ENDOMETRIOSIS

Introduction:

The socio–economic changes in human life and the altered reproductory practices like delayed first conception, limited number of pregnancies, cause various adverse changes in women’s health. Endometriosis is one such disease which will affect the reproductive capacity of the female and disable them with its symtomatology.?

DEFINITION:

Endometriosis is defined as the presence of functioning endometrial tissue, including glands and stroma, outside the uterus. It is called endometriosis interna or Adenomyosis when it is found in the myometrium.

Endometriosis is a painful reproductive and immunological disease affecting millions of women worldwide. Till recent years this disease has not received much attention though the number of patients are increasing and leading to rise in the incidence of hysterectomy. It is more prevalent than breast cancer, yet continues to be treated as an insignificant. Even in this age of medical advances endometriosis remains a conundrum to patients and practitioners alike. woman ranging from adolescence to post-menopause.? The disease can be so painful as to render a woman or teen unable to care for her self or her family or attend work, school or social functions studies have even shown an elevated risk of certain cancers in woman with Endometriosis. Medical and surgical treatments having so many disadvantages can give partial relief to the patient and there is no absolute cure.

The most frequent sites of implantation are the pelvic viscera and the peritoneum. Endometriosis varies in appearance from a few minimal lesions on otherwise intact pelvic organs to massive ovarian endometriotic cysts that distort tubo-ovarian anatomy and extensive adhesions often involving bowel, bladder and ureter. Considerable progress has been made in understanding the pathogenesis, spontaneous evolution, diagnosis and treatment of endometriosis.

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There is a need to bring the Ayurvedic treatment into lime-light for endometriosis, because the modern line of treatment has got some disadvantages like prolonged administration of hormones which has got lot of disadvantages. If the conservative treatment fails surgery is the only alternative Ayurveda can give a better solution for endometriosis through a varied range of treatments which does not pose any hazards to the patient.

Enodmetroma is an area of endometriosis usually in the ovary that has enlarged sufficiently to be called a tumor. An endometrioma filled with old blood resembling tarry or chocolate coloured fluid is called a Chocolate cyst.

Incidence and prevalence:

During the last couple of decades the incidence of endometriosis has been increasing due to the post-ponement of first conception and adoption of small family norm. Even increasing awareness among the gynecologists and development of advanced diagnostic techniques is one factor for more identity of the cases (women of proven fertility) the prevalence of endometriosis ranges from 3% to 43%.:.

Age:
Even though it is common in between the ages of 15 – 45 years, it is one of the reproductive age group disorders. It is a chronic disease, which gains its existence gradually.

Aetiology:
The exact etiology is not known. But so many theories are put forwarded.

The important theories are as follows:

1.?????? Sampson’s theory of retrograde menstruation: This theory states that retrograde flow of menstrual debris through the tubes at the time of menstruation causes viable endometrial cells to reach the peritoneal cavity and implant there. Experimental creation of retrograde menstruation is resulted in wide spread endometriosis in animals.

2.?????? Familial tendency – genetical.

3.?????? Narrow cervix favouring ante grade menstruation.

4.?????? Immunological factors: Deficient cellular immunity with impaired clearance of regurgitated endometrial cells due to deficient function of natural killer cells or macrophages.

5.?????? Local factors: cell adhesion molecules such as integrins or cadherins may be involved in the implantation of endometrial fragments

6.?????? Role of oestrogen: Endometriosis is an oestrogen dependent condition.

Pathogenesis:

Retrograde menstruation: The endometrial fragments get implanted in the peritoneal surface of the pelvic organs. Subsequently cyclic growth and shedding of the endometrium at the ectopic sites occur under the influence of the endogenous ovarian hormones.

Coelomic metaplasia: According to Meyer and Ivanoff chronic irritation of the peritoneum by the menstrual blood may cause coelomic metaplasia which results in endometriosis. The mullerian tissue remnants may be tapped within the peritoneum which undergoes metaplasia and be transformed into endometrium.

Direct implantation: The endometrial or decidual tissues start to grow in susceptible individual when implanted in the new sites.

Lymphatic theory: The normal endometrium may metastise the peri-lymyph nodes through the draining lymphatic channels of the uterus.

Vascular theory: It is through the direct spread from blood vessels.

Pathology: The endometrium including glands and stroma in the ectopic sites has got potentiality to undergo changes under the action of ovarian hormones.

Proliferative changes are constantly seen but the secretory changes are absent due to deficiency of steroid receptors in the ectopic endometrium. Cyclic growth and shedding continue till menopause. The periodically shed blood may remain encysted and the cyst may sometimes become tense and ruptures.

As the blood is an irritant, there is dense tissue reaction surrounding the lesion with fibrosis.

If encysted the cyst enlarges with cyclic bleeding. The serum gets absorbed in between the periods and the content inside becomes chocolate coloured. Hence the cyst is called chocolate cyst which is commonly located in the ovary.

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Naked eye appearance:

It depends on the organs involved, extent of the lesion and reaction of the surrounding tissues.

