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Infertility
Sexual Problems
Women's Health
Total Health
  study

Objective
Hysterectomy is the most commonly performed operation after cesarean section now days. In this study we have treated the patients by stretching the limits of conservative management using integrated approach to save the uterus. This is retrospective analytical study of last 4 years.
Method
 We have chosen 780 patients from the pool of 2880 OPD patients who presented with gynaec complaints. These patients were divided into 3 groups
Group A-relapses of gynaec signs and symptoms after traditional medical  management either by us (about 28%) or by other doctors (about 72%).
Group B-patients coming for second opinion as they had been advised hysterectomy by other doctors.
Group C-patients coming for 3rd or 4th opinion regarding hysterectomy whether it is really indicated or not?.
Result
In Group A- none of the patient had to undergo hysterectomy.
In Group B-2 patients were advised myomectomy and 2 patients were advised laproscopic ovarian cystectomy but no hysterectomy was adviced. All these patients had undergone surgical treatment with integrated approach.
In Group C-total 5 patients were advised myomectomy/laproscopic cyst excision and adhesiolysis.
2 patients were advised hysterectomy for large adenomyotic uterus along with severe endometriosis.
Introduction
Hysterectomy has become 2nd most commonly performed surgery after cesarean section not only in India but USA too. Most common indication is DUB where routine conservative medical management fails to provide relief and patient’s family is completed. Other common indications for hysterectomy are-cervical dysplasia, fibroids, adenomyosis, chronic pelvic pain, severe endometriosis, prolapsed etc.


We had performed 1200 + hysterectomies through abdominal, vaginal, NDVH and TLH/LAVH in initial 12 years of  our practice. In their follow-up we noticed that their concerning sign and symptoms were cleared after surgery but patients had some or the other problems even In late years though it did not seemed relevant to hysterectomy e.g. Pelvic pain,leucorrhoea,abdominal discomforts like gaseous distension,indigestion,irregular bowel movements,frequency of urine,dysurea,backache,jointpains,headache,sleeplessness,numbness/burning sensation in limbs,tiredness etc.In long term few patients had problems with liver and gall bladder and nervous system too. Though it seemed not related but still the patient who had undergone hysterectomy did not become disease free. That means the root cause of problems is not uterus but somewhere else. Uterine complaints do occur due to hormonal imbalance and infections which is caused by accumulation of toxins leading to weak defense system by affecting immunity.


So we treated patients by stretching limits of conservative treatment by using integrated approach to cure their root cause and making them disease free.

Material and method
Criteria for exclusion
Following cases were not included in our study and they belong to  1.1% of total gynaec OPD patients in our hospital that is 32 patients in 4 years.
Genital cancer
Procedentia
Large symptomatic fibroid
Severe endometriosis

Patients included in this study are those who have completed their family and >30 yrs of age, where hysterectomy could have been advised if conservative medical management failed. Mainly the patients suffering from DUB, chronic cervicitis, leucorrhoea, pelvic pain, ovarian cyst, fibroids, adenomyosis and grade 1-2 prolapse uterus.

In last 4 years out of 2880 OPD patients, about 780 patients were taken into this study. All these patients belonged to Gorakhpur and nearby 15 districts. These patients were divided into 3 groups.


Group A-430 patients coming with relapse of gynaec complaints after routine medical management by us(120 patients-about 28%) or by other doctors (310 patients-about 72%).In our patients who came with relapse of symptoms had undergone medical management along with life style changes but the patients coming after other doctor's treatment had taken medical treatment only.
Group B-273 patients who came for 2nd opinion as they have already been advised hysterectomy by other doctors.
Group C-77 patients coming for 3rd/4th opinion for hysterectomy advice.


In routine conservative medical management we used hormonal treatment, antibiotics and vaginal pessaries,cryo/electrocautrisation of cervix and minor surgical procedures like surgical curettage,polypectomy (cervical & endometrial) along with life style modification and pelvic floor exercises.
In integrated approach, along with allopathic treatment we used naturopathy, ayurvedic panchkarma, diet and nutritional therapy, herbal medicine, psychotherapy and counseling, mind therapy, yoga and pranayam
Conservative major operative procedures like myomectomy, ovarian cystectomy, adhesiolysis and endometriotic cystectomy and fulguration of endometriotic implants are advised to relevant patients along with integrated approach.


