Musculoskeletal Key Fastest Musculoskeletal Insight Engine Home Log In Register Categories » About Gold Membership Contact Search... Endometriosis—Nei Ji 20 Endometriosis—Nei JiBarbara Kirschbaum Endometriosis (nei ji , “inner accumulation”) is a benign disorder that affects approximately 20–30% of women with fertility problems. It occurs exclusively during women’s reproductive years and is diagnosed most frequently 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. Causes and Pathogenesis from the Biomedical Perspective 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. Depending on the severity of endometriosis, the affected organs can even adhere to each other. This can lead to symptoms that are not subjectively linked to the menstrual cycle, such as pain during defecation or urination. Parallel to the mechanical problems triggered by endometriosis, around 45% of affected women show a luteal corpus insufficiency (functional weakness of the corpus luteum) and around 20% show an anovulatory cycle, which likewise limits fertility. Until now, biomedicine has failed to provide a conclusive theory for the origin of endometriosis. There are many theories, however, that explain the mechanism by which it spreads. The so-called displacement theory states that menstrual blood enters the fallopian tubes and is displaced from there into the abdominal cavity. Endometrial cells also spread through the lymph drainage paths and the vessels. Whenever these cells get stuck in one place, an endometriosis lesion can form there. Because numerous lymphatic and vascular connections exist between the uterus, ovaries, fallopian tubes, and the lesser pelvis, lesions can occur in the entire lower abdomen. The theory of direct expansion states that endometriosis is caused by the direct penetration of endometrial tissue from the outside of the uterus into the bladder, ureter, and intestine. We also find descriptions of immunological changes that lead to localized inflammations around the endometriosis lesions. This reaction is partly responsible for the pain associated with endometriosis. Thus, we find considerably more macrophages in women with endometriosis than in women without this condition, while the activity of the natural killer cells is reduced. Symptoms It must be noted here that this condition can run its course without detectable complaints by the patient, as a result of which she will frequently only learn about an existing endometriosis from a laparoscopic diagnosis in the context of testing fallopian tube patency. The following symptoms can indicate endometriosis: severe pain during menstruation lower abdominal pain also independent of the cycle pain during sexual intercourse pain during bowel movements diffuse pain in the lower abdomen and/or stomach and back menstrual disorders (e. g., spotting, hypermenorrhea) difficult, also painful urinary voidings, which arise cyclically Endometriosis and Fertility There are several reasons why endometriosis impacts fertility in spite of fallopial patency. Mobility and patency of the fallopian tubes are, of course, 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. Biomedical Diagnosis Occasionally, the gynecologist is able to palpate areas that are hardened or sensitive due to endometriosis. Endometrial cysts can be detected by ultrasound examination as well. Ultimately though, laparoscopy 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; hence this method of examination includes a treatment as well. In clinic, we have observed repeatedly that patients became pregnant within 6 months after this procedure. By means of different classifications (e. g., the endoscopic endometriosis classification, EEC), the endometriosis is then divided into four stages, according to its severity: 1. minimal 2. mild 3. moderate 4. severe Some biomedical physicians, however, consider this division as less than ideal because it generally fails to establish any correlation with the severity of pain or with infertility. Biomedical Therapy In general, the recommended treatment for women with fertility problems who suffer from endometriosis is laparoscopy with simultaneous removal of the endometriosis lesions. If necessary, hormonal deficiencies are balanced. Very frequently, in vitro fertilization (IVF) is suggested and carried out. Clinical Picture and Therapy from the TCM Perspective Endometriosis as such is not mentioned in the TCM classics. We can hence see it as a “modern” disease because it can only be detected by means of biomedical diagnostics (ultrasound, laparoscopy). With regard to a differential diagnosis, the clinical picture is composed of: painful menstruation (dysmenorrhea, tong jing abdominal masses (ji ju ) and ) As usual, we examine and evaluate the signs and symptoms of female patients specifically in relation to the menstrual cycle. Nevertheless, the contemporary practitioner cannot do without the biomedical findings and will attempt to interpret the nature of the dispersed endometrial tissue from the TCM perspective and treat accordingly. As such, the diverse types of pain that are caused by endometriosis (e.g., pain during menstruation, lower abdominal pain that occurs also independently of the cycle, pain during sexual intercourse and/or pain during bowel movements) certainly 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 ( ). 