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Pelvic endometriosis:

There are small black dots called ‘Powder burns’ seen in the uterosacral ligaments and pouch of Douglas. Scarring of the peritoneum surrounding the implants is also a typical finding.

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CLINICAL FEATURES/ SYMPTOMATOLOGY (patient profile):

• The patients are mostly nulliparous.
  Age between 15-45 early cases is asymptomatic.
• Two main features are pain and infertility.
• Most of the cases are accidentally discovered in laproscopy or laparotomy.

• Progressively increasing secondary dysmenorrhoea. Pain starts a few days prior to menstruation gets worsed during menstruation and takes time to get relief of pain. Dysmenorrhoea and dyspareunia are common
• Abnormal menstruation: Menorrhagia is the predominant abnormality.
• Dyspareunia: It is deep and initially it is worse predominantly and pain persists for several hours after coitus. It is due to stretching of the structures of the pouch of Douglas or direct contact tenderness. Common is endometriosis of retrovaginal septum.
• Pelvic pain: The pain varies from pelvic discomfort, Lower abdominal pain or backache due to adhesions, scarring, stretching of the peritoneum. Frequency of micturition, dysuria or even haematuria is present.

• Painful defeacation, diarrhea, rectal bleeding may present when sigmoid colon and rectum are involved.
• Infertility is more often of the primary variety.

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Examination and diagnostic findings:

Abdominal examination: Abdominal palpation may not reveal any abnormality. A mass may be felt in the lower abdomen in the case of enlarged chocolate cyst or tubo-ovarian mass due to endometriotic adhesions. The mass is tender with restricted mobility.

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Diagnosis:

Pelvic examination: Speculum examination reveals vaginal/ cervical deposits which are bluish in colour. These molecules are tender to touch.

Bimanual examination reveals nodular and tender uterosacral ligaments. Uterine mobility is restricted and it may be fixed in retroversion.

Classical clinical symptoms suggesting endometriosis:

Progressively increasing secondary dysmenorrhoea

Dyspareunia

Infertility.

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Confirmation:

1.?????? In ultra sonography of the pelvis – the ovarian endometromas may be seen as well marginated masses with slightly irregular walls and low level internal echoes.

2.?????? Double punctate laparoscopy or by laparotomy

3.?????? Serum marker CA125 – A moderate elevation of serum 125 is noticed in patients with severe endometriosis.

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Clinical presentation:

Endometriosis should be suspected in woman with sub –fertility, dysmenorrohea, dyspareunia, or chronic pelvic pain. How ever, endometriosis may be asymptomatic.

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PAIN:? In adult woman, dysmenorrohea may be especially suggestive of endometriosis if it begins after years of pain – free menses. The dysmenorrhea often starts before the onset of menstrual bleeding and continues through out the menstrual period.? The distribution of pain is bi-lateral.?? Local symptoms can arise from rectal, ureteral and bladder involvement. Lower back pain can occur. Possible mechanisms causing pain in-patients with endometriosis include local peritoneal inflammation, deep infiltration with tissue damage, adhesion formation, fibrotic thickening, and collection of shed menstrual blood in endometriotic implants, resulting in painful traction with the physiologic movement of tissues.

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INFERTILITY: The infertility is caused due to the involving of the ovaries and causing adhesions that block tubo- ovarian motility and ovum pickup,?? Endometriosis is associated with an increased rate of spontaneous abortion-up to 40% compared with a normal spontaneous abortion rate of 15-25%.

ENDOCRINOLOGIC ABNORMALITIES:
Endometriosis has been associated with anovulation, abnormal follicular development, luteal insufficiency, and pre- menstrual spotting (the lutinized unruptured follicular syndrome,) and galoctorrhea and hyperprolactinemia.

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DIFFERENTIAL DIAGNOSIS:

Benign ovarian tumour – for chocolate cyst.

Rupture of chocolate cyst may simulate the condition of rupture of ovarian tumour, disturbed ectopic pregnancy or appendicitis.

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Complications:

upture of chocolate cysts ---an acute abdomen condition may result? which may even lead to peritonitis

Infection of chocolate cyst.

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Staging:

The diagnosed endometriosis should be appropriately staged for the following reasons.

1.?????? To predict prognosis

2.?????? To choose therapy

3.?????? To evaluate the treatment protocol

The staging is based on the area of adhesions:

Stage 1 (minimal)??? - 1-5 cms
Stage II (mild)????????? - 6-15 cms
Stage III (moderate) - 16-40 cms

Stage IV (severe)????? - >40 cms

Symptoms:

• Painful nodular swelling over or adjacent to the scar which increases in size and bleeds during periods.
• Umbilicus: Nodular painful swelling which increases in size and becomes tender during periods.
• Bladder: dysuria frequency, haematuria and abdominal pain during periods.
• GUT: Rectum, sigmoid colon, small intestines are common sites periodic colicky pain on defeacation during periods.

