The Three Treasures Newsletters
WINTER 2003
ENDOMETRIOSIS
WESTERN MEDICAL PERSPECTIVE
Definition
Endometriosis is a condition resulting from the presence of actively
growing and functioning endometrial tissue in locations outside
the uterus. The areas where endometriosis may occur are widespread
and usually multiple. They include:
| • |
the ovaries |
|
• |
sigmoid colon |
| • |
uterine wall |
|
• |
rectum |
| • |
Fallopian tubes |
|
• |
ureters |
| • |
abdominal scars |
|
• |
bladder |
| • |
umbilicus |
|
• |
vagina |
Occurrence
The incidence of endometriosis is currently on the increase. The
following groups may be affected by it:
| • |
women between the ages of 25-40 who have not
had children |
| • |
teenagers (previously not thought
to be commonly affected) |
| • |
women who have undergone elective tubal sterilization |
| • |
familial incidence (7% relative risk of developing
it if a first-degree female relative has it) |
| • |
there seems to be a correlation between endometriosis and
the use of tampons, intercourse during menstruation and the
use of the intrauterine contraceptive device (the coil) |
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:
proposed by Samson who believed that menstrual blood was 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. |
| • |
celomic metaplasia:
proposed by Meyer and Ivanoff who suggested that all tissues
in which endometriosis arises are embryologically derived
from celomic epithelium, i.e. peritoneal cells change into
endometrial tissue. Chronic irritation of the peritoneum by
menstrual blood may cause celomic metaplasia, which can subsequently
result in endometriosis. |
| • |
direct implantation: according to this
theory, endometrial tissues are displaced into an implant
in the new sites. This explains why endometriosis may be found
in surgical scars. |
| • |
genetic and immunologic factors:
there is a 5.8 percent familial incidence among immediate
female siblings, an 8.1 percent risk if the mother had endometriosis
and a 7 percent 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 extrauterine 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. |
Pathology
There are three diagnostic histologic features of endometriosis.
They are:
| • |
endometrial glands |
| • |
endometrial stroma |
| • |
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
10cm in size (known as endometriomas or "chocolate cysts"
and which may rupture. 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.
Clinical manifestations
The most commonly seen symptoms and signs of endometriosis are as
follows:
| I. |
dysmenorrhoea (severe pain beginning before
menstruation and continuing almost to the end) |
| II. |
pelvic pain |
| III. |
lower backache radiating to the anterior thigh |
| IV. |
heavy periods |
| V. |
irregular bleeding |
| VI. |
infertility (since inflammation, scar tissue
and adhesions in the pelvis may obstruct the passage of an
egg along the fallopian tube) |
| VII. |
dyspareunia |
| VIII. |
pain sometimes accompanied by nausea and vomiting or diarrhoea |
| IX. |
pain on defecation |
| X. |
rectal pressure |
| XI. |
tender and enlarged ovaries |
| XII. |
pelvic nodularities and thickenings |
It is important to note, however, that 30-35% of patients with endometriosis
do not suffer any pain or discomfort, though they may suffer from
other manifestations such as infertility or pelvic masses. Also,
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.
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.
Diagnosis is, however, fraught with difficulties and is affected
by subjectivity. Laparoscopy relies entirely on the visual and very
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.
CHINESE MEDICINE 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.
Excessive physical work or exercise
Excessive physical work or exercise can weaken the Spleen, Liver
and the Kidneys and adversely affect the Chong and Ren Mai. This
is especially the case during puberty when the Chong and Ren Mai
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.
Excessive exercise, especially at puberty, during the period or
when pregnant, will weaken the Spleen and Kidneys possibly leading
to a whole host of problems including a deficiency of Yin, Yang,
Qi or Blood and stagnation of Qi and Blood.
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 causing Blood to stagnate.
Tampons
Tampons block the normal downward flow of menstrual blood thereby
leading to stagnation of Blood.
Too early sexual activity
Too early sexual activity (i.e. during puberty) damages the Chong
and Ren Mai and renders the Uterus more vulnerable to Blood stasis
later in life.
