What is endometriosis and what causes it and how TCM can treat it?
Endometriosis is a disease of adolescents and reproductive-aged women characterized by the presence of endometrial tissue outside the uterine cavity and commonly associated with chronic pelvic pain and infertility. Endometriosis often presents as infertility or continued pelvic pain despite treatment with analgesics and cyclic oral contraceptive pills. Traditional Chinese Medicine(TCM) have been shown to treat endometriosis and over my article, I will introduce the basic fundamentals on how TCM can help to manage your endometriosis and fertility issues.
In this disorder, dispersed uterine tissue (endometrium) appears in the abdominal cavity and forms so-called endometriosis lesions. These lesions cause localized inflammatory lesions that change the surrounding tissue and can trigger the formation of adhesions. With regard to fertility, this is highly problematic since it can lead to occlusion or agglutination of the fallopian tubes, as a result of which neither semen nor egg can pass through.
The adhesions caused by endometriosis can lead to impaired mobility of the ovaries and fallopian tubes as well as to a disturbed reception of the ovum. This means that this disorder frequently affects the functions of the fallopian tubes (i.e., reception of the ovum, ovum transport, fertilization, and embryo transport). Nevertheless, the fallopian tubes are not affected in all women who suffer from endometriosis. Endometriosis lesions often occur on one or both ovaries, in which case cysts can develop, most notably chocolate cysts. When these cysts are removed and analyzed, a brown viscous substance (old menstrual blood) is found that looks like chocolate. In addition to the uterus and peritoneum, endometriosis can also spread to the intestines and the bladder.
As most women with endometriosis report the onset of symptoms during adolescence, early referral, diagnosis, identification of disease and treatment may mitigate pain, prevent disease progression and thus preserve fertility.
How do I know if I have endometriosis? What are the first signs of endometriosis?
Clinical presentation of endometriosis varies in women. Patients often present with symptoms such as
- severe pain during menstruation(dysmenorrhea)
- lower abdominal pain also independent of the cycle
- pain during sexual intercourse(dyspareunia)
- pain during bowel movements(dyschezia)
- painful urination (dysuria)
- diffuse pain in the lower abdomen and/or stomach and back
- menstrual disorders (e.g., spotting, hypermenorrhea)
- intermenstrual bleeding
- difficult, also painful urinary voidings, which arise cyclically
Often, endometriosis can be asymptomatic, only coming to a clinician’s attention during evaluation for infertility.
How is endometriosis diagnosed?
Endometrial cysts can be detected by ultrasound examination and laparoscopy, the latter constitutes the most precise diagnostic procedure. This method can determine both the extent and the localization and activity of the endometriosis. If endometrial tissue is found, it is often removed during the laparoscopy; therefore this method of examination includes a treatment as well.
Conventional Mainstream Clinical Approach
The management of endometriosis requires a multidisciplinary approach with
[i] surgical diagnosis and debulking of disease load,
[ii] hormonal treatment to suppress and delay recurrence and progression of disease,
[iii] pain managment strategies best provided by a pain center clinic that develops individualized care plans and pelvic therapy.
Symptomatic endometriosis is typically treated by surgical or medical treatment both equally effective. Despite the availability of treatments of associated pain, recurrence of endometriosis is not uncommon. Choice of medical treatments is done based on side effect profile, cost and personal preference. Non-steroidal anti-inflammatory drugs (NSAIDs) and low-dose combined oral contraceptive pills (COCPs) such as ethyl estradiol and progestins are the first choice drugs [1]. If patients do not respond to NSAIDs in three months a second line of treatments is used which includes progestins (oral, injectable and intra-uterine), androgens, and gonadotropin releasing hormone agonists (GnRH) which reduce moderate to severe pain of endometriosis [2].
Surgical techniques include excision or removal of endometrial implants, ablation of uterosacral nerves by employment of endocoagulation, electrocautery or laser treatment, presacral neurectomy, and hysterectomy with bilateral salpingooophorectomy [3]. They have 50–80% success rate in reducing symptoms. Unfortunately, endometriosis recurs in 5 to 15% of cases even after hysterectomy and bilateral oophorectomy.
