Endometriosis, Uterine fibroids, and Ovarian Cysts

Paul Reller, L.Ac.

Abnormal tissue growths in the reproductive tract are a prevalent problem with women today, especially in industrial countries, and result in serious problems with fertility, pregnancy and menstruation, and often result in symptoms of pain and menstrual irregularity. Endometriosis is a pathology of the uterine lining, or endometrium, and affects over 5-10 percent of women in the United States. Many cases of endometriosis are asymptomatic and go unreported and unnoticed, so the exact percentage of women who experience these abnormal tissue growths is impossible to determine. Symptoms related to uterine fibroids develop in an estimated 30-50 percent of women by the age of 40. Understanding endometriosis, uterine fibroid and ovarian cyst formation is thus important to all women, and maintenance of the health of these tissues, and homeostasis is something that shouldn't be ignored. The specialized tissues that line the uterus, which we call the endometrium, may grow abnormally even outside of the uterus, most commonly up into the Fallopian tubes, as well as into the ovaries, and in rarer cases, into the outer intestinal layers, the pelvic cavity, the liver, the lung, and even the brain. While endometriosis is not technically a cancer, it may act like a cancer in its ability to spread in the body.

Endometriosis may occur at any time during the reproductive years, but most commonly will be diagnosed at age 25-30. Uterine fibroids are growths that may occur in the uterus, and are classified according to the layer of the endometrium or outer uterine wall where they occur. Ovarian cysts and other abnormal lesions of the ovaries and fallopian tubes are growths that may come and go, and may interfere with reproductive function. Polycystic ovarian disease is a type of ovarian cyst pathology that may be associated with other endocrine pathologies as well. The link to all of these abnormal tissue growth pathologies is hormonal imbalance. Sexual steroid hormones stimulate the cells and tissues of the reproductive tract to go through appropriate changes during menstrual cycles, and hormonal imbalance may result in abnormal tissue changes and inappropriate growth, just as hormonal imbalance may result in a premenstrual syndrome.

The causes of endometriosis and uterine fibroids remain unclear even after decades of extensive scientific study. What we do know is that a variety of pathological causes may contribute, such as hormonal imbalance, retrograde flow of the menstruation, immune reaction to retrograde menstrual flow, allergic reaction, autoimmune reaction, reaction to environmental chemicals and toxins, birth defects, tissue lesions, chronic inflammation, and inherited tendencies of cells to express as endometrial cells. Recent research shows that a common trait of pathological endometrial tissue is progesterone insensitivity, and an imbalance of estrogen receptors and growth factors, such as VEGF, an epidermal growth factor.

The body must maintain a balance of estrogen and progesterone for healthy function, and this balance changes during the menstrual cycle, as different tissue needs are present for preparing the uterine lining for egg implantation and growth. Various types of estrogen and progesterone receptors express during the menstrual phases, and are also modulated by the balance of estrogen and progesterone. These estrogen receptors and growth factors vary within the menstrual cycle, and a complex array of modulating and regulating factors keeps all of this function healthy. Complementary Medicine, and Traditional Chinese Medicine specifically, seeks to restore this healthy complex homeostasis, thus restoring function and healthy tissue growth and maintenance. Complementary Medicine will recognize that some or all of these many causative factors combine in the etiology of these health problems, and work to address them all with a holistic treatment protocol. Modern allopathic medicine will usually try to narrow the treatment focus to one cause, and this approach is what keeps the understanding of the pathology of these diseases unclear, and the standard treatment ineffective, except when the disease becomes severe and needs surgical intervention.

The physiological mechanisms that drive endometriosis and uterine fibroid growth may also be responsible for a majority of breast, uterine and ovarian cancers

These same underlying homeostatic imbalances that are seen in endometriosis and uterine fibroids, such as the imbalance of estrogen receptors and growth factors, and progesterone insensitivity, are also now recognized as integral to a majority of breast, uterine and ovarian cancers, and researchers have noted a twofold increase in risk of developing ovarian cancer with endometriosis in general, and a further fourfold increase in high risk endometriosis with infertility problems. One of the important reasons for utilizing Complementary and Integrative Medicine when diagnosed with endometriosis, uterine fibroids, or ovarian cysts, is to correct these underlying homeostatic imbalances that increase the risk of cancers in these tissues later in life.

Frequently seen in ovarian cancers is the prescence of clear cell carcinoma, and there has been speculation that clear cell tumors develop from endometriosis. Further investigation into this histological connection found that the expression of hepatocyte nuclear factor-1beta (HNF-1beta), which is related to liver cells, or hepatocytes, is significantly upregulated, or genetically overexpressed, in clear cell carcinoma of even benign ovarian tumors, or cysts, when these tissues are related to endometrial tissues that are affected by endometriosis. In fact, 40% of endometriotic cysts without a finding of cancer in biopsy also expressed HNF-1beta with inflammatory states. Such findings indicate that more systemic imbalances underly the development of endometriosis and ovarian cancers, and that a more holistic approach should be utilized to try to correct these imbalances. Now, Traditional Chinese Medicine (TCM) has always sought to define health problems by empirical observation and subsequent theories of holistic connections between homeostatic systems in the body. TCM physicians have long linked liver dysfunction to menstrual pathology and endometriosis, as well as problems with ovarian pathology and infertility. Such research as this (see research links below in information resources) show that TCM physicians hundreds of years ago were correct with their theories. Modern allopathic medicine gives the patient a number of therapies to act in specific ways, with surgery and drugs, to save the patients with more threatening aspects of these diseases, but does little to correct the underlying health imbalances that cause them. This is where the intelligent patients integrate Complementary Medicine and the Licensed Acupuncturist and herbalist to help restore health homestatic mechanisms and prevent future health risks.

