Introduction
Endometriosis is the abnormal growth of endometrial cells outside the uterus. It is a complex and painful disease affecting women in their reproductive years. The name comes from the word “endometrium” which is the tissue that lines the inside of the uterus and is built up and sloughed off each month during the menstrual cycle. In endometriosis, such tissue is found outside the uterus and in these areas, the endometrial tissue develops into what are called growths, implants, nodules, lesions or tumors(1).
The most common locations of endometrial growths are in the abdomen involving the ovaries, the fallopian tubes, outer surface of the uterus, the bladder and the lining of the pelvic cavity (1). Sometimes the growths are also found on the intestines, in the rectum or the rectovaginal septum, the vagina, cervix or vulva. Endometrial growths have also been found outside the abdomen in lungs, arms, and thighs however, these locations are uncommon (1).
Endometrial growths are generally not malignant; they are a normal tissue growing outside the normal location (1). Like the lining of the uterus, endometrial growths respond to the hormones of the female reproductive system. They build up tissue each month, then break down and cause bleeding. However, unlike the lining of the uterus, the endometrial growths outside the uterus have no way of leaving the body. The result is internal bleeding, inflammation and scarring (1). The most serious consequence of this scarring is infertility (1). Other complications can include rupture of growths, which may spread these cells to other areas.
Endometrial lesions first appear as clear vesicles, then become red, and then progress to black over a period of 7-10 years. Clear lesions are seen at an average age of 21.5 while black lesions are seen at 31.9 years (2). This relationship between age and color of lesions confirms the progressive nature of the disease. In 47-64% of women, this disease will progress without therapy (2). The incidence of endometriosis is about 5 percent among American women, compared to less than one percent in European women (3).
Symptoms
The most common symptoms of endometriosis include chronic pelvic pain, pain before and during periods, painful intercourse, heavy or irregular bleeding, repeated miscarriages and infertility (4). Other symptoms may include painful urination or bowel movements, back pain and intestinal upset with periods. Infertility affects 30-40% of women with endometriosis and is a common result with the progression of the disease (2).
Some women with endometriosis have no symptoms even in the more advanced stages of the disease. However, pain during or around the time of the period is experienced by most women affected (2). This pain which interferes in some way with all activities of daily living can be excruciating at times (5). In a recent German survey, of the 20-29 year old women being treated for endometriosis, 90% reported menstrual pain, 80% infertility, 71% pelvic pain, and 46% menstrual irregularities (5). In another study, the pain was found to interfere with sleep in 78% and caused depression in 81% of the women (5).
It is interesting to note that the amount of pain experienced is not necessarily proportional to the extent of the disease or size of the growth. Small growths called “petechial” have been found to be more active in producing prostaglandins which explains the severity of the symptoms that occur with small growths (6). Prostaglandins are a group of fatty acids found in most tissues of the body where they act as second messengers within cells and are acted upon by hormones. Prostaglandins are involved in the normal shedding of the endometrial lining during menstruation and can contribute to pain, cramping, and digestive disturbances of dysmenorrheal (1).
Etiology
The cause of endometriosis is not known. A number of theories have tried to explain the causative factors of this disease, however none can account for all the cases. The most common theory is the “retrograde menstruation” also called the “trans-tubal migration” theory (1). This theory suggests that during menstruation some of the blood and endometrial tissue backs up into the fallopian tubes, implants in the abdomen, and grows. In other words, the blood backs up instead of exiting through the vagina and the endometrial cells present attach to the nearby pelvic organs and begin to grow (1). Some of the experts on endometriosis believe that all women experience some menstrual tissue back up however, not all women develop the disease. It is believed that an immune or a hormonal problem allows this tissue to take root and grow in women who develop endometriosis (7). Retrograde menstruation may involve an increase in estrogen or an increased sensitivity to estrogen (7).
Another theory suggests that the endometrial tissue is distributed from the uterus to other parts of the body through the lymphatic system or the blood (7). This theory is supported by some rare cases were endometrial tissue has been found in such distant areas as the lungs and the retina. Another group of researchers cite the same evidence to suggest that remnants of embryonic tissue, from when the woman was an embryo, may later develop into endometriosis in different parts of the body (7).
