A Survey of TCM Treatment for Endometriosis Academic research paper on "Clinical medicine"

Review

A Survey of TCM Treatment for Endometriosis

HAN Yu-fen \ HOU Li-hui \ ZHOU Ya-jie 2 & WU Xiao-ke 1

department of Obstetrics and Gynecology, the First Affiliated Hospital, Heilongjiang University of Traditional Chinese Medicine, Harbin 150040, China

2Harbin Municipal Red Cross Centre Hospital, Heilongjiang, China

Endometriosis (EM) refers to the disorders caused by the endometrial tissues growing out of the uterine cavity but in other parts of the body, which may include the progressive dysmenorrhea, dyspareunia, sterility, and abnormal menstruation. EM occurs mostly in the pelvic cavity, and it falls into the TCM category of 'dysmenorrhea', 'irregular menstruation', and 'sterility'.1 Modern medicine holds that the ectopic endometrium still has the growing function, which, under the influence of estrin and progestogen, periodically exfoliates with hemorrhage. The blood fails to be normally discharged, which will accumulate in the focal region, and adhere with the surrounding tissues and organs, leading to the above-mentioned clinical problems. With complicated pathogenic mechanisms, broad pathological process, and the malignant biological behavior of infiltration, transfers and recurrent, this disease has drawn great attention by both the domestic and foreign medical circles. In recent years, TCM has presented various therapies in multiple ways for the treatment. The following is a brief account.

THE TCM INTERNAL TREARMENT

The criteria for clinical therapeutic effects of EM are mostly taken for the Diagnostic and Therapeutic Criteria of the Integrated Chinese and Western Medicine for Endometriosis revised by the Professional Board of Obstetrics and Gynecology of the Society of Integrated Chinese and Western Medicine on the Third Scientific Conference. 1) Cured: All the clinical symptoms and signs, including

the pelvic mass, disappeared, with pregnancy or fertility within two years for the infertility cases. 2) Markedly effective: The clinical symptoms basically disappeared, the pelvic mass reduced, but the local signs still existed; and the patient may have pregnancy. 3) Improved: The clinical symptoms were alleviated, the pelvic mass remained the same, with no aggravation of the symptoms within 3 months after withdrawal of the herbal administration. 4) Failed: No improvement of the clinical symptoms, and with a tendency of the local pathological changes.

The TCM internal treatment for endometriosis generally involves the syndrome-differentiation treatment, the periodic therapy, and the special-prescription treatment.

The syndrome-differentiation treatment

In view of the pathogenesis of interior obstruction of blood stasis, the principle of differential treatment for this disease is usually centralized on promoting blood circulation and removing blood stasis. Modern pharmacological researches have proved that the method of promoting blood circulation and removing blood stasis has the effects of improving hemodynamics and blood rheology, and antithrombosis. It can also help promoting the decomposition and resorption of blood stasis, softening the adhesion, decreasing mass, inhibiting inflammation and abnormal proliferation, alleviating pain, and regulating the immune function.2

Based on the fact that Xue Jie (^ Resina Draconis) has the effects of improving general and local microcirculation, promoting the resorption of local focus, decreasing PG concentration, and alleviating clinical symptoms, WANG De-mei,3 taking Xue Jie Resina Draconis) as the main

drug in the prescription, applied the method of promoting blood circulation and removing blood stasis in the treatment for 156 cases of EM. The patients were divided randomly into two groups, each consisting of 78 cases. In this series, there were 39 cases of endometrioma, 98 cases of uterine chocolate cyst, and 19 cases of EM in other parts. In addition to the basic prescription, Xue Jie (^ Resina Draconis) was added for the Xue Jie group. The control group just used the basic prescription, containing Dan Shen ( ^ # Radix Salviae Miltiorrhizae), Dang Gui (Radix Angelicae Sinensis), Shi Jian Chuan Herba Salviae

Chinensis), Shui Zhi (7K£M Hirudo), San Leng (H^ Rhizoma Sparganii), E Zhu ( ^ ^ Rhizoma Curcumae), and Yi Mu Cao Herba Leonuri).

