A case of endometriotic cyst treated with homoeopathic medicines

Endometrial ovarian cysts are one of the most common gynecological disorders found among reproductive-age women. They account for the commonest surgical interventions, undertaken not only by gynecologists but also by pelvic surgeons in these age groups. In this context, endometrial ovarian cysts should be considered as an area of the interdisciplinary approach. Here we present a case of 22 years old female having irregular periods, dysmenorrhea with heavy menstrual bleeding for the last 9 months, she had consulted with Gynecologist and was diagnosed with a left ovarian Endometriotic Cyst. She was treated with conventional medical therapies for the last 1year but had no successful result. After she came under homoeopathic treatment (Pulsatilla followed by Medorrhinum) and showed normal USG findings within one year. This case demonstrates the positive role of constitutional anti-miasmatic homoeopathic treatment in Endometriotic cysts.

Endometriotic cyst, homoeopathy, constitutional medicine, Pulsatilla, Medorrhinum

Endometriosis is one of the common benign gynecologic disorders characterized by the presence of uterine endometrial tissue, such as endometrial glandular epithelium and stroma, outside the normal location. The endometriotic cyst is an ovarian endometriosis that contains chocolate-like fluid due to the accumulation of menstruation-like hemorrhagic blood in the cyst during the woman's reproductive period. It is well-known fact that ovarian cancer arises in endometriotic cysts. However, the mechanism of malignant change potential of the endometriosis in the endometriotic cyst is not yet elucidated [1]. Endometriosis is a chronic benign estrogen-dependent disease. It is present commonly in patients of reproductive age, and its prevalence in this age group is estimated at 5 –10%. Endometriosis is defined as the presence of active endometrial tissue outside the uterine cavity, especially on the peritoneum of the minor pelvis, in the myometrium, ovaries, and fallopian tubes, as well as extraperitoneal sites. Endometriotic lesions can also be present in the intestines, urinary bladder, lungs, and brain tissues. Based on the site of the lesions, the disease is classified as peritoneal, ovarian, or deep infiltrating endometriosis [2]. Etiopathogenesis of endometriosis is still not fully understood. There are many theories on the etiology of this condition. The most widely accepted one is Sampson’s theory, according to which the formation of ectopic endometrial tissue is a consequence of retrograde menstruation. During this process, some of the endometrial debris leaves the uterus with small volumes of menstrual blood, reaches the abdominal cavity via the fallopian tubes, and is implanted into the peritoneum, usually within the pelvis [3]. Furthermore, immune and genetic factors are postulated to play a crucial role in the etiopathogenesis of endometriosis [4]. The common manifestations of endometriosis are dysmenorrhea with heavy menstrual bleeding, pelvic pain, dyspareunia, infertility, and sometimes pain during defecation. Ovarian endometriosis is the most common type of this condition. Ovarian endometrial cysts (endometriomas) are found in 20 –55% of women with endometriosis [5]. An ovarian mass can be qualified as an endometrial cyst based on its features in ultrasonographic presentation, based on the criteria that have been published by the International Ovarian Tumor Analysis (IOTA) collaboration in 2013. These criteria include size, shape, echogenicity of the lesion, the structure of its capsule, presence of any projections to the cyst’s lumen, vasculature, and relationship with surrounding anatomical structures [6]. International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 407 ~ Ovarian endometriotic cysts are more frequently located on the left ovary ( ∼60%); this is justified by