Endometriosis

Chinese Medicine for Endometriosis

Endometriosis, defined by the presence of viable endometrial tissue outside the uterine cavity, is among the most common gynaecologic disorders affecting women of reproductive age. According to the theory of TCM, the etiology of endometriosis is Blood stasis. Blood stasis causes a Fire syndrome and the accumulation of Damp-heat in the lower part of the body (“Lower Jiao”). As most of the patients with endometriosis suffer from the symptoms of pelvic inflammation, the accumulation of Heat and Blood stasis are the main pathologic changes. Although the pathogenic factors and pathogenesis are complex, the keys are Dampness, Heat, and Stasis.

CHM and acupuncture have gained satisfactory curative effects in treating endometriosis. In one clinical research, a Chinese medicinal formula with Radix ec Rhizoma Rhei as the main ingredient was used to treat 76 patients with endometriosis, and the total effective rate was 80.26% (Wang et al., 1991). Another clinical research, with removing Blood stasis, resolving Phlegm, softening and resolving the Lump as the therapeutic principles, successfully treated 46 endometriosis patients with a total effective rate of 91.3% (Liu, 1994). Ketong Decoction, with Radix codonopsitis pilosulae, Radix paeoniae rubra and Rhizoma ligusticum wallichii as the main herbs (ingredients), respectively obtained a curative rate of 81.0%, 75.9% and 58.3% in treating endometriosis patients of I, II, and III stages, all higher than those of the controls (Yu, 1998). Neiyixiao Recipe (including Rhizoma sparganii, Rhizoma curcumae, Hirudo, Eupolyphaga sinensis walker, Squama manitis, Semen cuscutae, Herba epimedii, etc) has also been found to be effective in treating endometriosis by tonifying Kidney and removing Blood stasis (Liu et al., 1998). NYF (consisting of Radix ec rhizoma rhei, Semen persicae, Ramulus cinnarnomi, Rhizoma sparganii, Spica prunellae and Carapax et Plastrum testudinis) has been found to have good clinical effects in treating endometriosis., which had significantly decreased the prostaglandin F 1α (PGF1α) levels and increased the 6-keto- PGF1α/ thromboxane B 2 (TXB2) ratio and the level of β-endorphin in the patients (Yu et al., 2003). Yushi Neiyi Fang, consisting of Radix Astragali, Pollen Typhae, Semen Persicae, Hirude Nipponica Whitman and Herba Epimedii gained a total effective rate of 91.67% in treating 36 patients with endometriosis (Song et al., 2005). A study with the purpose to observe the clinical efficacy of Quyu Jiedu Recipe, which consisted of Caulis sargentodoxae, Flos rosae rugosae, Flos lonicerae, Fructus forsythiae, Radix salviae miltiorrhizae, Radix paeoniae rubra, Cortex moutan, in treating endometriosis, and to explore the changes of the levels of vascular endothelial growth factor (VEGF) and cell proliferative nucleoprotein antigen (Ki-67) before and after treatment, showed that before treatment, the VEGF and Ki-67 expression positive rates and their mean optic density (MOD) were higher in patients than in healthy women, while, after treatment, the positive rate and MOD of VEGF expression significantly lowered, but those of Ki-67 changed insignificantly, and the comparison between the two treatment groups showed no significant difference (Lian et al., 2007).

For those patients with post-operational relapsed endometriosis, Chinese medicinal herbs have also gained satisfactory curative effects. Zhu treated 31 patients of post-operational relapsed endometriosis with integrated TCM and Western medicine and gained a total effective rate of 90.32%, in which, Radix salviae miltiorrhizae, Cortex moutan, Radix paeoniae rubra, Pollen typhae and Semen persicae, Hirudo were used as the main herbs (Zhu, 1998). Another research aiming to observe the clinical efficacy and safety of Yiweining (YWN, a Chinese medicinal formula, consisted of Radix angelicae sinensis, Rhizoma corydalis, Rhizoma curcumae, Semen persicae, Radix paeoniae rubra, Flos carthami, Radix salviae miltiorrhizae, Carapax et Plastrum testudinis ) and gestrinone (GT) in treating post-operational patients of stage III endometriosis found that the recurrence rate in the YWN group and the GT group were 5.0% and 5.3% respectively, showing insignificant difference between the two groups and the adverse reaction rate in the YWN group was lower than that in the GT group, which concluded that the application of YWN to prevent the post-operational recurrence of endometriosis was effective and safe, and its efficacy was similar to that of GT (Yang et al., 2006). Another research was also conducted to investigate the effects and the mechanism of E-leng Capsule (consisting of Rhizoma sparganii, Rhizoma curcumae, Radix Paeoniae rubra and Radix salviae miltiorrhizae) in preventing and treating post-operation recurrence of ovarian endometriotic cysts (Cao et al., 2008). The 12-month follow-up showed that recurrence presented in 1 patient in the treatment group (3.3%), and 6 in the control group (20.0%), showing significant difference between them and the expressions of tissue inhibitor of metalloproteinase-1(TIMP-1) mRNA in eutopic and ectopic endometrium were both higher in the treatment group than the control group, while the expressions of matrix metalloproteinase-9 (MMP-9) mRNA were lower, indicating that E-leng Capsule can reduce the invasive ability of endometrium tissue probably by regulating the balance of MMP/TIMP, namely, increase the expression of eutopic and ectopic endometrial TIMP-1 and decrease the expression of ectopic endometrial MMP-9, and thus achieve its preventive and therapeutic effects on the recurrence (Cao et al., 2008).

