• Brown or pigmented endometriosis appears as small dark brown spots. The blood lost from this endometrial tissue during the time of menstruation has nowhere to go and gets trapped and may cause pain, depending on the site of implantation. The old dried blood then gives these spots a dark brown appearance. These peritoneal lesions are most active when they are superficial and hemorrhagic and become less active over time as dead and fibrotic tissue forms.

• Chocolate cyst is the name given to endometriosis which forms a cyst in the ovary. The blood from this tissue is encapsulated in a cyst and becomes thick and dark brown and appears like chocolate.

• Pale pink, white or non-pigmented endometriosis looks like pale lesions on the surface of different parts of the pelvic cavity. These lesions have not yet become brown because they have not developed far enough to bleed, but they seem to be active in secreting substances which inhibit conception. They may also be more active in producing prostaglandins and be associated with more pain than older lesions. It can take 7–10 years for these lesions to become red and then dark as they age and become fibrotic.

• superficial endometriosis sits on the surface of the membrane and seems to be more implicated in infertility

• deeper endometriosis penetrates a few millimeters into the membrane and the underlying tissues and causes pain.

Distortion of the Position of Tubes or Ovaries

If there is a significant amount of endometriosis in an inconvenient place, near the fallopian tubes or ovaries for example, it is not difficult to see how the distortions it causes could prevent conceptions by preventing the egg and the sperm meeting. Over time, the fallopian tubes may become inflamed and blocked by adhesions. Thus, ectopic pregnancies are more common in women with endometriosis. Even mild endometriosis is associated in most cases with peri-ovarian adhesions which may interfere with ovulation or transport of the egg between ovary and fallopian tube.³

Immune Dysfunction

Endometriosis is characterized by a low-grade inflammation in the pelvis, which manifests as an increase in peritoneal fluid, increased number of macrophages and their secretions, i.e. prostaglandins, proteolytic enzymes and cytokines.⁴

Macrophages are large cells which mop up cellular debris and bacteria and other foreign material; one of their jobs is to kill off sperm that swim all the way out of the tubes and into the abdomen. When there is endometriosis present, there are increased numbers of macrophages⁵ which become more active and go on their seek and destroy missions with great vigor. Unfortunately, these vigilantes can enter the fallopian tubes and pick off sperm before they have had a chance to meet the egg. In women with partners who have poor sperm counts, this can be quite disastrous, leaving no sperm at all to fertilize the egg. Additionally, the cytokines which macrophages produce are toxic to sperm affecting their mobility and ability to fertilize the egg, providing yet another impediment to fertility.^6,7 Cytokines and chemokines such as tumor necrosis factor-alpha, and interleukins IL-1, IL-6, IL-8, etc. contribute to the pathogenesis of endometriosis by enhancing attachment, angiogenesis and/or proliferation of ectopic endometrial tissues in the pelvis.⁸

The disease is further characterized by impaired T-cell mediated cytotoxicity, natural killer (NK) cell activity and B-cell function.

Production of Secretions which Obstruct Fallopian Tubes

The type of endometriosis that sits superficially on the membrane surrounding the pelvic structures has been shown to have glands similar to that found in the endometrium. These glands secrete mucus. This mucus can coat the fimbriae or the ovary, preventing the transfer of the egg to the tube. Such a phenomenon has been observed in animal studies.⁹

Increased Prostaglandin Production

Endometriosis is associated with increased levels of prostaglandins (PGE₂ and PGF), which may have a deleterious effect on the patency and flexibility of the fallopian tubes. Muscular contractions of the uterus are also increased causing pain and possibly interfering with implantation.¹⁰

LUFS and Low Progesterone

Endometriosis is associated with a higher incidence of the ovulatory disturbance called luteinized unruptured follicle syndrome (LUFS) and lower progesterone levels in the luteal phase.

Things can go awry just before ovulation if luteinizing hormone (LH) levels are less than adequate. A developing follicle may respond to the extent that it forms a corpus luteum and produces progesterone but there is not enough LH to soften the follicle casing and allow the release of a mature egg. A luteinized unruptured follicle (or LUF) is formed. The amount of progesterone this LUF produces is often less than usual and for fewer days, and is the basis of an inadequate luteal phase or luteal phase defect. Obviously, conception is impossible in such cycles since there is no egg released, and even if there were, the progesterone support is such that implantation and development of an embryo is unlikely. It is estimated that endometriosis results in anovulation in up to 20% of cycles of some patients.