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 with regard to conception. Because blood stasis is generally triggered by other pathologies, the practitioner must look 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 Alas, it is possible that this differentiation and the resultant treatment strategies might not lead to the desired treatment success since clinical experience has shown that the treatment of endometriosis in accordance with the above-listed patterns frequently fails to alleviate the pain or abnormal bleeding to our satisfaction. According to our experience, women with endometriosis often suffer from an accumulation of phlegm that binds with the blood. Phlegm can form directly as a result of blood stasis. The jin fluids and essence (jing) can congeal and transform into phlegm, which then blocks the channels and network vessels.2 It is interesting to note that in some women with endometriosis a whitish mucous membrane can be seen 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. The entanglement of phlegm and blood leads us to a complicated pathology that is very difficult to resolve, while at the same time causing a pronounced blockage of the qi flow in the channels and network vessels, which leads to extreme pain, cyst formation, and adhesions. 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. Some modern physicians in the People’s Republic of China who have completed a biomedical education in addition to their TCM training are trying to find a correlation between the biomedically understood macroscopic and microscopic findings and TCM, in order to add the missing aspects in the category of dysmenorrhea ( ). Let us briefly describe this perspective here. With regard to detecting the activity level of peritoneal or ovarian endometriosis (see Schweppe 2002 in Feige3), active lesions show a pale red to red color while inactive lesions in the abdominal cavity appear black or brown. From the TCM perspective, this active pale red coloration could possibly correspond to the blood that is leaving the channels due to the underlying blood stasis. The black inactive lesions indicate that the blood that has left the channels has transformed into “dead” blood. Both conditions belong to the category of blood stasis in the uterus and in the lower abdomen. An important aspect of the therapy will therefore consist of quickening and moving blood as well as treating the cause of stagnation. The “dead” blood has thus assumed a shape, which brings us to the category of abdominal masses ( ). As far as the patient’s vitality permits, we now have to integrate the strategy of “breaking blood” into the prescription. Interesting in this context is also the description of the disorder by means of macroscopic criteria (according to Schweppe, 1984 in Feige3). According to this approach, nodular lesions are dark red to blue-black. They are mostly palpable as rough and solid hardenings that are sensitive to pressure. The description of this pathologically changed tissue accords with the TCM definition for masses due to blood stasis. These nodular lesions are responsible for a serious symptom picture according to biomedicine as well. In TCM, blood stasis patterns related to the menstrual cycle are seen as responsible for severe pain. Both blood stasis and phlegm accumulation lead to a repletion state in the lower burner. 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. If the biomedical diagnosis shows that the fallopian tubes are occluded, we can assume that a retention of damp-heat in the lower abdomen is or was present. In the context of an underlying blood stasis, the physiological fluids can congeal and the blood flow can be further impaired, as a result of which occluded fallopian tubes may occur. Even if the reasons for the development of the endometriosis can be found in a vacuity state such as insufficiency of qi and blood, the disorder itself, if it leads to impaired fertility, is characterized by repletion, due to stagnation of qi, blood, and phlegm. This has consequences for the treatment strategy, which must, however, be oriented around the timing of a potential fertility treatment. Eliminating the repletion state by softening accumulations and by moving and breaking blood are treatment methods that we should not employ when a woman is attempting to get pregnant. These should be applied in the preparatory phase, which can last up to 6 months. Treatment Prior to any Attempt to Become Pregnant Here, the key 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. This channel not only originates in the uterus, but also regulates the flow of qi and blood in the lower abdomen. The pattern differentiation for dysmenorrhea and abdominal masses provides a useful orientation for analyzing the patient’s symptoms. Experience has shown that treatment with acupuncture is 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 quieting the spirit because the recurrent pain causes