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ENDOMETRIOSIS

by Jane Lyttleton

Jane Lyttleton has worked in women's health centres for the last six years and has, by forming fruitful liaisons with gynaecologists, gained valuable experience in treating a wide range of women's health disorders. She has recently returned from her second trip to China where she worked in the gynaecology department of The Red Cross hospital in Hangzhou, and from London where she gave a seminar to students and practitioners of the London School of Acupuncture and T.C.M.

She is currently a Lecturer in Acupuncture at the N.S.W. College of Natural Therapies.

This is the first of what I hope will be an informative and interesting series on women's health disorders commonly encountered in the clinic. In each of these articles I intendto take one disease or syndrome and examine it from both an orthodox medical and a traditional Chinese medical viewpoint. A thorough knowledge of the background, diagnosis, prognosis and range of treatments available is not only important for you the practitioner but is also important for your patient who may have been given a label for her disorder by her specialist or GP but with no or limited discussion of its meaning or implications.

I have chosen endometriosis to begin this series because it is a disease cropping up more and more frequently in my clinic. It can be a very incapacitating condition with far reaching implications like infertility. Western medicine offers drugs or surgery
which can control but cannot cure it. Although in its early days I am very encouraged by results using TCM and hope that you can use the information here to achieve the same results.

Endometriosis (EM) is the name given to the condition of ectopic endometrial tissue i.e. the sort of tissue which normally rows only inside the uterus is growing outside of it. It is usually attached to pelvic organs, although rarely it has been found in other sites.

The term 'endometriosis' was first coined in the 1920's, however, diseases with similar symptoms were described in texts of the 1800's. Prevalence of the disease appears to be increasing although whether this is just a reflection of increased application of diagnostic tests is unclear. Winthrop Laboratories (who manufacture the drugs used to treat endometriosis) estimate that 25% of women of reproductive age in the USA have the disease, although the incidence actually diagnosed by laparoscopy is close to 9%.

The symptoms which may be experienced include the following:

pain during period (97% of cases)
pain between periods (62%)
pain on intercourse (59%)
pain with bowel movements (68%)
infertility (47%)
fatigue, exhaustion (64%)

as well as constipation, lower back pain, and other symptoms associated with the period like headaches, dizziness, nausea, stomach upsets and heavy bleeding.

The symptoms vary according to the stage of development of the disorder and the site of the implantation of the endometrial tissue. Like the endometrium inside the uterus the ectopic tissue is under hormonal influence and will undergo the normal sorts of changes the endometrium experiences during the period cycle viz, proliferation, maturation, then sloughing and bleeding. This puts unnatural pressure on the pelvic organs and the debris accumulates in the pelvic cavity - hence the pain experienced before, during and after periods.

There are several postulated routes of transmission of the endometrial tissue. However, while it is now easy to diagnose the condition with laparoscopy it is not at all apparent just how the endometrial tissue got to be outside of the uterus. It may be a congenital ectopic location, and there has been some evidence that endometrial cells can be disseminated by the lymphatic or blood circulation. But the theory attracting the most attention is the 'Retrograde Menstrual Flow' theory which proposes that ectopic implants occur after seeding by menstrual flow which has been forced up the fallopian tubes and into the pelvic cavity. The site for the implant would depend upon where the endometrium cells attached i.e. the bowel wall, the fallopian tube, the ovary, the pouch of Douglas etc. Since the laparoscopy has become a common technique it has been seen that in fact every woman probably loses some menstrual blood through the fallopian tubes but it does not always cause an implant. Perhaps it is the quantity of blood lost this way which is important. The strong cramps of dysmenorrhoea may force considerable amounts of blood backwards. Or the use of tampons or sexual intercourse during a period may exert negative pressure forcing blood through the fallopian tubes. Israeli women who have strong prohibitions against sex during periods and do not use tampons have a much lower incidence of EM than do American women. It would be interesting to ascertain the prevalence of EM amongst Chinese women who have similar restrictions. It has also been suggested that too many periods may be a precipitating factor. Modern woman has fewer children, starting later in life, and breast feeds for a shorter time than did her forebears. For example a typical woman living in a developed country who has two children may have more than 400 periods in her lifetime, whereas the Kung bush women who have children earlier and breast feed for longer may have only 50.

EM has been nicknamed the career woman's disease because it was frequently diagnosed in professional women in their 30's who were having difficulty becoming pregnant. However with the widespread use of laparoscopy EM is being found more and more frequently in younger women and teenagers complaining of pain.

