Endometriosis

CHAPTER 65 Endometriosis

Western medical perspective

Aetiology

Although many theories exist, the pathogenesis of endometriosis is still not fully understood in the Western medical world. The following are some of the most common theories

Retrograde menstruation and tubal reflux

This was proposed by Samson who believed that menstrual blood is forced out along the fallopian tubes into the peritoneal cavity. He suggested that menstrual blood contains fragments of endometrium which may implant on pelvic structures and grow. Excessive uterine contractions characteristic of primary dysmenorrhoea (often present in women with endometriosis) may contribute to a bidirectional menstrual flow from the uterus.

Coelomic metaplasia

This was proposed by Meyer and Ivanoff who suggested that all tissues in which endometriosis arises are embryologically derived from coelomic epithelium, i.e. epithelium of the peritoneal cavity. In this hypothesis, peritoneal cells would change into endometrial tissue. Chronic irritation of the peritoneum by menstrual blood may cause coelomic metaplasia, which can subsequently result in endometriosis.

Direct implantation

According to this theory, endometrial tissue is displaced into an implant in the new sites. This explains why endometriosis may be found in surgical scars.

Genetic factors

There is a 5.8% familial incidence among immediate female siblings, an 8.1% risk if the mother had endometriosis and a 7% risk if a female sibling has endometriosis. These figures suggest a polygenic and multifactorial inheritance for endometriosis.

Lymphatic dissemination

Halban suggested that normal endometrium might ‘metastasize’ via lymphatic channels and thus spread to extra-uterine sites where implantation and growth would produce the characteristic lesions of endometriosis.

Vascular theory

This theory was proposed by Navratil who suggested that normal endometrium was deported via the veins to remote areas of the body.

Immunologic factors

Recent research has suggested involvement of the immune system in the pathogenesis of endometriosis. Women with this disorder appear to exhibit increased humoral immune responsiveness and macrophage activation while showing diminished cell-mediated immunity with decreased T-cell and natural killer cell responsiveness.

There seems to be a correlation between endometriosis and the use of tampons and intra-uterine contraceptive devices (the coil), and with intercourse during menstruation. It has been suggested that intercourse during menses might increase tubal activity and increase the backflow of the menstrual cycle through the tubes and thus increase the risk of endometriosis. However, there are no statistics to bear this out and indeed some even hold the opposite view, i.e. that sexual intercourse during the period may help to prevent endometriosis. As we shall see below when we discuss the aetiology of endometriosis from the Chinese perspective, sexual intercourse during the period may indeed be a factor in the development of endometriosis.

The following are the risk factors in endometriosis:

• Family history of endometriosis.

• Early age of menarche.

• Short menstrual cycles (<27 days).

• Long duration of menstrual flow (>7 days).

• Heavy bleeding during menses.

• Inverse relationship to parity.

• Delayed childbearing.

• Defects in the uterus or fallopian tubes.

• Hypoxia and iron deficiency may contribute to the early onset of endometriosis.

Some of the risk factors above are interesting from the Chinese perspective. In fact, early age of menarche, the inverse relationship to parity and the delayed childbearing are all risk factors that are related to having more menstrual cycles. In other words, having an early menarche, few children and delayed childbearing mean that the woman will have more periods than one who starts her periods later, has more children and has children earlier in life.

As we discussed in Chapter 4 on aetiology, some doctors have advanced the hypothesis that the increasing incidence of endometriosis may be correlated with the increased number of menstrual cycles between the time of menarche and that of the first pregnancy.

Aetiology

• Retrograde menstruation and tubal reflux: menstrual blood forced out along the Fallopian tubes into the peritoneal cavity.

• Coelomic metaplasia: tissues in which endometriosis arises are embryologically derived from coelomic epithelium, i.e. epithelium of the peritoneal cavity. In this hypothesis, peritoneal cells would change into endometrial tissue.

• Direct implantation: endometrial tissue is displaced into an implant in the new sites.

• Genetic factors: there is a 5.8% familial incidence among immediate female siblings, an 8.1% risk if the mother had endometriosis and a 7% risk if a female sibling has endometriosis.

• Lymphatic dissemination: normal endometrium might ‘metastasize’ via lymphatic channels and thus spread to extra-uterine sites.

• Vascular theory: normal endometrium deported via the veins to remote areas of the body.

• Immunologic factors: involvement of the immune system in the pathogenesis of endometriosis.

Pathology

There are three diagnostic histologic features of endometriosis. They are:

1. endometrial glands

2. endometrial stroma

3. evidence of haemorrhage.

