ENDOMETRIOSIS

• The presence of functional epithelium in sites other than the uterine mucosa is termed endometriosis
• An oestrogen-dependent disease frequently resulting in substantial morbidity, severe pelvic pain, multiple surgeries, and impaired fertility
• Characterized by microscopic internal bleeding, development of painful endometriomas, inflammation, fibrotic scarring, and formation of adhesions; distortion of pelvic anatomy may also be present
• Leading cause of gynecologic hospitalization and hysterectomy

Common sites :

• Ovaries
• Pelvic peritoneum
• Pouch of Douglas
• Uterosacral ligaments
• Rectovaginal septum
• Sigmoid colon

Remote sites

• Umbilicus
• Abdominal scars
• Episiotomy scars
• Lungs

• The exact cause of endometriosis is not fully understood. Possible explanations include:
• Retrograde menstruation: Menstrual blood enters the fallopian tubes and the pelvis instead of leaving the body in the usual way
• Embryonic cell growth: At times, embryonic cells lining the abdomen and pelvis develop into endometrial tissue within those cavities
• Foetal development: Endometriosis can be present in a developing foetus, but pubertal oestrogen levels are thought to trigger the symptoms
• Surgical scar: Endometrial cells can move during a procedure such as a hysterectomy or C section
• Endometrial cell transport: The lymphatic system transports endometrial cells to various parts of the body
• Genetics: There may be an inherited component
• Hormones: Endometriosis is stimulated by the hormone oestrogen
• Immune system: Problems with the immune system can prevent the destruction of extrauterine endometrial tissue

Risk factors

• Age: common in women aged 30 to 40 years
• Nulli-parity
• Medical history: Having a pelvic infection, uterine abnormalities, or a condition that prevents expulsion of menstrual blood
• Menstrual history: Menses lasting more than 7 days or menstrual cycles of less than 27 days
• Caffeine, alcohol consumption, and lack of exercise: These can raise levels of oestrogen

• One third of patients are asymptomatic
• Progressively increasing secondary dysmenorrhoea
• Deep-seated pain
• Pain starts few days before menstruation, worsens on menstruation and even persist after cessation of bleeding
• Abnormal menstruation – Menorrhagia, Polymenorrhoea & Epimenorrhagia
• Deep dyspareunia (painful coitus)
• Chronic pelvic pain
• Infertility – due to adhesions and endometriotic cysts
• Symptoms related to the organs involved – dysuria, haematuria, dyschezia (painful defaecation), hemoptysis, etc.

• Clinical diagnosis - Classical symptoms of progressively increasing dysmenorrhoea, dyspareunia, and infertility
• Pelvic examination
  • Speculum examination- Bluish powder burn lesions on the cervix or the posterior fornix of the vagina 
  • Bimanual examination- Fixed retroverted uterus, nodularity in the pouch of douglas and uterosacral ligaments, unilateral or bilateral adnexal mass (Chocolate cyst) 
• Serum marker - CA 125 (Cancer antigen 125) – Moderate elevation
• Ultrasonography - Transvaginal ultrasonography – to identify the classic chocolate cyst of the ovary 
• Laparoscopy - Considered as the gold standard for diagnosing endometriosis. May show endometriotic implants and adhesions

Surgical Interventions

• Laparoscopy- Surgical destruction recommended to remove lesions, lyse adhesions, preserve the uterus and ovarian tissue, restore normal anatomy
• Hysterectomy/ Oophorectomy/ Salpingo oophorectomy - Bilateral oophorectomy rarely indicated in women < 40 years undergoing hysterectomy for endometriosis

 Nonsurgical Therapies 

• Medical Therapies - Gonadotropin-releasing hormone agonists (GnRH), oral contraceptives, Danazol, aromatase inhibitors, and progestins are mainstays
• Alternative Therapies- physical therapy, diet, and nutrition, etc

Ayurvedic Treatment

Internal Medicines

• Sukumara Kashaya 
• Gandharvahasthadi Kashaya – in deep-seated Pelvic pan
• Dhanwanthara Kashaya – in Chronic Pelvic pain
• Saptasaara Kashaya – in cases of Dysmenorrhoea
• Kana Shatahwadi Kashaya – in Endometriotic cyst
• Trayantyadi Kashaya - Menorrhagia with Endometriotic cysts
• Kanchanara Guggulu – in cysts 
• Satahva choorna
• Hingu Triguna Taila (Samana) – in Endometriotic cysts

Procedures

• Snigdha Virechana - in Menstrual irregularity and Endometriotic cysts
• Madhu tailika vasti
• Uttara Vasti –Mahanarayana Taila, Kshara Taila, Karpasasthyadi Taila 
• Yoni Pichu – Mahanarayana Taila, Kshara Taila, Karpasasthyadi Taila