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AYURVEDIC CONCEPT OF ENDOMETRIOSIS

STREE SABDA NIRUKTI the stree sabda has got its origin from the dhatu “sthai”. It gives the meaning of making united or keeping united. In Veda’s stree is compared with “’prithvi” or earth and the purusha is compared with akasha. As the way earth unites in her self the rain dropped from the sky, the same way stree unites the sukra or veerya in her expelled by man. YATHEYAM PRITHVEE MAHEE BHOOTANAM ---------- (ATHARVAVEDA 6197) among the vimshati yoni vyapad and Ashtarthava vyapad described in all the classics, any one single condition cannot be equated with endometriosis. Basing on the classical symptoms of endometriosis i.e., dysmenorrhoea, infertility, dyspareunia and menorrhagia, some of the yonivyapad and arthava vyapad can be considered in a group as the disease endometriosis.

As per Prof. P. V. Tiwari vataja yoni vyapad can be considered as endometriosis. This entity has been dealt in Charaka, Sushrutha and Astanga sangraha respectively.

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The clinical conditions which have been explained in Ayurvedic classics and which can be considered as endometriosis are vataja yoni vyapad, udavartani yoni vyapad, vandhya yoni vyapad, paripluta yoni vyapad, vamini yonivyapad, antarmukhi yoni vyapad, asrija yoni vyapad and? asrigdhara.

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These are the conditions which can be taken as pelvic endometriosis. The description of extrapelvic endometriosis condition suggests the symptoms of granthi and that is dealt further in the essay.

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Before going to the analytical description of endometriosis and Ayurvedic concepts of it a brief understanding regarding the nidana, samprapti of yoni and arthava vyapad is necessary.

In Ayurveda the disorders of the female reproductive system are explained in the classics under the entity of yoni vyapad and arthava vyapad. The word yoni refers to the structural aspect i.e, the organs of female reproductive system all together¹.

The word arthava refers to the functional aspect of the female reproductive system².

It refers to the ovum i.e, stree beeja or oocyte as well as the endocrinal system which produces the hormones i.e, the hypothalamus-pituitary ovarian endometrial axis.

The word raja purely denotes the menstrual blood.

In the explanation of srotases by Sushrutha, he has given special emphasis for the artavavaha srotas³. The moola of arthavavaha srotas is garbhashaya and arthava vahini dhamani. i.e, the uterus along with its three layers, the ovaries and the fallopian tubes⁴.

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This explanation indicates that yoni vyapad and arthava vyapad i.e, the diseases of female reproductive system pertaining to uterus and abdomen and the endocranial system also are the diseases or vyapad of arthavavaha srotas. Infact arthavavaha srotas pertains to major organs to the minute cells of female reproductive system.

The injury or any pathology in the arthavavaha srotos causes dyspareunia (maidhunasahishnutha), infertility (vandhyatwa), and amenorrhoea or deficiency of gonadal hormones (arthava nasha)⁵.

By studying all the above factors and analyzing the 20 yoni vyapads and 8 arthava vyapads⁶ the condition endometriosis can be related to a group of yoni vyapad? and artava vyapad but not any single entity explained in the classics. Basing on the important and most prominent clinical features of endometriosis i.e dysmenorrhoea, infertility, dyspareunia, chronic pelvic pain etc. the similar conditions explained in Ayurvedic classics i.e, udavarthini (dysmenorrhoea), vandyathva (infertility), paripluta (dyspareunia) vatala yoni vyapad (chronic pelvic pain) and other conditions like vamini, asruja (implantation defects) antarmukhi yoni vyapad (excessive anteversion- causing antegrade menstruation) in a group can be considered as endometriosis.

Because the major symptoms of endometriosis are not covered under a single entity in Ayurveda, all the entities which has got the similar features of endometriosis aretaken under one roof and considered as vata pittaja arthva vaha sroto dushti. Basing on the dosha predominance i.e, vata pitta and the dushya i.e, arthava vaha srotos.

Basing on this dosha dushya sammurchana the principle of treatment can be formulated with more authenticity.

Further explanation of the different yoni vyapad conditions, including their nidana, samprapthi and lakshanas and Asrigdara along with etiology, pathology and symptomatically with modern concept, leads to more analytical understanding.

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Samanya nidana of yoni vyapad:-

Abnormal ditetics and mode of life (midhyahara viahara) (nutritional factors and irregular factors like smoking), abnormalities of artava and beeja (defective ovum and spermatozoa). The curses or anger of god (idiopathic) are the causes of yoni vyapad according to Charaka⁷.

Sushrutha opines that a very young or weak lady does excess coitus with a man having big sized penis, her vayu gets aggrevated and with holds pitta and shleshma already vitiated, reaches the yoni and produces various disorders⁸.

The above description indicates the involvement of nutritional factors and the irregular habits like smoking, drug use, exercise etc, which comes under the immunological factors of etiology as there are said to come under the category of midhyahara vihara.

The point of beeja dosha explained by Charaka clearly quotes to the genetic factors as it says risk of endometriosis is seven times greater in first degree relatives. Beeja dosha also indicates the genetical transformation of disease from mother to child.