TCM and Complementary Medicine may be integrated into standard care not only as a preventitive medicine, but as a successful adjunct to treat these abnormal tissue growths themselves, and also as a sensible adjunct to more successfully recover from surgical interventions and restore homeostatic hormonal balance as much as possible. A high recurrence rate of endometrioma is seen after laparoscopic cystectomy, which is utilized when the pathological endometriosis tissues have travelled to the ovaries. Current treatment guidelines in standard medicine have suggested that a course of hormonal suppression with drugs should be utilized to prevent this recurrence. Studies in 2009 (cited below in information resources) show that some randomized placebo-controlled trials indicate that this therapeutic approach has no significant effect on the recurrence rate of ovarian endometriosis. The side effects of this drug therapy are also harsh. Another approach is to integrate Complementary Medicine into the protocol to reduce recurrence of the ovarian endometriosis. This type of therapy is gaining recognition rapidly, with evidence of clinical success, and is able to incorporate a variety of therapeutic protocols individually tailored, with inexpensive monitoring of key active hormonal metabolites in saliva and veinous blood stick samples. There is no reason that this safe and healthy approach should not be integrated into care. Waiting until large studies are performed and go through the stages of human clinical trials, which is underway but underfunded, is not a sensible option for patients today when deciding whether to utilize these extremely safe treatment protocols.

Diagnosing Endometriosis and Understanding the relationship to other common health problems

A diagnosis of endometriosis is only fully confirmed with a surgical procedure and biopsy, usually utilizing laparoscopy, a minimally invasive surgical technique that allows the surgeon to use a thin surgical tool with cameras instead of creating a large incision. Until this procedure is performed, the medical specialist cannot fully confirm the diagnosis of endometriosis. Many medical experts state that ultrasound, CT and MRI studies are not indicated to diagnose endometriosis, and that a physical exam and history by a competent gynecologist should be enough to confirm suspicion of endometriosis and warrant a laparoscopic exam. The initial steps in diagnosis, though, usually include a pelvic exam and ultrasound, and these most often occur with a complaint of recurring pelvic pain, which can range from a mild to severe cramp, and occur on both sides of the pelvis, the low back, the rectal area, and may even be felt radiating down the legs. These various pain complaints are most often attributed to other disorders. If standard treatment does not correct these pain complaints, and they persist, the patient is advised to seek out a gynecology exam and be assessed for endometriosis.

Many cases of endometriosis do not involve pain, though, and the severity of pain is not indicative of the severity of the endometriosis. Often, endometriosis is suspected when the patient is being worked up for a fertility assessment, and in many cases there is no complaint of pain. Sometimes, the pain may only be felt as menstrual cramping during bleeding, or premenstrually, and sometimes only pain during sex, or dyspareunia, may occur. Some patients even without pain may complain of urinary urgency, frequency, or pain with urination. Of course, the course of symptoms will vary depending upon the location of the endometrial growth. Even women with a small area of endometriosis may be affected by infertility issues related to the disease. Even small tissue changes may create adhesions in the fallopian tubes or ovaries, impeding normal travel of the ova, and small endometriotic lesions may release hormonal and growth factors that may be detrimental to embryos and gametes. Many cases of endometriosis are thus overlooked and even diagnostic laparascopy may not find the endometrial lesions.

Mild endometriosis may also be secondary to hormonal problems that have also caused infertility. In this case, the endometriosis may not be directly inhibiting fertility, but you may want to resolve the underlying health problems before getting pregnant, even if utilizing in vitro, or other chemical and mechanical methods of fertilization. Since these underlying problems may have some impact upon the pregnancy and fetus, it is always wise to try to resolve these issues before pregnancy. Since in vitro, and other methods of inducing pregnancy are expensive, it is also wise to try to resolve issues of endometriosis or underlying problems with hormonal balance before starting these expensive procedures. While standard medicine has little to offer in this regard, Complementary Medicine has an increasing array of safe and effective therapies to correct these problems and restore healthy function and tissue quality. Fertility drugs, such as clomiphene may also cause endometriosis, due to the periods of excessive estrogens, follicle stimulating and luteinizing hormones induced by these drugs, which may excessively stimulate endometrial growth. While these strong hormonal changes may sometimes have a beneficial effect on endometriosis as well, these effects and tissue changes vary from patient to patient.

One underlying health problem that is often seen in cases with endometriosis and uterine fibroids is irritable bowel syndrome, or a syndrome that resembles IBS. Constipation, loose stools, diarrhea, abdominal bloating, chronic fatique, depression and anxiety are often seen in patients with endometriosis. These problems may worsen during menstrual periods. If the endometrial growth occurs in the outer intestinal tract, these symptoms may, of course, be directly tied to endometriosis, but indirect tissue adhesions and growths, as well as the inflammatory and clotting factors that may be released from abnormal endometrial tissues, may also cause these intestinal symptoms. The underlying mechanisms of inflammation and hormonal imbalance may be causative of both IBS and endometriosis, as tissue abnormalities from one disease may have a causative effect, or at least a contributing effect, on the other. Holistic medicine looks at the whole picture and treats the patient individually to provide a more thorough treatment approach, and in many such circumstances, this could be a key to an effective cure and prevention. Other health problems that are shown to have a potential link to endometriosis are fibromyalgia, subclinical hypothyroidism, chronic fatique syndrome, and rheumatoid arthritis. We see from this list that a wide variety of dysfunctions could contribute to tissue abnormalities such as endometriosis, uterine fibroids, and ovarian cysts. No matter what your approach to specific problems is, integrating with a knowledgeable Complementary Medicine physician, such as a Licensed Acupunturist, who supplies a holistic perspective and approach is sensible.

