Endometriosis (EDM) is a relatively common Gynecological pathology affecting up to

30 % of the Australian female population between the ages of 20 and 45. Due to
this commonality and the potentially invasive nature and undesirable effects of
biomedical intervention, it is worth exploring alternatives or adjuncts in its
management. There are a number of papers which support the implementation of
Chinese Medicine (CM) in the treatment of this pathology, with many researches
claiming success rates of up to 80%. This review will discuss the research based
advantages of CM intervention, while presenting the current biomedical explanation
of, and treatment of this pathology.
Chinese medicine perspective on EDM
Endometriosis, termed Neiyi in mandarin is seen from the CM perspective as being
basically that of a blood stagnation condition (Marchment, 2007, p.57) with the
further development of inappropriately located abdominal adhesions and glomus.
With regard to the underlying Pathomechanism of EDM It is normal for there to be a
degree of back flow of blood during the period due to various factors such as
stagnation of Liver Qi which sees blood coursing back into the pelvic cavity, which is
often termed retrograde menstruation. A prevailing theory in CM which incorporates
the biomedical perspective, is that of compromised immunity. In those whom an
immune response may be weak, the process of cleaning up (Phagocytosing) the
affected areas is reduced. This allows endometrial tissue to build up inappropriately
and induces the condition. What is known in CM is that blood stasis is seen as the
main manifestation with the actually underlying causes of Dysmenorrhea being
determined by still further underlying CM differentials, highlighted later in this
paper.
EDM is often categorized into two distinct manifestations or groups, being weak and
strong. Strong endometriosis sees the presence of distinct lesions, severe pain, with
a heavy and clotted menses. The main option here is surgery/Laparoscopy which
sees good but all be it often short term results because the origin has not been
dealt with. Weak type EDM may often involve some quite severe symptoms such as
intense pain and debility however laparoscopy shows fairly mild and undefined
lesions with patients reportedly feeling much worse after the procedure than before.
Here debility and lethargy accompanied by pain are reported to be the main
complaints in patients of weak type following the procedure. As we will see, CM
intervention has the best explanation as to why this negative outcome if is often the
case. Other Biomedical treatment options include Diathermy and hormonal therapy
with the use of progesterone. (Colledge, 2010, p.916)
Underlying CM patterns which manifest into EDM
Qi stagnation: (Strong type) this creates tension within the abdomen which slows
down Blood flow leading to its stasis. This coupled with the channel pathways of the
Liver, both internal and external, which run from the Liver into the pelvic cavity and
along the sides of the uterus respectively.
Kidney Yang deficiency: (Strong type) Due to Yangs characteristic dynamic and
moving quality, a decline here can result in the slowing down of blood movement

within the pelvis and is consequent stagnation, resulting in EDM via two
mechanisms. Blood stagnation will often be difficult to shift during normal
menstruation, this creates a dynamic where back flow of blood and its consequent
inappropriate placement occurs within the pelvic cavity. Also blood stagnation is
likely to eventually manifest as Qi stagnation which will also result in a backward
course of blood during period as above. Cold retention may also occur via Yang
deficiency and further compound the condition.
Blood Deficiency: (Weak type) Here there is inadequate blood which easily becomes
stagnant. These patients are often weaker constitutionally, which explains the high
response to pain and the debility experienced. These patients also feel more
debilitated after surgery due to consumption of Qi and blood. Qi deficiency can also
be a factor here where there is inadequate Qi to drive the movement of blood
leading to its stasis.
Biomedical perspective on EDM
Biomedically EDM falls into the idiopathic category with no clear explanation as to
its exact causative Pathomechanism, however there are some theories surrounding
this. A familial component is observed therefore it is proposed that a genetic factor
may be involved, however this factor has not been proven to date. This may
correlate to a Kidney deficiency or pre heaven deficiency state in CM. Being that the
cells of the endometrium have a commonality in origin with the cells of the
peritoneal it is proposed that inflammation may cause a transformation from one
cell morphology to the other and induce EDM. The symptom picture is clearer than
any proposed underlying Pathomechanisms, along with the disease process and
manifestation. Chiefly severe pain during menstruation is characteristic of EDM,
however this pain is different from mere Dysmenorrhea and will extent to the flank,
pelvic cavity, and abdomen and back in many cases, and the condition can also at
times be asymptomatic with regard to pain. When pain does occur this is due to
tissues which are biologically similar endometrial tissue, being inappropriately
located outside of the uterus, this is referred to as ectopic endometrium, (Mcance,
2010, p.838). Lesions or adherences of these tissues can occur in various locations
in the pelvic and abdominal cavities, most commonly, ovaries, uterine ligaments,
rectovaginal septum, and peritoneum. During the normal process of menstruation
which commences in response to elevated estrogen levels, endometrial tissue
begins to shed from all locations ie either uterus or otherwise, this induces the
functional pain experienced. Some sources claim that this tissue will actually
proliferate with time. As endometrial tissue begins to break down during
menstruation inflammation takes place, which explains the neuropathic and more
severe pain experienced from a biomedical perspective. A sequelae of inflammation
may result in the development of fibrosis, scaring and adhesions. Further symptoms
suggestive of EDM include, pain during intercourse and in pelvic region, increased
menstrual bleeding, changes in bowel activity during menstruation with the
possibility of rectal bleeding, but only laparoscopy will confirm the condition.
Biomedical treatment may involve the use of laparoscopy followed by removal of
the masses, and this is not a final cure in that often the endometrial tissue will
simply reoccur. Other treatments include the use of the oral contraceptive pill which