A fourth cause of endometriosis is nosocomial infection or accidental transfer of endometrial tissue during gynaecological surgery. This has been reported to occur after operations like a D & C (dilation and currettage), caesarean section, laparotomy, amniocentesis and episiotomy. The endometrial implant often grows along the line of sutures. It is certainly worthwhile advising patients who are scheduled to have any abdominal, vaginal or cervical surgery to avoid dates just before, during or just after a period when endometrial tissue could adhere to the scalpel or other surgical instrument. Similarly operations to investigate infertility (salpingogram, Rubin insufflation) should never be scheduled for a time near the period, nor after a D & C.

Orthodox medicine offers three types of treatment for endometriosis.

  1. Administration of a synthetic testosterone to suppress oestrogen and progesterone secretions by the ovaries, i.e. induce a pseudo menopause, so that the cyclic growth of the implant is stopped and atrophy or shrinking occurs. The drug (danazol or daocrine) is often given for 3-9 months after which time the tissue may have shrunk enough to ameliorate symptoms or allow surgery. The side effects include weight gain, muscle cramps, decreased breast size, flushing acne, growth of facial hair, voice changes, liver dysfunction and vaginitis.

  2. Surgery is carried out for severe EM, often after a course of danazol. As much endometrial tissue is removed as possible, although complete removal is difficult. The ovaries may also be removed. Women whose infertility is related to EM often become pregnant after surgical removal of the growths.

  3. A state of pseudo pregnancy is induced by giving continuous non-cyclic oestrogen and progesterone for 6-9 months. Pregnancy has been observed to control EM somewhat though not cure it. The remission is often around seven years. Side effects may include nausea, cramps, oedema, spotting, headaches, acne, vaginitis, infertility, breast tenderness, weight gain, depression, nervousness, eye cataracts, altered sex drive, appetite change, hair loss.

Many women with suspected or diagnosed EM choose not to use any of the above methods for treatment but prefer an alternative without side effects. Chinese medicine offers a good alternative if applied correctly over a period of 3-9 months. While a Chinese medicine diagnosis can be made without the sorts of findings that investigative techniques like laparoscopy give, it is useful to have such findings as a starting reference point. Therefore if a woman comes to me for treatment of suspected (but undiagnosed) EM I usually request an ultrasound which, under ideal conditions, will give us some idea of the extent of the disorder - and something to compare six months down the line when a second ultrasound may be done. (Laparoscopy, during which the extent of the EM can be clearly seen and the tissue biopsied, is at present the only definitive way to diagnose the condition. However it involves a general anaesthetic and surgery to the abdomen so the second-best but less intrusive method, the ultrasound, may be preferable).

Differential diagnosis of EM according to TCM principles is similar to that of dysmenorrhoea. However in EM the pooling of the 'extra-meridial' blood in the pelvis itself becomes the pathogenic factor viz. 'Stagnant Blood'. Pain persisting at the end of the period is a result of this pooling or stagnation and is therefore classified as a 'shi' symptom, whereas in dysmenorrhoea pain at the end of the period is indicative of a 'xu' condition. Bearing in mind that 'stagnation of blood' is always the pathogenic factor in EM, it can appear in 4 different situations.

1. Blood and Qi stagnation

Clinical manifestations:

-distending sensation of breasts and abdomen

-pain in lower abdomen before, during or after period which may be severe

-flow may be dark and clotted, or not smooth i.e. a stop/start flow. Tongue: may appear dark or have dark or purplish regions on it Pulse: wiry

Treatment:

Points such as the following may be chosen:

Qihai Ren-6 To regulate the Qi in the body Tianshu ST-25 To regulate the Qi in the abdomen Taichong LIV-3 To tonify liver to move Qi more smoothly Guilai ST-29 To remove stagnation of blood in and near the uterus Diji SP-8 To circulate stagnant blood

2. Cold accumulated in the uterus

Clinical manifestations:

An attack of cold to the uterus congeals the blood and the Chong and Ren channels become obstructed.

-chills and pain in the lower abdomen which respond to warmth.

-the flow may have a purple or dirty tinge and be clotted. Tongue: white coating Pulse: will feel retarded

Treatment:

Treatment is directed towards warming the meridians, dispelling cold and regulating blood to dispel stasis.

Sanyinjiao SP-6 } Warm needle technique on Qihai Ren-6 } these points will dispel Guanyuan Ren-4 } cold from the uterus

Qichong ST-30 To deobstruct the Chong and Ren channels Xuehai SP-10To regulate the blood

3. Accumulation of heat from long term stagnation of blood

Clinical manifestations:

-abdominal pain may be relieved by cold and is worse with pressure

-feels feverish during the period with thirst, restlessness and constipation Tongue: yellow coat, dark spots on tongue body Pulse: choppy or rapid

Treatment:

Treatment aim is to clear the heat and resolve stagnation.