Studies have also found that women diagnosed with endometriosis have a higher incidence of autoimmune diseases, allergies, asthma, hypothyroidism, chronic fatique syndrome, and fibromyalgia. Since there is typically about a 10 year delay between onset of symptoms and a diagnosis of endometriosis, with most patients and their physicians attributing pelvic pain to other problems, the association with this broad array of other health problems is unclear, and research is ongoing to elucidate the pathological connections. A research study of 3680 patients that were surgically diagnosed with endometriosis, carried out by the George Washington University School of Public Health and Health Services in Washington, DC, together with the Endometriosis Association in Milwaukee, Wisconsin, found that 20% of these patients had been diagnosed with another serious disease. The largest prevalence of associated diseases included fibromylagia or chronic fatique syndrome, and these patients often were also diagnosed with an autoimmune disorder or endocrine disease, especially hypothyroidism, either subclinical or a clinical presentation. Of the autoimmune diseases, Lupus, Sjogrens, and Rheumatoid Arthritis had the highest association. Rates of concurrent allergies, asthma and/or eczema among this study group were over 60% of patients. The general population has a rate of occurence of these conditions of 18% for allergies, 12% for asthma, and 5% for eczema. For the women that had a diagnosis of both endometriosis and fibromyalgia or chronic fatique syndrome, the rate of concurrent allergies, asthma and/or eczema rose to 88% of the endometriosis patients. For those with a concurrent diagnosis of an endocrine disease such as hypothyroidism, the incidence was about 72%. The lead investigator for this study, Dr. Ninet Sinall, from the National Institute of Child Health and Human Development, stated: “As well as finding an increased prevalence of this wide range of diseases and conditions among women with endometriosis, we found that they reported significant pain and disability and, very worryingly, that there was typically a 10 year dealy between the onset of pelvic pain and diagnosis.”

Obviously, considering this broad set of strongly associated health problems, a complex set of immune, hormonal and even neurological factors may underlie the manifestation of endometriosis. This points to the need to holistically assess and treat these various problems and their causes.

Standard therapy in the treatment of uterine fibroids, or leiomyomas

Most experts in the field of gynecology agree that the majority of women with uterine fibroids should be monitored for rate of growth and symptoms, and that treatment should be limited to symptom relief except where the growths affect quality of life. This is because even surgical resection, or removal, of the fibroids, often results in a return of fibroid growth, unless the underlying causative factors are addressed holistically. Standard treatment of more severe uterine fibroids involves surgical resection, or uterine artery embolization (post-childbearing), which is also referred to as uterine fibroid embolization (UFE). Improved surgical techniques include less invasive laparoscopy and hysteroscopy, achieving myomectomy, or removal of the myomas (fibroids). A complete hysterectomy, or removal of the uterus, is still utilized, though, and in fact, the most prevalent justification for hysterectomy is the uterine fibroids, or leiomyomas. A study by Mount Sinai Medical Center of New York, in 2008, accessed just the records of hysterectomies on the Empire Blue Cross Blue Shield database for the years 2001 to 2005, and found that for claims related to a hysterectomy-associated diagnosis, that for 295,148 claims, 1,972 hysterectomies were performed and 5,077 hysterectomy alternatives, an improvement from the previous decade. The average age was 39, and the mean age of those undergoing hysterectomy or hysterectomy alternative was 46 to 50 years of age. Leiomyomas, or advanced uterine fibroids, were associated with the majority of hysterectomies performed. Abnormal bleeding was associated with the majority of hysterectomy alternatives (PMID: 18667172). This study shows that only about 2 percent of hysterectomy-related diagnoses result in a hysterectomy or hysterectomy alternative. Medications are usually prescribed to merely relieve symptoms, although contraceptive synthetic hormones may be prescribed in an attempt to modulate the fibroid growth. For nearly 98 percent of women with a hysterectomy-related diagnosis, there is little that standard medicine offers, rather than a wait-and-see, especially for women under the age of 46. For these women, Integrative and Complementary Medicine offers an array of treatments to address the hormonal and inflammatory dysfunctions underlying uterine fibroids.

Uterine fibroid embolization involves the insertion of a small catheter into the femoral artery and guided tubes directed to the arteries and arterioles supplying the fibroids blood. Embolic agents are then injected into these arteries or arterioles to deprive the fibroids of nutrient blood, causing them to gradually shrink. The most optimistic studies claim an 85 percent rate of effect, with a majority of women achieving significantly decreasing symptoms of pain, pressure, bloat or discomfort. Uterine fibroid resection, or myomectomy, is performed less than 40,000 times per year in the United States, much less than the hysterectomy. The American College of Obstetricians and Gynecologists (ACOG) recognizes this procedure only for women who need the surgical resection due to advanced symptoms, where the fibroids appear to inhibit fertility, and who want to have more children. Hysterectomy is still the treatment of choice for advanced fibroid growth. Complications of myomectomy include adhesion formation, excess blood loss, ureter damage, urinary complications, damage to internal organs, blood clots, or postoperative infection. A regrowth of the fibroids often occurs over time. Laparoscopic radiofrequency ablation (RFA) is also now applied to the reduction in fibroid growth, and is recommended for women with asymptomatic uterine fibroids, or smaller growths. Here, a guided catheter delivers electrical energy that heats the fibroid tissues to destroy cells, and this is usually performed in an outpatient setting. This procedure has been applied to postoperative bleeding, liver tumors, and cardiac arrhythmias in the past. The long-term success is still being evaluated.