The primary benefit of surgery for infertility associated with endometriosis is to enhance the probability of natural conception [4]. Surgery for infertility or pain increases the spontaneous post-operative pregnancy rate [5]. On the other hand, surgery for endometrioma could lead to reduced ovarian function and the possible loss of the ovary. Therefore, the decision of surgery should be made carefully, particularly in women with advanced age, bilateral disease, impaired ovarian reserve, who had previous surgery for endometriomas, or long-term infertility, who are incompatible with natural conception due to tubal or male factors.
How does endometriosis affect my fertility chances?
There are several reasons why endometriosis impacts fertility in spite of fallopial patency.
- For some women, they may experience pain during sex and the pain becomes so intense around the time of ovulation that sex is totally out of the question.
- Women with endometriosis tend to have more fluid surrounding their ovaries. This fluid contains active immune cells, which may or may not attack sperm or the ovulated egg.
- Mobility and patency of the fallopian tubes are highly significant, but the mobility of the ovaries is also important. And in women with existing endometriosis this is frequently impaired due to its adhesion to the abdominal wall and uterus.
- The uterus itself can also be affected by this disorder. Its mobility ensures that the sperm can reach the fallopian tubes. This movement can be impaired, as a result of which endometrial tissue ends up in the abdominal cavity, while at the same time the transport of semen fails to take place. When endometrial tissue enters the abdominal cavity, an overreaction of the immune system can result. This in turn leads to an increased tendency to inflammations in the peritoneum, which over time causes adhesions.
I'm diagnosed with endometriosis. Can I get pregnant if I have endometriosis? What are the chances?
Technically you still can get pregnant with endometriosis. However, there will be increased risk of ectopic pregnancies, leading to miscarriages. Surgery can be performed to remove endometriosis lesions, but risks associated include the possibility that endometriosis symptoms may actually get worse, and create disruption of blood flow to the ovaries. Surgery can also result in scar tissues that complicate pregnancy and fertility. That said, surgery also result in successful pregnancy in 30 to 80 percent of women, depending on the severity of the disease.
IVF and other assisted reproductive technologies are an alternative option to fertility. However, the sheer cost and stress coupled with it deters many women. Choosing to pursue pregnancy with endometriosis is a personal choice as many factors including severity of endometriosis and your age play an important role in determining the quality and quantity of your eggs.
Can endometriosis go away on its own?
Usually endometriosis recedes with menopause and during pregnancy. In some cases, symptoms may simply go away. Lifestyle and diet play an important role here.
What foods to avoid/take if I have endometriosis?
1.Increase your omega-3 intake
Omega-3 fats possessed anti-inflammatory properties that can combat ongoing inflammation(endometriosis is considered one) in your body. It is usually found in fatty fish and plant sources.
Having a high ratio of omega-3 to omega-6 fats in your diet is beneficial for women with endometriosis. [13] One study found that women who consumed a diet high in omega-3 fats were 22% less likely to have endometriosis, compared to women who consumed low amounts. [14]
However I don’t recommend fish oil supplements due to the high levels of mercury found. I usually recommend my patients to buy algae omega-3 supplements as they are the primary source found in fish oil anyway.
Ovega-3 (Vegan)
With 500mg of omega-3s, Ovega-3 provides the same heart-healthy benefits of traditional omega-3 supplements and oils but without the unpleasant fishy aftertaste and impurities associated with some omega-3 fish oils. The very simple reason being it is plant-based, not fish-based.
Ovega-3 cut out the middleman – fish– found in many other heart health dietary supplements and have gone directly to the source by using algae, to deliver the multiple health benefits of omega-3 fatty acids.
What is DHA and EPA?
DHA and EPA (docosahexaenoic and eicosapentaenoic acids) are omega-3 fatty acids that play crucial roles in heart health. DHA also helps to ensure that the cells in the brain, retina, heart and other parts of the nervous system develop and function properly.
With Ovega-3, you get 500 mg of high quality, sustainable omega-3s without a fishy aftertaste or risk of ocean-borne pollutants and toxins. Plus, you’ll gain a peace of mind knowing you’re doing the right thing for your heart, mind and more.*
Each capsule provides omega-3s from algae, including 270 mg of DHA and 135 mg of EPA. It comes with 80 soft gels, ONLY one soft gel to be taken daily with food.Omega 3 is essential for your fertility health and I strongly recommend you to get Ovega-3.