Guilai ST-2 To remove stagnant blood Tianshu ST-25 To regulate intestines Hegu L.I.-4 To circulate blood and Qi Xuehai SP-10To regulate blood and remove heat Xingjian LIV-2 To reduce heat in the liver and the blood

4. Qi Xu

Clinical manifestations:

In this case the Qi fails to lead the blood, giving rise to stagnation.

-the abdominal pain is relieved by pressure or warmth

-there may be physical or mental fatigue. Tongue: pale or mauve Pulse: thready

The treatment principle is to regulate and tonify the Qi to move the blood.

Qihai Ren-6 } To regulate and tonify Qi Shanzhong Ren-17 }

Quchi L.I.-11 } To regulate blood and Qi Xuehai SP-10}

General treatment approaches:

Treatments need to be applied regularly for 3-9 months. I often treat only in the latter 2 weeks of the cycle (when the stagnation of blood is becoming more apparent) in all types except type 4, where tonification treatments are useful in the first part of the cycle as well. Treatments include the sorts of points mentioned above, combined with points which follow the cyclical changes of the Ren and Chong channels at different stages of the menstrual cycle. (These will be discussed in a future article). Chinese herbs are usually included in the treatment. (A discussion of these will also occur in a future article). Progress should be monitored by close attention to all details pertaining to the period especially the type of flow. As symptoms improve it is interesting to check progress with an ultrasound.

The case histories I shall choose to illustrate each type of condition will not always be the ones with the expected or desired outcome. I have always gained most valuable clinical experience when things have not turned out as the textbook says they should.

The first case I am going to describe for you falls into the fourth category of EM, the Qi- Xu type. You will remember that in these women the Qi is too weak to lead the blood and stagnation results.

____________________

Sarah was 22 years old when I first saw her, a tall, handsome, athletic looking woman who complained of extreme lethargy. She worked part-time as a nurse, a job which did not explain the fatigue of an apparently healthy young woman. Two weeks before she saw me she had her IUD removed. The routine examination uncovered some swelling near her ovaries and an ultrasound was recommended. This revealed 2 ovarian cysts, the left sided one being 6cm in diameter and the right sided one was a 3cm endometriotic mass. The diagnosis of endometriosis was made and was thought to be the cause of her exhaustion.

Sarah's menstrual cycle had always been irregular - usually between 40 - 62 days. With the period she experienced abdominal cramps and the flow was heavy and clotted.

Before the period she developed sore breasts, bloating, irritability and constipation.

She had received diathermy to the cervix to remove dysplastic cells.

She suffered back pain which was exacerbated by her work.

Her face appeared a little pale and dull and she spoke very quietly, with hesitation.

Pulse: thready and deep, with wiriness on the liver position. Tongue: body pale, coating slightly greasy

Apparently, from the irregularity of the menstrual cycle since puberty, there was a kidney disorder resulting in an imbalance of the Ren and Chong channels. (Later when I started treating her mother for menopausal difficulties I discovered this was a familial trait). Her constitution was Qi-Xu and resulting from this was some Liver Qi stagnation and blood stagnation.

Treatment was aimed at tonifying Kidney Qi and adjusting Liver Qi. Points such as Guanyuan Ren-4 and Qihai Ren-6 were used, first weekly and then fortnightly for several months. Other points included Pishu BL-20, Ganshu BL-18, Shenshu BL-23, Taichong LIV-3, Sanyinjiao SP-6, Xuehai SP-10, Quchi L.I.-11, Siman KID-14. 'Dang Gui Shao Yao San' was prescribed to tonify Kidney and help remove blood stagnation. She received 18 treatments over 6 months after which time her energy picked up, her period pain was much reduced, the flow was lighter with no clots and her premenstrual symptoms had improved. Her cycles however remained long and unpredictable. It appeared that the Qi was stronger and flowed with less obstruction in the abdomen but that the Chong and Ren imbalance remained. An ultrasound at this point showed that the small cyst had shrunk from 6cm to 1.5cm. She felt happy to discontinue treatment.

____________________

The second case falls into the category of cold accumulated in the uterus but it is especially interesting for the suddenness and severity of the cold attack.

Alexis first consulted me in October of 1985. She was 34 years old and had always been ruggedly healthy. She gave the following history. In May 1985 on day 4 of her period she suddenly experienced intense abdominal pain with severe all over chills and she collapsed. She was hospitalised and given I.V. fluids and antibiotics for suspected toxic shock syndrome.

On the day of her collapse Alexis was due to leave for a hard earned holiday after a period of overworking. She felt restless and excited but otherwise quite well.