No matter whether you choose to have a myomectomy, hysterectomy, UFE, RFA, or just monitor the fibroid growth and symptoms, Complementary Medicine may provide important integrative treatment considerations, and more importantly, address the array of underlying health problems that cause this abnormal growth. Acupuncture, electroacupuncture, herbal medicine, and nutrient medicine are increasingly studied to provide a proven array of adjunct therapies. Considering that a high percentage of women will suffer from uterine fibroid growths by age 40, and that a majority will be treated with just monitoring of growth and symptoms, the utilization of Integrative and Complementary Medicine seems like a sensible approach, and is becoming increasingly utilized by proactive patients. The side effects of this treatment is better overall health, reduction of risks of the spread of leiomyomas, improved quality of life, and prevention of an array of health problems.

Various causes and contributing factors are found in the study of Uterine fibroids, or leiomyomas

Research has revealed a variety of associations between other health problems and uterine fibroid formation, typically called leiomyomas in medicine. Hormonal growth factors, metabolic imbalances, hormonal imbalance, chronic inflammatory conditions, low grade deep tissue infections, environmental estrogen mimics, etc. have been linked, resulting in an unclear direction of approach in standard medicine. Holistic medicine may look at the individual and all of these potential underlying problems to correct the problem of uterine fibroids. Increasingly, uterine fibroid, or leiomyoma, tissues are found clinically throughout the body, with biopsies of abnormal growths revealing the origins of the abnormal cells as the uterine lining. Leiomyomas have been found in the intestinal wall, diverticula, rectum, bladder, Bartholin’s glands of the vagina, lung, liver, brain, sinus, arterial walls, Fallopian tubes, and pelvic cavity. Standard medicine provides an uncertain and often frustrating experience with treatment of uterine fibroids, and the time to integrate Complementary Medicine is early in the course of growth, understanding and systematically dealing with related health problems and causative factors to reduce the risk of spreading and complication, as well as to improve quality of life.

Underlying health problems associated with uterine fibroids, or leiomyomas, include variants in the expression of insulin-like growth factors, E-cadherin (calcium dependent membrane proteins associated with inflammatory tissue adhesions), the inflammatory cytokines interleukin-12R beta1 and TNF-alpha, genetic and epigenetic factors, and imbalances of hormones and hormone receptors. As of 2010, uterine fibroids are still not well understood, but like endometriosis, numerous scientific studies point to a multifactorial cause. Since the mid-1990s, it has been understood that complex interactions of steroid hormones and local growth factors, coupled with chronic inflammatory dysfunction, is responsible. At first, estrogens were thought to be central to this equation, but in time, it was discovered that progesterones also were integral to fibroid formation. Many studies showed how progesterone, synthetic progestins, and progesterone receptors modulated fibroid growths. An imbalance within the menstrual cycle of estrogens and progesterones create the environment for abnormal regulation of uterine tissue growth. Synthetic progestins, commonly used in contraceptives and hormone replacement therapy, may also stimulate unwanted growths. Monitoring of the estrogen progesterone balance, as well as the chief related hormone in the inflammatory cascade, cortisol, gives a clearer picture of these relative hormonal and inflammatory regulatory imbalances that cause the formation and perpetuation of uterine fibroids. Treatment with low dosage topical bioidentical hormone creams, coupled with acupuncture and herbal/nutrient medicine, provides the patient and the treating team with sensible options, that are safe and conservative, to integrated into care.

One very puzzling fact eluded scientific understanding for many years. This is the fact that uterine fibroids do not increase in size during pregnancy, and in fact, sometimes decrease in size, despite large increases in sexual steroid hormone levels, which are known to drive this tissue growth. On the other hand, growth of uterine fibroids often seems to cease after menopause, implying that lower levels of steroid hormones decrease stimulation of fibroid growth. If only the levels of steroid hormones were important, fibroid growth should accelerate during pregnancy. The answer to this puzzle was that a balance of estrogens and progesterones occurred during pregnancy that made this happen. This finding is now applied to treatment of fibroids with Complementary Medicine. Use of bioidentical hormone therapy and guided by simple testing with active metabolites in saliva samples allows the physician to help the body achieve a hormonal balance that is physiologically normal, which may reverse the growth of uterine fibroids, as compared to the use of synthetic progestins, which are used to block natural hormonal mechanisms, and create their own hormonal imbalance in the body.

The key study in this regard was conducted in Japan in 2003, where it was shown that the synthetic progestin levonorgestrel, in an implanted IUD, both stimulated uterine fibroid growth and inhibited it. The chemical progestin augmented the Bcl-2 protein, that induced apoptosis, or programmed cell death, in the fibroid cells, but inhibited the cytokine TNFalpha (tumor necrosis factor) in these cells, which would normally promote tumor cell death. Studies since then have recognized that hormonal, growth factor, and immunomodulating cytokine receptors on the outside and inside of these cells create a complex protection for the human organism against abnormal tissue cell growth. A homeostatic balance works to restore these natural protections to reduce fibroid growth and reestablism controls in these tissues. This is the goal of Complementary Medicine. To read this important study, click here: http://www.ncbi.nlm.nih.gov/pubmed/14667973

Other growth factors have also been implicated in the formation of uterine fibroids. Insulin-like growth factors (IGFs) and intracellular signaling molecules such as p-AKT, a protein kinase, or signaling molecule, that plays a role in cell proliferation, apoptosis, transcription, cell migration, and glucose metabolism, have been found to perhaps be part of a cascade that drives the excess growth of fibroids. A study (cited below) by New York University School of Medicine, in 2009, found that altered expressions of IGFs and related downstream proteins were found in one third of fibroids, with higher levels seen in larger fibroids. Locally, these growth factors seem to drive increased fibroid growth, but this seems driven by a complex interaction between circulating hormones, locally produced hormones, and various types of receptors to both estrogen and progesterone. Levels of androgens, Luteinizing hormone, and even Leptin have been implicated as well in this complex feedback, or crosstalk. Some research has explored the role of insulin resistance in the pathology as well. In pathologies such as uterine fibroids, which are often difficult to treat, a more comprehensive and holistic restoration of health may be needed to effectively reduce the fibroid growths.