The typical lesion will show an abundance of inflammatory cells and fibrous connective tissue.

Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the ovary or as larger cysts which may be up to 10 cm in size (known as endometriomas or ‘chocolate cysts’) and which may rupture (Plate 65.1). In the ovary, the process is almost always bilateral. There is usually considerable fibrosis and puckering of the ovarian surface in the region of the cyst as well as adherence to neighbouring structures.

In the other most frequently involved areas, i.e. throughout the pelvic peritoneum, the lesions are normally smaller and more numerous and are surrounded by dense, fibrous scar tissue (Plate 65.2). Endometriosis is frequently accompanied by mesothelial hyperplasia of the pelvic peritoneum. Mesothelial hyperplasia most commonly involves the surface of the ovaries, the Fallopian tubes, the pelvic peritoneum and the omentum.¹

From the Chinese perspective, mesothelial hyperplasia indicates Dampness. Dampness is a frequent secondary pathological factor in endometriosis (after Blood stasis).

Endometriosis develops mostly in women of reproductive age and regresses after menopause or ovariectomy, suggesting that the growth is oestrogen dependent. Indeed, the lesions contain oestrogen receptors as well as aromatase, an enzyme that catalyses the conversion of androgens to oestrogens, suggesting that local oestrogen production may stimulate the growth of lesions.

Clinical manifestations

The most commonly seen symptoms and signs of endometriosis are:

• dysmenorrhoea (97%)

• pelvic pain (62%)

• lower backache radiating to the anterior thigh

• heavy periods

• irregular bleeding

• infertility (47%)

• dyspareunia (59%)

• pain sometimes accompanied by nausea and vomiting or diarrhoea

• pain on defaecation (68%)

• rectal pressure

• tender and enlarged ovaries

• pelvic nodularities and thickenings

• fatigue (64%).

The clinical manifestations of endometriosis given by the USA Endometriosis Association differ slightly from the above and they are:

• dysmenorrhoea (96.2%)

• dyspareunia (59.6%)

• heavy periods or irregular bleeding (65.3%)

• infertility (44%)

• pain sometimes accompanied by nausea and vomiting (57.7%)

• diarrhoea (79%)

• dizziness, headaches with period (59%)

• fatigue (82.1%)

• low-grade fever (29.4%)

• low resistance to infection (39.1%)

• no symptoms (2.6%).²

Interestingly, there is no direct correlation between the severity of the pain and the extent of endometriosis: thus, a woman with advanced endometriosis may suffer less pain than a woman with the beginning stages of the disease.

There is no direct correlation between the severity of the pain and the extent of endometriosis: the Chinese explanation of this phenomenon is that the amount of pain depends on the severity of Blood stasis.

Diagnosis

Diagnosis of endometriosis is made principally by taking a clinical history. If it is suspected, confirmation is usually obtained by laparoscopy which shows endometriotic cysts and deposits. Definitive diagnosis can be made by microscopic examination of excised tissue that demonstrates both glands and stroma.

A diagnostic laparoscopy is the ‘gold standard’ for diagnosing endometriosis. A diagnosis of endometriosis should not be considered unless the endometriosis has been seen during a laparoscopy. Most gynecologists also insist that a biopsy of the endometrial tissue be examined by a pathologist before confirming the diagnosis (Plate 65.3).

Usually, if minimal to moderate endometriosis is found, a diagnostic laparoscopy will be combined with an operative laparoscopy to remove any endometriotic lesions and adhesions. This means that the endometriosis can be diagnosed and treated at the same time, and only one operation is needed. Diagnosis is, however, fraught with difficulties and is affected by subjectivity. Laparoscopy relies entirely on the visual and subjective assessment of the pelvis by the operator and consequently is prone to misinterpretation and subjectivity.

Another difficulty is that the symptoms of endometriosis are very similar to those of other diseases, e.g. pelvic inflammatory disease, ovarian tumours and irritable bowel syndrome, making differential diagnosis problematic.

Treatment

The main aim of Western medical treatment of endometriosis is to halt menstruation so that cyclical endometrial bleeding is prevented and any areas of endometrium outside the uterus may have an opportunity to recede. To this aim, many drugs are used:

• Combined contraceptive pill.

• Progestins.

• Mirena® intra-uterine device (IUD).

• Gonadotropin-releasing hormone (GnRH) agonists.

• Aromatase inhibitors.

• Painkillers.

Combined contraceptive pill

There are many different types, each of which contains a specific low-dose combination of synthetic oestrogen and progestagen (progesterone). It alleviates the pain of endometriosis by suppressing menstruation and inhibiting the growth of the endometrial implants.