Kasyapa says that exessive intake of panchakarma as the cause for artava vyapad.

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Samprapthi (pathogenesis) of yoni vyapad & artavavyapad:

The apana vata which gets aggrevated due to the above factors vitiate pitta and kapha and fills the yoni and produce various disorders of yoni vyapad.

By the cosumption of vata prakopaka aahara the aggravated vata takes the raja which is also vitiated, along with it and? increases the amount of? it? and produces asrigdhara.

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Vatala or vatika yoni vyapad:

A woman of vata prakruthi when consumes diet and indulges in other activities capable of aggrevating vata, it gets provoked and reaches yoni and produces pricking pain, stiffness, roughness and numbness and fatigue and lethargy. Chakrapani says that the painful, frothy and thin menstrual blood occurs even in intermenstrual period⁹. This condition is characterized with pain which is more in magnitude. Prof.P.V.Tiwari opines this condition as endometriosis.

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Asruja or raktha yoni:

Due to excessive use of articles capable of aggrevating rakta and pitta, the rakta situated in reproductive organs gets vitiated by pitta and after achievement of conception there is excessive bleeding per vaginum. Chakrapani explains that excessive bleeding leads to abortion and the woman remains without offspring so it is termed as Apraja¹⁰.

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Udavarthini or udavartha yoni vyapad:

Due to the movement of the adharaniya vegas (natural urges) in reverse direction, the aggrevated vayu (apana vayu) moving in reverse direction fills yoni (uterus). This yoni seized with pain, initially throws or pushes the raja (menstrual blood) upwards and then discharges it with great difficulty. The lady feels immediately relief following discharge of menstrual blood. As in this condition the raja moves upwards or inverse direction, it is termed as udavarthini¹¹. This condition is also characterized by painful frothy menstruation, general malaise and discharge of clotted blood^12,13.

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Pariplutha yoni vyapad:

A woman having predominance of pitta with holds her natural urges of sneezing and eructation at the time of coitus, then the vitiated pitta, getting admined with vayu reaches yoni and produces its abnormalities. The yoni becomes inflamed and tender and she gets painful menstruation. She also suffers from pain in lumbosacral and groin region etc¹⁴. this condition is also characterized with severe dyspareunia and diarrhea etc^15,16.

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Antharmukha yoni vyapad:

When a woman after meals indulges in coitus, sleeping in abnormal posture, then her vayu situated in yoni getting pressed by food produces different types of pain and cracks the mouth of yoni (cervix). There is severe pain in yoni (vagina) and dyspareunia¹⁷.

Vamini yoni vyapad:

The disorder, in which, sukra is expelled with or without pain, within six to seven days of its entry into the uterus is termed as vamini¹⁸. Yoni which vomits or excretes bija admixed with raja and associated with vata is also termed as vamini¹⁹.

Vandhya yoni vyapad:

Even though the description of vandhya according to Charaka and Sushrutha denotes beeja dosha and nashatwa which are incurable²⁰, for the convenient purpose of childlessness the term vandhya is used to denote infertility.

Due to non acceptance of bija or garbha by vitiated yoni in various yoni vyapad and destruction of bija in arthava dusti (menstrual disorders) the conception does not take place. In yoni arsa condition also as a complication i.e, due to destruction of artava conception will not occur. Kashyapa says that girl passing urine with? quivering or flopping stream (sphalita mutratwa) are also infertile.

In Harita classification of vandhyathva, he explains six types, out of which kakavandhya (one child sterility), anapathya (primary infertility) and garbha sravi (repeated abortions)are important which are related to endometriosis²¹.

Under the classification of Charaka, Sapraja and Apraja are the two conditions which are important regarding endometriosis²².

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ASRIGDARA:?

Charaka has described the only symptom is presence of excessive bleeding during menstruation. Susrutha says that when same menstruation comes in excess amount, for prolonged period, even without normal period of menstruation, and different from the features of normal menstrual blood or denoting the features of specific dosha is known as asrigdara.dalhana has described clinical features of asrigdara as burning in lower portion of groin, pelvic region, back, region of kidney and flanks and severe pain in uterus.

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Dosha vivechana:
Basing on the description of yoni vyapad the dosha predominace can be taken as vata and pitta. Udavarthini, vatala, vandhya, antharmukhi are purely vataja dominated disorders. Paripluta and vamini are vatapittaja disorders. Asraja and raktha yoni are pittaja disorders.

Asrigdara even though explained in four categories it is mainly dominated by vata.

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Dooshya:
Dooshya is considered as arthavavaha srotos. The dushti or vaigunya lakshanas of srotos²³ clearly indicates the involvement of arthavavaha sroto dushti or dooshya got affected by vata and pitta.