There are also a number of other theories which suggest that the disease may begin before the woman is born (8). Those who subscribe to this theory are of two slightly different opinions. One group believes that portions of adult tissue may retain the ability they had in the embryonic stage, to transform into reproductive tissue under certain circumstances (8). Others suggest that during the embryonic stage, the endometrial cells may develop in the wrong location, giving rise to endometriosis during the woman’s reproductive years. In both cases, researchers believe that the influx of reproductive hormones which begins with the onset of puberty, create conditions that triggers this transformation (8).
The cause of endometriosis remains a mystery. Some clues point to an excess of estrogen (1,8). The North American women who have the condition are typically between the ages 25-40 and are childless (2). Both pregnancy and progesterone treatment alleviate the symptoms. Women who have not had a full-term pregnancy are more likely to have endometriosis because apparently, the longer a woman does not have a child, the more estrogen she is exposed to during her lifetime (7).
Other clues indicate that endometriosis may have an autoimmune component (7). In one study, all women tested had high levels of auto antibodies which are secreted when the body mounts an immune response to its own tissue (7). These auto antibodies are responsible for the inflammatory response which causes the pain associated with endometriosis.
Other risk factors for the development of endometriosis include environmental toxins and alcohol (9). In 1994, the environmental protection agency linked endometriosis to dioxin exposure in several animal studies. Female monkeys exposed to dioxin developed endometriosis. Similarly, PCB exposure was also implicated in development of endometriosis (9). Dioxin, a highly toxic substance, is a chemical component of some herbicides and is also a by-product of waste incineration. PCBs are a highly toxic byproducts of waste incineration. It is interesting to note that the chemical structure of dioxin and several other pesticides are similar to that of human estrogen (9). These substances are present in the food supply as contaminants and are ingested and stored in the adipose tissue (9). Other than environmental toxins, alcohol also seems to have a role in the development of endometriosis. A study found that women who drink alcohol have a 50% higher risk of developing endometriosis than those who abstain (3).
Diagnosis
Diagnosis of endometriosis is considered uncertain until proven by laparoscopy (2). Laparoscopy is a minor surgical procedure done under anesthesia in which the patient’s abdomen is distended with carbon dioxide gas in order to make the organs easier to see (3). Then, a laparoscope, a small tube with a light at the tip, is inserted into a tiny incision made on abdomen. The surgeon can then move the laparoscope around the abdominal cavity and see the endometrial implants. Endometriosis is categorized by and diagnosed in four stages based on the location and type of growth (2). Stage 1 or minimal disease is characterized by superficial filmy adhesions; stage 2 or mild disease has superficial and deep filmy adhesions; stage 3 or moderate disease has both filmy and dense adhesions; and stage 4 or severe disease has only dense adhesions either superficially or deep (2).
It would seem that the symptoms would be sufficient to diagnose a patient with endometriosis however laparoscopy is the only conclusive method (2). This is primarily because many of the symptoms associated with endometriosis can have other causes and secondly, some of the women afflicted do not have any symptoms even in stage 4 of the disease (2). A doctor can often feel the endometrial implants during a pelvic exam but medical protocols consider it bad practice to treat this disease without confirmation of the diagnosis (2). Ovarian cancer sometimes has the same symptoms of endometriosis and treatment with hormones, particularly with estrogen, which is a common treatment for endometriosis could cause a cancer to grow faster (2). Laparoscopy also shows the locations, extent and size of the implants and may help the doctor and patient make better informed decisions for long-term care and pregnancy.
Researchers are looking into a blood test to assist in the diagnosis of endometriosis. Ca-125 is a cellular protein found in pelvic organs that appears to be elevated in cases of moderate to severe endometriosis (6). This is still in the experimental stages and laparoscopy is expected to remain the conclusive diagnostic method.
Treatment
The medical treatment of endometriosis is aimed at controlling the pain and/or shrinking the endometrial tissue (4, 6). Treatment has varied over the years but no cure has been found. A total hysterectomy, which is the removal of the uterus and the ovaries is considered to be the only definitive cure (6, 10). There are three broad treatment methods: treatment with drugs, treatment with surgery, and combination of drugs and surgery (10).