2. Avoid trans fat
Trans fats are created when liquid unsaturated fats are blasted with hydrogen until they become solid. Manufacturers typically create trans fats to give their products a longer shelf life and more spreadable texture.
One study has shown that women who ate high levels of trans fats had a 48% increased risk of endometriosis. [15]
3. Avoid red meat
One study has shown that replacing red meat, especially processed red meat, with another protein source may improve inflammation, usually associated with endometriosis.[16] Additionally, one study has found that women who ate more meat and ham had an increased risk of endometriosis, compared to those who ate little meat or ham[14].
4. Eat plenty of vegetables, fruits and wholegrain
Fruits, veggies and whole grains contain high levels of vitamins, minerals and fiber. Ensuring that your diet consist of them allows your body to take in essential nutrients and they may be potentially helpful if you have endometriosis.
One study investigated the direct relationship between endometriosis and eating fruits and green vegetables and has found out that a diet with plenty of fruits and vegeatables was associated with a lower risk of endometriosis. [17]
5. Limit caffeine and alcohol
Doctors usually recommend patients with endometriosis to reduce their caffeine and alcohol intakes. And this is partly supported by studies showing that women with endometriosis often consume higher amounts of caffeine and alcohol than women without the disease[18]. However, a cup of coffee each day and occasional glass of alcohol certainly won’t hurt as well.
How TCM diagnoses Endometriosis?
Endometriosis (known in TCM as 内积 nei ji, “inner accumulation”) is a benign disorder that occurs exclusively during women’s reproductive years and is usually diagnosed between the age of 30 and 40. In its development, it is dependent on hormones, occasionally disappears completely during pregnancy, but can recur after childbirth. Endometriosis declines with the onset of menopause. Endometriosis was not mentioned in any TCM classics as it is only diagnosed by using modern day technology. It can be classified under painful menstruation (dysmenorrhea, tong jing 痛经) and abdominal masses (ji ju 积聚).
Endometriosis common symptoms include pain during menstruation, lower abdominal pain that occurs independently of the cycle, pain during sexual intercourse and/or pain during bowel movements, which usually indicate a large amount of Qi stagnation and blood stasis. In the differential diagnosis of these types of pain, we would generally adhere to the standard disease patterns for dysmenorrhea (痛经). Blood stasis will always play a significant role in this context, because this stagnation causes obstructions in the uterus and its vessels, which in turn affects the normal functioning of the ren mai and chong mai, two meridians associated with blood and fertility, with regard to conception.
In my practice, I also look out for signs and symptoms that point to the root pattern. These include:
- stagnation due to cold
- retention of damp-heat (with heat in the blood)
- liver Qi congestion
- insufficiency of Qi and blood
- insufficiency of liver and kidney yin
I won’t elaborate the above as they each represent a set of symptoms by themselves therefore it is not wise to self-diagnose yourself. It is better to leave this job to a certified skilled TCM physician.
According to my experience, women with endometriosis often suffer from an accumulation of phlegm that binds with the blood(痰瘀互结). The fluids and essence (jing) can congeal and transform into phlegm, which then blocks the channels and network vessels.[11] It is interesting to note that in some women with endometriosis present with a whitish mucous membrane on the underside of the tongue, giving it a milky appearance, instead of the congested sublingual veins that we would expect as a sign of blood stasis.
Ovarian cysts, which are common in endometriosis and can contain not only bloody but also runny or sticky fluid, are certainly a sign of accumulating dampness and phlegm that has furthermore combined with blood.
Both blood stasis and phlegm accumulation lead to a repletion state in the lower burner(we have top, middle and lower burner in our body, and lower burner is the area of body below our belly button). If this pathology persists for a long time, ovarian cysts, endometrial tissue, or uterine myomas develop. Phlegm and blood stasis prevent qi, blood, and essence from reaching the uterus and can thereby lead to an impairment of the fallopian tubes. The ren mai and chong mai are unable to fulfill their function of storing essence and preparing the uterus for fertilization. Fertility is therefore impacted considerably also from the TCM perspective, because deep-lying disease patterns that have caused the stagnation can be responsible for this problem.
How TCM treats endometriosis?