Pathology
The Western disease entity of "endometriosis" broadly
corresponds to the Chinese disease-symptom of "Painful Periods":
in other words, the pathology, patterns and treatment for Painful
Periods is applicable to endometriosis. However, there is an important
difference. It is generally agreed by all Chinese gynaecologists
that in endometriosis there is always Blood stasis and that endometriosis
should be treated as "Abdominal Masses" in Chinese gynaecology.
In other words, the endometrial lesions should be considered a form
of abdominal masses even though they are not palpable. The important
implication of this is that, in the herbal treatment, herbs that
"break Blood" and dissolve masses should be chosen.
| I. |
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, place the emphasis on Biao, i.e.
Blood stasis only if the period is very painful. |
| II. |
There is always a Kidney deficiency
and disharmony of Liver and Spleen |
| III. |
Retention of menses is an important factor, often occurring
after childbirth. "Retention of menses" refers to
an insufficient discharge of blood during menstruation. |
| IV. |
The temperature chart is flat in endometriosis
for two reasons, one due to Biao, the other to 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). |
| V. |
Yang not growing enough during phase 4 so that Yin pathogenic
factors are not expelled (see Winter 2002 Newsletter). |
| VI. |
As modern women have a much higher number of
menstrual cycle throughout their lifetime, it means they will
have all the more "retention of menses". This is
due to earlier menarche, later menopause, fewer children,
shorter breastfeeding. |
Treatment Principle
| I. |
Use Tong Xia method (penetrating
downwards) to stop pain |
| II. |
To stop pain, calming the Heart
is also important |
| III. |
Treat Biao and Ben, i.e. invigorate Blood and
tonify the Kidneys |
| IV. |
Invigorating Blood only is not enough. It is
far better to regulate the menses according to the 4 phases
(see Winter 2002 Newsletter) |
| V. |
Must 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. Obviously not if there Liver-Fire or Damp-Heat. |
Treatment Strategy
| I. |
Treat Ben by tonifying the Kidneys
(Yang or Yin). Important to tonify the Kidneys in 2nd and
3rd phases |
| II. |
Acupuncture treatment to promote
ovulation: a) Ren-3 Zhongji, SP-6 Sanyinjiao, KI-12 Dahe;
b) Ren-4 Guanyuan, Ren-3 Zhongji, SP-6 Sanyinjiao, Zigong.
Start when cervical secretion appears. |
Differentiation Of Endometriosis
The main patterns appearing in endometriosis and the relevant remedies
are as follows:
| I. |
Liver-Blood stasis (Stir Field
of Elixir, Harmonizing the Moon, Invigorate Blood and Stem
the Flow) |
| II. |
Stagnation of Cold in the Uterus
(Warm the Menses) |
| III. |
Damp-Heat in the Uterus (Drain Redness) |
| IV. |
Damp-Phlegm in the Uterus (Clear the Palace) |
| V. |
Kidney-Yang deficiency (Unicorn Pearl) |
| VI. |
Kidney-Yin deficiency (Growing Jade) |
| VII. |
Blood deficiency (Precious Sea) |
Rather than discussing these patterns one by one, I shall discuss
common combinations of patterns seen in practice.
As for the remedies to invigorate Blood listed above, the following
are the guidelines for their use:
| I. |
Harmonizing the Moon:
this is the main remedy to treat the Biao of endometriosis,
i.e. invigorate Blood and dissolve masses. It contains herbs
that "break Blood" and dissolve masses. Generally,
this remedy is used in phases 4 and 1. However, do not use
this remedy if the period is heavy (see below). |
| II. |
Stir Field of Elixir:
this remedy invigorates Blood and is less strong than Harmonizing
the Moon. It is used in phases 4 and 1 and it can replace
Harmonizing the Moon in phase 1 if the period is heavy. |
| III. |
Invigorate Blood and Stem the Flow:
this remedy is used in phase 1 if the period is heavy. Therefore,
a common protocol to treat the Biao of endometriosis when
the period is heavy is to use Harmonizing the Moon in phase
4 and Invigorate Blood and Stem the Flow in phase 1. |
Combinations Of Patterns
1) KIDNEY-YANG DEFICIENCY WITH BLOOD STASIS AND DAMPNESS
Clinical manifestations
Painful periods, abdominal pain which is relieved by warmth, mid-cycle
hypogastric pain, possibly abdominal masses, lower backache, scanty
or heavy periods, dark blood with clots, vaginal discharge, feeling
cold.
