Endometriosis is a condition which has puzzled doctors for a long time. It is associated with painful periods, pain during intercourse, spotting before periods and infertility. But not always so: there are many cases of severe endometriosis discovered by accident during investigation or surgery for something else, or during a hysterectomy, which have never contributed to any difficulty with periods or with conceiving. And, on the other hand, bad period pain and great difficulty falling pregnant are sometimes seen to be associated with almost insignificant amounts of endometriosis seen on laparoscopy. Premenstrual spotting occurs in the majority of endometriosis cases.

The disease is defined by the presence of endometrial tissue somewhere in the pelvic cavity but outside the uterus. Rarely, endometrial tissue can be found in other locations in the body. To date, laparoscopy is the only reliable way to diagnose endometriosis.

Endometriosis tissue not only varies in its appearance but also in how deeply it attaches to the membrane covering the pelvic cavity and the organs. This too influences its effect on the body:

● superficial endometriosis sits on the surface of the membrane and seems to       be more implicated in infertility

● deeper endometriosis penetrates a few millimetres into the membrane and         the underlying tissues and causes pain.

● If there is a significant amount of endometriosis in a very inconvenient     

   place, such as the fallopian tubes or ovaries, it is not difficult to see how     

   the distortions it causes could prevent conceptions. But this is the reason     

   for difficulty in conceiving in only 5% of cases.

● Endometriosis tissue may affect fertility by attracting or activating

   more macrophages to the area. Macrophages are large cells which

   mop up cellular debris and bacteria and other foreign material.

   The peritoneal cavity of a woman has quite a large number of macrophages 

   and one of their jobs is to finish off sperm that swim all the way out of the

   tubes and into the abdomen. When there is endometriosis present, the 

   macrophages seem to become more activated and go on seek and destroy

   missions with great vigour.

   Unfortunately these vigilantes can enter the fallopian tubes and pick off     

   sperm before they have had a chance to meet the egg. In women with

   partners with poor sperm counts this can be quite disastrous, leaving no

   sperm at all to fertilise the egg.

   These same macrophages have also been shown to produce

   cytokines, which are chemicals which are toxic to sperm and to

   embryos, providing another damaging blow to fertility.

● The type of endometriosis that sits superficially on the membrane

   surrounding the pelvic structures has been shown to have glands

   similar to that found in the endometrium. These glands secrete

   mucus. This mucus can coat the fimbriae or the ovary, preventing

   the transfer of the egg to the tube. Such a phenomenon has been

   observed in animal studies.

● Endometriosis is associated with increased levels of prostaglandins (PGE     

   and PGF), which appear to have a deleterious effect on the patency and

   flexibility of the fallopian tubes.

● endometriosis is associated with a higher incidence of the ovulatory

   disturbance luteinised unruptured follicle syndrome (LUFS) and lower

   progesterone levels in the luteal phase.

The primary aim of the TCM doctor in the treatment of endometriosis

has always been to remove Blood stagnation. Symptoms such as severe stabbing period pain, clotty menstrual flow and palpable nodules or masses in the abdomen appear to verify the diagnosis of stagnant Blood.

A patient presenting to a TCM clinic with endometriosis will be diagnosed according to her main symptoms and her constitution. When treatment is prescribed as part of an infertility treatment, the doctor will be particularly mindful of reinforcing Kidney Yang and resolving Blood stagnation. Liver Qi stagnation and Spleen Qi deficiency may also contribute and some cases of endometriosis will exhibit elements of Heat or Cold or Damp.

We do know that menstrual blood travels not only downwards from the uterus and out through the cervix but also upwards through the fallopian tubes and out into the peritoneal cavity. This small quantity of blood carries with it bits of discarded endometrium. Women with strong uterine cramps (due to Liver Qi stagnation) are more likely to lose more menstrual flow upwards through the tubes.

The blood and the tissue will either be reabsorbed, or will remain and establish itself somewhere in the pelvic cavity. If Kidney Yang is strong, then movement of Qi in the pelvis will mobilise the menstrual debris, which shouldn’t be there, and it will be efficiently reabsorbed. A weaknessof Kidney Yang, on the other hand, will allow the accumulation of blood and tissue such that it stagnates.