Very few studies have looked at the effectiveness of the combined oral contraceptive pill in treating the pain-related symptoms of endometriosis. Nevertheless, the existing evidence suggests that its effectiveness in alleviating pain is similar to that of the other hormonal drugs during treatment, and there is no difference 6 months after stopping taking the pill.

Progestins

Progestins are a group of drugs that behave like progesterone. They have been used since the mid-1950s to treat the symptoms of endometriosis. They are also sometimes referred to as gestogens, progestogens or progestagens.

Progestins on the market include Alesse®, Brevicon®, Cyclessa®, Demulen®, Genora®, Levlen® and many others. The progestins are effective treatments for the symptoms of endometriosis. However, like all the hormonal drugs used for endometriosis, they have side effects, which some women find intolerable. They are safer and cheaper than the GnRH agonists and danazol, which some gynecologists believe makes them appropriate for women who need prolonged or repeated treatments.

It is not known precisely how progestins relieve the symptoms of endometriosis, but they probably work by suppressing the growth of endometrial implants in some way, causing them to gradually waste away. They may also reduce endometriosis-induced inflammation in the pelvic cavity.

At the dosages usually used for endometriosis, most women will stop ovulating and menstruating during treatment. The levonorgestrel intra-uterine system does not always stop ovulation. In the first 3–6 months, many women will experience spotting, but some may experience heavy or prolonged bleeding. Later, most women will have lighter periods than previously, and some will have no periods.

Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment. Women who have had long-acting injections may experience prolonged delays in the return of menstruation, and a few women may not menstruate for more than a year after their last injection.

Side effects of progestins

The side effects of progestins vary from progestin to progestin depending on their chemical nature and the dosage used. Nevertheless, women usually experience fewer side effects with progestin treatment than with GnRH-agonist or danazol treatment. Most women will experience at least one or two mild to moderate side effects, and some may experience several.

The main side effects are acne, bloating, breakthrough bleeding, breast discomfort, depression, dizziness, fluid retention, headaches, irregular bleeding, lethargy, moodiness, nausea, prolonged bleeding, spotting, vomiting and weight gain.

The levonorgestrel intra-uterine system is sometimes expelled by the uterus, particularly in the first year. Infrequently, it may perforate the uterus (particularly if inserted within 6 weeks of a vaginal birth, or 12 weeks of a Caesarian birth), or lead to a pelvic infection (especially in the first 3 weeks after insertion). The side effects of progestins are reversible and they usually disappear soon after completing treatment.

Little research has been conducted into the effectiveness of the progestins for the treatment of endometriosis. Nevertheless, the results of clinical trials conducted to date suggest that the different progestins are equally effective, and that when taken continuously (every day) they relieve endometriosis-associated pain as effectively as the other hormonal drugs. They are not usually effective when taken only during the luteal phase (second half) of the menstrual cycle. The progestins control pain symptoms in approximately three of four women and they may not relieve symptoms completely. Symptoms often recur following treatment months or years after treatment ceases.

Mirena® IUD

The Mirena® IUD is a small, plastic, T-shaped intra-uterine device that is increasingly being used to treat women with endometriosis. It contains a progestogen that is released into the uterus over a period of 5 years. It is sometimes also known by its generic name, levonorgestrel intra-uterine system or LNG-IUS. Studies indicate that the Mirena® IUD is an effective treatment for endometriosis, and may have the potential to be a long-term treatment for women who want to postpone pregnancy. As indicated above, progestins relieve the symptoms of endometriosis by suppressing the growth of endometrial implants, causing them to gradually waste away. They may also reduce endometriosis-induced inflammation in the pelvic cavity.

At the dosages usually used for endometriosis, most women will stop ovulating and menstruating during treatment. The levonorgestrel intra-uterine system does not always stop ovulation. In the first 3–6 months, many women will experience spotting, but some may experience heavy or prolonged bleeding. Later, most women will have lighter periods than previously, and some will have no periods. Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment.

Side effects of Mirena® IUD

Side effects of the Mirena® IUD include irregular bleeding, pelvic pain or weight gain. The most common side effect of Mirena® is irregular vaginal bleeding, which includes erratic bleeding, frequent spotting or light bleeding between periods, heavy bleeding, and longer or shorter periods. However, these problems usually settle after 3–6 months.

Although the levonorgestrel in the IUD is released into the uterus, a small amount is absorbed into the bloodstream. The amount of levonorgestrel in the blood is about one-seventh of that found in the oral contraceptive pill, so there are fewer side effects than with the oral progestogen treatments for endometriosis. Side effects often disappear after 4–6 weeks.