tension and fear in many afflicted women. In addition, we can effectively treat the blood stasis by opening the chong mai.4 Nevertheless, in our experience the application of acupuncture alone appears not to be effective enough as a proven treatment of endometriosis. Under all circumstances, the use of Chinese medicinals is indicated here. If the patient’s symptoms only occur before and/or during menstruation, treatment with Chinese medicinals should begin in mid-cycle. During menstruation, we generally give a prescription for 3–4 days that serves to move the blood so that no residual blood remains, and to relieve pain. Occasionally, this treatment is intensified by an anal enema with Chinese medicinals. In the case of endometriosis, however, you should add medicinals to the basic prescription to disinhibit the channels and network vessels, stimulate blood circulation, and, if necessary, soften masses. Important Medicinals for Opening the Channels These include: ji xue teng (Spatholobi caulis), 10–30 g. This herb stimulates uterine contractions and is therefore contraindicated during pregnancy. Use with caution also in heavy menstrual periods!1 lu lu tong (Liquidambaris fructus), 6–9 g. Opens the channels and network vessels. It relieves pain caused by qi stagnation and blood stasis, and should in the treatment of endometriosis be combined with blood-moving medicinals. Contraindicated during pregnancy. Use with caution also in heavy menstrual periods! bai jiang cao (Patriniae herb), 9–15 g. Enters the blood level to eliminate blood stasis and relieve pain. It is effective for abdominal masses and abdominal fullness. At the same time, it clears heat, eliminates toxins, and drains pus and intestinal abscesses. Important Medicinals for Breaking Blood These include: wu ling zhi (Trogopteri feces), 3–10 g. Enters the blood level, activates blood circulation, and relieves pain. With pu huang (Typhae pollen), 4.5–12 g, very effective for relieving severe menstrual pain. san leng (Sparganii rhizoma), 3–10 g. Treats the most serious blood stasis, characterized by severe pain and abdominal masses. Its effect is increased by e zhu (Curcumae rhizoma), 4.5–12 g, and yan hu suo (Corydalis rhizoma), 3–9 g. Beware! San leng and e zhu are contraindicated during pregnancy and in heavy menstrual periods. mo yao (Myrrha), 3–9 g. Activates the blood circulation and relieves pain; is particularly effective in combination with ru xiang (Olibanum), 3–9 g. Medicinals for Treating Anomalies in the Fallopian Tubes The following medicinals are recommended: hong teng (Sargentodoxae caulis), 15–30 g. Opens the channels, eliminates blood stasis, and relieves pain. Traditionally, it is used for the treatment of acute appendicitis and intestinal abscesses that are caused by heat and toxins as well as by qi stagnation and blood stasis. Its ability to both disinhibit the channels in the lower abdomen and to eliminate heat and toxins has broadened its application also to the treatment of adhering and blocked fallopian tubes. zao jia ci (Gleditsiae spina), 3–10 g. Eliminates toxins, draws out pus, and activates the blood circulation. It is effective for the treatment of blocked and adhering fallopian tubes after inflammations in the abdominal cavity.1 bai jiang cao, see above. lu lu tong with chuan lian zi (Toosendan fructus), 3–9 g. Can be employed for blocked fallopian tubes. Together, they move liver qi and blood.5 sang ji sheng (Loranthi seu visci ramus), 9–30 g, and si gua luo (Luffae fructus retinervus), 6–12 g, for blocked fallopian tubes.5 Together they remove blockages from the network vessels. hu zhang (Polygoni cuspidati rhizoma), 9–30 g. For pain due to blood stasis with simultaneous presence of damp-heat. Medicinals for Treating Abdominal Masses These include: san leng, 3–10 g, and e zhu, 4.5–12 g. mo yao, 3–12 g, and ru xiang, 6–9 g. Both are used for treating pain-causing abdominal masses and dysmenorrhea. To treat abdominal masses effectively, we combine these with other medicinals from the blood-moving category, such as san leng, 3–10 g, and e zhu, 4.5–12 g, tao ren (Persicae semen), 4.5–9 g, and hong hua (Carthami flos), 3–9 g. In the treatment of abdominal masses (breaking blood, softening masses), animal parts are particularly effective. Most of them are not available in Western countries. These include dan nan xing (Arisaema cum bile), chuan shan jia (Manis squama), shui zhi (Hirudo), di bie chong (Eupolyphaga seu steleophaga), meng chong (Tabanus), bie jia (Trionycis carapax), and gui ban (Testudinis plastru). xia ku cao (Prunellae spica), 10–15 g. Softens masses in underlying liver qi stagnation and resulting heat and fire in the body. Its effect is strengthened by mu li (Ostreae concha), 15–30 g, and kun bu (Laminariae/eckloniae thallus), 10–15 g. hai zao (kun bu and Sargassum), 10–15 g. Dissolve phlegm, soften hard masses, and disperse lumps. In general, the above-mentioned medicinals should be added in accordance with the patient’s manifestation of pathology to any formula you have selected (see above). Only gold members can continue reading. 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