Endometriosis

[Luc de Schepper]

Endometriosis and Homeopathy

What to expect from homeopathy. How does Homeopathy differ in looking at a condition such as endometriosis? As you will see, to the contrary of what you might expect, Homeopathy is a true science, looking at each case

of endometriosis quite differently than allopathy or modern medical science. I hope to answer more of some questions that might have intrigued the sufferer of endometriosis and which at present time are left unanswered by modern medicine. Questions such as: "How did I come to this condition? Is there any way to prevent this condition? Is this condition just a different expression of the same root of an imbalance deep in our system, and this imbalance randomly expresses itself in different pathological expressions or diseases, one of them endometriosis? What about our offspring? What can we expect them to suffer from in case we suffer from endometriosis?

Can this all be answered by Homeopathy? Yes! Much more, it can be treated, cured and prevented.

Before I will answer one by one the above questions which are crucial to your goal of achieving health, I will outline in short the principles on which Homeopathy is based, comparing it with our approach to disease in allopathy

so you will see a distinct different approach to illness in general, and endometriosis in particular. Before I start explaining you what homeopathy can do for you the endometriosis patient, consider the advantages of homeopathy when compared to Allopathic (modern) medicine.

Homeopathic treatment is individualized-it considers the whole patient through symptoms (causality, mental, emotional and physical), rather than the disease as a name. Too often, we physicians think that our work is finished when we put a label on the patient. "Yes, you have endometriosis." Homeopathy does not need a name for a disease. It looks at the person as a whole and tries to find the contributing factors of disease. What does allopathy say about the causes of endometriosis? They have not been established-- in other words we don't know! We see that it can run in families (more in first-degree relatives like mother, sister, and daughter) and that the risk increases after age 30, or when having an abnormal uterus (exceptional). But does this knowledge leads to a therapy in which you can say, the endometriosis sufferer, "I know what to do now so I can say for sure, none of my offspring will suffer from this.? Not at all! So we just hope and pray that it will not effect our children. Are the measures (surgery, drugs with its multiple side effects) a guarantee for a "cure" for you the sufferer? We already know the answer to this:

it is a resounded NO.

All remedies recommended in homeopathy have extensive human experiment. Contrary to what opponents of homeopathy would have you believe, all remedies are tested in the only scientific way, i.e. on normal, healthy individuals. This really should be taken over by modern medicine. I just saw on Larry King Reagan's doctor speaking about Alzheimer and he asked volunteers for studies with new untested drugs. Doctors should be the first ones

to do this on themselves like homeopathic physicians have been doing this for two centuries now.

The homeopathic method of prescribing on a totality of symptoms is designed to be curative, not just palliative and suppressive as when takes a sleeping pill for insomnia. Little in allopathic medicine is directed at reparation.

This is just the contrary of what is often said by your doctor. Drugs used in endometriosis are geared towards suppressing the activity of the ovaries and therefore slow down the growth of the endometrial tissue. But suppressing

is exactly what it means--suppressing, not curing with all dire consequences as a result.

Homeopathy has its time-tested usefulness. Remedies used two hundred years ago are still used with the same efficacy as then for the same diseases. Allopathic medical fads run their course and disappear rapidly, whereas homeopathy is practiced all over the world. In fact it is the second most widespread form of medicine practiced in the whole world.

There is no drugging effect, and there are no side effects from homeopathic remedies. Unwanted effects are homeopathic aggravations, recognized by the well-trained homeopath and easily managed. I am sure when you take Danazol (acne, wt gain, lower voice, beard growth, vaginal dryness, bleeding between periods, mood swings, liver malfunction, etc.) or the birth control pill (increased appetite, vein thrombosis, bleeding, nausea) or the gonadotropin releasing hormone agonists (GnRH agonists) with side effects such as hot flashes, loss of calcium from the bones, dryness of the vagina and mood swings. Drug treatment according to our own medical findings does not cure your endometriosis, when you stop them, the disease usually returns. So in other words, if you don't opt for surgery with a total hysterectomy. Serious side effects can result from those drugs! Surgery is advised to

women with moderate to severe endometriosis, again this does not lead to a cure according to allopathy. Why? Because it addresses the end result of the illness--the weeds, but not at all the root, the why you got this in the first place. And then there is the risk of adhesions with every removal of endometrial tissue. Only removal of both ovaries prevents recurrence of endometriosis but is this solution for these young women? Obviously not!

