Abstract
Background: Endometriosis is the cause of chronic pelvic pain in 70% of all chronic pelvic pain cases in women in the United States. Traditional Chinese Medicine may present either an adjunct or optional treatment for women with chronic pelvic pain due to endometriosis.
Objective: To detail possible effects of Traditional Chinese Medicine on pelvic pain secondary to endometriosis through presentation of a single case.
Design, Setting, Patient: A nulliparous 43-year-old woman presented with endometriosis and fibroids. The patient was treated twice weekly for a 6-month period in a Traditional Chinese Medicine clinic in Berkley, CA. Treatment included 6 months of acupuncture at the following points: CV 3, 4, and 5; ST 25 and 36; GV 20; LI 4; LV 3; KI 3; SP 6 and 9; and Zi Gong Xue and Ah Shi points along with 1 month of herbal treatment in the form of both tea and tea pills.
Intervention: Acupuncture and herbal formulas.
Main Outcome Measures: Decrease in pain level and symptoms measured by patient assessed value of pain through the Pain Quality Assessment Scale.
Results: Patient overall disposition and pain level improved for a 6-month period.
Conclusions: Acupuncture did have some positive effect on pain management.
Keywords: endometriosis, acupuncture points, infertility, dysmenorrhea, Traditional Chinese Medicine, acupuncture treatment
Introduction
In endometriosis, the tissue that normally lines the uterus builds up in other areas of the pelvis, outside the uterine cavity.1 Symptoms of the disease include, but are not limited to, dysmenorrhea, infertility, and menorrhagia. Up to 15% of all women of reproductive age2 and 70% of female chronic pelvic pain patients have endometriosis.3 This article documents a case of a 43-year-old woman with no history of pregnancy who presented with endometriosis and fibroids in late 2016.
The woman was diagnosed with endometriosis in her early teens and fibroids were diagnosed in 2016. Her endometriosis caused monthly debilitating pain during the beginning of her menstrual cycle and generally caused her to miss 1 to 2 days of school as a teen and 1 to 2 days of work as an adult. The pain was in her back and lower abdomen, radiated down her legs medially to her ankle, and ranged from dull to sharp. Before her fibroid diagnosis, she generally took 400 mg of Motrin in conjunction with hot tea and gin or rum for the pain.
From 2014 to 2016 her pain had increased in level and had become more frequent. Instead of occurring only in the first 2–3 days of her menstrual cycle, she started having pain at intermittent times. The pain quality at intermittent times was described as sharp or dull with a “pulling” sensation and, at times, better with heat. In 2016, an ultrasound scan showed 3 intramural fibroids. The largest was 2.5 cm in diameter. In addition to the fibroid pain, she generally ached due to fibromyalgia, which she was diagnosed with in 2014. Postdiagnosis of fibroids and fibromyalgia, she started Norco and Flexeril as directed.
By the time she sought out acupuncture, in late 2016, she had been given a single intramuscular 6-month dose of Lupron to stop her menses and shrink her fibroids, but the patient could not recall doses of her other medications and could only state how many pills she took daily. She did not provide physical pills for a dose check.
Her menses was regular, but heavy with dark clots at its beginning. Her cycle was normal in length and she had no leukorrhea between menses. Other symptoms during premenstrual syndrome (PMS) included breast distension, abdominal pressure, severe pain in lower back (described as a level 8–10 when it occurred), and tense wrist muscles. She generally was cold and had a bloating and heaviness in the abdomen. Her pain made it difficult to stand or walk.
In 2016, her diet consisted of standard American meals with the addition of sweets. She often craved for high-carbohydrate sweets, especially liked cookies and cakes, and had gained 75 pounds between 2014 and 2016 (2 years). She claimed she was always tired and always physically “hurt.”
Many of her female family members had histories of fibroids, but none for infertility, endometriosis, or fibromyalgia.
On physical examination, the patient's hands were cold to touch. She was pallor, tall, and her ankles and feet were edematous. Her tongue had a thick white coat and her pulse was slow, choppy, and wiry.
Methods
Acupuncture Rational
She was diagnosed with endometriosis and fibroids due to Kidney Yang Deficiency and Spleen Qi Deficiency with Blood Stasis and Liver Blood Deficiency. The treatment plan was to Tonify Kidney Yang, Tonify Spleen, and Tonify and Move Blood.
Details of Treatment
Acupuncture points used included CV 3, 4, and 5; ST 25; GV 20; LI 4; LR 3; ST 36; KI 3; SP 6 and 9; Zi Gong Xue; Ah Shi points; and, auricularly, Shen Men. All points were needled per Chinese Acupuncture and Moxibustion (CAM)4 recommendations according to depth and gauge of needle and were stimulated manually, both on initial insertion and after 15 minutes of being in the patient. The patient's total time with needles in was 30–45 minutes for each session.
Herbal formulas were rotated depending on the phase of the patient's menstrual cycle. The formulas prescribed were Shao Fu Zhu Yu Tang, as tea pills, and Gui Zhi Fu Ling Wan modified by adding Huang Qi,5 as tea. The patient took each formula twice daily during its respective part of her cycle.
