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Introduction

Cancer can be defined as the abnormal growth of cells. These cells rapidly reproduce at a single fixed location in the body, despite space constraints and can invade or spread to other parts. Hence, cancer is considered a critical disease.

In the present era, endometrial cancer is the most common cause of death in women. Till 2015, around 3.8 million women were affected by endometrial cancer, out of which around 89,900 were deceased, with 5 years of survival rate in the United States. Most of the time, endometrial cancer occurs after menopause. The first sign is most often vaginal bleeding not associated with a menstrual period. Other symptoms include pain with urination, pain during sexual intercourse, or pelvic pain. The leading treatment option for endometrial cancer is surgery. In more advanced cases, radiation therapy, chemotherapy or hormone therapy may also be recommended.

Ayurveda, an ancient science of medicine, has not directly mentioned cancer, but it has been described in its own terminology. Cancer can be correlated with Arbuda, Granthi, Vidradhi, Visarpa, etc. Most proper correlation can be done with Arbuda vydhi due to the signs and symptoms.  Treatment measures like shodhan, bhaishajya chikitsa, single drug therapy, pathya-apathya mentioned for Arbuda vyadhi can also be used in the treatment of endometrial cancer.

Though there are various measures of treatments are available for endometrial cancer, prevention is a need of the hour. Hence, the evidence-based study of endometrial cancer, which provides preventive as well as curative measures from Ayurveda, is necessary.

Aim–

• To assess and conduct a comprehensive review of the role of Ayurveda in the management of Endometrial Cancer.

Objectives –

• To find out evidence related to the nidan panchak of Endometrial Cancer in Ayurveda.
• To assess the management of Endometrial Cancer from Ayurveda.

Materials:

• Dissertations and catalogues related to cancer
• Ayurvedic Compendia
• Cancer-related research articles from journals
• Other allied sources, like websites and databases. 

Methodology –

• A brief search is done to find out evidence related to Endometrial cancer from available material like Ayurvedic Samhita, databases, and websites.
• Collected data is compiled and arranged to assess cause, clinical features and available treatment of endometrial cancer.
• Also, the data are correlated with Ayurvedic literature, and the role of Ayurveda in the management of endometrial cancer is assessed.
• Evidence of research about endometrial cancer in the field of Ayurveda is also compiled to assess further scope.

Discussion

Facts about endometrial cancer:

Based on the American Cancer Society's Cancer Facts & Figures 2015 report, here are the key estimates for endometrial cancer in the United States for 2015:

• Till 2015, around 3.8 million women were affected by endometrial cancer.
• Out of which around 89,900 were deceased.
• With 5 years of survival rate in the United States.
• Most of the time, endometrial cancer occurs after menopause.
• This makes it the third most common cause of death in cancers that only affect women, behind ovarian, endometrial and cervical cancer.

Signs and symptoms of endometrial cancer-

• Vaginal bleeding or discharge not related to menstruation (periods).
• Vaginal bleeding after menopause.
• Difficult or painful urination.
• Pain during sexual intercourse.
• Pain in the pelvic area.

Stages of Endometrial Cancer -

Once endometrial cancer is confirmed, further testing is conducted to determine whether cancer cells have extended within the uterus or reached other areas of the body.

Endometrial cancer is classified using the stages outlined below:

Endometrial cancer in Ayurveda:

           In the ancient Ayurvedic classics like Charaka Samhita and Sushruta Samhita, cancer is described as Arbuda (major neoplasm) or Granthi (minor neoplasm) and Tridoshaja/Sannipataja as the malignant stage of neoplasm or abnormal growth. There are a few conditions which can be correlated with endometrial cancer, like granthi, apachi, vidradhi, and gulma, as below –

From the above table, the most suitable correlation amongst these with the endometrial cancer is the arbuda (raktarbuda).

According to Acharya Sushruta, the father of ancient surgery, arbuda is defined as -

 The swelling, which is circular, fixed, slightly painful, big in size, broad-based, slowly growing and does not suppurate, is caused by the vitiation of tridosha in any part of the body.

Other Acharyas like Madhavakara and Acharya Vagbhata have also described Arbuda.

Clinical pathology according to Ayurveda:  

Dosha:             kapha Pradhana tridosha         

Dushya:           mamsa, Rakta, sira

Akruti:             inverted edges of ulcer (unnahyati), malignant growth (mansapinda mansakura), no pus formation (apaki)

Srotas:            raktavaha, mamsavaha,             

                      However, there is no separate mention of garbhashaya arbuda[ endometrial cancer] anywhere in the classical texts. We can correlate the endometrium to garbhashayya when we study the tryavarta yoni, which is described in the texts of –

Ashtang Sangraha as –

Endometrium resembles garbhashayya with three spirals (tryavarta yoni). 

A.S.Sha. 5/91.

Sushruta Samhita as –

Yoni (genital tract), resembling the shape of the interior of a conch shell, has three folds. As the mouth of the Rohit fish is shaped, the uterus also has the same feature and shape, which is 3rd part of the tryavarta yoni.          

 Su.Sha. 5/55-56

           Thus, the description provided in the above reference corresponds to that of the endometrium.

Treatment:     

According to the American Cancer Society, the main modalities of endometrial cancer treatment are -

• Surgical procedures
• Radiation therapy: external beam radiation Brachytherapy [internal radiation]
• Chemotherapy
• Hormone therapy
• Symptomatic management.