ultimately prevents the build up of endometrial tissue and menstruation so

therefore prevents the condition, along with the use of GnRH agonist which blocks
ovarian release of pituitary hormones, but these will result in the absence of
menstruation in order to prevent the condition and of course the potentially
undesirable effect of inability to conceive. Other strategies enlist the use of NSAI
drugs and other forms of pain relief. The condition sees a high percentage, up to
50% of women, infertile and in fact around 25% of women undergoing IVF have the
condition. (Smith, 2011, p.1) Infertility is likely due to the formation of fibroids or
scar tissue along with adhesions which can block the passage of ovum along the
fallopian tube as well as blocked implantation of the embryo. Due to this it is
important that effective and affordable treatment, either CM or not, be validated
scientifically and applied.

History of Chinese Medical treatment approach

In China Biomedically defined Endometriosis has been treated with a wide range of
herbal strategies beginning primarily in 1960s with the introduction of laparoscopy
from the west. Since 1979 extensive research commenced in china regarding the
use of herbal formulas to treat the condition with a focus on the drug Gossypol,
which sees success in 90% of cases with results maintaining in 63% of patients post
intervention. (Please see Appendix A)
Contradiction between Chinese medical and Biomedical perspectives
There is glaring contradiction between these two approaches which comes about in
part due to the trend of combining aspects of each. In modern Chinese medicine a
compromised immune system is seen as being an integral aspect of the
development of the condition, where backflow of menstrual blood essentially
becomes deposited in the various tissues outlined above, and when coupled with a
compromised immune respond, manifests as DSM. However from the Biomedical
text book perspective we see inflammation ie an immune response causing the pain
seen. Clearly both perspectives cannot be correct at once.
Research
A 2011 Cochrane database systemic review of 24 studies found two suitable parallel
randomized control trials. Treatment took place over a 3 month period,
implementing CM herbal intervention in the treatment of post laparoscopy EDM.
Here laparoscopy was performed only for diagnostic purposes and endometrial
tissue was not removed during the procedures. According to the authors, at end
point CM intervention was shown to have similar results as the prevailing
pharmaceutical Gestrinone (Please see Appendix B). 158 women were included in
this review based on selection criteria of confirmed diagnosis via Laparoscopy in
addition to vaginal and rectal ultrasound and most importantly all women where