Various causes and contributing factors are found in the study of ovarian cyst pathology as well

Ovarian cyst pathology may be divided into a variety of types. Simple ovarian cysts are frequently seen, often benign, and may come and go. Polycystic ovary disease, on the other hand, may be related to a variety of underlying imbalances, or even the migration of diseased endometrial tissues in endometriosis. Polycystic ovarian syndrome is a more systemic and complex presentation which involves problems with endocrine regulation, especially a relative androgen excess, and is often linked to diabetes or Metabolic Syndrome with insulin resistance, as well as obesity. The patient and the physician should not try to oversimplify the differential diagnosis and typing, or the understanding of the disease, when ovarian cysts are detected. A wide variety of presentations may occur, and just because the classic presentation is not seen does not indicate that a serious problem does not exist, or that some form of therapy should not be initiated. Often, standard medicine has a wait-and-see attitude with many of these diagnoses, or a one-size-fits-all approach. Perhaps a more sensible approach is to pursue an individualized diagnosis and consult a Complementary Medicine physician, such as a Licensed Acupuncturist and herbalist, with some expertise, to integrate into your care and initiate effective therapies hopefully before the problem worsens.

The classic presentation of the Polycystic Ovary Syndrome (PCOS) features an array of signs and symptoms, but not all of these are present in most cases. These signs and symptoms include irregular menstruation, temporary cessation of menstruation (amenorrhea), and infertility, all of which are related to anovulation, or problems with ovarian function and ovulation. Other common signs are problems with weight gain unresponsive to increased exercise and dieting, which we term obesity, and may also be related to insulin resistance, as well as increases in acne (related to androgen hormone changes), and in more severe cases, other excess androgen signs, such as a mild increase in body hair growth (hirsutism), and even sometimes inexplicable secretion of milk from the nipples. Abscence of one or some of these signs does not rule out PCOS. Various menstrual irregularities could also be signs of PCOS, as changes in the balance of hormones, and the effects upon luteinizing hormone (LH), a key hormone of the second half of the menstrual cycle, or premenstrual phase, is highly associated. The abscence of normal breast development in the young woman may also be an important sign.

These signs, irregular menstrual patterns, obesity, hirsutism, and deficient breast development may not always be dramatic, and are not all expected to be present, but studies have shown that presence of two or three of these signs has a 71% sensitivity for positive diagnosis of PCOS with followup. For instance, there is a prevalence of some obesity in PCOS patients ranging from 30-75% in various studies. On the other hand, a thin patient may still have insulin resistance, which is highly correlated with excessive androgen production. Guidelines are in place where specialists may analyze these four common signs in relation to the individual patient and other explanations for the signs, as well as cross reference of association with PCOS, to guide the rather complicated initial diagnostic assessment. There is a degree of specificity of 98% when utilizing these intitial guidelines correctly. The real individual diagnosis and clarification, though, comes with subsequent testing. Usually, this initial diagnostic assessment is used when the patient comes in for other health problems, but PCOS is suspected. There is still no good system of diagnosing PCOS that presents with less than dramatic symptoms. Today, a majority of PCOS diagnoses may be made with a connection to infertility, as more and more women seek fertility assessment and treatment. It is widely considered that PCOS may be underdiagnosed in the U.S.

Follow-up testing for PCOS involves ultrasound of the ovaries, laparoscopic exam (not usually performed in PCOS diagnosis, but laparoscopy for other abdominal diseases often include exam of the ovarian appearance), blood tests or saliva tests revealing abnormalities of androgens (testosterone, DHEAS, or androstenedione), as well as SHBG (sex hormone binding globulin). A high SHBG level could indicate adrenal insufficiency and low androgen production, and a low SHBG level could also be associated with obesity, peripheral thryoid pathology, and PCOS. These variables allow various levels of circulating testosterone to be seen in PCOS pathology, and a complete hormone profile, preferrably with active hormone metabolites tested in saliva and veinous blood stick allows a more thorough and thoughtful analysis. Other tests may be performed in a follow-up that are less specific, such as levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH), but do clarify the underlying causes and imbalances in individual cases. If Metabolic Syndrome or obesity is suspected, lipid panels and glucose tolerance tests may be indicated. To rule out other related disorders, prolactin levels, thyroid hormone panels, and level of 17-hydroxyprogesterone (active progesterone metabolite) may be evaluated. Thorough testing wil provide a picture for the physicians and patient that will help clarify a more comprehensive treatment protocol, especially when integrating Complementary Medicine, which may treat a variety of underlying or related disorders.

A variety of adrenal and thyroid problems, often subclinical, and a relationship between these and metabolic problems, often underly or are associated with PCOS

Polycystic ovary syndrome (PCOS, or POS) is currently one of the most frequently seen hormonal pathologies in women between puberty and menopause, and much of it is associated with excess androgen production, most of it of a subclinical nature. In the past, MDs suspected a pituitary or adrenal tumor, but we now know that in most cases, the excess androgens are actually produced by the immature ovarian eggs, which form the cysts in polycystic ovary syndrome. Waiting for a diagnosis of a clinical disease of androgen excess, such as Cushing's Disease or pituitary tumor, to associate this endocrine imbalance with the development of PCOS is not sensible. This is not to say that pituitary tumors do not often underly the polycystic ovarian syndrome. Most cases of pituitary tumor are not diagnosed. In 2001, researchers (Arafah and Nasrallah) at Case Western University and Univerity Hospitals of Cleveland, Ohio, released a study of pituitary tumors that showed an incidence in the population of the United States estimated at 10% of the population (some studies showed up to 20% incidence). This was based on autopsy series, but a more recent review of MRI studies in otherwise healthy individuals confirmed this rate of incidence. The researchers found no clear record of the frequency of clinically diagnosed pituitary tumors, but found that the estimations of this diagnosis is much lower than the incidence in autopsy and MRI studies.