the menstrual reflux theory and the anatomical differences between the left and right hemipelvis [7]. In hormonal therapies, the ovarian endometriomas may be decreased in their volume [8]. however, when these therapies are discontinued, ovarian endometriotic cysts frequently grow. Alternatively, endometriomas may be excised at laparoscopy. However, the recurrence rate of endometriomas after surgical intervention is between 11.7 and 30.4% at 2–5 years follow- up [9]. Furthermore, surgical treatment of ovarian endometriotic cysts may decrease the ovarian reserve [10]. In the case of surgical intervention, healthy ovarian tissue may be inadvertently removed particularly when the procedure is performed by surgeons with limited experience [11]. Furthermore, the changes in the ovarian reserve may also be related to the presence of the ovarian endometriotic cysts per se. A histopathological investigation of the functional morphologic features of the ovarian cortex surrounding benign cysts demonstrated that endometriomas are associated with reduced follicular number and activity compared with teratomas or other benign cystadenomas [12]. It is observed that women with endometriomas have lower anti-Mullerian hormone (AMH) levels and antral follicle count compared with women who do not have ovarian cysts, suggesting that the presence of endometrioma per se is associated with a reduction in ovarian reserve [13]. Ovarian endometrioma rarely exceeds 10 – 15 cm in diameter [14, 15] Approximately 0.7% to 1.0% of patients with endometriosis have lesions that undergo malignant transformation [16]. When the diameter of an ovarian cyst exceeds 10 cm, malignancy must be suspected [17]. Case report A 22 years old female presented at OPD of NHRIMH, Kottayam in January 2020, with complaints of having irregular menses for the last 9 months. Her menstrual cycle was irregular with profuse dark, clotted bleeding associated with severe vomiting, lower abdominal pain, and weakness of the body. Flow lasts for 5 to 6 days. She consulted the gynecologist and was diagnosed with an endometriotic cyst on the left ovary. (USG Findings on 09/02/19 showed enlarged left ovary with two cystic lesions measuring 4.5x4.2 cm and 3.0x3.0 cm (Fig.1). She was under allopathic treatment for the last year. Then she stopped medications when there was no improvement in the symptoms. She had complaints of hemorrhoids with bleeding and burning pain during stool for 2 years. History There was a history of Dengue fever at the age of 18 yrs. Took allopathic treatment and got relief. Family history Father – Diabetes Mellitus, Hypertension Mother – Hypothyroidism Brother - Diabetes Mellitus. Mental generals Reserved, Affectionate, Sensitive. Physical generals Her appetite was good. Thirst reduced. There was a desire for spicy things+++ & aversion to meat++; She had constipation with dry hard stool and hemorrhoids with occasional bleeding. Thermally patient was hot. Menarche at the age of 13 th year. Menses was regular and without pain for the first 2 years, later dysmenorrhea with profuse bleeding started. The nature of the blood was dark and clotted for 5-6 days, associated with severe abdominal pain, vomiting, and weakness of the body. Regionals Warty growth on the back of neck, face, and both axilla. Head – Hair fall and Dandruff General Physical Examination The patient is moderately built and nourished, No Pallar, Cyanosis, Icterus, Clubbing, Oedema, Lymphadenopathy, Temperature: 98.6º F. (Afebrile), Height:160 cms, Weight:55 kgs, Pulse rate:70 bpm, Respiratory cycle: 18cpm. Bp-110/80 mm of hg. Investigations R/E Blood Examination –All parameters were within the normal limit. USG Abdomen and Pelvis- enlarged left ovary with two cystic lesions measuring 4.5x4.2 cm and 3.0x3.0 cm (on 09- 02-2019) Clinical Diagnosis: Endometriotic Cyst. Analysis of the case Pulsatilla was selected based on the totality and reportorial