Drug or hormonal therapy aims at suppressing the activity of ovaries and slowing the growth of endometrial tissue (6). Some doctors recommend the long-term use of low-estrogen, high-progestin birth control pills unless a woman is trying to get pregnant (6). This form of treatment tends to lighten or even stop menstruation which keeps the stray endometrial tissue from growing. Of the drugs used to treat endometriosis, birth control pills have the mildest side effects (6, 10).
Another hormonal treatment approach is to suppress the body’s production of estrogen. There are a number of drugs in this category and they generally work by reducing or shutting down the production of Follicle Stimulating Hormone (FSH) and Leutenizing Hormone (LH). One such drug is called Danazol which is a powerful drug with actions similar to that of the hormone Testosterone (10). It works by reducing FSH and LH levels and is taken for six to nine months at a time. Danazol has been shown to improve symptoms and shrink the size of the implants for 89% of the women who take it (10). However, women who use it may have serious side effects including pseudo-menopause, hot flashes, vaginal dryness, joint pain, muscle cramps, weight gain, depression, irritability, and acne (6). In extreme cases, there is masculinization which manifests as voice changes, reduction in breast size and overgrowth of body hair (10). In addition to these, about 30% of women treated with Danazol experience infertility later on and for those who conceive, there is a high rate of recurring pain after pregnancy (10). Because of its many side effects, Danazol is seldom used anymore.
The most commonly used hormonal drugs are called Gondotropin-releasing hormone agonists (GnRHa) (6). These are derived from Gonadotropin-releasing Hormone (GnRH) which is a hormone secreted by the pituitary. These drugs shut down the production of FSH and LH by overloading the pituitary’s production facilities. In effect, the GnRH analogs put an end to ovulation without removing the ovaries (6,10). The resulting condition is a near menopausal state characterized by an absence of menstruation and a significant reduction in estrogen levels which in turn stops the endometrial growths and reduces the pain of endometriosis. Side effects include hot flashes, mood swings, vaginal dryness, and calcium loss from bone. The side effects are halted by going off of these medications and fertility is regained (10). GnRH analogs can be taken as a nose spray called Nafarelin (synarel) which relieves the symptoms and shrinks the implants. In a study involving 247 women trated with Nafarelin for six months, 85% had their implants shrink or disappear and other symptoms relieved (10). However, six months after treatment, the symptoms returned to half the women who had been initially helped. Side effects of Nafarelin are similar to discomforts of menopause and include hot flashes, vaginal dryness, less frequent or no menstruation, as well as headaches and nasal irritation (10). Another GnRH-a used in the treatment of endometriosis is Leuprolide which is administered as an injectable drug called Lupron or monthly implants beneath the skin called Zoladex (2, 10). The mechanism of action and the side effects are the same as that of Nafarelin. Treatment with Lupron consists of one injection a month for six months. In clinical studies, the effectiveness of Lupron can be compared to Danazol without all the potential side effects (2, 10).
In addition to hormonal drugs, pain killers are commonly prescribed. These are non-steroidal anti-inflammatory drugs (NSAIDs) and include Naprosyn, Ponstel, Rufen, Meclomen, Motrin and a few others. In cases of severe pain, narcotic drugs such as Codeine, Oxycodone, or even Morphine may be prescribed (6, 10).
When there is moderate to severe endometriosis, drug therapy will not be sufficient to alleviate the symptoms and surgery may be necessary (10). In general surgery is needed when patches of endometrial tissue are larger than 1.5-2.0 inches, when there are significant adhesions in the lower abdomen or pelvis, for endometrial growths that are obstructing one or both fallopian tubes, or when the pain is severe and not alleviated by drug therapy (10). Often the tissues are removed during laparoscopy when the definitive diagnosis is made (2). Laparoscopy is a minor surgical procedure done under anesthesia in which the patient’s abdomen is distended with carbon dioxide gas to make the organs easier to see and a laparoscope (a tube with a light at the end) is inserted through a tiny incision made on the abdomen (3). Laparoscopic surgery may involve electrocautery, burning of the tissue with electrical current, or laser to remove endometrial tissue. The advantage of this surgical approach, besides a shorter and less expensive hospital stay, include less likelihood of complications; reduced tissue injury , bleeding and scar tissue formation; rapid diagnosis and treatment; and an easier, faster and less painful recovery (10). It is an effective method of directly attacking the causes of pain and infertility which are the main concerns of the sufferers. The potential side effects of laparoscopy are mainly associated with instrument insertion, heat injury, and potential anesthetic complications (10).