The progestogen-related side effects include acne, decreased libido, headache, lower abdominal pain, low back pain, nausea, period pain, sweating, tender breasts, water retention and weight gain.

Women using the Mirena® IUD are more likely to develop benign ‘simple’ ovarian cysts. The most common symptom of a simple cyst is abdominal pain that does not resolve with simple painkillers. Such cysts usually disappear without treatment in 2–3 months.

The Mirena® IUD system is designed to minimize the risk of infection, but there is still a slight risk of developing a pelvic infection while using the IUD, particularly in the first 3 weeks after insertion. Such infections are usually related to sexually transmitted diseases. Overall, about 1.5% of women will develop an infection with 5 years of use of the IUD.

Table 65.1 lists the various types of progestins for endometriosis.

Table 65.1 Types of progestins used for endometriosis

GnRH agonists

The GnRH agonists are a group of drugs that have been used to treat women with endometriosis for over 20 years. They are modified versions of gonadotropin-releasing hormone, which ‘orchestrates’ the menstrual cycle.

All the GnRH agonists are very similar chemically, but they come in different forms: 3-monthly injection, monthly injection, daily injection and nasal spray. When used in combination with add-back medication, the GnRH agonists are effective and generally well tolerated by most women.

GnRH agonists stop the production of oestrogen by a series of mechanisms. This deprives the endometrial implants of oestrogen, causing them to become inactive and degenerate. Through downregulation, agonists are able to exert a prolonged suppression effect.

Most women will stop bleeding within 2 months of starting treatment. However, some will experience 3–5 days of vaginal bleeding or spotting about 10–14 days after beginning treatment. There is usually an improvement in symptoms within 4–8 weeks of beginning treatment.

The return of ovulation and menstruation after stopping the medication is very variable. Most women will menstruate within 4–6 weeks of their last spray of buserelin or nafarelin, or within 6–10 weeks of their last injection of goserelin, leuprorelin or triptorelin.

Table 65.2 lists the various types of GnRH agonists for endometriosis.

Table 65.2 Types of GnRH agonists

Side effects of GnRH agonists

The side effects of the GnRH agonists are largely the result of the low levels of oestrogen in the body and they therefore may cause menopausal-like symptoms. Side effects are common, and most women will experience at least one or two. The severity of the side effects varies from mild to severe, and some women will find them intolerable. Most women will experience hot flushes (flashes) or night sweats or both. The other common side effects are insomnia, decreased libido, headaches, mood swings, vaginal dryness, decreased breast size, acne, muscle pains, dizziness and depression. The menopausal-type symptoms usually disappear soon after treatment ceases.

The most serious side effect of treatment with a GnRH agonist is thinning of the bones, particularly the bones of the spine. When the levels of oestrogen in the body are low, the rate of breakdown of the bones’ matrix becomes greater than the rate of regeneration, so the bone matrix becomes less dense. The decrease in bone density is typically about 4–6% at the end of a 6-month course of treatment. It is thought that most of the bone lost during treatment regenerates within 6 months of completing treatment, and that 18–24 months after completing treatment probably most, if not all, the lost bone has been replaced. Therefore, a single 6-month course of treatment will not usually be detrimental for women with normal bone density. However, in women at risk of developing the condition, treatment with a GnRH agonist could predispose them to developing osteoporosis.

Danazol (Danocrine®)

Danazol has been used to treat women with endometriosis since the 1970s. It was the most commonly used drug in the early 1980s, but its use declined markedly after the introduction of the GnRH agonists in the late 1980s and early 1990s.

Danazol is a synthetic androgen. Androgens are responsible for the functioning of the male reproductive system and the development of the male characteristics, such as facial hair and a deep voice. The ovaries also produce small amounts of androgens.

Danazol is an effective treatment for endometriosis, and has the same effectiveness as the other hormonal treatments. However, it has many androgenic side effects, including weight gain, increased body hair and acne. Its unpleasant side effects and its tendency to adversely affect blood lipid (cholesterol) levels mean it is not usually the first choice of treatment for endometriosis.

Like all the other hormonal treatments, danazol does not cure endometriosis permanently. Rather, it suppresses its growth and development temporarily, so the disease may recur following treatment. Danazol has a multitude of effects on the body. Some of these effects combine to produce high levels of androgen and low levels of oestrogen in the body. This hormonal environment stops menstruation and suppresses the growth of endometrial implants, causing them to degenerate.

Most women will stop ovulating and menstruating by the second month of treatment, though this may depend on the dosage used. The symptoms of endometriosis usually begin to diminish by the end of the second month. Most women will resume ovulating and menstruating within 4–6 weeks of stopping treatment.

