 1 cup [60ml], filter and consume. This is also a good remedy for constipation.
Apart from this medicines like Abrakh, Vang, Suvarna, Pradarantak Lauh etc are very useful but need expert guidance.
DOES PANCHAKARMA HELP ?
Panchakarma may help a long way in curing endometriosis. The nature of treatment deepends on the physicians discretion. Generally Basti tratment [medicated enemas] will do the trick. This treatmnet fortifys the Apana Vayu which is responsible tpo bring about healthy cycles. The Basti treatments maybe complemented with Uttar Basti [enemas through Vagina] which help fortify the uterine walls.
DOES AYURVEDA MANAGEMENT ALSO HELP CONCEIVE ?
Absolutely, Ayurveda focusses in rectifying the system from the core not just managing it symptomatically. So when the balance is achieved the body becomes receptive to conception.
HOW ABOUT VEDIC ASTROLOGY ?
Use of certain gemstones do help in control of symptims. Depends upon the natal chart of the patient. Generally heavy bleeding is associated with Mars in the 12th house. The use of Emerald, Coral and Sapphire helps a lot.
Intake of this gemstones in form of Bhasmas[calcinied ash] have proven to be highly beneficial. I particularly use the Nilam Pishti [Blue sapphire preparation] with good effect.
CAN AYURVEDA EFFECTIVELY MANAGE PAIN ?
Ayurveda has limited resources when it comes to pain management not because of lack of medicines but more due to government norms and lack of quality materials. Hence initially the pain can be managed by use of NSAID. However within 14 -15 days of treatment the requirement of painkillers is absolved. There are very good effective medicines like Nidrodaya Vati, Shoolhar Vati which allievates pain but need supervison. For pain during menses I recomend a few formulations
1>Boil 100gms of Gorakhmundi [Sphaeranthus indica] in 4 litres of water and reduce to 1 litre. Filter and store ina glass bottle. consume 50ml of this mixture 2 times a day for 10 days just before menses. This is very beneficial treatment but requires a somewhat regular cycle.
2>250ml of water, 25gms Jaggery, 45gms of cow’s ghee, 5gms Dried ginger powder, 5gms Ajwain powder, 2gms Turmeric powder. Mix Jaggery with water then add rest of the ingredients. Boil the mixture till it reduces to half [130ml]. Divide into two parts. Consume 1st part on first day of menses, 2nd part on the second day. Make the preparation again on the 3rd day and consume for 2 days. regular consumption of this during periods eases the flow, prevents clots and eases pain. The medicine is bit unpalatable but can be adapted with time.
ARE THERE ANY SIMPLE HOME REMEDIES TO TREAT ENDOMETRIOSIS ?
1>One simple and effective home remedy is the use of castor oil. Warm castor oil [when heating do not put the oil on flame but keep the bottle in warm water] and pour it in a vessel. Soak 2 cotton blobs in it. Insert one in teh navel and second in the vagina before sleeping. Continuos use of this helps strengthen the uterus and in many cases provided cure. I use this method effectively in many cases.
2>5 gms of cumin seeds powder consumed with warm water for a period of 3 months also helps in endometriosis and provides very good relief3>Complete abstinence from salt during menses [3 days] is a very effective way to control bleeding and alleviate the symptoms. Salt is a major factor is cure of this disease. I have found women who can control or abstain from salt recover very fast and also increase their chances of fertility.
ROLE OF YOGA
Yoga in all auto-immune disorders helps immensely as it changes glandular and hormonal functions. Yog done without use of Bandhas is of no use and hence I would recommend patients to undertake Yogic exercises under supervision of an Ayurveda consultant as Yoga is a part of ayurveda and it requires proper knowledge of body functions and Marma points. Do not undertake exercises advertised or from word of mouth as testimonials. What works for others may not work for you. More importantly understand what one is trying to achieve and combine it with proper lifestyle and medication under expert guidance so that the overall quality of life increases. As project of NLAM, elite Hatha Yog sequences of therapeutic nature are being taught under the Marma Yog cluster. Yog Teachers who wish to gain the knowledge can know more about it at [www.marmayog.in].
I have tried to cover a general aspect of this disorder. I have purposely kept the medicine list brief to avoid confusion with multiple formula and only effective and safe formulations have been mentioned. Feedback, queries and comments appreciated as always….