Practical plan for the Endometriosis Patient with Homeopathy and Answers to Previous Questions

Time-Line for Order of Treatment and Diagnosis: the big difference with allopathy!: This will answer the question, How did I come to this?

For a physician, every investigation into an illness starts with a good inquiry. Getting the facts together, the symptoms with their modalities and the different factors in the patient's lifestyle contributing to the disease are essential if we want to be successful in restoring the patient's health. Yet, most of the time, the physician often neglects the most important question: "What happened in your life when you became sick or just before you became sick?" I see enough doctors' reports from my patients. They are explicit enough in the description of symptoms and the enumeration of the different illnesses, but they rarely link the onset of the disease to a meaningful event in the patient's life. Yet, it is most often the clue to the solution. For you Endometriosis patient, this will be your first task. Communicate to your physician the exact circumstances and the first symptoms observed. Some examples that I have seen in practice will clarify this. I might see ten endometriosis patients with almost identical symptoms. They will be treated identical in allopathic medicine with the few drugs, which address some of the symptoms. Yet, these ten patients have ten different beginnings or aetiologies. They were "never well since" a heartbreak, an operation because of sensitivity to anesthesia, a delivery, an intestinal infection with a loss of liquids, taking the birth control pill, an acute fear situation like one almost died in a car accident, recurrent intake of antibiotics, a sunstroke, death of a family member, etc. I can make this list ten pages long and this is exactly what your doctor needs to do. The regular medical doctor will treat these different beginnings in the same way, simply because they have the same endings! How can we be so shortsighted? But these beginnings (triggers) have decreased your resistance and will lead to illness, endometriosis in your case. And a homeopathic physician can tell who among the population is at risk to get endometriosis even when exposed to the same trigger! Because the question can be posed, "Why if a "grief" can lead to endometriosis, why is not everyone getting it when suffering a grief?

A diseased state is to be viewed as a decrease in vital energy (Qi in Chinese medicine). Once this energy has reached a certain low level, the patient is susceptible to viruses, bacteria, yeast and parasites, which are consequences, not causes! When are we going to learn in Western medicine to put the horse before the cart, not behind it? It is this attitude that makes us lose the battle against cancer, AIDS and other serious chronic disease. So the first question I ask you the endometriosis patient is, "What happened in your life on the moment that you became aware of the first symptoms of endometriosis (and we mean the months preceding your symptoms)??? This is the first important factor to discover. It is the trigger that has put the lit on the fire, it is not the only factor because no matter what the trigger is, the terrain has to be just right to start something like endometriosis. This terrain is what we refer to in Homeopathy as the Miasms, which correspond basically, to your genetic background. It corresponds to what you received from your parents and what you will transfer to your offspring. More about this a little later.

When a homeopathic physician looks at the ten above mentioned Endometriosis patients, he will possible come up with ten different remedies, in spite of these patients having almost the same symptom picture. Does it not make more sense to treat the root of the problem, and not merely the little sick branches. Yet most doctors, alternative or classical, do not more than branch cutting, simply because they do not know how to restore the sick root. Allopathic medicine with its strong opinion about germs does not have the tools to repair the beginnings of Endometriosis. So they keep on using the few medications that cover some of the symptoms of Endometriosis or resort to surgery. Yet all these measures fail to address the beginnings of Endometriosis or why you got endometriosis in the first place!. Only "total" health modalities like acupuncture, chiropractic but especially homeopathy is capable of turning Endometriosis patient's lives around.

Genetic Background (Miasms) or the Fertile Ground for Illness

The second factor that plays a role in getting endometriosis is what we already alluded to: the genetic background. Homeopathy is able to determine what people and who of your children is able to get endometriosis. How?

By looking at both parents' family history and see what Miasm is predisposed. (A miasm is a defect, a groove, a predisposition to certain illness, a weakness, we inherited from our ancestors. Obviously we all have defects but

in case of endometriosis, we are talking about the sycotic: miasm. Endometriosis is however only one expression of this Sycotic miasm. What are some of the other expressions?

