This is a case report of a 36 year old married female with an endometrioma (well defined lesion of 5.8 x 4.1.c.m as on 5.1.08). The diagnosis was repeatedly verified by ultrasound reports (attached). Generally, people rush to other systems for quick relief. But in this case the patient came to me after the diagnosis and treatment from another system. The scope of homoeopathy in treating such cases establishes its place in medical science for prevention of surgery. She was successfully treated by individualized homoeopathic treatment with Kali Carb. After the treatment, for a period of about six months, ultrasonography reports revealed normal study.
Introduction: Endometrioma: Part of the condition known as endometriosis. Endometrioma is a type of cyst formed when endometrial tissue (the mucous membrane that makes up the inner layer of the uterine wall) grows in the ovaries. It affects women during the reproductive years and may cause chronic pelvic pain associated with menstruation. Endometriosis is the presence of endometrial glands and tissue outside the uterus. Women with endometriosis may have problems with fertility.
Endometrioid cysts, often filled with dark, reddish-brown blood, may range in size from 0.75-8 inches. Endometrioma is also referred to as an endometrioid cyst. Endometriosis is a common gynaecological disorder in which endometrial tissue (glandular epithelium and stroma) is found outside the uterine cavity. It affects 20–40% of women who complain of sub-fertility, although it can be found also in 5–10% of fertile women. Endometriosis mostly presents as superficial and deep pelvic peritoneal implants, adhesions and ovarian cysts. Characteristic symptoms include dyspareunia, severe dysmenorrhoea and chronic pelvic pain. For almost a century, academic opinion held that endometriosis was a disease caused by shedding of menstrual endometrium and its dissemination throughout the pelvis . The origin of ovarian endometrioma, endometriotic deposits within the ovary, is known; however, most authors believe that they result initially from a deposit of endometrium passed through the Fallopian tube, causing adherence of the ovary to the pelvic peritoneum and progressive invagination (folding inwards) of the ovary. If this is true, an endometrioma would be a pseudocyst (false cyst), the wall of which is the inverted ovarian cortex (centre) and hence the removal of this cyst wall might involve removal of normal ovarian tissue, with possible adverse implications for future fertility
Transvaginal ultrasound is an increasingly accepted technique for the diagnosis of an ovarian endometrioma. The primary indications for treatment of ovarian endometrioma are the symptoms of pelvic pain and dyspareunia (pain during or after sexual intercourse). The evidence suggests that the most effective approach to treatment is surgical.
Homeopathic treatment for the case: Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the symptoms of the case and symptoms similarity using a holistic approach. This is the only way through which a state of fine health can be regained by removing all the signs and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat endometriosis, hepatomegaly or renal stone, but also to address its underlying causes and individual susceptibility. As far as the therapeutic medication is concerned, several remedies are available to treat these conditions that can be selected on the basis of cause, sensations and modalities of the complaints. For individualized remedy selection and treatment, we should always keep in mind to treat the patient not the disease.
Discussion and conclusion: The case showed relief in symptoms and pathology with homoeopathic medicine prescribed on symptoms of the case which covered the totality of symptoms. Ultrasonography examination revealed endometrioma. she was treated according to homoeopathic principles and followed up for 6 months, resulting in total relief of signs and symptoms. Kali Carb was selected on the basis of symptoms covering the totality. Kali Carb not only relived presenting complaints, but also reduced the other associated symptoms like weakness, back pain, loss of appetite etc., thus upholding the principle of homoeopathy as a ‘holistic approach’. This is verified in the present study.
Present complaints- – Heavy periods for first 2 days which gradually lessen and continue for 8 days; abdominal pain even after periods; has lots of clots in periods now from last 2 months; continuous brown uterine discharge for the whole month.
Present complaints in details– Last one year she had these complaints for which she was under treatment by her gynecologist with no relief in her complaints. After the medication, bleeding stops, pain subsided but her problem remains the same. She was advised for surgery. Loss of appetite. Acidity, Weight increases
Other complaints on further enquiry – heaviness sensation in abdomen since last 6-8 months after taking fatty foods, aggravation at evening, rich food causes nausea feeling, sour eructation’s and belching, rumbling sound in abdomen, aggravation at night, prefers loose garments. Backache more while lying, before menstruation, better by taking support, weakness. She always feels tired and desires to lie down. Always feels fatigue.
History of present illness-due to abnormal menstrual bleeding ultrasonography advised by the gynecologist and then problem confirmed, i.e. a well defined lesion 5.8 x4.1.c.m noted on 5-1-08, (next 9-1-08,5-4,21-6,23-12) in region of right ovary. High resolution trans vaginal sonography (9-1-08) advised after that every alternate month. Usg done with no improvement (all reports attached) and then patient came to me.