Another surgical approach is Laparotomy (6). Unlike laparoscopy, this procedure involves the opening up of the abdominal cavity and is considered major surgery. This is done when endometriosis is so widespread and perhaps accompanied by other related diseases that it can not be handled through the tiny incision used in laparoscopic surgery (10). For example, bladder, bowel and kidney involvement may require special surgical procedures only possible with Laparotomy (10). Also if there are very large cysts to be removed or large endometrial growths that form a mass involving a number of organs, Laparotomy is the only practical method. (10) There are a number of other operations and related tests that may need to be performed as part of the treatment for endometriosis. These may include: Neurectomy, cutting or blocking the nerves that transmit the pain of endometriosis; Salpingectomy, removal of a fallopian tube; Intravenous pyelogram, an X-ray examination of kidney, bladder, and uterus using an injected dye; as well as several other procedures to look for adhesions in colon, lungs and other areas (10).
The third approach in the treatment of endometriosis is to use the combination of drugs and surgery (6,10). In this method, medicines are used for six weeks prior to surgery to shrink endometrial tissue and ease the surgical removal. Following the surgical removal, doctors may prescribe a low dose estrogen-progestin birth control pill to be taken for up to nine months (6).
Unfortunately, the relief of symptoms that follows surgery is frequently only temporary (10). As a last resort, a total hysterectomy is performed which involves the removal of the uterus and both ovaries. Menopause also generally ends the activity of mild to moderate endometriosis. In cases of severe endometriosis, post-menopausal hormone replacement therapy can reactivate the disease (10).
Etiology of Chronic Disease According to Ayurveda
According to Ayurveda, most chronic disease come about when toxins (ama) accumulate in tissues and start to disrupt the delicate balance of the tissues. Toxic build up can also obstruct the channels of circulation and elimination in the affected areas (11, 12). This blockage prevents proper nutrition from reaching the tissues and also prevents the removal of the tissue waste. As a result of this toxic buildup, the natural defenses are lowered and the natural biological rhythms are disrupted (11,12).
This is the very process whereby all chronic disease, including endometriosis is created. In the case of endometriosis specifically, chronic toxin accumulation in the reproductive tissue irritates the tissue into responses that result in the slow accumulation of excess tissue (13). Since the accumulation of ama is the underlying factor here, it is vital to stop the process of ama creation and accumulation. This can be done through various means including: improving digestion by regulating the digestive fire (Agni), eating foods that are nourishing and easy to digest, ensuring proper elimination, and by balancing the mind (12,13).
Endometriosis According to Ayurveda
According to Dr. David Frawley, Endometriosis is primarily a Kapha problem due to the increasing buildup of cells and overgrowing much like a tumor (11). Endometriosis can also be thought of as a Pitta problem because of the involvement of blood, hormones, and menstruation as well as the inflammatory nature of the disease (14). Vata is also involved in a number of ways. One is the painful nature of endometriosis which places Vata at the center of the imbalance. Then, there is the involvement of Apana Vayu in the downward movement of menstrual flow and also the involvement of vata in the circulation of blood. Perhaps the most obvious sign of the role of Vata is the displacement of endometrial cells from their original location in the uterus to places outside. Therefore, endometriosis is a Sannipatika condition involving all three doshas although the proportion of each may vary to a certain extent according to the individual patient.