Symptoms can either be on the mental, emotional or physical plane. Patient's can either show symptoms only on the physical plane, others more sick on the emotional plane and the most sick have symptoms on the mental plane.

I invite all of you to think about of how many of these symptoms you have or you see in your children/parents.

Mental for people with endometriosis: Forgetfulness for things just done, just said, Thoughts vanishing while speaking, bad memory for recent things, not old things. Imagine of you have to study this way: the only good energy

is at night, starting around 20 - 2-3 h. But during the day, teenager's exhibit dreaming, inattention, restlessness, can't sit still, in other words many of our kids and maybe some among you have suffered from what they call now in general terms ADD and ADHD. But it belongs to the same root as endometriosis.

Emotional symptoms: Thrill seekers, passionate people, love sex and talking about it, they prefer a short but exciting life above and long and boring one. Life has to be full of fun and thrills, unfortunately this can lead to criminality as the border is easily transgressed all in the name of fun, in search of the next new thrill. But definitely a great deal of our sycotic children are ADD or ADHD: children. A sycotic person is one of extremes, never finding the middle ground.

Physical symptoms: warts, cysts, asthma, tumors, polyps, and any "hyper" activity of any gland, besides all the "-itis" diseases.

So what about treatment? Do you understand now why in allopathic medicine we have to say that surgery neither drugs is capable to eradicate endometriosis? And if we eradicate (rather suppress) its other expressions and the ones I have mention to you will appear. So in other words, if I suppress physical expressions, either the emotional or mental that I have mention will appear if you are not strong; if you are strong the endometriosis will come back. Why? Because we don't treat the root, the trigger and the miasmatic background. We have those remedies in Homeopathy tailored to each individual, this has nothing to do with a protocol. We are all different, we came to what we are in a different way, it is the sum of whatever happened in your life, and the only thing you have in common now is the endometriosis. And even that is not always expressed in the same way. Now you understand that the remedy you get from a homeopath, after answering so many more questions than to your regular physician, is the sum of your genetic make up and what happened in your life, so in other words it covers the beginnings of the disease, it focuses on them, on the root, because only such eradication can lead to a normal state. I hope that every endometriosis patient would learn about the magic of homeopathy in the eradication of their suffering.

Endometriosis (from Greek ἔνδον - endon, "within", and μήτρα - mētra, "womb") is a gynecological medical condition in which cells from the lining of the uterus (endometrium) appear and flourish outside the uterine cavity

(ovaries). The uterine cavity is lined by endometrial cells, which are under the influence of female hormones. These endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often < with the menstrual cycle.

Typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 5–10% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is

pelvic pain in various manifestations. Endometriosis is a common finding in women with infertility.

A major symptom of endometriosis is recurring pelvic pain. The pain can be mild to severe cramping that occurs on both sides of the pelvis, in the lower back and rectal area, and even down the legs.

The amount of pain a woman feels correlates poorly with the extent or stage (1 - 4) of endometriosis, with some women having little or no pain despite having extensive endometriosis or endometriosis with scarring, while,

on the other hand, other women may have severe pain even though they have only a few small areas of endometriosis.

Symptoms may include:

dysmenorrhea – painful, sometimes disabling cramps during menses; pain may get worse over time (progressive pain), also lower back pains linked to the pelvis

chronic pelvic pain – typically accompanied by lower back pain or abdominal pain

dyspareunia – painful sex

dysuria – urinary urgency, frequency, and sometimes painful voiding

Throbbing, gnawing, and dragging pain to the legs are reported more commonly by women with endometriosis. Compared with women with superficial endometriosis, those with deep disease appear to be more likely to

report shooting rectal pain and a sense of their insides being pulled down. Individual pain areas and pain intensity appears to be unrelated to the surgical diagnosis, and the area of pain unrelated to area of endometriosis.

Many women with infertility may have endometriosis. As endometriosis can lead to anatomical distortions and adhesions (the fibrous bands that form between tissues and organs following recovery from an injury), the causality may be easy to understand; however, the link between infertility and endometriosis remains enigmatic when the extent of endometriosis is limited. It has been suggested that endometriotic lesions release factors which are detrimental to gametes or embryos, or, alternatively, endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon; for this reason it is preferable to speak of endometriosis-associated infertility in such cases. In some cases it can take a woman with endometriosis 7–10 years to conceive her first child, to most couples this can be stressful and daunting.