CHIKITSA SUTRA AND CHIKITSA OF THE YONI VYAPAD AND? ASRIGDARA RELATED TO ENDOMETRIOSIS

Vatala yoni vyapad:
Chikitsa sutra:

1.?????? Vatahara chikitsa with sneha, sweda and basti with vatahara drugs²⁴.
2.?????? Pichu dharana with vata hara tailas.
3.?????? Uttara vasti with guduchyadi taila.? For 7 days²⁵

Aushadha prayoga:

1.?????? Shatavari grutha in a dose of 5 gm with luke warm water is given twice daily. After uttara vasti
2.?????? Tab. Chandraprabhavati—two? tab’s twice daily with milk

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Chikitsa sutra Udavarthini yoni vyapad:
Vatahara? chikitsa is adopted

1.?????? Sneha with trivrutha sneha.
2.?????? Sweda with mamsa rasa of gramya and anupa desa animals.
3.?????? Dashamula ksheera basti.
4.?????? Ashokarishta??15 ml? twice daily? with equal water.
5.?????? Tab. Chandraprabhavati two tabs twice daily with milk

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Chikitsa sutra of Asraja or raktha yoni:

Rasayana, jeevaniya, prajasthapaka chikitsa is adopted

1.?????? Uttara vasti with kasmari ghrutha is advised. For 7 days
2.?????? Phala ghruta two tsf with milk is given twice daily? after? uttara vasti?

Chikitsa sutra of vamini and pariplutha:

Rasayana , jeevaniya, garbhashapaka chikitsa is adopted.

1.?????? Sneha and sweda with vatahara dravyas.
2.?????? Panchavalkala tail pichu dharana in yoni.
3.?????? Phalaghruta? two? tsf? with milk is given twice daily

Chikitsa sutra of antar nukha yoni:

Vatahara chikitsa is adopted

CHIKITSA SUTRA OF PRADARA:

1.?Rasayana? chikitsa? and? adhogata raktapitta? hara chikitsa? is adopted
2.?Asthapana? vasti with? nyagrodadi kashaya? is given
3.?Uttara vasti with? satavari ghruta is given for 7 days
4.?Kushmanda avalehya? 5gm?? twice daily? with milk? after uttara vasti
5.?Chandraprabhavati - two tabs, twice daily with milk

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Analysis:

Basing on the description of endometriosis and different yoni vyapad and the arthava vyapad conditions the Ayurvedic concept of endometriosis can be explained. As it is not possible to relate any single disease explained in the classics can be taken as endometriosis, the disease like udavarthini, vandhya, apraja and raktha yoni, vamini, paripluta yoni vyapad? and Asrigdara arthava vyapad can be taken in a group as endometriosis and it can be termed as vata pittaja disorder of arthava vaha srotos.

The udavarthini yoni vyapad which is vataja yoni vyapad satisfies not only symptomology with the classical features of dysmenorrhoea (kastarthava) which is one of the important symptom of endometriosis, but also the theory of retrograde menstrual flow which is one of the aetiological theory can be seen in the explanation of udavarthini.

The cause of udavarthini that has been explained by Charaka i.e, the aggrevated apana vayu moving in upward direction or reverse direction fills the yoni and the yoni seized with pain pushes the raja upwards i.e, the retrograde flow of menstrual blood. This point clearly states the possibility of retrograde menstrual flow which is one of the cause of endometriosis. Basing on this explanation udavarthini yoni can be considered one among the vataja vyapads that simulates endometriosis.

The yoni vyapads like apraja, vandhya, vamini are related to the conditions of failure of conception as well as implantation defects, which is caused due to the anovulatory cycles, leutinized unerupted follicleand corpus luteum insufficiency etc.

The term vandhya is used buy Charaka to denote the beeja dosha i.e, congenital abnormality and Sushrutha’s explanation suggests amennorhoea i.e, nastarthava. But in Charaka’s explanation he says apraja and sapraja are the curable conditions of childlessness i.e, primary and secondary infertility. According to Haritha vandhya word denotes six types of conditions that lead to childlessness.

The conditions apraja and sapraja i.e, primary and secondary infertility respectively pushpagnijataharani given by Kashyapa and the conditions of Kakavandhya (one child sterility), anapathya (primary infertility) satisfies the condition of primary and secondary infertility caused due to endometriosis. These conditions fall under the category of anovulatory cycles except sapraja vandhya, and kakavandhya which denotes the conditions of secondary infertility caused due to the endometriosis because of which tubal motility is altered and the capacity of sperm transport is decreased because of the affected uterine endometrium.

The conditions of vamini and apraja or asraja denote the condition of luteal phase defect and early embryo reduction which are the probable causes of infertility caused due to endometriosis.

Paripluta yoni vyapad which is characterized with dyspareunia according to Sushrutha and dysmenorrhoea according to Charaka can be taken as the condition caused due to the deposits of endometriosis present in the ligaments and vatala yoni vyapad or vatika yoni vyapad to some extent suggests with the explanation of Charaka i.e, pricking pain, stiffness, roughness, numbness etc, in yoni. The deposition of the endometrial tissue in the pelvis causes pain and roughness. Chakrapani’s version of inter-menstrual bleeding in the vatala yoni vyapad is one of the important features which is suggestive of relation with endometriosis.

