Endometriosis: Support from Chinese Medicine

Endometriosis affects 10% of people who menstruate every year.¹ That’s just the people who get a formal diagnosis. What is endometriosis? It is a very painful menstrual condition in which the uterine lining (endometrium) grows and bleeds outside the uterus in “adjacent pelvic organs such as ovaries, fallopian tubes, pelvic ligaments, vagina, sigmoid colon, rectum, ureters or bladder.”² In rare cases, it may be found outside of the pelvic area. The causes of endometriosis are still unknown and it is a condition that may be experienced by any menstruating person, regardless of gender expression.

Symptoms may include:

• severe and painful periods
• heavy bleeding
• pain with intercourse
• infertility
• pain with bowel movements and urination
• abdominal pain
• diarrhea and constipation
• fatigue
• depression
• hopelessness

My own path to becoming a licensed acupuncturist began when I sought help for the treatment of endometriosis from Traditional Chinese Medicine. You can read more about my experience in How Acupuncture Changed My Life (A Story for Endometriosis Awareness Month). Acupuncture and Traditional Chinese Herbal Formulas were extremely effective in relieving my pain without the side effects of Western medications.

In this article, we’ll discuss endometriosis diagnosis in Western and Chinese Medicine terms; Chinese herbal formulas according to pattern differentiation; self-care to involve patients in their healing; and how to be an advocate for our patients to get the care that they need.

Diagnosis in Western Medicine

It can sometimes take years for people to get a diagnosis of endometriosis from Western medical doctors. Part of this may be due to the symptoms presenting like other conditions; including Irritable Bowel Syndrome (IBS), Pelvic Inflammatory Disease (PID) or ovarian cysts. Another factor is that physicians may overlook or downplay their patients’ pain. For transgender and nonbinary people, it may also be difficult to feel safe asking for the care they need.

Diagnosis is done with a laparoscope inserted through the navel/umbilicus. A laparoscopy “can provide information about the location, extent and size of the endometrial implants” and the “surgeon may take a tissue sample (biopsy) for further testing.”³

How Laparoscopy Results are Useful for TCM Diagnosis

Laparoscopies can show the type of cysts, location, and spread of endometrial adhesions, and these signs are part of the TCM diagnosis. A dark brown or ‘chocolate’ cyst may indicate Blood stagnation. White cysts may indicate Phlegm. According to Giovanni Maciocia, the three types of abdominal masses are due to Qi stagnation, Blood stagnation, and Phlegm:
“Masses from stagnation of Qi come and go, are movable on palpation and change location. If there is pain, the pain has no fixed location and is accompanied by a pronounced feeling of distension.
Masses from stasis of Blood are fixed in location, they are not movable on palpation and feel quite hard. If there is pain, it is fixed and stabbing in character.
Masses from Phlegm feel soft on palpation and have a fixed location. There is usually no pain.”4

Patterns and Herbal Formulas

Here are some of the patterns and herbal formulas that may help to differentiate treatment strategies when working with patients with endometriosis.

Full Patterns

Qi Stagnation

Signs may include irritability, breast distention and tenderness, painful menstruation, a dusky purple tongue, and a wiry pulse. The following formulas could be considered:

• Xiao Yao San/Wan (Free & Easy Wanderer teapills): may be more appropriate with signs of Liver Blood Deficiency
• Shu Gan San/Wan (Soothe Liver teapills): may be more appropriate with signs of Liver overacting on the Spleen and Stomach
• Jia Wei Xiao Yao San/Wan (Free & Easy Wanderer Plus teapills): may be more appropriate with signs of Liver Qi Stagnation turning into Fire

Blood Stagnation

Signs may include severe fixed stabbing abdominal pain that worsens with pressure, dark purple menstrual blood with clots, dusky purple tongue, and a choppy pulse. Consider these formulas:

• Tao Hong Si Wu Tang Wan (Tao Hong Si Wu teapills)
• Ge Xia Zhu Yu San/Wan (Stasis in the Lower Chamber teapills): for more intense pain than Tao Hong Si Wu Tang
• with Gui Zhi Fu Ling San/Wan (Cinnamon & Poria teapills): there may be more signs of Heat

Cold Stagnation

Signs may include bleeding between periods, prolonged menstrual bleeding, abdominal pain that is better with warmth, and feeling of cold in the lower abdomen, pale tongue, and a slow pulse. Formulas to consider are:

• Wen Jing Tang Wan (Warm Cycle teapills): the focus is the treatment of Empty Cold
• Shao Fu Zhu Yu San/Wan (Stasis in the Lower Palace teapills): the focus is on Full Cold

Damp-Heat

Signs may include vaginal discharge, burning sensation, blood with small clots, dark urine, yellow sticky tongue, and a slippery pulse. Formulas to consider are:

• Qing Re Tiao Xue Tang: the treatment strategy is on clearing Heat and cooling the Blood
• Er Miao San: the focus is on resolving Damp and clearing Heat