Other symptoms may be present, including:

Constipation

chronic fatigue

In addition to pain during menstruation, the pain of endometriosis can occur at other times of the month. There can be pain with ovulation, pain associated with adhesions, pain caused by inflammation in the pelvic cavity,

pain during bowel movements and urination, during general bodily movement like exercise, pain from standing or walking, and pain with intercourse. But the most desperate pain is usually with menses and many women

dread having their periods. Pain can also start a week before menses, during and even a week after menses, or it can be constant. There is no known cure for endometriosis. There are some additional conditions that are seen

in increased frequency among people with endometriosis, but where there is uncertainty whether these are factors that predispose to endometriosis or vice versa.

Endometriosis bears no relationship to endometrial cancer. Current research has demonstrated an association between endometriosis and certain types of cancers, notably ovarian cancer, non-Hodgkin's lymphoma and brain

cancer. Endometriosis often also coexists with leiomyoma or adenomyosis, as well as autoimmune disorders. A 1988 survey conducted in the US found significantly more hypothyroidism, fibromyalgia, chronic fatigue

syndrome, autoimmune diseases, allergies and asthma in women with endometriosis compared to the general population.

Complications of endometriosis include:

Internal scarring

Adhesions

Pelvic cysts

Chocolate cyst of ovaries

Ruptured cyst

Bowel obstruction

Environmental

There is a growing suspicion that environmental factors may cause endometriosis, specifically some plastics and cooking with certain types of plastic containers with microwave ovens. Dioxin exposure has been found a very

likely cause of endometriosis in one well known study by The Endometriosis association that found that 79% of monkeys developed Endometriosis after receiving doses of dioxin. Other sources suggest that pesticides and hormones in our food cause a hormone imbalance.

Tobacco smoking: The risk of endometriosis has been reported to be reduced in smokers. Smoking causes decreased estrogens with increased breakthrough bleeding and shortened luteal phases. Smokers have an earlier than normal (by about 1.5–3 years) menopause which suggests that there is some toxic effect of smoking on the follicles directly. Chemically, nicotine has been shown to concentrate in cervical mucous and metabolites have been

found in follicular fluid and been associated with delayed follicular growth and maturation. Finally, there is some effect on tubal motility because smoking is associated with an increased incidence of ectopic pregnancy as well

as an increased spontaneous abortion rate.

Aging brings with it many effects that may reduce fertility. Depletion over time of ovarian follicles affects menstrual regularity. Endometriosis has more time to produce scarring of the ovary and tubes so they cannot move

freely or it can even replace ovarian follicular tissue if ovarian endometriosis persists and grows. Leiomyomata (fibroids) can slowly grow and start causing endometrial bleeding that disrupts implantation sites or distorts the endometrial cavity which affects carrying a pregnancy in the very early stages. Abdominal adhesions from other intraabdominal surgery, or ruptured ovarian cysts can also affect tubal motility needed to sweep the ovary and

gather an ovulated follicle (egg).

Pathophysiology

While the exact cause of endometriosis remains unknown, many theories have been presented to better understand and explain its development. These concepts do not necessarily exclude each other. The pathophysiology of endometriosis is likely to be multifactorial and to involve an interplay between several factors.

Broadly, the aspects of the pathophysiology can basically be classified as underlying predisposing factors, metabolic changes, formation of ectopic endometrium, and generation of pain and other effects. It is not certain,

however, to what degree predisposing factors lead to metabolic changes and so on, or if metabolic changes or formation of ectopic endometrium is the primary cause. Also, there are several theories within each category,

but the uncertainty over what is a cause versus what is an effect when considered in relation to other aspects is as true for any individual entry in the pathophysiology of endometriosis.

Also, pathogenic mechanisms appear to differ in the formation of distinct types of endometriotic lesion, such as peritoneal, ovarian and rectovaginal lesions.

Metabolic changes

Endometriosis is a condition that is estrogen-dependent and thus seen primarily during the reproductive years. In experimental models, estrogen is necessary to induce or maintain endometriosis. Medical therapy is often

aimed at lowering estrogen levels to control the disease. Additionally, the current research into aromatase, an estrogen-synthesizing enzyme, has provided evidence as to why and how the disease persists after menopause and hysterectomy.