Endometrial Changes and Reduced Implantation Rates

Although appearing histologically normal, the endometrium and inner myometrium (the junctional zone) in women with endometriosis and adenomyosis show marked functional disturbances. The lining has aberrant responses to ovarian hormones such that factors important for implantation are affected.10,11 Implantation and placentation involve deep invasion of the junctional zone and it may be the failure to do this properly that accounts for the increase in premature births and other adverse pregnancy outcomes seen in women with endometriosis.¹²

Disruption in the deepest layer of the endometrium may also explain functional abnormalities such as hyperperistalsis, dysperistalsis and inordinate smooth muscle proliferation associated with endometriosis and adenomyosis which can affect the way sperm are transported.¹³

Other studies have suggested that there are disruptions to shedding of the uterine lining during menstruation in endometriosis sufferers, which leads to abnormalities in the uterine lining in the subsequent luteal phase.¹⁴

All of the above possibly contribute to the observed reduced embryo implantation rate.¹⁵

Reduced Oocyte Quality

Studies with IVF patients receiving donor eggs have shown that success rates were reduced when the oocytes were from women with endometriosis indicating that the disease affected in some way the quality of the donated oocytes.¹⁶

Ovarian Reserve may be Lower in Endometriosis

Studies on infertile women with mild or minimal endometriosis show reduced ovarian reserve (measured by AMH). Whether this is an association or a cause is not known.¹⁷ Surgical removal of endometriomas can also have a deleterious effect on ovarian reserve (measured by AMH).¹⁸

Diagnosing Endometriosis

Endometriosis, as you may have gathered, is a multifarious type of disorder which can manifest in many guises. Sometimes, there are no bothersome symptoms at all. Often there is period pain and sometimes there is also pain with intercourse. Infertility is involved in some cases and not in others. And the ways that endometriosis contributes to infertility is at many different levels, the quality of the eggs, the integrity of the uterine lining, the way the tubes and uterus move, the distortion of tubes or ovaries or the inflammation and over-activity of the immune system. Any diagnosis a Chinese medicine doctor comes up with, should keep in mind all these possibilities. Figure 5.1 outlines some of the etiologic relationships relevant to the development of endometriosis.

There are some characteristic signs that are recognized by doctors working in infertility clinics in China, which will alert them to the possible presence of endometriosis. These are distinctive patterns on the basal body temperature (BBT) charts (see below) and spotting before periods, which is also recognized by Western doctors as strongly indicative of endometriosis. These two signs, together with some of the clinical symptoms mentioned earlier – especially period pain getting worse with age and accompanied by a bearing-down sensation in the abdomen or palpation of nodules along the sacrospinal ligament – constitute as definite a diagnosis of endometriosis that a doctor working in China without a laparoscope can reach.

It must then be remembered that to a TCM doctor, the unique and individual presentation of each patient is what will determine the appropriate treatment.

BBT Patterns

You will recall from our discussions in Chapter 3 that the typical BBT chart has a low phase, which begins at (or just prior to) the beginning of the period, and a high phase, which begins at ovulation and persists until the next period. The two changes to this pattern which can suggest endometriosis are:

Targeting the Lesion

The emphasis of TCM treatment for endometriosis usually involves clearing Blood stagnation. Endometriosis is a Western medical label not a TCM one, but the scientific medical understanding of this disease has contributed to the notion that this is a disease characterized by blood being where it shouldn’t and unable to escape the body, i.e., what we call Blood stasis. Symptoms such as severe stabbing period pain, clotty menstrual flow and palpable nodules or masses in the abdomen verify the diagnosis of stagnant Blood.

The mark of a skilful doctor is to keep close sight of exactly what requires changing, maintaining awareness of the constellation in which it appears. In the case of endometriosis the central part of the picture is the lesion which can manifest in various guises:

Table 5.1 lists the theoretical relationship between these different types of lesions and their treatment principles.