 Observation


1.    Table-number of patients

                               No of patients
Condition              group A      group B      group C
DUB                         129             94                28
Cervicitis                 108             61                19
Pelvic pain               43               21                4
Ovarian cyst            63               41                 7
Fibroid                      44              40                  13
Adenomyosis          22               14                  6
Prolapse  gr1/2       21                2                    -
   

2.. Table-age group

 

Age group
                  

                   Total pts       30-40yrs       40-50yrs      >50 yrs
Group A      430              195                172               63
Group B       273              135                116              22
Group C       77                 38                  35                4
3 .table -Symptomatic relief in 3 months

                       Total pts      yes          no      lost follow-up
Group A          430              385         45         22
Group B          273               205         68        15
Group C          77                 56            21         4

  The patients who lost follow up showed remarkable relief in their 1st/2nd follow up visits but due to long distances,socio-economic conditions they might have not come for further follow up.

 

4. table-total cure in 6 months
                       Total pts          yes       no        lost follow-up    remark
Group A          430                 370                     38                      no hysterectomy
                                                                                                       3 lap ov cystectomies
                                                                                                        1 myomectomy
Group B          273                 237                      21                      2 pts lap ov cystectomy
                                                                                                         2pts myomectomy
Group C          77                   67           2            6                        2 hysterectomies
                                                                                                        2 myomectomies
                                                                                                        3 lap ov cystectomies   
                                                                                                         Along with adhesiolysis
 

Post treatment surveillance kept up to 6 months. Patients were called 2-3 times during this period. Lots of patients followed up regularly but those who could not come personally, we inquired with their family members and relatives or neighbors or telephoned them to inquire about their health.
Result
The total study shows that out of 780 patients 674 patients followed up regularly and undergone treatment protocol. Only 2 patients required to undergo hysterectomy ,i.e. 0.29% as they were suffering from adenomyosis along with endometriosis causing them severe dysmenorrhoea and anaemia.Their physical condition did not allowed to extend the treatment as we were also bound to our time limit of trial up to 6 months only.


However, we have strong feeling that these two patients who had to undergo hysterectomy could have been saved if this protocol could have been extended further.


Now about the conditions which we have excluded from this study like CA, procedentia, large symptomatic fibroids and severe endometriosis which constitutes 1.1% of gynaec OPD patients. We think that these conditions can be avoided if the management would have been started in the beginning of the sigh and symptoms of their respective gynaec complaints, as these conditions evolve slowly over the period of time due to ignorenece, negligence, lack of hygiene, malnutrition and lack of proper management. We can make marked difference by placing more emphasis on patient education towards preventive aspect of disease, training of health care providers at grass root level and doctor’s attitude towards hysterectomy.

We have treated 4 cases of HSIL/CIN 3( which are considered as precancerous lesion) for 6 months on our conservative line of treatment using integrated approach and cured them off completely. This shows definite value of indication however the sample size is  small so it requires  further study.

Discussion

By nature’s grace, women are more strong and resilient than men as they are chosen for procreation.Till the time a woman menstruates regularly and before menopause, she is less prone to heart diseases and osteoporosis compared to men in the same age group. This is well known scientific fact.


   According to ayurveda our body functions on the balance of 3 Doshas-Kapha, Vata and Pitta.Health is balanced state of Doshas.Improper diet and activity that is Aahara vihara, imbalance Doshas, abnormal and weak Dhatus are the main causes for the diseases. Vitiation of any of the dosha brings changes in body’s function e.g. when Kapha increases, menses get scanty and delayed, when Vata increases, one experiences painful menses and with Pitta increase, menses becomes heavy and irregular.


   According to naturopathy, accumulation of Vijatiya dravya (toxins) in body weakens its immunity and lack of vital life force to throw them out lead to problems. The site of accumulation of such toxins decides the sign and symptoms. The basic principle of naturopathy is-all the diseases are one, so their reason is also one that is why their treatment is also one that is to get rid of vijatiya dravya from the body. Germs don’t cause diseases. Most important thing to remember is that treatment of patient (whole body) has to be done not of the disease.