Tongue: Swollen, Pale with Purple sides.
Pulse: Deep-Weak-Slippery-Wiry.
Treatment Principle
1. Menstrual phase: invigorate Blood, eliminate stasis. Harmonizing
the Moon.
2. Post-menstrual phase (about 7 days): Warm and tonify Kidney-Yang,
tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): Warm and tonify Kidney-Yang,
tonify Spleen-Qi, resolve Dampness. Clear the Palace or Drain
Redness if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): Invigorate Blood, eliminate
stasis, resolve Dampness. Harmonizing the Moon.
2) KIDNEY-YANG DEFICIENCY WITH COLD IN THE UTERUS AND
DAMPNESS
Clinical manifestations
Severe abdominal period pain, pain central, pain relieved by the
application of heat, menstrual blood scanty with small, dark clots,
feeling cold, white vaginal discharge, lower backache, feeling
of fullness and heaviness.
Tongue: Pale-Bluish or Bluish-Purple with sticky-white
coating.
Pulse: Deep-Weak-Tight.
Treatment principles
1. Menstrual phase (about 5 days): invigorate Blood, eliminate
stasis, scatter Cold, warm Yang. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang,
tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): tonify and warm Kidney-Yang,
tonify Spleen-Qi, resolve Dampness. Clear the Palace or Drain
Redness if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate
stasis, scatter Cold, resolve Dampness. Harmonizing the Moon.
3) KIDNEY-YIN DEFICIENCY WITH BLOOD STASIS AND DAMPNESS
Clinical manifestations
Painful periods, stabbing or heavy abdominal pain, mid-cycle hypogastric
pain, possibly abdominal masses, sore back, scanty or heavy periods,
vaginal discharge, dizziness, tinnitus.
Tongue: without coating.
Pulse: Floating-Empty and Slippery-Wiry.
Treatment Principle
1. Menstrual phase (about 5 days): Invigorate Blood, eliminate
stasis. Harmonizing the Moon.
2. Post-menstrual phase (about 7 days): nourish Kidney-Yin, tonify
Spleen-Qi. Growing Jade.
3. Mid-cycle phase (about 7 days): Nourish Kidney-Yin, tonify
Spleen-Qi, resolve Dampness. Clear the Palace or Drain Redness
if there is Damp-Heat.
4. Pre-menstrual phase (about 7 days): invigorate Blood, eliminate
stasis, resolve Dampness. Harmonizing the Moon.
4) BLOOD STASIS WITH KIDNEY-YANG DEFICIENCY WITH DAMP-PHLEGM
IN THE UTERUS
Clinical manifestations
Painful periods, abdominal pain which is relieved by warmth, mid-cycle
hypogastric pain, soft and moveable abdominal masses, tingling
limbs, dizziness, lower backache, scanty or heavy periods, dark
blood with clots, excessive vaginal discharge, feeling cold.
Tongue: Swollen, Pale with Purple sides.
Pulse: Deep-Weak-Slippery-Wiry.
Treatment Principle
1. Menstrual phase: invigorate Blood, eliminate stasis. Harmonizing
the Moon.
2. Post-menstrual phase (about 7 days): warm and tonify Kidney-Yang,
tonify Spleen-Qi. Unicorn Pearl.
3. Mid-cycle phase (about 7 days): Warm and tonify Kidney-Yang,
tonify Spleen-Qi, resolve Dampness and Phlegm. Clear the Palace.
4. Pre-menstrual phase (about 7 days): Invigorate Blood, eliminate
stasis, resolve Dampness and Phlegm. Harmonizing the Moon.
NEW DISTRIBUTORS
We are pleased to announce the appointment of two new distributors:
Kan Herb Company (USA - West Coast)
6001 Butler Lane
Scotts Valley
California 95066, USA
Tel: 1-800-543 5233 or 1-831-438 9450
Fax: 1-831-438 9457
Email: customer@kanherb.com
Website: kanherb.com
Pragon Ltd (Czech Republic, Slovakia)
Imrychova 883
14300 Prague 4
Czech Republic
Tel: +420 2 2431 1373
Mobile: +420 602 611 604
NEW REMEDY NAME
Please note that the name of the remedy Calm the Spirit has been
changed to Calm the Shen.
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