Let us examine the Charaka Samhita for verification of above statements. According to Charak, that which can be diagnosed as a vatic disorder has the qualities of roughness, instability, dislocation, division, attachment and piercing pain (15). Among these qualities dislocation (dislocation of cells from inside to outside of endometrium), attachment (of ectopic endometrial cells to other organs), and piercing pain are the main characteristics of endometriosis. Of the pittika symptoms mentioned, only hemorrhagic patches and thickening of skin are present in endometriosis (15). Among the kaphaja symptoms mentioned, chronicity is the only one that applies to endometriosis (15).
Of the three sources found, one strongly emphasizes the role of pitta in the etiology of endometriosis and another considers vata as the main cause through the involvement of the mind (12-14). I personally consider it a condition of Vata pushing Pitta pushing Kapha out of balance. My rationale for this is the very definition of endometriosis which is the growth of endometrial cells outside the uterus. This to me, places Vata at the base of the problem. Also, if we consider the modern medicine’s theory of retrograde menstruation, we can see the involvement or rather the obstruction of Apana Vayu which holds Pitta (blood) and causes it to move up and around. Pitta then becomes vitiated causing heavy bleeding and inflammation. This pitta vitiation creates an irritation which induces kapha to enter to provide comfort by coating the irritated area. The kapha influence then causes a buildup of cells and overgrowth. Thus, the Sannipatika nature of the disease.
According to the Charak, there are twenty types of Yoni Vyapat or vaginal disorders, none of which seem to describe endometriosis individually. However, Madhava Nidhanam, a text of clinical symptomology, has references to disorders that have some similarities to endometriosis. The reference that I considered closest to endometriosis was that of Yoni Kanda or vaginal tumor (16). The text states:” If the mass is rough, discolored, and fissured, it is of vata origin; burning sensation, red color, accompanied by fever, is of pitta origin; blue and resembling a flower of linseed and having itching are found in that of kapha origin. Presence of all three symptoms is that caused by the increase of all three doshas are seen as the features of this disease” (16).
Treatment
Since disease is a result of toxin accumulation, poor nutrition, poor digestion, and imbalances of the mind and nervous system, treatment must include steps to correct the imbalances and reverse the process of disease (12,13). The goal of the Ayurvedic approach is to enliven the body’s natural self-healing abilities to not only treat endometriosis, but also to prevent disease in general and create a state of health and well-being.
Since endometriosis is a condition of ama accumulation, the treatment should focus on detoxification/reduction or Shodana therapy in order to remove the ama and get the doshas back into their original locations (13,14). Therefore, Pancha Karma is indicated along with Agni therapy. Most importantly, the liver should be cleansed or tonified as it has a role in menstruation and hormone production (14).
Prior to Pancha Karma the dietary and digestive issues must be addressed. There are two parts to the digestive issues: one is the problem of insufficient Agni which is a precursor to ama formation and the other is the issue of proper nutrition (12). A highly nutritive and easily digestible diet with sufficient amounts of digestive herbs should be the first step toward treatment. A good example of this is the CCA Sannipatika food program (17). The patient can be placed on the food program for forty days and given herbs to support proper digestion and elimination. This will help cleanse some of the ama, provide nourishment and enough time to nourish all seven tissues, and regulate the agni to prevent further ama production. At the end of this period the patient will be ready to proceed with Pancha Karma for deep cleansing.
The process begins with daily Ayurvedic oil massages and body treatments to loosen up the ama, collect it from different parts of the body, and bring it back to the digestive system for elimination (17). These treatments will also help pacify the mind and the emotions as the patient undergoes cleansing. According to several sources, a combination of Abhyanga, Swedana, shirodhara and Basti are given daily for seven days or more while the patient consumes a diet of broths and light kitchari (13,14,17). At the end of this period, the ama has returned to the digestive system and needs to be eliminated. Also, by this time during the course of treatment, Vata dosha has become pacified and it’s excess eliminated. The next step is to eliminate the excess pitta through Virechena. Patient is given castor oil and placed on a diet of broth for 24 hours (14, 17). Through the purgation that results, pitta ama is eliminated from the small intestine, thus pacifying the second dosha involved in the causation of endometriosis. None of the sources studied mention the use of Vamana therapy for kapha elimination in the treatment of endometriosis. Perhaps this is because endometriosis is primarily a condition of Vata pushing Pitta which eventually pushes kapha out of balance. As it was hypothesized earlier in this paper, it is likely that the irritation caused by Pitta induces Kapha dosha to thicken the tissue in some areas, resulting in endometrial buildup which later on form the adhesions. Thus, it is believed that when Vata and Pitta doshas are successfully reduced, Kapha dosha will retract in response.