Modifications were done to the prescription according to the symptoms. Results showed that the total effective rate of the Xue Jie group was 92.31%, and that of the control group was 46.15%, showing a significant difference between the two groups (P<0.01). The recurrence rate of the Xue Jie group was 6.41%, and that of the control group was 23.08%.

YANG Feng4 divided EM into the following 4 types of qi-stagnation and blood stasis, cold-accumulation and blood stasis, kidney-deficiency and blood stasis and interior obstruction of stagnant heat, and gave oral medication of Hong Teng prescription, containing Hong Teng (¿10 Caulis Sargentodoxae), Bai Jiang Cao (ittW^ Herba Patriniae), Mu Dan Pi Cortex Moutan), Dan Shen (## Radix Salviae Miltiorrhizae), Tao Ren (-f^ Semen Persicae), Zi Cao Radix Lithospermi), Xiang

Fu Rhizoma Cyperi), Sheng Pu Huang

Pollen Typhae), Yan Hu Suo (M iH ^ Rhizoma Corydalis), Sheng Mu Li Concha Ostreae),

and E Zhu Rhizoma Curcumae). The effective rate for the type of qi-stagnation and blood stasis (19 cases) was 89%, which for cold-accumulation and blood stasis (15 cases) was 80%, which for kidney-deficiency and blood stasis (20 cases) was 85%, and that for interior obstruction of stagnated heat (28 cases) was 96.4%.

LIAO Wei5 conducted observation on the treatment of EM, with one group treated with the Chinese prescription for replenishing qi, removing blood stasis and softening the hard masses, and the other group treated with Mifepristone. No significant differences were found in the total effective rate between the two groups. However, after the treatment, the cancer antigen 125 (CA 125) in the Chinese herbal group was significantly decreased, and patients in this group with irregular menstruation were also cured, which was beneficial to pregnancy. This suggests that Chinese herbal treatment for EM has different mechanism from the western medical treatment, which does not inhibit ovulation and is more appropriate for women having the desire to get pregnancy.

The periodic therapy

In clinic, EM usually attacks periodically, and gets worse progressively. Based on the law of wane and wax of yin and yang in the kidney and qi and blood in the Chong and Ren Channels shown in the menstrual cycle, satisfactory therapeutic effects can be got by the application of different prescriptions and treating principles at different periods of the menstrual cycle.

WANG Wei-chang6 thinks that dysmenorrhea in EM cases is closely related with interior invasion by cold-damp and interior retention of blood stasis, and that blood stasis due to cold-accumulation is the key for occurrence of EM and is the main causative factor for dysmenorrhea. Therefore, it is not advisable to apply simply the method of promoting blood

circulation and removing blood stasis, yet the treating principle of warming the middle-jiao to remove pathogenic cold should be abided in the whole course of the treatment. Since the attack of pain is also closely related with the menstrual cycle, the periodic treatment can be adopted. Before the menstrual period, Siwen Tang (Hfi^ Decoction Containing Four Warm Ingredients) can be used, containing Wu Zhu Yu (M^^ Fructus Evodiae), Rou Gui Cortex Cinnamomi), Xiao Hui Xiang ( 'h ^ § Fructus Foeniculi), Pao Jiang baked ginger),

Yan Hu Suo (M^MM Rhizoma Corydalis), Wu Ling Zhi Faeces Trogopterori), Mo Yao

Myrrha), and Bai Shao (Radix Paeoniae Alba), which gives the effects of warming the middle-jiao to eliminate cold, regulating the flow of qi to check pain, promoting blood circulation and removing blood stasis, and alleviating the symptom of pain. During the menstrual period, Fuwei Tang Decoction

for Location Restoration) can be used, containing Rou Gui Cortex Cinnamomi), Ma Huang Herba Ephedrae), Yan Hu Suo (M^MM Rhizoma Corydalis), Juan Bai (^tt Herba Selaginellae), Ma Bian Cao Herba Verbenae), Zhi Cao Wu