Some animal experiments have ever been conducted to explore the mechanism of Chinese herbs and acupuncture in treating endometriosis. Two researches were conducted to explore the effects of Yiweining (YWN, a Chinese medicinal formula, consisting of Radixp paeoniae rubra, Rhizoma curcumae, Rhizoma corydalis, Radix scutellariae, Semen coicis, etc.) on the cytokines and the expressions of metalloproteinase-2 (MMP-2) and cyclooxygenase-2 (COX-2) mRNA of the model rats with endometriosis (Qu et al., 2005; Qu et al., 2006). Their results showed that the contents of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and interleukin-8 (IL-8) in the peripheral blood of the model group were apparently higher than the false-operation group, and YWN had reduced the amount of TNF-α, IL-6, and IL-8 in the serums of the model group’s rats, which concluded that YWN could prevent the growth of ectopic endometrium by inhibiting the synthesis and secretion of TNF-α, IL-6, and IL-8 (Qu et al., 2005). There were also significant differences in the expressions of MMP-2 and COX-2 mRNAs between the untreated group and the high-dose YWN-treated group (Qu et al., 2006). In the prescription of YWN, Radix paeoniae rubra is the main herb to resolve dampness, remove blood stasis, and reduce Fire, which adapts to the pathogenesis of endometriosis. Rhizoma curcumae could remove blood stasis, promote flow of Qi, soften solid masses and relieve pain, promote the circulation of the efficient components of the drugs in Blood. All these herbs, used together, play a role of promoting the circulation of blood and removing blood stasis and act as monarch herbs. Rhizoma corydalis can promote the flowing of Qi and relieve pain in order to increase the function of promoting the circulation of blood and removing blood stasis.

Radix scutellariae and Semen coicis in the prescription function together to reduce Fire and resolve dampness (Qu et al., 2005; Qu et al., 2006).Acupuncture also has good curative effects in treating endometriosis. Acupuncture at Xuehai (SP-10) and Sanyinjiao (SP-6) acupoints were found to have a better therapeutic effect on the model rats with endometriosis, which could down-regulate the abnormal increase of MMP-2 levels to inhibit the invasion of ectopic tissue to extracellular matrix, thus reducing the ectopic tissues (Chen et al., 2008). In a clinical research to compare the therapeutic effects of the combined use of Shu-Mu acupoints, routine needling method and Western medicine treatment on the patients with endometriosis, the researchers found that the total effective rates were similar in the three groups and the Shu-Mu acupoints combination group was superior to other two groups in improvement of dysmenorrhea, irregular menstuation, lumbago and sacrodynia, anus engorge, moreover, the serum CA125 levels in the Shu-Mu acupoints combination group were significantly decreased (Sun and Chen, 2006).

Endometriosis is a common cause of pelvic pain in women, which has a negative influence on the ability to work, on family relationships and sense of worth. Acupuncture may be used as an adjunct in treating endometriosis pain (Lundeberg and Lund, 2008). In a case report, two adolescent girls wit endometriosisrelated chronic pelvic pain of more than 1 year experienced modest improvement in pain as measured by oral self-reports of pain on a scale from 1 to 10, as well as self or family-reported improvement in headaches, nausea and fatigue after undergoing between 9 and 15 treatments over a 7- to 12-week period and no adverse effects were reported, which provided a preliminary evidence that acupuncture may be an acceptable and safe adjunct treatment for some adolescents with endometriosis-related pelvic pain refractory to standard anti-endometriosis therapies (Highfield et al., 2006). Ear acupuncture therapy has also demonstrated satisfactory curative effects in treating 37 cases of dysmenorrhea due to endometriosis in a clinical research (Xiang et al., 2002).

At present, a randomized controlled trial is being conducted to test the hypothesis that TCM (acupuncture and CHM) reduce endometriosis-related pelvic pain as effectively as nafarelin therapy without causing the pseudo-menopausal side effects that accompany gonadotropin-releasing hormone-α (GnRH-α) therapy in Women’s Health Research Unit of the Oregon Health Sciences University and the Oregon College of Oriental Medicine, U.S.A. In the study, women were randomly assigned to receive either 12 weekly treatments of TCM or 12 weeks of the FDA-approved GnRH-α treatment. The protocol (NCT00034047) is funded by the National Center for CAM (NCCAM). This will likely prove to be a landmark study in alternative endometriosis therapy.

A great number of clinical researches as well as animal experiments have demonstrated the eminent efficacy of CHM and acupuncture in treating endometriosis. However, large-scale, multi-centre, randomized, double-blind and placebo-controlled clinical researches should be conducted in the future and a standard therapy of TCM should be established.

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