Hyperprolactinemia, in recent years, has been found to be a very prevalent occurence, often associated with PCOS or infertility, though, and 40-45% of pituitary tumors are thought to be prolactin secreting. Almost all pituitary tumors in the studies were either small or very small (microadenomas), and most frequently extended superiorly toward the hypothalamus and optic nuclei. Hypothalamic dysfunction is another subclinical health problem garnering much attention in medical research. The majority of the pituitary tumors secreted other hormones besides prolactin, though, and these other hormonal excesses could also play a part in the polycystic ovary syndrome, namely FSH (follicle stimulating hormone), LH (luteinizing hormone), and growth hormone (GH). Indirectly, pituitary tumors that secrete TSH (thyroid stimulating hormone), ACTH (adrenocorticotropic hormone), and other hormones, could also play an indirect role in the multifactorial underlying cause of polycystic ovarian syndrome. As stated, a large percentage of these pituitary tumors do not present a clinical presentation of direct symptoms and signs, and go unnoticed and undiagnosed. To prevent or reverse the growth of pituitary tumors, one needs to understand the causes of these tumor growths and correct the health imbalances, usually unseen, that drive growth of pituitary tumors.

As stated, though, more recent research has demonstrated that the source of the excess androgens that drive polycystic ovarian syndrome mainly come from the immature ovarian eggs themselves, which may form cysts if conditions arise where the ovarian cycle is adversely affected. There may be multiple underlying causative factors in PCOS, and these various factors may be part of a cycle of dysfunction. Treating just one part of this syngergistic cycle of underlying problems may not adequately treat the syndrome. The polycystic ovary syndrome is associated with a variety of endocrine problems, or hormonal imbalances, as well as metabolic disturbances, and in recent years there is evidence of an autoimmune component. Some medications are also associated with PCOS, such as valproic acid (Depakote), which is an anti-seizure medication that is now used to treat a variety or disorders, including bipolar disorder (manic depressive syndromes), mood disorders, migraine headaches, and even ADHD in children. Valproate is associated with both metabolic effects such as weight gain, adverse neurohormonal affects, and liver impairment, all of which could be factors contributing to PCOS. There is currently a high prevalence of autoimmune thyroiditis among patients with PCOS, and a strong association with hyperparathyroid dysfunction, especially a subclinical hyperparathyroid disorder that is relative to a subclinical hypothyroid presentation.

It is this variety of underlying factors that may contribute to PCOS that makes this problem difficult for both the patient and the physician to understand, treat and prevent. While PCOS is difficult to understand due to the variance in presentations and its multifactorial cause, it has become accepted in recent years that a variety of health imbalances work together to create the syndromes of ovarian cyst formation. Once again, an individualized holistic approach is needed to treat a variety of systemic health problems at once, including hormonal imbalance, metabolic disorder, insulin resistance, and perhaps even autoimmune dysfunction. Complementary Medicine can provide a thorough detailed approach individualized to each woman.

Insulin is a hormone that it closely related to the sexual hormones, estrogens and progesterone. A strong relationship has been seen in scientific studies between insulin resistance, Type 2 diabetes (or more accurately Metabolic Syndrome), and polycystic ovarian syndrome. These hormonal associations have also been linked to the levels of sex hormone binding globulin (usually a high SHBG is associated with PCOS, but a low level could also have significance). One aspect of subclinical hypothyroid dysfunction is the dysfunctions associated with sex hormone binding globulin (SHBG), which is the primary blood plasma transport protein for sex steroid hormones and regulates the bioavailability of these hormones to target tissues. SHBG levels are also linked to peripheral thyroid receptor dysfunctions, as high SHBG levels indicate adrenal insufficiency (low production of active androgens) and are associated with problems at the peripheral thyroid receptors. Adrenal stress syndromes of a subclinical nature are also tied to peripheral thyroid receptor dysfunction and central thyroid disorders. There is a strong relationship between adrenal hormones, thyroid hormones, sex steroid hormones, and insulin metabolism, and the low levels of SHBG could be one factor that explains these links.

Epidemiological studies, or demographic studies, have also revealed that low plasma SHBG (sex hormone binding globulin) levels are an early indicator of insulin resistance and predict the development of Metabolic Syndrome to actual Type 2 Diabetes Mellitus in both men and women. Studies have indicated that both women with PCOS and Type 2 diabetes, and PCOS patients not diagnosed with Type 2 diabetes, both show a strong association with lower levels of SHBG. To see such as study, click here: http://www.ncbi.nlm.nih.gov/pubmed/21178921. The lesson to be learned here is that broad syndromes of subclinical hormone and metabolic disorder are linked in a complex manner to polycystic ovary syndrome, and that a more complex holistic approach to treatment should be integrated into a sensible treatment strategy.

Polycystic ovary syndrome is disassociated from polycystic ovary disease in many cases, although there are overlaps. Polycystic ovary disease, but not polycystic ovary syndrome (PCOS) is a common finding in premenopausal women with a diagnosis of Type 2 diabetes (or insulin resistance and Metabolic Syndrome). This is thought to be because the dysfunction of the pituitary-hypothalamic-adrenal axis, a hormonal feedback endocrine system, and suppression of gonadotropins, especially luetinizing hormone (LH) secretion, seen in premenopausal states, may play a role in the overall abscence of PCOS, but the formation of ovarian cysts, or polycystic ovaries (PCO) is still commonly seen in premenopausal women. This indicates that luetinizing hormone and hypothalamic dysfunction is an important part of the syndrome, but that the deficiencies and relative imbalances of estradiol and progesterone in premenopausal states still drives the formation of ovarian cysts. We see from this that a wide variety of presentations may be seen in the individual patients with ovarian cysts, and that a more individualized and careful analysis is helpful to guide therapy.