Treatment to target implants of endometriosis (Zheng Jia, or masses, in TCM) involves the use of heavy handed ‘Blood busting’ herbs and those that reduce inflammation by clearing Damp and Heat. Table 5.2 lists some of these herbs and substances. (See also Appendix 2.)

We can incorporate these substances in potent formulas designed to break down endometriosis tissue. Such formulas are only used short term, and often just at or near the time of greatest pain, usually the period. Some of these animal products are toxic and are used in small doses for a specific time for a specific purpose. Wu Ling Zhi, however, is one substance that can be used in the longer term and in women of weak constitutions with Blood stasis. We shall see the use of some of these substances in formulas used during the period.

Treating Infertility Associated with Endometriosis

Most of our discussion of treatment will however be somewhat broader than a narrow focus on breaking down endometriosis tissue. As Western medical researchers discovered more about this disease, so did TCM doctors, who developed their treatment protocols of infertility caused by endometriosis, in different directions. For example, in the infertility clinics in China, doctors found that more pregnancies resulted if treatment of women with endometriosis targeted the Kidneys, with removal of Blood stasis only when and if necessary. Of course, this dovetails neatly with the discovery that some endometriosis lesions contain no extravasated blood at all and that such tissue can produce secretions which clog up the system – Phlegm-Damp we call it in TCM. Treatment which boosts Kidney Yang is generally rather effective at clearing such Phlegm-Damp.

A patient presenting to a TCM clinic with endometriosis will be diagnosed according to her main symptoms and her constitution. When treatment is prescribed as part of an infertility treatment, the doctor will be particularly mindful of reinforcing Kidney Yang and resolving Blood stagnation. Liver Qi stagnation and Spleen Qi deficiency may also contribute and some cases of endometriosis will exhibit elements of Heat or Cold or Damp. To understand the part that Blood stagnation plays it is necessary to explore further our understanding of the way endometriosis is formed and how we relate this to TCM concepts (Fig. 5.1).

Our knowledge about the anatomy and behavior of endometriosis is still limited and so some of these ideas may change or be expanded in the future.

We do know that menstrual blood travels not only downwards from the uterus and out through the cervix but also upwards through the fallopian tubes and out into the peritoneal cavity (retrograde menstruation). This small quantity of blood carries with it bits of discarded endometrium. Women with strong uterine cramps (due to Liver Qi stagnation) are more likely to lose more menstrual flow upwards through the tubes. The blood and the tissue will either be reabsorbed, or will remain and establish itself somewhere in the pelvic cavity. If Kidney Yang is strong, then movement of Qi in the pelvis will mobilize the menstrual debris, which should not be there, and it will be efficiently reabsorbed. A weakness of Kidney Yang, on the other hand, will allow the accumulation of blood and tissue such that it stagnates and creates the basis for Zheng Jia or masses to develop.

The bits of endometriosis tissue which develop in the pelvic cavity will be either non-pigmented (i.e., not bleeding) or pigmented because they contain blood vessels. The non-pigmented lesions can develop into the pigmented ones if they develop the blood vessels and start to bleed during the menstrual phase. The non-pigmented types of endometriosis are associated with infertility for reasons not yet fully understood but possibly because they produce secretions which coat the fimbrial ends of the tubes. The treatment which will most directly address this type of endometriosis is one which will strengthen the Kidney Yang and clear Phlegm-Damp. The development of the non-pigmented types of endometriosis is probably facilitated in Spleen Qi-deficient individuals. In this case, treatment must also address the Spleen Qi to facilitate removal of Damp.

The pigmented endometriosis, containing tissue which responds to the hormonal changes, which makes the uterine lining bleed, is the type more likely to cause pain, especially if it is implanted more deeply than just the surface of the peritoneum. Removal of this type of lesion requires the use of Blood-moving herbs and Kidney Yang tonic herbs. The pigmented lesions, especially under the influence of Qi stagnation, can form substantial Zheng Jia in the form of nodules and masses and scar tissue. In these cases, there may be both pain and infertility: the latter may be absolute if the masses have damaged or obstructed the tubes. Treatment calls for the use of strong Blood-‘breaking’ herbs backed up with Kidney Yang tonics. Table 5.1 charts these relationships.