followed by placebo with the general improvement of the patient. To complete the cure, MEDORRHINUM was selected as an anti sycotic nosode. There was a slight aggravation of the uterine symptoms followed by the rapid improvement of the patient which was evident by USG findings. USG Reports of various stages during the treatment are attached in Fig 1-5. Follow up of the case given in table 1. International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 408 ~ Fig 1: Pelvic USG Before treatment International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 409 ~ Fig 2: Pelvic USG during treatment International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 410 ~ Fig 3: Pelvic USG during treatment International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 411 ~ Fig 4: Pelvic USG during treatment International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 412 ~ Fig 5: Pelvic USG during treatment Repertorial totality 1. Mind – Reserved 2. Mind -Affectionate 3. Mind - Sensitive 4. Rectum – Hemorrhage from anus-stool-during 5. Female genitalia -Menses, Dark. 6. Female genitalia -Menses-Copious 7. Stomach-Vomiting-Accompanied by menses 8. Stomach – Thirst less 9. Skin-Warts 10. Generalities – Food and drinks-Spices-Desire 11. Generalities – Food and drinks-Meat-Aversion International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 413 ~ Repertorial analysis Puls -57/22 Phos -49/22 Sulph -48/22 Natrum mur -47/22 Ars -43//22 Nitric-acid -42/22 Sepia -38/22 Lyco -36/22 Nuxvomica -52/21 Selection of medicine After reportorial analysis, PULSATILLA was selected as similimum, which covers reserved, affectionate, sensitive, thirstless, irregular, and painful menses, desire spices, and aversion meat. Prescription: PULSATILLA 1M/1D on (18/1/2020) Table 1: Prescription with follow-up Follow- up date Indications for prescription Medicine with dose 16/3/20 LMP- 8/2/20 Dysmenorrhea slightly reduced than before. Vomiting, lower abdominal pain and weakness during menstruation are also reduced. No bleeding per rectum, but burning pain persists. Placebo 24/4/20 The intensity of dysmenorrhea was reduced. Vomiting and abdominal pain were also reduced. No bleeding per rectum, burning pain slightly reduced. Bowel movements improved LMP- 10/4/20 USG Findings (21/4/20)- left ovarian endometriotic cyst. The size of the cyst compared to the previous scan is decreased. (Figure 2.) Placebo 22/5/2020 LMP-10/4/20 Menses not appeared Burning pain during stool remains. Hair fall persists Warts on the nape of the neck- No change Pulsatilla 10M/1D 24/7/20 The patient feels generally better. LMP-13/6/20 Vomiting during menses reduced. Slight cramping pain on the lower abdomen during menstruation. Weakness during menses reduced. Burning pain during stool slightly reduced. USG Findings on 22/7/20 (Figure.3) Placebo 13/11/2020 LMP-18/9/20 Menses not appeared Dysmenorrhoea and associated complaints got reduced Warts on the neck and back persist Hairfall and dandruff persist Medorrhinum 1M/1D 18/12/20 LMP-23/11/20 Slight lower abdominal pain during the first two days. USG Findings-Enlarged left ovary with a hemorrhagic cyst and endometriotic cyst. (Fig.4) Placebo 12/2/20 General improvement LMP - 08/02/21 Menses regular Dysmenorrhea reduced. Stool –Regular, no bleeding, and pain Warts on the back of the neck and axilla are starts to reduce in size. USG Findings- No significant sonographic abnormalities were detected. (Fig- 5) Placebo

Homoeopathy is a wholistic system of medicine and the treatment is based on the totality of symptoms. In this case, PULSATILLA [18, 21] 1M was prescribed as the similimum [19] by considering prominent mental symptoms such as reserved, affectionate, sensitivity, thirstlessness, and also by considering the characteristic menstrual complaints. As we all know ovarian cysts are sycotic in nature and MEDORRHINUM [20, 21] was selected as an anti sycotic nosode to complete the cure.

Results of this case indicate that constitutional and anti- miasmatic treatment is effective in the endometriotic cyst.