^^ Radix Aconiti Kusnezoffii Preparata), San Leng (H^ Rhizoma Sparganii), E Zhu Rhizoma

Curcumae), Dang Gui ( ^ fi Radix Angelicae Sinensis), Chi Shao Radix Paeoniae Rubra),

and Zhi Shui Zhi (®7KM Hirudo Preparata), which, based on the effects of warming the menses and eliminating cold, can also give the effects of promoting blood circulation and removing blood stasis, and softening and resolving hard masses.

XING Yu-xia7 treated EM according to the menstrual cycle. Before and during the menstrual period, the treating principle was based on promoting blood circulation and removing blood stasis, and warming yang and regulating the flow of qi to stop pain, with the use of such drugs like Dan Shen Radix

Salviae Miltiorrhizae), Hong Hua ( ^X ^ Flos Carthami), Chao Wu Ling Zhi (^i^M parched

Faeces Trogopterori), San Leng (^ ^ Rhizoma Sparganii), E Zhu Rhizoma Curcumae), Zhi

Mo Yao {W&M Myrrha Preparata), Rou Gui Cortex Cinnamomi), Yan Hu Suo (M^MM Rhizoma Corydalis), and Xue Jie (^^ Resina Draconis). After the menstrual period, the treating principle was for replenishing qi and nourishing the kidney, and eliminating blood stasis and resolving hard mass, with the use of such drugs as Shan Yao (Lb ^ Rhizoma Dioscoreae), Chuan Xu Duan (j 11 Radix Dipsaci), Dan Shen (^ # Radix Salviae Miltiorrhizae), Zao Jiao Ci Spina Gleditsiae),

Shan Zhu Yu Fructus Corni), Tu Si Zi

T Semen Cuscutae), San Leng (Rhizoma Sparganii), E Zhu Rhizoma Curcumae), Tu Bie Chong (i^^, Eupolyphaga seu Steleophaga), Yan Hu Suo (M^MM Rhizoma Corydalis), Shi Jian Chuan (^M^ Herba Salviae Chinensis), and Xue Jie Resina Draconis). 3 months constituted a treating course. After one course of the treatment, 8 cases were cured, 19 cases were markedly effective, 26 cases improved, and 5 cases failed. The total effective rate was 91.4%.

The special-prescription treatment

Here, the special prescription refers to the prescription specially formulated for this disease based on the differential theory and clinical experience. LI Guang-rong8 thinks that under the cyclic action of sexual hormones, the ectopic endometrium of the patient would have local hemorrhage and necrosis, similar to 'blood stasis' called in TCM. Therefore, in the treatment, the focus should be laid on promoting blood circulation and removing blood stasis. Dan Chi Yin was

used, containing Chai Hu (^SJI Radix Bupleuri), Dan Shen Radix Salviae Miltiorrhizae), Chi Shao

Radix Paeoniae Rubra), E Zhu Rhizoma Curcumae), and Wu Ling Zhi (i M $h Faeces Trogopterori). A clinical observation was conducted in 42 such cases. The results showed that 14 cases were markedly effective, 24 cases improved, and 4

cases failed. The total effective rate was 90.48%, the therapeutic effect for dysmenorrhea was 85.75%, and the therapeutic effect for infertility was 39.41%.

ZHANG Hui-qin9 thinks that this disease is mostly due to deficiency in the origin and excess in the superficiality, and with a long duration of the illness. Long-term use of the drugs for eliminating blood stasis will cause consumption and damage of the vital-qi, and the insufficient qi will fail to promote the blood circulation, leading to a vicious cycle and worsening the condition. So, the modified Buyang Huanwu Tang Decoction Invigorating

Yang for Recuperation) was used for the treatment, which, meanwhile eliminating the pathogens, has the effect of reinforcing and replenishing the vital-qi, thus yielding a total effective rate of 93.9%.