given the correct CM differential diagnosis of having EDM due to Qi and Blood
stagnation with underlying Kidney deficiency in conjunction with their EDM. As a
side note According to the authors there was no significant statistical difference
between recovery rates. Factors such as pregnancy rate post laparoscopy were
similar with a rate of 69.6% seen in the CM group and 59.1% in the Gestrinone
group. One trial in this review discussed the use of the CM herbal Nei Yi Wan and
the implementation of a CM herbal enema, (Please see Appendix C) as treatment
protocol, with the use of the Biomedical drug Danazol (Please see Appendix D) as
control. The second trial again used Nei Yi Wan along with the herbal enema as
treatment compared to the Biomedical drug Gestrinone as control. (Please see
Appendix B)
Results confirmed that CM can be just as effective as Biomedicine in the treatment
of strong type EDM. Purely from a symptomatic relief perspective, with CM
intervention showing a value of 95.65% vs 95% for Gestrinone intervention. 24
months post end point the incidence of pregnancy among the CM group showed 4
confirmed pregnancies at 3 months, 17 at 4 to 6 months, 8 at 7 to 12 months with 1
at 13 to 24 totaling 30 pregnancies. The Gestrinone group showed 0, 12, 12, 3 and
2 respectively, totaling 29 pregnancies. This is deemed to be statistically equivalent
with a rate of 69.6% for the CM group and 59.1% for control.
With regard to the second study included in this review CM intervention actually
showed vastly better results in subjective symptomatic relief, with a rating of 56.3%
for the CM group and 11.1% for Danazol. The study also compared the oral herbal
formula group and the herbal enema group and there was no significant statistical
difference between these, which gives further validity to CM herbal intervention in
the treatment of strong type EDM with Qi and Blood stagnation and underlying
Kidney Yang deficiency.
(Flower, 2012, pp.1-8)
A 2011 Cochrane review looked at 24 studies on EDN treated with acupuncture,
although the studies did appear to show good results with regard to pain
management, only one study was deemed to meet inclusion criteria. The study
involving 67 patients and compared acupuncture intervention against CM herbal
medicine intervention for pain symptoms. Pain scale reading were taken using the
15 point guideline for clinical research on the new Chinese Medicine treatment of
Pelvic Endometriosis scale. (Please see Appendix E) The acupuncture group showed
a statistically significant result with a rating of 12.19 2.42 pre-treatment versus
5.53 2.17 post-treatment, P < 0.05), whereas Chinese herbal medicine did not
have a statistically significant effect (11.22 3.11 pre-treatment versus 10.34
3.51 post-treatment, P > 0.05.
(Zhu, 2011)
In 2006 a successful acupuncture trial compared the following 3 treatments, the use
of Shu and Mu acupuncture point combinations, BL18, BL20, BL23, LV14, LV13,
GB25 with, LI4 Ren3 Ren4 SP6, and Danazol. The study determined that
acupuncture once again out performed Danazol in the treatment of EDM. Each

group consisted of 30 EDM cases and results were statistically similar across all 3
groups, with the Shu and Mu group being superior to the two other groups.
According to Jiu, Shu and Mu point combinations have an obvious therapeutic effect
on EDM with lower adverse effects than that of western medicine.
(Jiu, 2006)
A 2011 Cochrane review identified 2 acceptable acupuncture studies from a
possible 24 in which CM herbal intervention was compared to CM acupuncture
intervention in the treatment of EDM. This study however was determined by the
authors to be poor and inconclusive in spite of seemingly positive results in favor of
the acupuncture treatment group. The study was ignored based on the grounds of
poor quality methodology. While this study will not satisfy science it is still worth
examining these results further. Other reasons stated as to poor risk and bias was
the explanation that neither participants nor practitioners where blinded during the
trial. Science takes issue with this because here the placebo effect cannot be
entirely ruled out which according to this writer does not make any sense. This is
because it is not possible to blind the treating acupuncturist while also giving
genuine acupuncture treatment because point locations will be incorrect. The small
sample size of 67 participants was also sighted as an additional weakness in that 40
participants per group are the minimum requirement to satisfy science.
Results: Overall improvement as defined by the guidelines for clinical research on
new Chinese Medicine for treatment of pelvic EDM showed that acupuncture did
show an 81.1% improvement when compared to 26.7 for the CM herbal group. 11
out of 37 participants of the acupuncture group where cured and 3 participants from
the group of 30 CM herbal medicine group experienced cures with a total effect rate
of 91.9% and 60% respectively. These results may be considered adequate enough
to encourage CM practitioners to incorporate auricular acupuncture in their clinics
because after all at the end of the day there is no double blinding or bias control to
be seen in a clinical setting. However the study offers very little to go by as no
mention of the specific point combinations, herbal prescriptions or underlying CM
patterns can be found within the pages of the article.
(Zhu, 2001, pp.1-8)
Conclusion
This review has shown that there is indeed some evidence that CM intervention
either Herbal or acupuncture has an effect on and in many cases can cure incidence
of EDM beyond that of a mere placebo effect. Further research is needed in future in
order to validate this modality in the eyes of science. Perhaps at some point these
therapeutic approaches may move out of the realm of adjunctive or complimentary
medicine and fall into the category or merely medicine in the eyes of science.