Side effects of radiation and chemotherapy:

Common side effects of external beam radiation therapy and chemotherapy include-

• Fatigue (tiredness), Upset stomach, Diarrhea or loose stools (if radiation is given to the pelvis or abdomen), Nausea and vomiting, Skin changes like irritation, recurrent skin infections are common.
• Radiation to the pelvis can also irritate the bladder (radiation cystitis), causing discomfort and an urge to urinate often.
• Radiation can affect the vulva and vagina, making them sensitive and sore, and sometimes causing a discharge.
• Pelvic radiation can also affect the ovaries, leading to menstrual changes and even early menopause.
• Radiation can also lead to low blood counts, which can cause Anemia (low red blood cells), which can cause you to feel tired, leukopenia (low white blood cells), which increases the risk of serious infection, loss of appetite, loss of hair, mouth sores, and fatigue (tiredness).

Chemotherapy-induced toxicity to hematopoietic cells in the bone marrow can result in reduced blood cell counts (cytopenias). This can result in:

• An increased chance of infection (from a shortage of white blood cells)
• Bleeding or bruising after minor cuts or injuries (because of a shortage of blood platelets)
• Shortness of breath (due to low red blood cell counts).

Role of Ayurveda in the Management of Radiotherapy- and Chemotherapy-Induced Side Effects –

        Radiation and chemotherapy have many side effects that may affect the physical and mental status of the person. To deal with these complications, Ayurveda treatments can be effectively used.

For example:

• In cases of oral ulcers as a result of chemotherapy, the use of Yashthimadhu ghrita application can be very effective.  Efficacy of other drugs and other formulations such as medicated oils, ksheera kalpana [ medicated milk], ikshurasa[sugarcane juice], should be searched out.
• Similarly, in cases of nausea and vomiting, various drugs can be used according to the dosha predominance in the patient.
• According to Ayurveda, vomiting originates in Amashaya [stomach], which is a sthana of kapha; kaphahara treatment should be given.
• Acharya Charaka has indicated various combinations of drugs and diet in Chardhi chikitsa, like powders of jambu, badara, duralabha, musta, karkatashringi, etc.  These medicines could be used based on the patient's condition, along with other formulations like Dadimavaleha, etc.

Treatment for endometrial cancer according to Ayurveda -

Shodhana chikitsa – Though the raktarbuda is considered as asadhya according to ayurvedic acharya, there is no specific line of treatment given by them. But following management can be utilised –

• Swedana – mrudu, drava and upanah sweda
• Virechana
• Raktamokashana – Jalauka or Prachhana.

          Though Raktamokshna is the ideal modality for rakta and pitta dushti in endometrial cancer, it can't be done locally. Hence, by Siravedha karma sarvadehik raktamokashna can be done. 

Shamana chikitsa –

• Bahya –

• Lepan karma - with Rasanjana, Lodhra, Yashtimadhu, various kshara with gomutra, Shigru, Indrayava, Karvira, Surasa with Takra. 
• Yonidhavan – with Triphala kwatha, Yoni dhavana and Vrana ropana karma can be done.

• Abhyantara–

• Snehapan - with Draksha, Trivruta or Aragvadha siddha ghruta.
• Kalpa –

• For vranaropana - Chandraprabha, Shilajatu vati                
• For vaginal bleeding – Bola parpati, Chadraprabha gutika, Mahatiktaka Ghrita,

• Darvyadi kwatha

• Single drugs - like Ashoka, Daruharidra, Triphala, Yashtimadhu, Bhallataka, Rohitaka, Guggulu.                                     
• Shodhanadi gana drvaya-

               Various groups of drugs mentioned by Acharya Vagbhata in Shodhanadi Gana Sangraha are indicated in arbuda and granthi –Varunadi gana, Mushkakadi gana, Ushakadi gana [ useful in case of tumours], Mustadi gana, Lodhradi gana[ useful in diseases of the uterus].

Shastrakarma chikitsa –

Arbuda nirharana by Shastrakarma is the main treatment.

Rasayana Chikitsa –

            Oncologists/radiation oncologists emphasise the enhancement of the patient's immunity, as was said by Acharya also.

           So immunomodulators / rasayana drugs play a major role during chemotherapy that can prevent recurrence of the disease. The herbs like guduchi, bhallataka, and daruharidra.

Pathaya – Apathya –

Pathya – purana ghruta, jirna shali and shashtika, yava, mudga, shigru, padavala, various green vegetables, shilajatu, guggulu.

Apathya – Apathyatva of dravya depends upon the stage of cancer and the ongoing treatment of the patient. Mostly atisevana of madhura, amla, lavana rasa and guru, abhishyandi dravya can be apathyakaraka in endometrial cancer because these dravyas may enhance the disease as per their karma mentioned by Acharya Charaka. 

Various herbal medicines have anti-cancerous properties –

free radical scavenging, antioxidant, anti- inflammatory, antipyretic, analgesic, antibacterial, anti-mutagenic, wound healing, anticarcinogenic, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective and chemopreventive effects

Conclusion

Endometrial cancer is mostly correlated to Arbuda Vyadhi in Ayurveda. Patients with endometrial cancer can be supported by the holistic principles of Ayurveda in many ways.

 Thus, Ayurveda can be useful in:

• The slower the progression of endometrial cancer.
• Give symptomatic relief to patients with excessive bleeding.
• Minimises the side effects due to procedures like chemotherapy, radiotherapy and surgery.
• Rasayana therapy enriches rasa with nutrients to help one attain longevity.
• Improve comfort and the quality of life for individuals with cancer.

Further Scope –

• Ayurveda can be the co-therapy along with chemotherapy or radiotherapy; & Post surgery care, to minimise the side effects of these therapies.
• It can also be individually used to minimize sign & symptoms of endometrial cancer.
• Upakrama, like yonidhavana, yonipichu should be evaluated in future.
• Efficacy of different kalpas used in arbuda and pradara should be evaluated.
• Different formulations for single drugs like shigru, bhallataka, rohitaka, yashtimadhu, etc. should be evaluated.