The condition of chocolate cyst that is one of the features of pelvic endometriosis can be considered as the condition of vataja grandhi explained in classics. In the explanation of granthi, the points of production of knotty swelling, features of pain like stretching, pricking, cutting etc and discharge of blood after bursting are suggestive of the feature of the chocolate cyst.

The description of Asrigdara suggests the involvement of endometriosis in the myometrium that is the adenomyosis condition which is characterized by menorrhagia (Asrigdara) and dysmenorrohea as suggested?? by Dalhana .

Considering the points in critical analysis, the disease endometriosis can be taken in Ayurvedic concept as vata pitta arthava vaha sroto dusti.

It has been taken as vata pittaja because the yoni vyapads like udavarthini, vandhya, vatala, vamini etc are mainly vataja vyadhis. The condition paripluta and asraja are pittaja yoni vyapads. So the doshas can be taken as vata pitta and the dushya is artavavaha srotos.

Artavavaha srotos is taken as dushya because the moola for arthavavaha
srotos is garbhashaya and arthava vahini dhamani.

Pathogenesis:

The doshas i.e, vata and pitta vitiate the yoni i.e, the garbhashaya (arthava vaha srotos) and produce the above said vyapads. The arthava vaha srotos has also got the moola artava vahini dhamani. Artava vahini can be considered asper the description of dhamani that is explained in Sushrutha samhitha sutra sthana in the dhamani vyakarana shareera., (In the explanation of dhamani, it has been said that dhamaniis the structure which carries arthavadownwards.)as artava as the stree beeja or ovum and the channel that carries ovum is fallopian tube.

In the pathogenesis of endometriosis fallopian tube also plays an importantrole regarding the retrograde menstrual flow and also in causing infertility with the deficiency or alteration in tubal motility with the development of endometrial tissue adhesions. With this explanation it can be understood that endometriosis can be considered as vata pittaja arthava vaha sroto dushti as the injury or the disease to artava vaha srotos leads to maidhunasahishnutha (dyspareunia) and vandhyathva (infertility).

The doshas are vata pitta and the dushya is arthava vaha srotos i.e, garbhashaya (uterus) and arthava vahini dhamanii.e, (fallopian tubes). Even the western science also has the similar etiopathogenesis regarding endometriosis. The basic pathology starts from the uterus i.e, the endometrial cells travel through the retrograde menstrual flow through fallopian tubes causing ectopic implantation.

In the description of sroto vaigunya lakshanas or dushti lakshanas the sira grandhis and vimarga gamana are the important points in the view of endometriosis to explain the involvement or comparision of arthava vaha sroto dushti with endometriosis.

The vaigunya or dushti of sira granthi in arthava vaha srotos indicates the formatin opf chocolate cyst in pelvic endometriosis i.e, the prakopita doshas enter the arthava vaha srotos and because of the sanga (obstruction) they produce siragranthi due to vimarga gamana i.e, formation of chocolate cyst (sira granthi), caused by vimarga gamana (retrograde menstrual flow).

Even the asrigdara in classics, whichis particularly sannipata said as incurable. Even the adenomyosis condition is medically incurable. The treatment can be given for cases like histologically normal with out having any compilations, in Ayurveda.

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PRINCIPLES OF TREATMENT OF ENDOMETRIOSIS IN AYURVEDA

Basing on the modern explanation i.e, etiopathogenesis and clinical features and the comparative aspect of yoni vyapad with nidana, samprapti and lakshana, the treatment can be categorized into three groups.

Finally after observing the analytical aspect the treatment should be given to a condition where chronic pelvic pain (vatala yoni vyapad), dysmenorrhoea (udavarthini yoni vyapad), dyspareunia (paripluta yoni vyapad), implantation defects (vamini and asraja) are associated or other wise vatapittaja disorder of artavavaha srotos (endometriosis). The line of treatment should be vatapitta hara, Rasayana and prajasthapaka chikitsa.

The importance of dosha hara chikitsa i.e, vata pitta hara chikitsa is mainly the conditions which are compared to endometriosis are eliminated by vat and pitta. Even though pitta is anubandha dosha mainly the treatment should be vatahara as apana vata is the main controlling factor of female reproductive system.

The importance of Rasayana chikitsa is to treat the vaigunya of arthava vaha srotos, as the arthava is upadhatu of rasa dhatu and the Rasayana chikitsa is best for rasa dhatu, it should be adopted for artava vaha sroto vaigunya also.

Prajasthapaka treatment is important as the condition is usually associated with primary infertility (vandhya) and the modern science prefers to achieve fertility as a curative treatment for endometriosis.

For the granthi (chocolate cyst) granthi hara chikitsa has to be done.

Principles of treatment of endometriosis in Ayurveda:

For convenience of treatment the conditions are divided into groups.

I group: patients diagnosed with pelvic endometriosis associated with infertility (primary or secondary)

II group: unmarried patients with pelvic endometriosis

III group: patients with pelvic endometriosis in who have completed the family

IV group: patients with extra pelvic endometriosis

Treatment for group I:

Virechana is advised after menstrual period with trivruth lehya in a dose of 10-15gm.