THE TCM EXTERNAL TREATMENT

The TCM external treatment for EM can make the action of the herbs directly reach the affected area, and give no toxic side effects, which avoids the irritation of herbs to the gastric and intestinal tracts, and gives the effect of attacking the pathogens without damaging the vital-qi. It is an effective way for treatment of EM. 10

Chinese herbal enema

KONG Gui-ru11 thinks that the pathogenesis of EM is due to 'accumulation of blood stasis'. So, the herbs for promoting blood circulation and removing blood stasis, and eliminating heat and toxic materials, such as Hong Teng (¿10 Caulis Sargentodoxae), Bai Jiang Cao (ftW^ Herba Patriniae), Pu Gong Ying (ff£ ^ Herba Taraxaci), Yu Xing Cao Herba

Houttuyniae) and Zhi Xiang Fu Rhizoma

Cyperi Preparata), were used together with some western anti-inflammatory agents for rectoclysis in 50 cases of EM. The treatment started 3 days after the menstrual period, and was given once every night for 10 days as one therapeutic course. After 3 such therapeutic courses in succession, 15 cases were cured, 20 cases had marked effects, 9 cases improved,

and 6 cases failed, with a total effective rate of 88%.

SUN Hong12 treated 49 cases of EM with the self-made prescription use for enema, which consisted of Mu Dan Pi (tt^^ Cortex Moutan) 9 g, Chao Chi Shao parched Radix Paeoniae

Rubra) 9 g, E Zhu Rhizoma Curcumae) 9 g, Fu Ling Poria) 12 g, Zao Jiao Ci Spina

Gleditsiae) 12 g, Shi Jian Chuan Herba

Salviae Chinensis) 15g, Bai Jiang Cao (feW^ Herba Patriniae) 15 g, Ru Xiang Resina Olibani) 6 g, and Mo Yao (MM Myrrha) 6 g, and were made into 100-150 ml decoction for use. The enema was given once daily, 14 days forming one therapeutic course. After the enema treatment for 2-3 courses, the total effective rate was 91.7%.

The medicinal plaster therapy

WANG Jing, et al. used the plaster therapy with She Xiang (M§ Moschus) at Shenque (CV 8) to treat secondary dysmenorrhea due to severe endometriosis. 0.05 g of the man-made She Xiang (M§ Moschus) was put into Shenque (CV 8) by a toothpick, 2 drops of 20% alcohol were dripped in, and then a piece of She Xiang (M§ Moschus) plaster was stuck on the point. The plaster therapy should be done once every 48 hours, starting from one week before the menstrual period, 3 months constituting a treating course.

YAO Yu-rong, et al.14 treated 113 cases of EM with Keyizhongzi Dan ( ^^fti^). The ingredients were Shui Zhi (7KÈM Hirudo) 30 g, Chao Chuan Shan Jia parched Squama Manitis) 30 g, Yan Hu

Suo (MffiM Rhizoma Corydalis) 30 g, Zhi Mo Yao (W&M Myrrha Preparata) 30 g, Zhi Ru Xiang (®f L # Resina Olibani Preparata) 30 g, Yin Yang Huo (S ^M Herba Epimedii) 30 g, Tu Si Zi (^T Semen Cuscutae) 30 g, Chao Du Zhong parched

Cortex Eucommiae) 30 g, Chuan Xiong ( jl| ^ Rhizoma Ligustici Chuanxiong) 25 g, Da Huang (^ ^ Radix et Rhizoma Rhei) 35 g, Mu Xiang Radix Aucklandiae) 25 g, Rou Gui Cortex

Cinnamomi) 20 g and Wu Gong (^te Scolopendra)

4 pieces, which were mixed together and ground into powder for use. Each time, 10 g of the powder was used with warm water to make herbal paste, and was applied on the umbilicus, called the point Shenque (CV 8), and then covered and fixed with a piece of adhesive plaster. The therapy was given once every 3 days, 10 sessions constituting one therapeutic. The total effective rate was 94.3%.