Personal history-Dietetic errors-irregular food habits,
married, 2 sons, 10 and 5 years
Homoeopathic characteristics and observations
Thermal reaction-chilly patient catches cold easily, likes open air
Appetite-doesn’t want to take food, heaviness sensation constant belching, eructations
Craving-sour, sweet, egg, prefers hot food
Thirst– extreme for cold water
Tongue-slight white coating, moist
Taste- bitter taste
Bowel – irregular, pain in lower abdomen before passing stool, pain during bowel movements, constipation during periods
Urine – urinary urgency, frequency, and sometimes painful voiding
Perspiration- profuse on slight exertion, especially on upper lips
Sleep-sound sleep, likes sleeping
Menstruation– early, prolonged and profuse. Painful, sometimes disabling cramps during menses; pain may get worse over time, accompanied by lower back pain. Throbbing, and dragging pain in the legs, pain also starts a week before menses, during and even after menses. Spotting between periods during general bodily movement like exercise, pain from standing or walking, feels week during periods (previous character of menstrual bleeding),with all these complaints she suffered from dyspareunia also.
Mental symptoms-weeping disposition, irritable, brooding, likes company; doesn’t want to live alone, lack of will power, consolation aggravates.
Investigations – ultrasonography whole abdomen and T.V.S.
Diagnosis –after ultrasonography report : case of endometrioma
Final selection of medicine– 11.12.08 on the basis of symptom similarity, likes company, doesn’t want to live alone, irritable, backache, weakness, sweating.
Rx : Kali Carb 30 4 globules twice daily for3 days, with sac lac 30, 6 globules thrice daily for 15 days. As advised by her gynaecologist u.s.g. again done on 23-12-08 in which no change seen.
Follow up – 27.12.08-heaviness in abdomen after taking rich food, sour eructation and belching, appetite is not improved. Bowels are irregular, but pain in lower abdomen before passing stool is not present, urinary urgency, frequency, and painful voiding is better. On the whole she feels no change. But as slight symptoms are changed, so Kali Carb 30 two doses only with sac lac 30, 6 globules thrice daily for one month.
22.1.09 – No change in backache, weakness, menstrual complaints. Heaviness in abdomen decreased, can’t tolerate rich food, sour belching and eructation’s still persist. Appetite not improved, bowels are still irregular, in urinary complaints she feels change. As a whole only slight changes are there so no change in the medicine, Kali Carb 30 two doses only with sac lac 30, 6 globules thrice daily for one month (as patient is going out so comes earlier to take medicine)
14.2.09 -Patient is absent but as reported there is no change in her complaints. Again period occurs with same menstrual character. After the studying the case high potency is prescribed Kali Carb 200, 4 globules twice daily for one day with sac lac and placebo 30 4-4 globules four times prescribed for one month (as patient is going out so comes earlier to take medicine which I took as a proof she is improving).
17.3.09 – Heaviness in abdomen improves, belching same, she still feels weakness and backache too, no change in bowel character, patient took medicine for two months, Kali Carb 200 4 globules twice daily for one day with nihilinium 30 and placebo 30 for two months prescribed.
23.5.09 – Patient is absent but as reported she feels better in her complaints and asked for one more month medicine. The complaints better on the whole. Marked improvement. Kali Carb 200 4 globules twice daily for one day with nihilinium 30 and placebo 30 for one month prescribed.
26.5.09 – ultrasonography reports revealed no pathology. Patient feels better in all her complaints.
· Hart R, Hickey M, Maouris P, Buckett W, Garry R. Excisional surgery versus ablative surgery for ovarian endometriomata: a Cochrane Review. Hum Reprod. 2005 Nov;20(11):3000-7.
· Cullen T, The distribution of adenomyoma containing uterine mucosa. Archs Surg 1920;1,215-283.
· Sampson J Peritoneal endometriosis due to menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol 1927a;14,422-469.
· Sampson J Metastatic or embolic endometriosis, due to menstrual dissemination of endometrial tissue into venous circulation. Am J Pathol 1927b;3,93.
· Hughesdon P The structure of endometrial cysts of the ovary. J Obstet Gynecol Br Emp 1957; 44,481-487.
· Brosens IA. Is mild endometriosis a progressive disease? Hum Reprod. 1994;9(12):2209-11.
· Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and adenomyotic nodules of the rectovaginal septum are three different entities. Fertil Steril. 1997;68(4):585-96.
· Yazbeck C, Madelenat P, Sifer C, Hazout A, Poncelet C. Ovarian endometriomas: Effect of laparoscopic cystectomy on ovarian response in IVF-ET cycles Gynecol Obstet Fertil. 2006;34(9):808-12.