The skilful approach to treatment is to appropriately target that lesion with unerring aim – whether with a scalpel, laser or acupuncture treatment or strong eliminating herbs to push out or break up obstructions or with gentle herbs to coax hormone levels to balance – and apply these precise arrows in a context of supports: supports for the Kidney Qi, the Spleen Qi, the Liver Qi or whatever it is an individual patient needs. If the ultimate aim is to push the endometriosis to one side to allow pregnancy to occur, then the ovaries, the follicles and eggs and the endometrium must become the central focus of the treatment plan. Maintaining treatment focus on the menstrual cycle at the same time as clearing the endometriosis lesions will bring greater clinical success and increase fertility.

You may remember from Chapter 4, that following and promoting the natural rhythms of the normal menstrual cycle is the basis of all fertility treatments. Thus, Kidney Yin and Blood are nourished in the first part of the cycle after the period and Kidney Yang is supported during the second half of the cycle.

The treatment of endometriosis as a cause of infertility does not differ from this principle but will place emphasis on certain key factors. First, particular emphasis will be placed on building Kidney Yang, since this is one of the causative factors. Strong Kidney Yang tonics will be applied during the luteal phase and the previous (follicular) phase will be primed appropriately to support the growth of Yang. Remember that Kidney Yang is usually built out of a Yin, Blood or Qi base, depending on the body constitution and the pathologic condition of each patient.

Second, if there are signs of stagnant Blood, such as severe period pain with clotty flow, palpable nodules or masses or laparoscopic evidence of bleeding endometriosis tissue in the abdomen, then Blood-regulating treatments will be employed. If treatment is following the natural rhythm of the cycle, then the time to use these herbs is during the period or around ovulation time. Depending on the degree of stagnation, i.e., whether the endometriosis is just small brown dots on the surfaces in the pelvic cavity or whether it is large substantial masses or endometriomas, we will use herbs which gently move the stagnant Blood or herbs which strongly break up Blood stasis (see Table 5.2 and Appendix 2).

Referring to Figure 5.1, you will see there are a number of places where Qi stagnation contributes to the formation of endometriosis. Any prolonged Qi stagnation will of course eventually lead to Blood stagnation because the Qi can no longer lead the Blood adequately. And Liver Qi stagnation, having its roots in emotional stress, is commonly involved. Qi-regulating herbs play an important part in prescriptions which treat endometriosis.

Similarly, Spleen Qi deficiency is frequently a component of Kidney Yang deficiency syndromes. It is the Spleen Qi deficiency which leads to the dragging-down sensation some women experience in the abdomen during the period and may contribute to the heavy bleeding or premenstrual spotting. When Kidney Yang is deficient, and especially when Kidney Yang and Spleen Qi are both deficient, then Damp accumulation will be a problem. Treatment will therefore often include herbs and acupuncture points which clear Phlegm-Damp and invigorate Spleen Qi. Where Damp obstructions persist, Damp-Heat may form, in which case stronger Heat clearing herbs will be necessary.

Whereas TCM treatment follows and corrects any disturbances of the menstrual cycle caused by endometriosis, Western medicine takes the opposite approach. It stops the cycle completely with the use of hormones which trick the body into thinking it is pregnant or menopausal. When the course of treatment is completed, endometriosis is reduced but frequently reoccurs over the next few months. This is because the cause has not been addressed, only the obvious manifestations. The TCM doctor endeavors to locate the original imbalance which allowed the endometriosis to develop in the first place (namely the Kidney Yang deficiency, Spleen Qi deficiency or Liver Qi stagnation) and to treat that, together with the outward manifestations (stagnant Blood, Phlegm-Damp and Damp-Heat); however, that is not to say that the TCM doctor necessarily has greater success than the Western doctor and his drugs. Endometriosis is a difficult disease to treat in any modality, but if the patient is prepared to pursue TCM treatment over 6–12 months the results are generally very encouraging.

TCM treatment of infertility caused by endometriosis begins at the start of a cycle, i.e., it begins with the maturing of a new egg and the growth of new uterine lining as the period is ending, usually around Day 4 of the new cycle. Our aim, of course, is to reduce or clear the manifestations (the endometrial implants and masses) of the disease, the ‘Biao’ in TCM. But this can only be done effectively and completely by treating the ‘Ben’ or the underlying imbalance itself which requires attention to all aspects and functions of the reproductive system during the menstrual cycle. This approach to treatment is especially important if improved fertility is the desired outcome. Treatment of a woman with endometriosis who has no desire to fall pregnant or has already borne children does not need to adhere so strictly to a monthly regimen, although in the opinion of many TCM doctors it is a superior approach.