Yoni prakshalana with panchavalkala kwatha.

Bala Taila uttara vasti for 7 days in rutukala i.e, from 5^th day of menstrual cycle to 12^th day or neelothpaladi taila in a dose of 10 ml followed by pichu dharana with bala taila pichu.

4.? Dadimadi grutha internally or phala grutha 2 tsp twice daily with milk after uttara vasti.

Chandraprabha vati, two tabs twice daily with water.

Kanchanara guggulu two tab”s twice daily with aragvada kwatha

The above treatment should be continued for three cycles.(? for 3 months)

Treatment for group II:

As these patients are unmarried, uttara vasti is not advised.

Virechana is given with trivruth lehya in a dose of 10 gm.

Sneha vasti is given with guduchyadi taila.

Ashokarista 15 ml thrice daily with equal water.

Chandra prabha vati two tabs twice daily.

Pancha tiktha guggulu ghrutha 1 tsp twice daily? with luke warm water (if cyst is present).

Treatment for group III:

1. Virechana is given with trivruth lehya in a dose of 10 gm.
2.?Panchavalkala or triphala quatha yoni prakshalana.
3.?Uttara vasti with dashamuladi taila in a dose of 10 ml in rutu kala for 7 days followed by pichu dharana.
4.?Tab. Chandraprabha avti two tabs twice daily.
5. Ashokarista 15ml thrice daily with water.
6.?Pancha tiktha guggulu ghrutha 1 tsp twice daily. After uttara vasti

Treatment for group IV:

1.?Granthi chikitsa is given
2.?Kshara karma can also be adapted.? ( external)
3.?According to the involvement of srotas the chikitsa should be selected.

MODE OF ACTION OF THE UTTARA VASTI AND THE DRUGS

In Sushrutha samhitha chikitsa sthana uttara vasti is indicated for artava doshas and vandhyatva and particularly for all yoni rogas uttara vasti is stated as best chikitsa as it is the complete chikitsa for vata vyadhis and the apana vata is a major factor of causing yoni and arthava vyadhis, obviously uttara vasti will be the ultimate treatment for endometriosis.

The endometrial layer is made up of mucous membrane and the dravya that is used in uttara vasti is sneha dravya i.e, a lipid. Lipids will get absorbed through the mucous membrane and the active principles of the drugs which are used in the form of sneha gets absorbed in to the circulation and enter through the circulation into the minute cells of the body and target organ. Locally also when the dravya gets absorbed the glands and stroma of the endometrium and the cells of the endometrium start functioning or start responding to the hormones which is failed because of the endometriosis.

The drug bala which is potentially a vata hara and praja sthapana helps in making the endometrium responsive for the hormones and preparing a healthy nidation for the zygote. It also helps the ovaries to produce a matured follicle and release of oocyte through its prajasthapaka action. Bala not only pacifies vata but also pitta shamaka. It is also having the properties of vedana sthapana and shotha hara. With this property it acts as pain killer and anti-inflammatory which reduces the inflammatory reaction induced in the surrounding pelvic tissues which is occurred because of endometriosis. It reduces the chronic pelvic pain. It is also having the properties of grahi and raktha pitta shamaka which helps in controlling menorrhagia.

So uttara vasti is the best procedure in conveying the properties of the medicine to the tissue.

The other important drug is guduchi. The guduchyadi taila explained in Charaka chikitsa and Sarangadhara samhitha indicates it as the best tridoshahara yoga. Guduchyadi taila cures all the vataja disorders. Guduchi is also Rasayana and vedanasthapaka dravya.

This can be used to treat the arthava vaha sroto dushti as it is best Rasayana and with its vedanasthapaka property it alleviates the chronic pelvic pain and dysmenorrhoea.

Dadimaadi grutha or phala grutha both will act as the garbhasthapaka and garbhasravahara and can give best results in vandhyatwa i.e, primary infertility and secondary infertility. Neelothpala is said to be garbhasthapaka and it is the best drug in garbhachalatwa (threatened abortion). This drug when given in the form of taila for uttara vasti it will be more beneficial. These yogas will not only act as vandhyatwa hara but also prevents the implantation defects like corpus luteum insufficiency, lutinized unruptured follicle and endometrial defects for nidation which are caused due to endometriosis.

Ashoka is another drug which is most useful in endometriosis. It acts as pain reliever (vedana sthapaka), haemostatic (raktha sthambaka). It stimulates uterine myometrium and regulates the contractions which help in preventing retrograde menstrual flow and it also helps to stimulate the ovaries which promote the proper functioning of ovaries. It prevents the dysmenorrhoea.

Chandra prabha vati is also a potential drug in the yoni vyapad and artava vyapad conditions as it contains the most potential drugs like guggulu and shilajit.? guggulu is said to be? rasayana as well as? vandhyatwahara,and vedanasthapaka and it is helpful with this property in treating? the? artavavaha sroto vaigunya.?