Side effects of Danazol

Danazol can cause many side effects the number and severity of which is sometimes related to the dosage being used. Reducing the dosage to the minimum needed to stop the periods may reduce the side effects experienced.

Many of the side effects are due to its androgenic effects. These include weight gain, acne, oily skin and hair, bloating, fluid retention, voice changes, increase in body hair, decreased breast size, decreased libido and enlargement of the clitoris (rare).

Weight gain is a common side effect. Most women experience weight gain, usually 1–5 kg (2.2–11 lb) but occasionally more. When treatment finishes, most women lose much of the weight gain within 1–2 months.

Some women experience a change in their voice. The change may involve a deepening of the voice, or it may become husky, or it may peter out at times.

Some of the side effects are due to the low levels of oestrogen in the body. These include hot flushes, night sweats and vaginal dryness.

Danazol can also cause other side effects, including irregular vaginal bleeding or spotting, skin rash, nausea, headaches, muscle cramps, tingling of the limbs, emotional instability, fatigue, adverse effects on blood lipid (cholesterol) levels and decreased glucose tolerance.

Most of the side effects disappear soon after completing treatment. However, some of the androgenic side effects, such as deepening of the voice, increased body hair (especially if profuse) and enlargement of the clitoris, are sometimes irreversible.

Long-term use is associated with a small risk of developing liver tumors and a theoretical risk of developing heart disease. If treatment lasts longer than 6 months, liver function should be monitored.

Aromatase inhibitors

Aromatase inhibitors are usually prescribed for women with endometriosis who have not had success with other treatments or who cannot use other treatments because of their side effects. Although the use of aromatase inhibitors is new in endometriosis, they have been used to treat post-menopausal women with some forms of breast cancer for nearly 10 years. In fact, aromatase inhibitors are currently the most effective non-toxic drugs for the treatment of post-menopausal breast cancer.

At the moment, the treatment of endometriosis with aromatase inhibitors is still experimental, because the research is still in its early days. Aromatase is a protein that is responsible for producing oestrogen. Normally, it is found in the ovaries, and to a much lesser extent in the skin and fat. Research has shown that aromatase is also found in high levels in the ectopic endometrial tissue of women with endometriosis, which contributes to the growth of their endometriosis. Inhibiting the aromatase suppresses the growth of the endometriosis and reduces the associated inflammation. This, in turn, significantly reduces pelvic pain.

Side effects of aromatase inhibitors

The most common side effects of aromatase inhibitors are mild hot flushes and decreased libido.

The following is my own assessment of the biomedical treatment of endometriosis and its possible effect in terms of Chinese medicine:

• Combined contraceptive pill: it merely masks the symptoms of endometriosis. Induces Blood deficiency.

• Progestins: same as above, they merely mask the problem. Progestins cause Dampness and Liver-Qi stagnation.

• Mirena® IUD: same as above. In addition, obstruction of the Uterus causes Blood stasis (which is the cause of endometriosis in the first place).

• GnRH agonists: again, they just mask the problem. They deplete Kidneys and Essence.

• Danazol: same as above. Causes Dampness and Phlegm.

• Aromatase inhibitors: they mask the problem by inducing menopause. They cause Kidney deficiency.

In conclusion, I do not combine Chinese herbal treatment with Western hormonal treatment because Chinese herbs cannot regulate the hormones naturally when the woman’s hormonal system is being manipulated artificially and ovulation suppressed.

Laser and diathermy

Endometriosis is also treated surgically with laser or diathermy. Usually, if minimal to moderate endometriosis is found, a diagnostic laparoscopy will be combined with an operative laparoscopy to remove any endometriotic lesions and adhesions. This means that the endometriosis can be diagnosed and treated at the same time, and only one operation is needed.

For the surgical treatment of endometriosis, the surgeon will aim to remove endometrial implants, separate any adhesions, and drain and treat any large cysts with the use of a laser beam. The advantage of laser surgery is that the effect of the laser is very precise and reduces tissue damage.

Diathermy, which uses an electric current, may be used to divide tissue as well as coagulate tissue, particularly blood vessels to control any bleeding.