Acupuncture treatment

LI Yuan-feng15 used auricular seed-embedding and herbal prescription for dysmenorrhea due to EM. The auricular seed-embedding with vaccaria seeds was applied starting from 5 days before the menstrual period on the auricular points of Subcortex, Endocrine, Sympathetic Nerve, Ear-Shenmen, Liver, Kidney, Internal Genitalia, and Tingzhong. The embedded seeds were pressed 3-5 times a day, lasting 30 min each time. The seed-embedding was done every 2 days alternately on both ears, altogether

5 times, with two menstrual cycles forming one therapeutic course. The results were quite good.

DING Zhe16, et al. think that EM is a main causative factor for secondary dysmenorrhea. In clinic, they applied vaccaria seed-embedding on the auricular points of Internal Genitalia, Endocrine, Liver, Kidney, Ear-Shenmen, and Sympathetic Nerve. The treatment began 3-5 days before the menstrual period, and lasted 3-5 menstrual cycles. The total effective rate was 97%.

RUAN Ji-yuan17, et al. think that the point-injection therapy with Chinese medicines can improve the ectopic endometrial adhesion and fibrosis. In clinic, they gave point-injection with salvia injectio at Zusanli (ST 36) and Xuehai (SP 10), or at Ciliao (BL 32) and Sanyinjiao (SP 6), with the two groups of points alternately used every other day, and 2 months constituting one therapeutic course. This therapy is good for symptom relief.

CHANG18, based on TCM syndrome-differentiation,

applied acupuncture treatment for EM. For the excessive heat syndrome, Baihui (GV 20), Ququan (LR 8), Shenmai (BL 62), Shenmen (HT 7), Xuehai (SP 10), Yinbai (SP 1), Zhongji (CV 3), and Zhaohai (KI 6) were selected; and for qi-insufficiency, Baihui (GV 20), Sanyinjiao (SP 6), Yangchi (TE 4), Yinbai (SP 1), and Zusanli (ST 36) were selected. Sometimes, auricular points of Ear-Shenmen, Uterus and Ovary were also used, with herbal prescription given in combination for a better therapeutic effects.

XIONG Yun-bim, et al.19 adopted electro-acupuncture starting from 4 days before the menstrual period at the points of Guanyuan (CV 4), Zhongji (CV 3), and Sanyinjiao (SP 6). The treatment was given twice daily, each lasting 30 min. Each month, a 5-days treatment formed one therapeutic course. After 5 treatment courses, of the 70 cases treated, marked effects found in 37 cases, 30 cases were improved and 3 cases failed. The total effective rate was 95.71%.

WANG Hui-min20 made a powder with Fu Zi (^T Radix Aconiti Preparata), Lu Jiao Shuang (^ftff Cornu Cervi Degelatinatum), Rou Gui (Cortex Cinnamomi), Ru Xiang Resina Olibani) and

Wu Ling Zhi (i^M Faeces Trogopterori) in the ratio of 5 : 2 : 1 : 1 : 1, and then mixed the powder with 20% alcohol to make the medicinal cakes, 0.5cm in thickness and 3 cm in diameter. The medicinal cake was put indirectly on Shenque (CV 8) with a piece of gauze in between, and then with a lighted moxa cone put on the cake. Along with the rising of temperature, the pungent, warm and aromatic medicinal action of the herbs would enter the lower abdomen, uterus, and channels and collaterals to produce the therapeutic effect. LIU Ya-xin, et al.21 obtained marked therapeutic effects for dysmenorrhea in EM cases treated by medicinal moxibustion.

THE TCM COMPREHENSIVE TREATMENT

In recent years, both the internal and external

treatments are clinically adopted in combination, which can quickly alleviate the clinical symptoms, and raise the therapeutic effects.