  Appropriate nutrition is the basic need to keep one healthy. With fast changing world, our food and food habits have changed a lot. Excessive use of junk food, packaged food and aerated drinks for which so many commercials we see on mass media contains lots of empty calories and chemicals in form of preservatives, additives, colors and taste enhancers. Since such products are promoted by film stars and cricketers, their sale has multiplied many times. Children are exposed to such junk food from very tender age. It has brought more calories and chemicals than the real nutrition. Level of xenoestrogen (artificial estrogen) has increased in our body due to excessive use of chemical fertilizers and pesticides, use of chemical fragrances and aerosols like body sprays and air fresheners and excessive use of plastic in our daily life right from storing food to drinking water from plastic bottles. Besides this, the milk we drink contains very high level of hormones as the milching animals are milked after giving pitocin injections. Even the chicken, eggs and meat, which are commercially grown on fodder containing growth hormones, contain high level of hormones. This is causing problems for everyone, right from layman to doctors, no one is spared. Along with accumulation of toxins, xenoestrogen is another important culprit, which is causing havoc in our body by creating hormonal imbalance and results in menstrual irregularity to cysts and fibroids. Initially while learning in medical college and during first 5-6 years of our practice, we have observed more cases of prolapse uterus and cervicitis.We used to do more vaginal hysterectomies compared to abdominal hysterectomies. Then after that we started observing more cases of menstrual irregularity, menorrhagia, DUB, endometriosis, PID and fibroids  among patients presenting with gynaec complaints.Now prolapse uterus cases are rarely seen . And i think the main reason behind this is, rampant cesarean and hysterectomies which are performed now a days. Now normal delivery rate has drastically reduced and uterus is removed for minor reasons too, which does not give chance for prolapse in old age.


Bacchedani niche sarakne ke liye bacchedani to honi chahiye sharir main.


As we have mentioned earlier accumulation of toxins and rising level of xenoestrogen, are main reason along with lack of proper nutrition for menstrual irregularities, DUB, endometriosis, ovarian cyst, fibroid, cervicitis and adenomyosis etc.
Mainly toxins enter in our body through nose and mouth. The food which is consumed is not fully digested by our digestive system and the remnant waste is also not fully excreted out of body, which eventually gets absorbed in our system and cause slow self poisoning.
Environmental pollution also plays very important role in causing increasing toxins in our system.


  Our life style changes have made us sedentary and more stressful. High stress level and lack of sleep causes endocrine changes and psychosomatic disorders. In today’s world more than 90% problems have psychosomatic origin. Here use of psychotherapy and councelling, hypnotherapy, yoga, pranayam and meditation has immense value in keeping their stress at check and helping them lead balanced life style.
 We used integrated approach in our extended protocol of conservative management. For initial symptoms we used allopathic medicine for immediate symptomatic relief and then we used principles of naturopathy and ayurvedic panchkarma, mind therapy, herbal medicine, nutritional therapy, regular exercises, yoga and pranayam to make them disease free and healthy.
   Most of the uterine and menstrual problems are just the effect of endocrine imbalance and accumulation of toxins and free oxygen radicals in the body which is the root cause. There is no point in removing the uterus.


   For example if the cause of malfunction of wooden door is termite and to correct it, if the door is removed, is it going to solve the problem? No….the termite will evade another door/window and slowly the whole structure and ultimately house will collapse. So the correct treatment is management of termite, not the removal of door, quite logical…..isn’t it? Similarly to make patient disease free we must treat the root cause not just sigh and symptoms.


Now about the conditions which we have excluded from this study like CA, procedentia, large symptomatic fibroids and severe endometriosis. Such patients were 32 out of total 2880 patients, which constitute 1.1% of patients presenting with gynaec complaints in our area. But the patients which came in our OPD for relapse of gynaec complaints were scared of cancer and those patients who came for 2nd , 3rd  or 4th opinion were shown fear of cancer in future to motivate them for hysterectomy. We think that these conditions can be avoided if the management would have been started in the beginning of the sigh and symptoms of their respective gynaec complaints, as these conditions evolve slowly over the period of time due to ignorance, negligence, lack of hygiene, malnutrition and lack of proper management. We can make marked difference by placing more emphasis on patient education towards preventive aspect of disease, training of health care providers at grass root level and doctor’s attitude towards hysterectomy.

Actaully in present scenerio,we should use our scientific advancement and knowledge in treating the root cause of the disease not just handling the effects and sign and symptoms.If we can do this,then very soon hysterectomy will become rarely heard surgery.So .......along with the health revolution,we need to revive nobel profession by keeping patient's benefit first .
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