Endometrial implants can be treated using two techniques: excision and coagulation. Excision removes endometrial implants by cutting them away from the surrounding tissue with scissors, a very fine heat gun or a laser beam. The technique does not damage the implants, so the gynecologist is able to send a biopsy of the excised tissue to the pathologist to confirm that it is endometriosis and not cancer or another condition. Excision allows the gynecologist to separate the implants from the surrounding tissue, thus ensuring that the entire implant is removed and no endometrial tissue is left. Coagulation destroys implants by burning them with a fine heat gun or vaporizing them with a laser beam. When coagulating implants, care must be taken to ensure that the entire implant is destroyed, so it cannot regrow. Care must also be taken to ensure that only the implant is destroyed, and no underlying tissue such as the bowel, bladder or ureter. The possibility of accidentally damaging the underlying tissue means that most gynecologists are wary of using coagulation on implants that lie over vital organs, such as the bowel and large blood vessels.

It should be noted that pregnancy usually induces a marked regression of the lesions. However, as infertility is commonly associated with endometriosis, this is rarely a practical solution to the problem.

Chinese medical perspective

Aetiology

Intercourse during menstruation

When a woman becomes sexually aroused, the Minister Fire goes upwards. If this happens when menstrual blood is flowing downwards, the two will ‘meet’, blocking each other and therefore leading to stagnation of Qi and Blood in the Uterus (Fig. 65.1).

Figure 65.1 Effect of sexual activity during the period.

Intercourse at too early an age

Intercourse at an early age damages the Directing and Penetrating Vessels (Ren and Chong Mai) because the Uterus is in a vulnerable condition at an early age. This may cause either a deficiency of the Directing and Penetrating Vessels or Blood stasis in the Uterus, in which case it may contribute to the development of endometriosis

By ‘early age’ I mean during puberty and certainly before puberty. I would consider sexual intercourse too early if it occurs within 2 years of puberty.

Excessive physical work or exercise

Excessive physical work or exercise can weaken the Spleen, Liver and Kidneys and adversely affect the Penetrating and Directing Vessels. This is especially the case during puberty when the Penetrating and Directing Vessels are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation in the Uterus.

Excessive physical exercise includes girls working on a farm, excessive sports, excessive running and also intensive ballet practice at puberty.

External Cold

Women are particularly prone to invasion of Cold just before, during and just after the period, as well as just after childbirth. When Cold invades the Uterus, it contracts tissues causing Blood to stagnate.

The Uterus is also particularly prone to invasion of Cold during puberty: this occurs when young girls play sports in shorts in winter, sit on damp grass or keep wet swimming suits on after swimming. These situations are aggravated also by the consumption of ice-cold liquids.

Please note that invasion of the Uterus by Cold occurs also in warm countries.

Tampons

Tampons block the normal downward flow of menstrual blood thereby leading to stasis of Blood.

Emotional stress

Emotional stress that leads to Liver-Qi stagnation (such as that from anger, frustration, resentment, worry, guilt, etc.) often leads to Blood stasis in women.

Pathology

In the pathology of endometriosis, there is always a Kidney deficiency and disharmony of Liver and Spleen.

Retention of menses

Retention of menses is an important factor, often occurring after childbirth. Dr Xia Gui Cheng attaches great importance to what he calls ‘retention of menses’ in the pathology of endometriosis. He says that the menses represent a way of getting rid of ‘old’ blood: if this discharge is insufficient, after some years endometriosis may develop.

It is interesting that we, as practitioners, tend to pay great attention to heavy menstrual flow but not enough to scanty menstrual flow. ‘Retention of menses’ can be judged only in relation to a woman’s menstrual constitution. For example, if a woman’s periods have always lasted 7 days and they then start to last 5 days, she has ‘retention of menses’: this would not be the case in a woman whose periods have always lasted 5 days. If a woman’s periods always lasted 5 days and then she starts having periods that last only 3 days, she has ‘retention of menses’.

Blood stasis

We can assume that in endometriosis there is always Blood stasis. The very appearance of the endometriosis lesions confirms this: they always look purple, sometimes reddish-purple and sometimes bluish-purple (see Plate 65.2). The Blood stasis accounts for the menstrual pain experienced with endometriosis.

Blood stasis is also a factor in the infertility that derives from endometriosis: from a Chinese perspective, the stagnant Blood in the Uterus may prevent implantation of the ovum.

Kidney deficiency

We can also assume that in endometriosis there is always an underlying Kidney deficiency: this may be of Kidney-Yang or Kidney-Yin but more often the former. The Kidney deficiency is also a contributing factor to the infertility that derives from endometriosis. From a modern perspective, a deficiency of Kidney-Yang is often the cause of a luteal insufficiency. As there is both Blood stasis (the Biao) and Kidney deficiency (the Ben), in treatment we should place the emphasis on the Manifestation (Biao), i.e. Blood stasis, only if the period is very painful.