Her next period (June 1985) was a normal one for her. Mild discomfort was experienced on the first day, the flow was a normal colour, not excessive and not clotted.

July 1985 On day 4 of this period, Alexis again collapsed with abdominal pain and chills. She was hospitalised and put on a drip as before. The episode was not as severe as in May.

August 1985 The next period was unusually heavy and clotted but she did not experience the severe pain and did not go into shock.

September 1985 On day 6 of this period, the pattern was repeated with severe abdominal pain, chills and fainting. In hospital this time she was investigated more thoroughly. An ultrasound revealed an 8cm endometriotic mass and 2 cysts.

When she consulted me after this period she had sore breasts, some persistent abdominal pain and a brown grainy discharge. Her energy was very low and she had had to cut down her work by more than half. She had been recommended surgery but chose to try other methods first.

Further questioning revealed a Yin-xu type constitution with restless sleep, fidgety legs, hot feet at night and a malar flush. A tendency to headaches, photophobia, nausea and the recent sore breasts indicated liver involvement. But the immediately important part of her symptom picture was the severe abdominal pain, chills and collapse. These symptoms indicated an attack of cold direct to the interior, the uterus being one of three organs which can be directly attacked by external cold. This attack of cold combined with menstrual bleeding over several days tipped the balance far enough for a collapse of yang to occur. Hence after 3 or 4 days of bleeding Alexis experienced shock and chills. She cannot recall an incident like getting chilled after swimming or consuming cold beer or ice-cream which would pinpoint the attack of cold, but at some point just prior to that first attack, when her protective energy was very low after overworking, the pathogenic factor invaded. Interestingly in three cases of EM I have seen in the last six months, all three women are keen exercisers and run and swim at the beach all year round.

Treatment for Alexis was aimed primarily at expelling the cold from the uterus, warming the interior and where necessary recovering the yang. She received two treatments before her next period. Warm needling was applied to Guanyuan Ren-4 and Sanyinjiao SP-6, combined with Taichong LIV-3 amongst other points. She was instructed to moxa Guanyuan Ren-4 at home.

October 1985 Period was very heavy, dark and clotted but no shock. There was some dull abdominal pain and lower back pain and diarrhoea. Evidently treatment was needed to further warm the uterus and since the yang collapse had been occurring every 2nd cycle she prepared some heating herbs to take on day 3 and 4 of the next period. These were a formula called 'Si Ni Tang' (aconite, liquorice, ginger). Moxa treatment continued.

November 1985 Period was still heavy but a fresh red flow with no clots and most importantly no pain, chills or collapse. She and I both breathed a sigh of relief as it appeared the cold had now been expelled. However her energy was still very low and treatment continued then to tonify blood and yin. Points such as Taichong LIV-3, Zusanli ST-36, Shenmen HE-7, Sanyinjiao SP-6, Qichong ST-30 were used. She also took herbs. Her energy improved quickly and she returned to full time work. She had no abdominal pain but did get sporadic spotting.

December 1985 Period was normal. No pain, no shock, good flow. Energy stayed high.

However it was not plain sailing from here because in the next month Alexis took on too much work, she moved house and a good friend was diagnosed with cancer.

Her energy dropped with all this stress and she experienced a sudden loss of brown blood at mid cycle. She noticed bloating and diarrhoea at the same time. Apparently the obstructed liver Qi had damaged the spleen Qi.

She had several more treatments aimed at tonifying the spleen, regulating the liver and tonifying the blood. Her energy picked up quickly and the spotting stopped.

January 1986 Period was normal, with no pain. She continued to overwork and as her energy got depleted again the spotting returned. It was accompanied by twinges in the abdomen. Once again treatments aimed at tonifying Qi and blood and regulating the Chong channel succeeded in reducing the spotting and abdominal discomfort and her energy recovered to normal levels, despite a heavy work load.

February 1986 Period normal in every respect. Energy holding very well.

She decided at this point to have another ultrasound. Much to our surprise the endometriosis was still apparent with no reduction in size of the mass. In retrospect, and with the knowledge I have now, I know this is because the treatment and especially the herbs, did not address the blood stagnation but concentrated on dispelling the cold and then tonifying her Qi and blood. However Alexis declined any further treatment because she felt completely well and symptom free. She planned to have another ultrasound about a year later the result of which I don't yet know.

This case history and its outcome emphasises the importance of incorporating western medicine findings into the TCM diagnosis, in this case 8cm of blood stagnation! The lesson of Alexis' case was well learned and the many patients with endometriosis who have consulted me in the last year have benefited greatly.

 

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