· Moore J, Copley S, Morris J, Lindsell D, Golding S, Kennedy S. A systematic review of the accuracy of ultrasound in the diagnosis of endometriosis. Ultrasound Obstet Gynecol. 2002 ;20(6):630-4.
· Brosens I. Endometriosis and the outcome of in vitro fertilization. Fertil Steril. 2004;81(5):1198-200.
· Farquhar C and Sutton C The evidence for the management of endometriosis Curr Opin Obstet Gynecol 1998;10,321–332.
· Yanushpolsky EH, Best CL, Jackson KV, Clarke RN, Barbieri RL and Hornstein MD Effects of endometriomas on oocyte quality, embryo quality and pregnancy rates in in vitro fertilization cycles: a prospective, case-controlled study. J Assist Reprod Genet 1998;15,193–197.
· Canis M, Mage G, Wattiez A, Chapron C, Pouly JL, Bassil S. Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril. 1992;58(3):617-9.
· Vercellini P, Vendola N, Bocciolone L, Colombo A, Rognoni MT, Bolis G. Laparoscopic aspiration of ovarian endometriomas. Effect with postoperative gonadotropin releasing hormone agonist treatment. J Reprod Medorrhinum 1992; 37(7):577-80.
· Donnez J, Wyns C, Nisolle M. Does ovarian surgery for endometriomas impair the ovarian response to gonadotropin? Fertil Steril. 2002 Jul;78(1):206-7.
· Agostini A, De Lapparent T, Collette E, Capelle M, Cravello L, Blanc B. In situ methotrexate injection for treatment of recurrent endometriotic cysts. Eur J Obstet Gynecol Reprod Biol. 2007; 130(1):129-31.
· Audebert A Ovarian endometrioma and infertility: when not to treat? Gynecol Obstet Fertil 2005;33(6):416-22.
· Tinkanen H, Kujansuu E. In vitro fertilization in patients with ovarian endometriomas. Acta Obstet Gynecol Scand. 2000; 79(2):119-22.
· Ho HY, Lee RK, Hwu YM, Lin MH, Su JT, Tsai YC. Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation. J Assist Reprod Genet. 2002;19(11):507-11. 7. Canis M, Pouly JL, Tamburro S, Mage G, Wattiez A, Bruhat MA. Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter. Hum Reprod. 2001;16(12):2583-6.
· Marconi G, Vilela M, Quintana R, Sueldo C Laparoscopic ovarian cystectomy of endometriomas does not affect the ovarian response to gonadotropin stimulation. Fertil Steril. 2002; 78 (4):876-8.
· Garcia-Velasco JA, Mahutte NG, Corona J, Zuniga V, Giles J, Arici A, Pellicer A. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, case-control study. Fertil Steril. 2004 May; 81(5):1194-7. S
· Maneschi F, Marasa L, Incandela S, Mazzarese M, Zupi E. Ovarian cortex surrounding benign neoplasms: a histologic study. Am J Obstet Gynecol. 1993;169(2Pt 1):388-93.
· Exacoustos C, Zupi E, Amadio A, Szabolcs B, De Vivo B, Marconi D, Elisabetta Romanini M, Arduini D. Laparoscopic removal of endometriomas: sonographic evaluation of residual functioning ovarian tissue. Am J Obstet Gynecol. 2004;191(1):68-72.
· Somigliana E, Infantino M, Benedetti F, Arnoldi M, Calanna G, Ragni G The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins. Fertil Steril. 2006; 86 (1):192-6.
· Wong BC, Gillman NC, Oehninger S, Gibbons WE, Stadtmauer LA. Results of in vitro fertilization in patients with endometriomas: is surgical removal beneficial? Am J Obstet Gynecol. 2004; 191(2):597-606; discussion 606-7.
· Nishida M, Watanabe K, Sato N, Ichikawa Y. Malignant transformation of ovarian endometriosis. Gynecol Obstet Invest. 2000. 50:18-25.
· Kennedy S, Bergqvist A, Chapron C, D'Hooghe T, Dunselman G, Greb R, Hummelshoj L, Prentice A, Saridogan
· E; ESHRE guideline for the diagnosis and treatment of endometriosis. The ESHRE Special Interest Group for Endometriosis and Endometrium Guideline Development Group. Hum Reprod. 2005; 20(10):2698-704.
. K.Koga, Y.Takemura, Y.Osuga1, O.Yoshino, Y.Hirota, T.Hirata, C.Morimoto, M.Harada, T.Yano and Y.Taketani. Recurrence of ovarian endometrioma after laparoscopic excision Human Reproduction 2006; 21(8); 2171–2174. . Fedele L, Bianchi S, Zanconato G, Berlanda N, Raffaelli R, Fontana E. Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery. Fertil Steril. 2006;85(3):694-9.