Traditionally, before hormone testing, TCM physician also differentiated patients with polycystic ovary disease and polycystic ovarian syndromes by classic differential TCM diagnosis. This type of diagnostic classification, observing signs and symptoms to differentiate patient types into predominantly adrenal insufficient (Shen Qi def) and liver dysfunctional (Liver Qi stagnant) patients, as well as predominantly spleen and pancreatic deficient (Pi def), coagulant and fibrin excess (phlegm-damp syndrome), and focal ischemic (blood stasis syndrome), are traditional differential classifications in TCM. Modern studies have seen some correlation in scientific study between this typing system and differential diagnosis based on sexual hormone levels. While this ancient diagnostic differentiation is still in use in TCM, modern TMC physicians also rely on modern diagnostic tests and data. The whole diagnostic picture is analyzed by the modern TCM physician to guide care, not just the ancient systems. Still it is curious to see strong scientific links that substantiate the objective relationship between these ancient and modern diagnostic systems. To see such as study, click here: http://www.ncbi.nlm.nih.gov/pubmed/20929122.

Fertility therapy for women with polycystic ovarian syndrome

Polycystic ovarian syndrome is thought to be the most common reproductive problem of young women, affecting 5-10% of women of reproductive age. Standard medicine will treat with synthetic hormones, insulin sensitizers, selective estrogen receptor modulators (SERM) such as clomifene, and in vitro fertilization (IVF). These treatments are expensive and present the woman with considerable side effects and risks of advers events. Synthetic hormones are associated with increased cancer and cardiovascular risk. Many patients are exploring Traditional Chinese Medicine before starting these therapies as a more conservative first line approach, to restore health to the reproductive system before taking fertility medications or performing IVF, or to increase chances of success with concurrent use of acupuncture and Chinese herbal medicine with fertility treatments and IVF (see the article on infertility on this website). SERM treatment, usually utilizing clomiphene, is associated with common adverse effects of hot flush, abdominal discomfort, visual blurring, and reversible ovarian enlargement and cyst formation with discomfort, in more than 1% of patients, and the chance of birthing twins or triplets is increased considerably to 10%.

Rates of success with these therapies have averaged about 34%, although some clinics report higher rates of success. Rates of success with acupuncture and herbal medicine also average about 34% in numerous studies. Randomized controlled trials report that a course of acupuncture before IVF, and sometimes after, will increase the chance of success considerably, although acupuncture at the IVF procedure will not increase success rate. Many fertility clinics now offer acupuncture as an adjunct therapy, but most of these clinics charge a considerable extra fee for the course of treatment preceding the IVF. This course of therapy from a private Licensed Acpuncturist is usually not expensive. A review of randomized controlled trials of Chinese Herbal Medicine for this treatment shows that concurrent use of Chinese herbal medicine with clomiphene increases the chance of success and shown no adverse effects or contraindications. To see such a review, click here: http://www.ncbi.nlm.nih.gov/pubmed/20824862

Women's Health

Hormonal deficiencies in Menopause, Infertility, Pre-Menstrual Syndromes, Anovulation, and related health problems

These last years have brought great clarity to the treatment of hormonal problems. The amount of knowledge from research in response to the failure of the synthetic hormone replacement therapy (HRT) has finally brought these problems and the cure into focus. In addition, we now see exactly how the hormonal deficiencies affect a wide variety of disorders. Estrogen deficiencies are a primary cause for problems with short term memory and attention problems, poor tissue healing, inflammatory disorders related to tissue calcification, and a variety of calcium related problems. Progesterone deficiencies create a relative estrogen excess even in estrogen deficient states, and are responsible for most menopausal and premenstrual symptoms and many cases of infertility, as well as the possibility of cancerous growth. Hormone dysfunction is a prime contributor to metabolic disorders and creates an added stress that contributes greatly to insulin resistance, diabetes and weight gain.

Not only deficiencies of estrogens and progesterone, but the homeostatic balance between these two classes of hormones have been found to be very important to the development and perpetuation of health problems. Even in younger patients without a post-menopausal deficiency, the relative excess or deficiency of estrogens and progesterone, which may vary within the menstrual cycle, are integrally tied to disease pathology. For instance, a relative progesterone deficiency in the luteal, or second half, of the menstrual cycle, is the cause of most premenstrual symptoms, and a continued imbalance has an effect on progesterone and estrogen receptors and sensitivity. Since the endocrine, or neurohormonal, system is a feedback system that must maintain a proper homeostatic balance, problems with estrogen-progesterone balance may lead to other hormonal problems that underly such disorders as endometriosis, ovarian cysts, and uterine fibroids, and may be related to various other common health problems in the body.

What do we do with this wealth of medical knowledge? Has it resulted in simple herbal cures? The answer is no. The endocrine system is the most complex system in the body. Fortunately, there are medical practitioners with the knowledge and skills to utilize a holistic approach to these problems. The integration of simple laboratory saliva tests, topical herbal creams, supplements and herbal formulas, with acupuncture, and guidance in your dietary regimen and lifestyle, has created a package of care that is phenomenally effective and tailored to the individual case. Finally, the knowledge and treatment options have accumulated over time to give me a treatment plan with guaranteed success.