Phew.. can you imagine how many things go through our mind when we are diagnosing you regarding your endometriosis? Therefore usually my initial consultation last around 45 to 60 minutes per session, because we have to do a great deal of diagnosis ourselves! Now onto the treatment part.
TCM treatment principle for endometriosis is to make the channels and network vessels passable, to move qi and blood, to transform phlegm, and, if necessary, to soften masses. Special attention is paid to regulating qi and blood in the chong mai to treat endometriosis with TCM methods. This channel not only originates in the uterus, but also regulates the flow of qi and blood in the lower abdomen.
What are the current TCM research regarding endometriosis?
In China, treatment of endometriosis using Chinese herbal medicine (CHM) is routine and considerable research into the role of CHM in alleviating pain, promoting fertility, and preventing relapse has taken place.
The pain-alleviating effects of acupuncture have been attributed to various physiological and psychological processes, such as activation of endogenous descending pain inhibitory systems, deactivation of brain areas that transmit pain-related signals, interaction between nociceptive impulses and somato-visceral reflexes, and the expectation of symptom relief. [6]
Cancer antigen 125 (CA-125), a well-established marker of epithelial cell ovarian cancer, is derived from coelomic epithelia, including those of the endometrium, fallopian tubes, ovaries, and peritoneum. [7] Amaral et al. reported that women with more advanced degrees of endometriosis showed higher CA-125 levels in both serum and peritoneal fluid.[8] However, studies have reported that acupuncture can reduce the level of serum CA-125, relieving the pelvic cavity pain that is associated with endometriosis.[9]
In a review done, there are grounds to believe that acupuncture can relieve pain in some patients. The effects of acupuncture as a pain-relieving treatment has in various studies been presented as an overall safe alternative treatment with very few and small (harmless) side effects, and furthermore with no effect on the environment. It could therefore also be regarded as a ‘sustainable’ treatment. [10]
Fundamental to the understanding of endometriosis in Chinese medicine is the notion of stagnation of Qi,or vital energy,as a prerequisite for the subjective experience of pain; and of blood, which tends to localise and intensify the experience of pain and can lead to the formation of distinctive, substantial lesions. Further information have to be derived from traditional methods of clinical assessment such as tongue and pulse diagnosis, investigation of a etiological factors, the subjective presentation of the symptoms of endometriosis (for example a description of the nature and location of the pain), and an evaluation of the general health of the patient as evidenced from sleep patterns, digestive status, and subjective sense of temperature for example.
How Green Sinseh treat Endometriosis?
Usually endometriosis patients are diagnosed only when they haven’t been able to conceive after a year or so. And not all patients present with severe menstrual pain as mentioned in our medical definition. Body constitution has to be diagnosed first before deciding on the TCM treatment plan on endometriosis. Usually Chinese herbal medications, acupuncture and moxibustion have to be incorporated in the treatment plan.
My personal experience is I find acupuncture particularly helpful when it is carried out in rhythm with the menstrual cycle. Especially 3–7 days before the onset of menstruation, its application can relieve lower abdominal and back pain. It is also important for calming purposes as the recurrent pain causes tension and fear in many afflicted women. In addition, it is found that we can effectively treat the blood stasis by opening the chong mai.[12]
Diet/Lifestyle plays a big part as well. It has been a common misconception that all endometriosis patients present with Blood Stasis constitution by TCM diagnosis, which is medically false because everyone is different. I have patients who don’t present with dark pale tongue, I even have patients with bright red tongue, indicating inner heat in them! So I still have to emphasise, body constitution is KEY to treatment.
If you have been diagnosed with endometriosis, and would like to book a consultation with me, please bring the following on your first visit.
- Ultrasound scan report
- Laparoscopy report(if any)
- Current medications
- Hormonal Profile (LH, FSH, Progesterone, Testosterone, Thyroid Hormones and Prolactin, if any)
- Semen Analysis of your husband
Your treatment plan will usually involve:
- TCM herbal prescriptions (3 packets per week dosage)
- Acupuncture (if you are willing)
- Moxibustion (if you are willing)
- Adherence to a diet that will nourish your body and combat endometriosis
Book an appointment to find out how I can help you with Endometriosis so that your fertility issue can be solved aptly.