Based on the TCM syndrome-differentiation and the concept of wholism, CHEN Dong, et al. 22 treated EM with oral medication of the self-made prescription Xiaoyi Fang The Prescription for Relieving

Endometriosis), which was combined with the ultrasonic penetration. The prescription was composed of Hong Hua (^X^ Flos Carthami), Dan Shen Radix Salviae Miltiorrhizae), San Leng (H^ Rhizoma Sparganii), E Zhu Rhizoma

Curcumae), Zao Jiao Ci Spina Gleditsiae), Ji

Xue Teng Caulis Spatholobi), Dang Gui (^

0 Radix Angelicae Sinensis), Bai Jiang Cao (feW^ Herba Patriniae), and Tu Si Zi (Semen Cuscutae), which were mixed and made into granules. One dose of the granules was infused in boiled water, 2/3 of which for oral administration once daily, and 1/3 for one-hour ultrasonic penetration on the body-surface projection area of the uterus and bilateral appendix with the continuous wave in a intensity of 1.8-2.1 W/cm2, 3 months constituting one therapeutic course. The results showed cure in 19 cases, marked effect in 11 cases, improvement in 7 cases, and failure in 5 cases. The total effective rate was 88.10%.

YANG Yi23 adopted the triple-therapy for treatment of EM in 40 cases. 1) The self-made herbal prescription Chushi Poyu Zhixue Tang (^iSfiÄ^^ Mffi Decoction for removing damp and blood stasis and stopping hemorrhage) was used for oral administration. The ingredients were Xiang Fu Rhizoma Cyperi), Hong Hua (^X^ Flos Carthami), Yi Mu Cao Herba Leonuri), Che Qian Zi (^

Semen Plantaginis), Dan Shen Radix

Salvia Miltiorrhizae), Niu Xi ( Radix

Achyranthis bidentatae), Cang Zhu Rhizoma

Atractylodis), Shan Yao Rhizoma Dioscoreae), E Zhu Rhizoma Curcumae), and Huang Bai (^

ft Cortex Phellodendri). The decoction was taken one dose daily. 2) The dregs of the decoction were decocted again into 100 ml of medicinal fluid to be used for enema in the evening. Before the enema, the bowels should be relieved; and the medicinal fluid should be retained for more than 4 hours, which was conducted once daily, and should be stopped during the menstrual period. 3) Point-injection with 2 ml salvia injectio or angelica injection into 2-4 of the following points: Guilai (ST 29), Shuidao (ST 28), Siman (KI 14), Daju (ST 27), Sanyinjiao (SP 6), Hegu (LI 4), and Taichong (LR 3). The injection was given once every other day, and suspended during the menstrual period. 3 months of treatment formed one therapeutic course. The therapeutic effects were evaluated after 2 courses of the treatment. The effective rate was 95% for dysmenorrhea, 97.5% for profuse menstruation, and 85% for a prolonged menstrual period. Among the 17 infertility cases, 14 got pregnancy, and 12 gave child birth.

To sum up, TCM may show its superiority in treating EM. Based on syndrome-differentiation, it can give the differential treatment, periodic treatment and special-prescription treatment. In view of the pathogenesis of EM, the therapeutic method for promoting blood circulation and removing blood stasis should be taken as the first choice in the treatment,24 with the other methods adopted for tonifying the kidney and soothing the liver, which can yield marked therapeutic effects. TCM treatment for EM may show the effects of alleviating dysmenorrhea, removing mass in the abdomen, regulating menstruation to help pregnancy, and improving the symptoms. In addition to the oral medication, the ways for TCM treatment also involve enema, acupuncture and external application. Many of the clinical researches have demonstrated that the herbal medicines can promote a quick atrophy and retrogression of the ectopic endometrium, and with less side effects and good long-term therapeutic effects.

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(Translated by WANG Xin-zhong