Treatment Regimen
The patient was treated twice a week for 6 months. She was noncompliant with regard to the herbal formulas after 1 cycle.
Other Components of Treatment
There were no other lifestyle or diet changes made. The patient was reticent to take supplements; she felt she had “too many pills to keep track of already.”
Results
After each treatment, the patient felt a decrease in pain levels. After 6 months, her pain level had reduced from a level of 10 (wherein she was immobile and often in the emergency room [ER]) to a level of 3 to 4. She could manage pain and had a better quality of life (QoL). In 6 months, she had become mobile (but still used a walker due to an earlier spinal injury). In addition, her fibroids had shrunk and she was not bleeding as heavily (she used normal-to-heavy sanitary napkins during the day instead of overnight pads). She also had less clots during the first 2 days of her menses than she had before treatment.
Analysis and Discussion
Herbs
Gui Zhu Fu Ling Wan helps dissolve the masses and unstick and move the blood from the endometriosis. This formula invigorates blood, removes Blood Stasis, and reduces pain. It warms the channels to smooth the blood flow and break up Stagnation. Huang Qi was added to this formula to aid Gui Zhi in treating painful obstruction due to Qi and Blood Deficiency in the patient's muscles (which was evidenced by her weakness and anemia). Huang Qi also Tonifies Qi, Blood, and Spleen, and raises the Yang. For this patient, this formula was taken either during her menses or 1 week prior, because it is gentle enough not to move blood so strongly as to create uncontrolled bleeding.
Before the Gui Zhu Fu ling Wan (3 weeks before the first day of menstruation), this patient took Shao Fu Zhu Yu Tang to expel the Blood Stasis of endometriosis, Warm the Channels, and stop pain. Shao Fu Zhu Yu Tang invigorates blood, but since it is a stronger blood mover than Gui Zhi Fu Ling Wan, the patient was instructed to take it for 2 weeks, in pill form at a dose of 5 tea pills 2 times a day, so as not to have excessive bleeding during menses.
The patient complied with this part of the treatment for 1 month. Since she had not taken the formulas after the first month of treatment and had been given Lupron before her Traditional Chinese Medicine treatment, there is no way to determine whether pain reduction was due to the effects of the formulas. Because endometriosis is an estrogen-dependent6 disease and Lupron decreases estrogen levels, the addition of Traditional Chinese Medicine treatment to the lingering effect of Lupron may have had an additive positive effect on the patient's pain levels.
Points
Pain in the low back and coldness in the low back indicated Kidney Yang Deficiency. Therefore, KI 3 and SP 6 were used to tonify the Kidneys. Because she had a thick white coat on her tongue, SP 9 was added to transform dampness. Also, her foggy headedness (loss of recall) indicated that there may be some dampness or phlegm involved, so that too was a reason for the use of SP 9. In addition to the aforementioned symptoms, the fact that she craved for heavy sweets, had bloating, and was always tired indicated Spleen Qi Deficiency. SP 6, ST 36, and SP 9 all helped with that by Tonifying the Spleen Qi. SP 6 also helped with edema and bleeding.
The patient's fatigue was also due to Blood Deficiency. She had fairly low hemoglobin levels (the level was 10). In addition, she bled heavily due to her fibroids and the sudden loss of blood lead to tiredness. LR 8 helped treat her Blood Deficiency and SP 6 coupled with LR 8 both smoothed and Tonified the Liver. ST 36 helped give the patient more energy by Tonifying Yang. In addition, LR 3 was prescribed to help with uterine bleeding and to Smooth the Liver, since she was often argumentative and angry.
To Tonify Kidneys and Kidney Yang either CV 3 or CV 4 was used.8 In addition, this helped with excessive uterine bleeding. It also helped warm the uterus that would alleviate pain in the back due to Cold. Zi Gong Xue was needled bilaterally both to help stop excessive bleeding and as a general point for endometriosis.
Sometimes CV 4 was used with GV 20 to stop excessive uterine bleeding. GV 20 was also used to Calm Spirit and benefit memory, and, since it lifts Yang Qi, it also helped with the bulging disks in the patient's spine.
Finally, ST 25 and LI 4 were used to help with digestion in general. They also treated the patient's edema and Qi Stagnation, and generally benefited her.
Conclusion
The acupuncture treatment used in this case helped both the patient's disposition and pain levels. Since Ah Shi points were also used, the overall treatment protocol would be different for another patient. In addition, since both formulas and pharmaceutical drugs were used by the patient, there is no way to identify the efficacy of the formulas on shrinking the fibroids or stopping the patient's bleeding. A future study could be performed wherein a specific set of points, without the addition of Ah Shi points or herbal formulas, are used to test the effectiveness of those points on treating symptoms of the disease. However, because the patient felt less pain and generally felt better directly after treatment, acupuncture may have had a positive effect on pain management and treating other consequences7 of endometriosis, thus, increasing the patient's QoL.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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