References
[1] Zito G, Luppi S, Giolo E, Martinelli M, Venturin I, Di Lorenzo G, Ricci G. Medical treatments for endometriosis-associated pelvic pain. Biomed Res Int. 2014;014:191967. doi: 10.1155/2014/191967. Epub 2014 Aug 7.
[2] Angioni S, Cofelice V, Pontis A, Tinelli R, Socolov R. New trends of progestins treatment of endometriosis. Gynecol Endocrinol. 2014 Nov;30(11):769–73. doi: 10.3109/09513590.2014.950646. Epub 2014 Aug 21.
[3] Champaneria R, Abedin P, Daniels J, Balogun M, Khan KS. Ultrasound scan and magnetic resonance imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstet Gynecol Scand. 2010;89(11):1374–84.
[4] de Ziegler Dominique, Borghese Bruno, Chapron Charles. Endometriosis and infertility: pathophysiology and management. Lancet. 2010;376:730–8.
[5] Jacobson TZ, Duffy JM, Barlow D, Farquhar C, Koninckx PR, Olive D. Laparoscopic surgery for subfertility associated with endometriosis. Cochrane Database Syst Rev. 2010:CD001398.
[6] Andersson S, Lundeberg T. Acupuncture–from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses. 1995; 45 (3): 271–281
[7] Jacobs I. Screening for ovarian cancer by CA-125 measurement. Lancet 1988; 16 (8590):889.
[8]Amaral VF, Ferriani RA, Sá MF, Nogueira AA, Rosa e Silva JC, Rosa e Silva AC, et al. Positive correlation between serum and peritoneal fluid CA-125 levels in women with pelvic endometriosis. Sao Paulo Med J. 2006; 124: 223–227.
[9] Sun YZ, Chen HL. [Controlled study on Shu-Mu point combination for treatment of endometriosis]. Zhongguo Zhen Jiu. 2006; 26 (12): 863–865. Chinese.
[10 Lund I, Lundeberg T. Is acupuncture effective in the treatment of pain in endometriosis? 2016 Mar 24;9:157-65
[11] Clavey S. Fluid Physiology and Pathology in Traditional Chinese Medicine. London: Churchill Livingstone; 2003.
[12] Kirschbaum B. Die 8 Außerordentlichen Gefäße in der Traditionellen Chinesischen Medizin. Uelzen: ML; 2000.
[13] Attaman JA, Stanic AK, Kim M, Lynch MP, Rueda BR, Styer AK.The anti-inflammatory impact of omega-3 polyunsaturated Fatty acids during the establishment of endometriosis-like lesions.Am J Reprod Immunol. 2014 Oct;72(4):392-402. doi: 10.1111/aji.12276. Epub 2014 Jun 5.
[14] Parazzini F, Viganò P, Candiani M, Fedele L. Diet and endometriosis risk: a literature review. Reprod Biomed Online. 2013 Apr;26(4):323-36. doi: 10.1016/j.rbmo.2012.12.011. Epub 2013 Jan 21.
[15] Missmer SA, Chavarro JE, Malspeis S, Bertone-Johnson ER, Hornstein MD, Spiegelman D, Barbieri RL, Willett WC, Hankinson SE.A prospective study of dietary fat consumption and endometriosis risk. Hum Reprod. 2010 Jun;25(6):1528-35. doi: 10.1093/humrep/deq044. Epub 2010 Mar 23.
[16] Battaglia Richi E1, Baumer B1, Conrad B1, Darioli R1, Schmid A1, Keller U1.Health Risks Associated with Meat Consumption: A Review of Epidemiological Studies. Int J Vitam Nutr Res. 2015;85(1-2):70-8. doi: 10.1024/0300-9831/a000224.
[17] Parazzini F1, Chiaffarino F, Surace M, Chatenoud L, Cipriani S, Chiantera V, Benzi G, Fedele L. Selected food intake and risk of endometriosis. Hum Reprod. 2004 Aug;19(8):1755-9. Epub 2004 Jul 14.
[18] Trabert B1, Peters U, De Roos AJ, Scholes D, Holt VL. Diet and risk of endometriosis in a population-based case-control study. Br J Nutr. 2011 Feb;105(3):459-67. doi: 10.1017/S0007114510003661. Epub 2010 Sep 28.