1. Yamaguchi K, Mandai M, Toyokuni S, Hamanishi J, Higuchi T, Takakura K, et al. Contents of endometriotic cysts, especially the high concentration of free iron, are a possible cause of carcinogenesis in the cysts through the iron-induced persistent oxidative stress. Clinical Cancer Research. 2008 Jan 1;14(1):32-40. 2. Leyland N, Casper R, Laberge P, Singh SS. SOGC. Endometriosis: Diagnosis and management. J Obstet Gynaecol Can. 2010;32(7, 2):S1-S32. 3. Jiang QY, Wu RJ. Growth mechanisms of endometriotic cells in implanted places: A review. Gynecol Endocrinol. 2012;28(7):562-567. 4. Yang CW, Chang CY, Lai MT, et al. Genetic variations of MUC17 are associated with endometriosis development and related infertility. BMC Med Genet. 2015;16:015-0209. 5. Hickey M, Ballard K, Farquhar C. Endometriosis. BMJ. 2014, 19. 6. Sayasneh A, Wynants L, Preisler J, et al. Multicentre external validation of IOTA prediction models and RMI by operators with varied training. Br J Cancer. 2013;108(12):2448-2454. 7. Vercellini P, Busacca M, Aimi G, Bianchi S, Frontino G, Crosignani PG. Lateral distribution of recurrent ovarian endometriotic cysts, Fertil Steril. 2002;77:848- 849. 8. Donnez J, Nisolle-Pochet M, Clerckx-Braun F, Sandow J, Casanas-Roux F. Administration of nasal Buserelin as compared with subcutaneous Buserelin implant for endometriosis, Fertil Steril. 1989;52:27-30. 9. Busacca M, Marana R, Caruana P, Candiani M, Muzii L, Calia C, et al. Recurrence of ovarian endometrioma International Journal of Homoeopathic Sciences http://www.homoeopathicjournal.com ~ 414 ~ after laparoscopic excision. American journal of obstetrics and gynecology. 1999 Mar 1;180(3):519-23. 10. Ferrero S, Venturini PL, Gillott DJ, Remorgida V, Maggiore UL. Hemostasis by bipolar coagulation versus suture after surgical stripping of bilateral ovarian endometriomas: a randomized controlled trial. Journal of minimally invasive gynecology. 2012 Nov 1;19(6):722-30. 11. Muzii L, Marana R, Angioli R, Bianchi A, Cucinella G, Vignali M, et al. Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: does the surgeon matter. Fertility and sterility. 2011 May 1;95(6):2116-9. 12. Maneschi F, Marasá L, Incandela S, Mazzarese M, Zupi E. Ovarian cortex surrounding benign neoplasms: a histologic study. American journal of obstetrics and gynecology. 1993 Aug 1;169(2):388-93. 13. Uncu G, Kasapoglu I, Ozerkan K, Seyhan A, Oral Yilmaztepe A, Ata B. Prospective assessment of the impact of endometriomas and their removal on ovarian reserve and determinants of the rate of decline in ovarian reserve. Human reproduction. 2013 Aug 1;28(8):2140-5. 14. Clement PB. Diseases of the peritoneum. In: Kurman RJ (ed) Blaustein’s pathology of the female genital tract, 4th and. Springer, New York. 1994;2:664-667. 15. Fedele L, Bianchi S, Bocciolone L, et al. Pain symptoms associated with endometriosis. Obstet Gynecol. 1992;79:767. 16. Reuter KL, Davidoff A, Cooney JV, Hunter RE. An unusually large endometrioma simulating an ovarian malignancy. Am J Radiol. 1988;151:834-835. 17. Hesla JS, Rock JA. Endometriosis. In: Rock JA, Jones HW (eds) Te Linde’s operative gynecology, 9th edn. Lipincott-Raven, Philadelphia. 2003, 599-603. 18. Allen HC. Allen’s Key Notes, Rearranged and Classified with Leading Remedies of The Materia Medica and Bowel Nosodes, Eighth Edition, 2016, B Jain Publisher (P) Ltd, New Delhi. 2003. 19. Samuel Hahnemann. Organon of Medicine. Sixth edition. New Delhi, B. Jain Publishers. 20. Vithoulkas G. Essence of Materia Medica.2nd Edn. New Delhi: B. Jain Publishers. 2002. ISBN: 81-7021- 138-7. 21. Boericke W. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory, Third Revised & Augmented Edition.