Retrograde menstruation

The theory of retrograde menstruation is the most widely accepted theory for the formation of ectopic endometrium in endometriosis. It suggests that during a woman's menstrual flow, some of the endometrial debris exits

the uterus through the fallopian tubes and attaches itself to the peritoneal surface (the lining of the abdominal cavity) where it can proceed to invade the tissue as endometriosis.

While most women may have some retrograde menstrual flow, typically their immune system is able to clear the debris and prevent implantation and growth of cells from this occurrence. However, in some patients, endometrial tissue transplanted by retrograde menstruation may be able to implant and establish itself as endometriosis. Factors that might cause the tissue to grow in some women but not in others need to be studied, and some of the possible causes below may provide some explanation, e.g., hereditary factors, toxins, or a compromised immune system. It can be argued that the uninterrupted occurrence of regular menstruation month after month for decades is a modern phenomenon, as in the past women had more frequent menstrual rest due to pregnancy and lactation.

Retrograde menstruation alone is not able to explain all instances of endometriosis, and it needs additional factors such as genetic or immune differences to account for the fact that many women with retrograde menstruation

do not have endometriosis. Research is focusing on the possibility that the immune system may not be able to cope with the cyclic onslaught of retrograde menstrual fluid. In this context there is interest in studying the relationship of endometriosis to autoimmune disease, allergic reactions, and the impact of toxins. It is still unclear what, if any, causal relationship exists between toxins, autoimmune disease, and endometriosis

In addition, at least one study found that endometriotic lesions are biochemically very different from artificially transplanted ectopic tissue. The latter finding, however, can in turn be explained by that the cells that establish endometrial lesions are not of the main cell type in ordinary endometrium, but rather of a side population cell type, as supported by exhibitition of a side population phenotype upon staining with Hoechst dye and by flow cytometric analysis.

The way endometriosis causes pain is the subject of much research. Because many women with endometriosis feel pain during or around their periods and may spill further menstrual flow into the pelvis with each menstruation, some researchers are trying to reduce menstrual events in patients with endometriosis.

Endometriosis lesions react to hormonal stimulation and may "bleed" at the time of menstruation. The blood accumulates locally, causes swelling, and triggers inflammatory responses with the activation of cytokines.

It is thought that this process may cause pain.

Pain can also occur from adhesions (internal scar tissue) binding internal organs to each other, causing organ dislocation. Fallopian tubes, ovaries, the uterus, the bowels, and the bladder can be bound together in ways that are painful on a daily basis, not just during menstrual periods.

Also, endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the central nervous system, potentially producing a variety of individual differences in pain that can, in some women, become independent of the disease itself.

Most endometriosis is found on these structures in the pelvic cavity:

Ovaries (the most common site)

Fallopian tubes

The back of the uterus and the posterior cul-de-sac

The front of the uterus and the anterior cul-de-sac

Uterine ligaments such as the broad or round ligament of the uterus

Pelvic and back wall

Intestines, most commonly the rectosigmoid. (Bowel endometriosis affects approximately 10% of women with endometriosis, and can cause severe pain with bowel movements)

Urinary bladder and ureters

Endometriosis may spread to the cervix and vagina or to sites of a surgical abdominal incision.

The only way to diagnose endometriosis is by laparoscopy or other types of surgery with lesion biopsy. The diagnosis is based on the characteristic appearance of the disease, and should be corroborated by a biopsy.

Surgery for diagnoses also allows for surgical treatment of endometriosis at the same time.

Doctors can often feel the endometrial growths during a pelvic exam, and these symptoms may be signs of endometriosis, diagnosis cannot be confirmed without performing a laparoscopic procedure.

Often the symptoms of ovarian cancer are identical to those of endometriosis. If a misdiagnosis of endometriosis occurs due to failure to confirm diagnosis through laparoscopy, early diagnosis of ovarian cancer, which is crucial for successful treatment, may have been missed.

Stage I (Minimal)

Findings restricted to only superficial lesions and possibly a few filmy adhesions

Stage II (Mild)

In addition, some deep lesions are present in the cul-de-sac

Stage III (Moderate)

As above, plus presence of endometriomas on the ovary and more adhesions.