Shilajit is also a proven drug in the reproductive disorders of the female with it’s vajeekarana and rasayana? properties.

Although a variety of treatment options are available, the most common being surgery or medication, many are associated with side effects that are as severe as the disease itself. As is the case with oral and injectable medicines –administered to prevent growth and break down of endometrial tissue -which often causes weight gain, acne and changes in hair growth, as well as hot flashes, vaginal drynes and bone thinning. In cases Because of the invasive nature of some treatments and the possibility of side effects with other existing treatment modalities there is a desperate need for a more effective way of addressing endometriosis.

SCOPE OF AYURVEDIC TREATMENT IN ENDOMETRIOSIS

Ayurveda can give better answer to treat endometriosis with out having any side effects with its unique range of disease eradicating treatments rather than suppressive and conservative treatments. Endometriosis associated with?? primary infertility with or with out cyst in the reproductive age group has got a promising treatment in Ayurvedic science. The modern science says that acheiving pregnancy is a better way of treating endometriosis in the reproductive age with infertility. Though it cannot give successful results for primary or secondary infertility. During? pregnancy the ectopic endometriotic tissue undergoes atrophic changes and spontaneous regression of the disease is possible, because estrogen levels drop during the pregnancy due to the suppression of GnRF’S, as the endometriosis is estrogen dependent condition. The way of treating both types of infertility is complex in modern science. The hormones which are used to induce ovulation, and other conditions which lead to infertility are having lot of side effects like weight gain, nausea, ocular disturbances etc.? The assisted reproductive technology which is adopted to treat in medically unmanagable for conditions, like tubal block, endometriosis, etc. Is highly costly and sophisticated and available only in major centers and it is not in reach to all the suffering community.?

Ayurveda can treat promisingly both types of infertility with simple and less costly treatments, like uttaravasti and drugs like bala, dadima etc are having potentiality to treat the infertility. Thus it can prove it’s effectiveness in treating endometriosis in the reproductive age group.

The exclusive criteria for the cases of endometriosis to treat in Ayurveda are?? the? cases which are having proved with the endometrial hyperplasia through diagnostic dilatation and curettage? particularly asocciated with adenomyosis? as it is having a possibility of malignant changes, the better option is surgical line of treatment that is total hysterectomy, provided the family is completed.

If the condition is not fit for surgery due to any medical, psychological or social reasons and the patient is strongly against surgery then Ayurvedic treatment can be carried on. With group 3 treatment explained in treatment concept.??

Panchatikta guggulu ghrita and kanchanara guggulu are having the potentiality to treat the conditions asocciated with cyst and tumors. The hormone danazol which is being used an alternative therapy for surgery is having disadvantages like developing acne, weight gain, hot flashes, mood disturbaces, osteoporosis etc, menopausal symtomps.

The cystic condition of ovary, the chocalate cyst needs surgical intervention?? to treat it. Where as Ayurveda can give better option of cyst reduction with potential medicines like Pancha Tikta Guggulu Ghrita and Kanchanara? Guggulu which are effective in granthi (cystic condition)

PROBABLE ACTION OF AYURVEDIC LINE OF TREATMENT
Vatahara chikitsa with uttara vasti may regress the ectopic endometrium and prevents further implantation of endometrial cells by correcting urdhvagamana (retrograde menstrual flow) of apana vata.???????????

Rasayana chikitsa may promote the decreased activity of immunological reaction i.e, decreasing the activity of natural killer cells which reduce the local cell immunity in the endometrium.

Prajasthapana chikitsa and garbhasthapana chikitsa helps in achieving conception thus indirectly giving a chance for the ectopic endometrium to get atrophied.

CONCLUSION
The information presented in this essay is useful regarding the importance of uttaravasti and other drugs which are having an ability to treat endometriosis. It can also bring out the exact strain of modern treatment in this disease. The following conclusions can be drawn.

1. The problem of administration of hormones for prolonged time and their side effects, failure of medical treatment leading to early hysterectomy etc, problems can be avoided with Ayurvedic line of treatment.

2.?Endometriosis is a world wide problem.

3.?In a single sitting treatment endometriosis along with infertility can be tackled very conveniently without any complications.

4.? Infertility treatment in Ayurveda is having more success rate comparative with modern treatment. Which is one way a cure for endometriosis

5. ART (assisted Reproductive Technologies)are highly expensive comparable to the Ayurvedic treatment of infertility.

6. Implantation defects of zygotes can be handled more effectively in Ayurvedic treatment.

7. Dyspareunia a very baffiliating problem which affects the marital harmony can be treated with simple treatment like pichu dharana.

8. The diagnostic procedures like laproscopy and ultra sound scanning are very expensive and are not in reach to the rural people, where as Ayurveda with the dosha dushya analysis and prediction with the lakshanas can give better answer without going sophisticated investigations. Then through Ayurveda service can be extended to rural people.

9. The role of uttara vasti can be taken as the ultimate solution for the disease “ENDOMETRIOSIS.”?