Cold, Dampness, Damp-Phlegm

Endometriosis is characterized by an insufficient growth of Yang during phase 4 so that Yin pathogenic factors are not expelled. Example of Yin pathogenic factors in endometriosis are Blood stasis, Dampness, Cold or Phlegm.

Thus, besides Blood stasis, other pathogenic factors include Cold, Dampness and Damp-Phlegm. These pathogenic factors form more easily when there is an insufficient growth of Yang in phase 4 due to Kidney-Yang deficiency.

Cold, Dampness and Damp-Phlegm may all obstruct the Uterus in the same way as stagnant Blood does and therefore prevent fertilization. Cold in the Uterus is a frequent pathogenic factor pertaining to the Manifestation: this is particularly frequent in young women. When it is retained for a long time, Cold in the Uterus injures Yang and leads to Kidney-Yang deficiency.

As for Dampness, in my practice, 50% of women with endometriosis present with Dampness.

Temperature chart

The temperature chart is flat in endometriosis for two reasons, one due to the Manifestation (Biao), the other to the Root (Ben). The temperature does not decrease enough during the period because of Blood stasis (Biao) and it does not increase enough after ovulation due to Kidney-Yang deficiency (Ben). The result is a temperature chart line that is somewhat flat (Fig. 65.2).

Figure 65.2 Basal temperature chart in endometriosis.

To summarize, the main Full patterns (Manifestation) in endometriosis are: Blood stasis, Cold in the Uterus, Dampness and Damp-Phlegm. The main Empty patterns (Root) are: Kidney deficiency (Yin or Yang) and Blood deficiency (Table 65.3).

Table 65.3 Summary of the main patterns in endometriosis

Manifestation	Root
Blood stasis	Kidney deficiency
Cold	Blood deficiency
Dampness
Damp-Phlegm

In my practice, here is the distribution of patterns I find in endometriosis. Please note that the total does not add up to 100% because every patient has more than one pattern (e.g. Blood stasis, Kidney-Yang deficiency and Dampness):

• Blood stasis: 80%.

• Dampness: 50%.

• Cold in the Uterus: 36%.

• Kidney-Yang deficiency: 36%.

• Kidney deficiency (Yang and Yin): 20%.

• Kidney-Yin deficiency: 10%.

Pathology

• There is always a Kidney deficiency and disharmony of Liver and Spleen.

• There is also always Blood stasis but also often Dampness.

• Retention of menses is an important factor.

• The temperature chart is flat in endometriosis for two reasons, one due to the Manifestation (Biao), i.e. Blood stasis, the other to the Root (Ben), i.e. Kidney-Yang deficiency.

• Endometriosis is also characterized by an insufficient growth of Yang during phase 4 so that Yin pathogenic factors (Blood stasis, Dampness or Phlegm) are not expelled.

• In endometriosis there is always Blood stasis, but in infertility due to endometriosis there are other factors at play and especially Kidney-Yang deficiency causing a luteal insufficiency.

• In treatment, we should place the emphasis on the Manifestation (Biao), i.e. Blood stasis, only if the period is very painful.

Treatment principles

Before discussing treatment principles, we should discuss the relationship between the biomedical entity of ‘endometriosis’ and Chinese medicine gynecological diseases. As discussed in previous chapters, Painful Periods, Heavy Periods or Bleeding between Periods are ‘diseases’ (bing) in Chinese medicine (hence the use of initial caps) but not in Western medicine. In Western medicine, painful periods, heavy periods and bleeding in between periods are symptoms, not diseases (Fig. 65.3).

Figure 65.3 Western versus Chinese diseases.

Old Chinese gynecology books would not have a chapter called ‘Endometriosis’ but they would have one entitled ‘Painful Periods’ (Tong Jing). The question arises, therefore, to what Chinese gynecological disease does endometriosis correspond? We can say with certainty that it definitely corresponds to ‘Painful Periods’ because this is a prominent symptom of endometriosis in 97% of cases. This means that if we refer to the treatment of the Chinese disease of ‘Painful Periods’, we can get some idea as to how to treat endometriosis.

However, endometriosis may also correspond to ‘Heavy Periods’ (Yue Jing Guo Duo) or to ‘Flooding and Trickling’ (Beng Lou). Moreover, most modern Chinese gynecologists also say that endometriosis must be treated not only as ‘Painful Periods’ but also as ‘Abdominal Masses’ (Zheng Jia). This is because the endometriotic lesions in the abdominal cavity can be considered as a form of ‘Abdominal Masses’ (from Blood stasis) even though they are not palpable.

