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.
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.
Symptoms
Clinical presentation of endometriosis varies in women. Patients often present with symptoms such as intermenstrual bleeding, painful periods (dysmenorrhea), painful intercourse (dyspareunia), painful defecation (dyschezia) and painful urination (dysuria). Pelvic pain may present before menstruation begins. Often, endometriosis can be asymptomatic, only coming to a clinician’s attention during evaluation for infertility.
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.
TCM Approach to 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]
How The Green Clinic treats 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 treatment plan. Usually Chinese herbal medications, acupuncture and moxibustion have to be incorporated in the treatment plan. Diet/Lifestyle plays a big part as well. It has been common misconception that all endometriosis patients present with Blood Stasis constitution, which is medically false because everyone is different. I have patients who dont 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.
Book an appointment with us to find out how we can help you with Endometriosis so that your fertility issue can be solved aptly.
[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
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