Empty Patterns

Qi & Blood Xu

Signs may include mild abdominal pain, bloating, fatigue, exhaustion, continuous menstrual bleeding, pale tongue and a thready, weak pulse. Consider these formulas:

• Nu Ke Ba Zhen San/Wan (Women’s Precious teapills) plus Yi Mu Cao: the focus is Qi and Blood Deficiency. Yi Mu Cao is added to Move Blood and Stop Pain.
• Shi Chuan Da Bu Wan (Ten Flavor teapills) plus Yan Hu Suo Zhi Tong Wan (Great Corydalis teapills): the focus is Yang Deficiency and Wei Qi Deficiency. Yan Hu Suo Zhi Tong Wan can be added depending on the severity of pain.

Yang and Blood Xu

In patterns such as this, signs may include dull or spasmodic abdominal pain relieved by warmth; cold intolerance, scanty pale blood, no clots, dull headache, dizziness, pale, swollen tongue and a deep, thin pulse. Formulas to consider:

• Dang Gui Bu Xue San plus Xiao Jian Zhong Wan (Minor Restore the Middle teapills)

Kidney and Liver Yin Xu

Signs may include dull abdominal pain that is relieved by pressure, scanty menstrual blood, dizziness, tinnitus, low back pain, fatigue, red tongue with no coat, and an empty or floating pulse. Formulas to consider:

• Gui Shao Di Huang Tang , which is a variation of Liu Wei Di Huang San/Wan (Six Flavor teapills) modified with the addition of Dang Gui and Bai Shao to Nourish Blood and Stop Pain.⁵

Self-care for Patients

Encouraging patients to be active participants in their healing from endometriosis can give them a sense of agency. Here are some ways they can contribute:

• Herbal formula compliance: Work with your patient to determine if raw herbs, powdered herbs, or pill form is easier for them to take consistently.
• Moxibustion: Patients can do moxibustion with a KuPun (aka ‘belly bowl’) for symptoms of pain and fatigue. You can also teach your patient how to use a ‘tiger warmer’ or ‘lion warmer’ moxa device on surgical scars.
• TCM Nutrition: Tailor anti-inflammatory nutrition recommendations to your patients according to differential diagnosis. Emphasize reducing the ‘four whites’: white flour, sugar, salt, and dairy.
• Exercise: Regular exercise can help relieve patients’ pain but may be challenging if the pain keeps them bedridden. In this case, encourage patients to exercise when they are not actively in pain.
• Essential oil blends: Aromatherapy can help patients access healing on an emotional and spirit level. These may be used alone on acupressure points or in conjunction with moxibustion on the abdomen when using a KuPun bowl.

Being an Advocate for our Patients

“I believe you” and “I’m sorry you’re in so much pain” are some of the things we can say to our patients that they may have not heard from other health care practitioners on their journey with endometriosis. Listening to our patients and showing them true compassion are so important.

If your patient has difficulty communicating their symptoms with Western medical doctors, they may need an advocate. I highly recommend they bring a trusted person to their appointments to be that advocate and ask the questions they may not be comfortable asking. For example, this may help them to get a laparoscopy if they decide to go that route.

There are also online communities such as Endo Warriors that you may suggest to your patients and other resources such as SpeakEndo.

Transgender men and nonbinary people also have challenges when it comes to endometriosis and may feel unsafe going to a gynecologist: “Some reasons why these patients may feel uncomfortable include the following: gendered intake forms, medical discrimination, judgmental doctors, and harassment.”⁶

Traditional Chinese Medicine can offer hope to people with endometriosis. They do not have to be alone or suffer in silence. Pattern differentiation and herbal formulas can be helpful. Giving patients self-care tools can empower and actively include them in their healing. May we always remember to include the compassion of the Shen and community support of the Yi which are very important components of care.

References

• ¹ https://www.who.int/news-room/fact-sheets/detail/endometriosis
• ² Maciocia, Giovanni Obstetrics & Gynecology in Chinese Medicine, p. 258.
• ³ https://www.mayoclinic.org/diseases-conditions/endometriosis/diagnosis-treatment/drc-2035466
• ⁴ Maciocia p. 792
• ⁵ Painful Periods and Abdominal Masses chapters in Maciocia, Giovanni Obstetrics & Gynecology in Chinese Medicine.
• ⁶ https://endometriosis.net/living/transgender-experiences

About the Author

Denise Cicuto has been a licensed acupuncturist for 15+ years, working in the San Francisco Bay Area. She brings her experience and wisdom as an acupuncturist, herbalist, and alchemist. Denise Cicuto is a Licensed Acupuncturist and Chinese herbalist and has certifications in Gua Sha, Alchemical Healing, and advanced training in pregnancy and postpartum care. When not working in her Alameda and San Francisco offices, Denise practices yoga, mindfulness meditation, bicycles, takes photographs, and does historical reenactment. You can learn more about Denise at cicutoacupuncture.com.