What difference does it make whether we treat endometriosis as ‘Painful Periods’ or as ‘Abdominal Masses’? There is an important difference in the herbal treatment. Abdominal masses from Blood stasis are treated not only by invigorating Blood but also by ‘breaking Blood’ and softening masses. Herbs that ‘break Blood’ strongly invigorate Blood and have a special function of dissolving masses. Examples of such herbs are E Zhu Rhizoma Curcumae and San Leng Rhizoma Sparganii.

Herbs that soften masses include Yi Yi Ren Semen Coicis, Zhe Bei Mu Bulbus Fritillariae thunbergii, Hai Zao Sargassum, etc.

When using herbal medicine, apart from treating the presenting patterns, it is necessary to use the method of ‘penetrating downwards’ (Tong Xia) to stimulate the downward flow of blood and to stop pain. Obviously this treatment method needs to be tempered if the periods are heavy. The ‘penetrating downwards’ method consists in stimulating the downward flow of Qi and Blood through the bowel movement with herbs such as Da Huang Radix et Rhizoma Rhei. When used in its prepared form, this herb also invigorates Blood.

In order to stop pain, besides the obvious treatment of invigorating Blood by treating the Liver, calming the Heart is also important. While the Liver stores Blood, the Heart governs Blood and its stasis also affects the Uterus (through the Uterus Vessel – Bao Mai – connecting Heart and Uterus). Herbs that stop pain by calming the Heart include Dan Shen Radix Salviae miltiorrhizae, Bai Zi Ren Semen Platycladi and Suan Zao Ren Semen Ziziphi spinosae.

It is necessary to treat both the Root and the Manifestation: this means tonifying the Kidneys and invigorating Blood (and if necessary expelling Cold or resolving Dampness). Many modern Chinese articles place the emphasis exclusively on invigorating Blood: in my opinion, this is not good practice. It is important to treat both the Root and the Manifestations and especially to do so by giving treatment according to the four phases.

He Xian Lin and Frosolone say:

Although there are many ways to achieve the same goal, one thing is agreed upon by all sources with regard to endometriosis. The major pathology is that of Qi and Blood stagnation. Both patterns need to be addressed but at the root of it all there is Kidney-Qi deficiency. Attention should also be paid to treatment according to the four phases and predominance of the most severe symptom (dysmenorrhoea or menorrhagia/metrorrhagia).³

Generally, I treat the Manifestation (e.g. Blood stasis) in phases 4 and 1 and the Root (e.g. Kidney deficiency) in phases 2 and 3. This is not a rigid rule as it is sometimes necessary to treat the Manifestation also in phase 3.

It is important to warm the Uterus even if there are no specific signs of Cold in order to ensure the growth of Yang in phases 3 and 4. This is an interesting concept and I follow it also if there is Kidney-Yin deficiency. Even in the presence of Kidney-Yin deficiency, during phase 4 I would use one or two herbs that warm the Uterus to ensure the growth of Yang during the luteal phase and to eliminate Yin pathogenic factors (such as Blood stasis, Dampness or Phlegm). Examples of herbs that I would use to warm the Uterus are Xu Duan Radix Dipsaci, Gui Zhi Ramulus Cinnamomi and Ai Ye Folium Artemisiae argyi. Obviously we cannot warm the Uterus if there is Liver-Fire or Damp-Heat.

Acupuncture and herbal medicine in the treatment of endometriosis

In my opinion, herbal treatment is essential in the therapy of endometriosis. I use herbal medicine to treat the patterns (e.g. Blood stasis, Kidney deficiency, Dampness, etc.) and acupuncture to regulate the Governing, Directing and Penetrating Vessels (Du, Ren and Chong Mai).

I give the herbal treatment always according to the phases as follows:

– Phase 1: invigorate Blood (or invigorate Blood and stop bleeding).

– Phase 2: tonify the Kidneys (and nourish Blood if necessary).

– Phase 3: tonify the Kidneys and Spleen; if necessary, resolve Dampness.

– Phase 4: invigorate Blood, expel Cold from the Uterus, resolve Dampness or Phlegm.

With acupuncture, I treat primarily the Penetrating Vessel (Chong Mai) because it is the Sea of Blood and because Blood stasis is one of its chief pathologies. However, I also treat the Directing and Governing Vessels (Ren and Du Mai). I treat the former especially if there is Kidney-Yin deficiency and the latter especially if there is Kidney-Yang deficiency.

Penetrating Vessel (Chong Mai)

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Tags: Obstetrics and Gynecology in Chinese Medicine

Jun 6, 2016 | Posted by admin in GYNECOLOGY | Comments Off

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