It is useful to review the guiding formulas and acupuncture protocols for each stage of the cycle, which were presented in Chapter 4:

Herbs and acupuncture points to specifically address the endometriosis can be added at different stages.

Post-menstruation

At this time, our main aim is to build the Blood and reinforce the Yin. Treatment at this time is particularly important for fertility but is not always so important in a woman who is not trying to become pregnant. The protocols suggested for the stages which follow (ovulation and the luteal phases), however, are considered important in the treatment of endometriosis even if pregnancy is not desired.

In the case of severe endometriosis in which the Blood stagnation is pronounced, Blood-regulating herbs can be added at the early phase of the cycle. However, great caution must be applied at this delicate (for the Yin) stage. Unless the woman’s constitution is very strong, there is the risk of damaging Yin with strong Blood movers. Better results are to be obtained by holding them until a later stage of the cycle (i.e., nearer to the period) or until the woman’s constitution can be improved. In many cases, however, some mild Blood-regulating herbs (see below) can be safely introduced. If the case of endometriosis involves the type of lesion that does not cause internal bleeding and the main problem is infertility rather than symptoms of Blood stagnation, then treatment will focus simply on following the Yin and Yang stages of the cycle. No additional Blood-moving herbs above those added routinely at ovulation and period time are required although herbs, which clear Damp may be needed.

Ovulation

If ovulation is associated with pain, as it is in many endometriosis sufferers, then we shall focus more pointedly now on dispelling any Blood stagnation and/or resolving masses if necessary. Caution must still be applied: in less robust women, very strong Blood breakers can upset the sensitive process of switching Yin to Yang, and therefore the process of ovulation itself. Acupuncture can be very helpful in encouraging the movement of Qi and Blood at this time. At the junction of Yin and Yang, attention must be paid to the rise of Yang, and strong Yang tonics must be employed now to ensure its rapid increase if the endometriosis is to be resolved. If Yang does not rise sharply at this point and the Qi and Blood do not move well, then the egg may not be released (as in luteinized unruptured follicle syndromes, or LUFS), or the tube may not successfully capture it or the luteal phase may be inadequate.

You may remember from Chapter 4, that a typical guiding formula to use at this time is the ovulation formula Bu Shen Cu Pai Luan Tang (below) or Wen Yang Hua Yu Fang (below) both of which reinforce Kidney Qi while moving Qi and Blood. When we are treating endometriosis we will add more Blood-moving and Kidney Yang tonic herbs.

If there is severe Blood stasis, then we need to resolve this but in most cases we reserve the Blood-breaking herbs until another time in the cycle if we want to safeguard the Kidney Yin and Yang and potential fertility. Herbs such as San Leng and E Zhu are usually too strong to use at this time unless there are significant and substantial masses or cysts which must be addressed.

Post-ovulation

After ovulation, the aim is to maintain good Yang levels and also to address Spleen Qi deficiency and Damp if that is part of the constitutional picture. Remember that the clinical approach in the second phase of the cycle is to:

These approaches depend on the body constitution and the pathologic condition. In the case of endometriosis, promoting Qi to build Yang is the most commonly used approach.

Herbal Formula: The formula of choice is:

Jian Gu Tang modified (Strengthen and Consolidate decoction) modified

Dang Shen	9 g	Radix Codonopsis Pilulosae
Bai Zhu	9 g	Rhizoma Atractylodis Macrocephalae
Cang Zhu	9 g	Rhizoma Atractylodes
Shan Yao	9 g	Radix Dioscorea Oppositae
Yi Yi Ren	15 g	Semen Coicis Lachryma-jobi
Tu Si Zi	9 g	Semen Cuscatae
Ba Ji Tian	9 g	Radix Morindae Officinalis
Lu Jiao Pian	9 g	Cornu Cervi Parvum
Xiang Fu	9 g	Rhizoma Cyperi Rotundi

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