Stage IV (Severe)

As above, plus large endometriomas, extensive adhesions.

Prevention

Use of combined oral contraceptives is associated with a reduced risk of endometriosis, apparently giving a relative risk of endometriosis of 0.63 during active use, yet with limited quality of evidence according to a systematic review.

Hormonal medication

Progesterone or Progestins: Progesterone counteracts oestrogen and inhibits the growth of the endometrium. Such therapy can reduce or eliminate menstruation in a controlled and reversible fashion. Progestins are chemical variants of natural progesterone.

Avoiding products with xenoestrogens, which have a similar effect to naturally produced oestrogen and can increase growth of the endometrium.

Hormone contraception therapy: Oral contraceptives reduce the menstrual pain associated with endometriosis. They may function by reducing or eliminating menstrual flow and providing estrogen support. Typically, it is

a long-term approach. Recently Seasonale was FDA approved to reduce periods to 4 per year.

Surgery

Procedures are classified as

Conservative therapy: when reproductive organs are retained, consists of the excision (called cystectomy) of the endometrium, adhesions, resection of endometriomas, and restoration of normal pelvic anatomy as much as is possible. There are combinations as well, notably one consisting of cystectomy followed by ablative surgery (removal of endometrium) using a CO2 laser to vaporize the remaining 10–20% of the endometrioma wall close to

the hilus. Laparoscopy, besides being used for diagnosis, can also be an option for surgery. It's considered a "minimally invasive" surgery because the surgeon makes very small openings (incisions) at (or around) the belly button and lower portion of the belly. A thin telescope-like instrument (the laparoscope) is placed into one incision, which allows the doctor to look for endometriosis using a small camera attached to the laparoscope. Small instruments are inserted through the incisions to remove the tissue and adhesions. Because the incisions are very small, there will only be small scars on the skin after the procedure. The patient usually can go home the day of the surgery and should be able to return to their usual activities.

Semi-conservative therapy: when ovarian function is allowed to continue, preserves a healthy appearing ovary, but also increases the risk of recurrence.

Comparison of medicinal and surgical interventions

Efficacy studies show that both medicinal and surgical interventions produce roughly equivalent pain-relief benefits. Recurrence of pain was found to be 44 and 53 percent with medicinal and surgical interventions, respectively. However, each approach has its own advantages and disadvantages.

Disadvantages of medicinal interventions

Adverse effects are common

Not likely to improve fertility

Some can only be used for limited periods of time

Advantages of surgery

Significant efficacy for pain control.

Has increased efficacy over medicinal intervention for infertility treatment

Combined with biopsy, it is the only way to achieve a definitive diagnosis

Can often be carried out as a minimally invasive (laparoscopic) procedure to reduce morbidity and minimize the risk of post-operative adhesions.

One theory above suggests that endometriosis is an auto-immune: condition and if the immune system is compromised with a food intolerance, then removing that food from the diet can, in some people, have an effect.

Various dietary recommendations are made in popular media. For example, common intolerances in people with endometriosis are claimed to be wheat, sugar, meat and dairy. Avoiding foods high in hormones and

inflammatory fats also appears to be important in endometriosis pain management. Eating foods high in indole-3-carbinol, such as cruciferous vegetables appears to be helpful in balancing hormones and managing pain.

However, these popular claims are typically not supported by scientific studies. According to one scientific study, diets high in fat and low in fruit and β-carotene were associated with a lower risk of endometriosis,

contradicting the typical idea of a healthy diet. Consumption of omega 3 fatty acids, particularly EPA, as a food supplement has been suggested as a therapy for endometriosis. Use of soy has been reported to both alleviate

pain and to aggravate symptoms, making its use questionable.

Physical therapy for pain management in endometriosis has been investigated in a pilot study suggesting possible benefit. Physical exertion such as lifting, prolonged standing or running does < pelvic pain.

Use of heating pads on the lower back area, may provide some temporary relief. Laboratory studies indicate that heparin may alleviate endometriosis-associated fibrosis.

Vaginal childbirth decreases recurrence of endometriosis. In contrast, endometriosis recurrence rates have been shown to be higher in women who have not given birth vaginally, such as in Cesarean section.

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