In an innovative approach, Dr. Frank Ros combines diet, herbal medicine, Pancha Karma and Ayurvedic acupuncture (Marma Therapy) to treat endometriosis (14,18). The acupuncture portion of the treatment focuses on the reproductive and endocrine systems and on the organs liver, gallbladder, spleen and stomach. They also consider kidney and bladder due to their association with the reproductive system. Pitta will relate to the liver and gallbladder as well as spleen, Vata will relate to the kidneys and bladder and kapha will relate to the spleen and stomach. The dhatus affected are Rasa dhatu (menstruation) and Rakta dhatu (blood) as well as majja dhatu (nervous system/ pain). The srotas involved are artavavaha srota and also monovaha srota due to the involvement of pain and emotions that accompany the condition. There are acupuncture points for each of the above organs, dhatus, and srotas but their names and descriptions are beyond the scope of this paper.
In a case study, Dr. Ros and his team outline their therapeutic approach to endometriosis (14). Their patient was a 31 year old mother of two with severe endometriosis for 2 years. She had tried laser cauterization to remove the endometrial growths but that had not reduced her pain. She also suffered from frequent migraines and outbursts of anger. The patient was first evaluated ayurvedically to determine Prakruti and vikruti. She was diagnosed as Sannipatika with a primary pitta vitiation based on a full Ayurvedic evaluation including pulse and tongue diagnoses. She was given castor oil virechena and asked to fast for the day until the evening. At the second visit a week later, she was counseled on remembering and releasing past emotional trauma which was successful in revealing some deeply suppressed emotions. The patient was given a combination of turmeric, fennel, coriander, ginger, cumin, fresh aloe gel, mixed in ghee and honey, 2 grams to be taken three times a day for three weeks. She was also asked to drink two liters of warm water in the morning for a week. She was also asked to do virechena just prior to the onset of her menstruation for the next two cycles.
The following week she continued with counseling and began a series of treatments starting with an abhyanga with marma pressure and acupuncture simultaneously and then swedaana in the form of sauna heat. The needles were placed on one side of the body at a time following the application of massage to the side. The needles were then removed and the patient was asked to turn over and the same thing was repeated on that side. The massage which focused on the lymph nodes and marma points, started with the patient lying on her stomach, lasted about an hour and a half, and was done so that each needle remained inserted for at least twenty minutes. On this visit she was given an extract of angelica, vitex, black cohosh, and myrrh to be taken 5 mls, initially three times a day for a week, the twice daily to be taken for six weeks altogether. On the fourth week, she was prescribed a cleansing diet of vegetable juices in the morning and kitchari for noon time and evening to be continued for a month. She was also given a commercial liver cleanser to be taken for two months.
The results of this combined treatment are as follows: After the first week patient felt %50 improvement at the time of her period, which continued to improve over time. After undertaking the liver cleansing regimen, she suffered several severe migraines until they went away altogether. Eight weeks after the start of the treatment, she no longer experienced any pain during her periods nor did she have any more migraines. The patient was followed up for eighteen months and she remained completely symptom free during this time.
This case study once again demonstrates the strength of the Ayurvedic model in understanding the imbalances on a fundamental level and visualizing the root causes of all disease. The treatment focuses on balancing the imbalances in the person and not on the treatment of the disease or its symptoms. The western model, though advanced in diagnostics, remains largely unsuccessful in treatment. This is not surprising given that the etiology remains unknown. Although there are a number of theories that try to explain the causes of endometriosis, none can account for all the symptoms nor could they ever reach the depth necessary to arrive at the underlying causative factors. Indeed, it is in the treatment of complex diseases such as endometriosis that the gifts of Ayurveda can be truly appreciated.
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