What do you do? You need to spend the time for a thorough history and consult. When you and your health provider are on the same page you can expect to get great results. In complimentary medicine you need to take a proactive approach to the therapeutic course and the adjustments in therapy that are needed. You need to gain an understanding and work with me to insure that lasting success is obtained. You’ll be glad you did.

Modern approaches to the medical treatment of endometriosis, ovarian cysts, and uterine fibroids

Standard medicine has long relied upon surgical treatment for symptomatic endometriosis, ovarian cysts, and even uterine fibroids. The standard guidelines called for monitoring to see if a more threatening pathology developed, and then performing excision of fibroids or cysts, removal of an ovary, or a hysterectomy (removal of the uterus). In 2003, hysterectomy was the most commonly performed gynaecological surgical procedure, with over 600,000 hysterectomies performed in the U.S. 90% of these hysterectomies were performed for benign conditions. More frequently in the last decade, the prescription of synthetic progestins, often in the form of oral contraceptive pills, is utilized. These drugs have well recognized risks of cancer themselves, as well as serious side effects with chronic use. More and more, the use of natural bioidentical hormone therapies, integrated into an evidence-based Complementary Medicine protocol, is now recognized as a viable option for the patient and physician. Monitoring and balancing of hormonal production with bioidentical plant hormones, combined with acupuncture, and herbal and nutrient therapy, provides the patient with a conservative treatment approach that has little or no side effects, and results in an improvement in health and reduction of future risk of health problems, especially cancers and cardiovascular problems. Integrating this type of therapy into your treatment plan is both sensible and effective.

Like hormonally driven breast, ovarian and uterine cancers, benign growths in these tissues may also be stimulated by a dysfunctional array of hormonal signals. Oversimplifying the problem by stating that estrogens create growths such as fibroids, and so anti-estrogen strategies should be employed does not correct the problem. In fact, it has been proven that progesterone receptor stimulation could also cause these abnormal tissue growths. In tissues that are highly reactive to hormonal stimulation, such as the breast, ovary, uterus, prostate, and thyroid, there are of course many more hormonal receptors than in other tissues, and with this comes a greater chance that hormonal imbalance will create an imbalance of cellular signals that will drive excess cell and tissue growth, and prevent the normal protective mechanisms from working properly.

In cancers, one of the best natural protections against excess mutations causing a dysfunction of the normal cell growth rates and vascularization is apoptosis, or normal programmed cell death. In cells that are affected heavily by hormonal stimulation, hormonal receptor types inside the cell and on the surface of the the cell may create different signalling mechanisms (alpha and beta types). When an excess of one type of hormonal receptor is created the normal mechanisms controlling apoptosis may not trigger, and anti-apoptosis mechanisms may be stronger than pro-apoptotic mechanisms. Over time, the cells survive too long, and the number of cell mutations that occur creates more dysfunction than the body's defenses can correct. Abnormal cell growth, or cancer occurs. This is often due to a relative deficiency of an active metabolite of the hormone, which causes more receptors to be formed on the outside of the cell. It could also be due to inflammatory processes altering the cell membrane and not allowing enough of the active hormonal metabolites to enter the cell. As we research these problems, we find that they can be quite complex. Searching for an easy and simplistic answer is not reasonable. Trying to restore the complex homeostatic mechanisms that have evolved over millions of years is more reasonable. Correction of the cellular environment that drives these abnormal growths and deters normal cell death, or apoptosis, is the treatment focus now of not only Complementary Medicine physicians, but also of a growing percentage of MDs.

With uterine fibroids, ovarian growths and uterine hyperplasia (endometriosis), utilizing nature to try to restore protective balance in the homeostasis is an intelligent choice. This means, though, that we have more than one goal to accomplish, and that there will be a number of products that are useful to accomplish this goal. Once again, in natural medicine, there is rarely a silver bullet, or magical cure. What is confusing is that a large number of therapeutic products are recommended that have a small effect, but are rather benign and simple remedies that are easy to market. Marketing is often the thing that makes treatment of these problems with nutrient and herbal medicine difficult, and is often the nemesis of the patient. Sound research and science is the friend of the patient, as this will show which remedies are indeed effective, and why. The patient should find a knowledgeable Complementary Medicine physician to guide the therapy based on sound science.

One thing that drives the growth of uterine fibroids is relative estrogen dominance, meaning that there is relatively excess estrogen in relation to progesterone during some part of the menstrual cycle. This usually occurs during the luteal phase, or second half of the cycle, when progesterone should dominate. A relative lack of progesterone in relation to estrogens at this time causes many of the symptoms of premenstrual syndrome, or PMS. Supplementation with a progesterone stimulating hormonal cream, utilizing bioidentical hormones, combined with other herbs and nutrients, not only relieves PMS symptoms, but protects the woman from possible uterine fibroid formation and endometriosis. Of course, correcting the underlying problems, rather than just treating the symptoms are also recommended. Chronic dependance on bioidentical hormones is not recommended. This often entails some correction of overall liver function, blood quality, and perhaps lipid balance, and perhaps some reduction in inflammatory states and immune enhancement. A TCM physician will assess various health parameters and make a differential diagnosis of how to individually correct the underlying health problems that cause PMS. Relative estrogen dominance is one aspect of the formation of uterine fibroids and endometrial growth, usually an intitiating cause, but a more complex estrogen dysfunction may be driving more chronic growth. Abnormal formation of estrogen receptors, aromatization of the active estrogen metabolites, conversion of other hormones to active estrogen in the tissues, and lack of inhibition of the formation of new blood vessels in the fibroids (angiogenesis) by specific estrogen active metabolites all play a role in fibroid pathology. Restoration of the normal cellular environment allows the body to correct these metabolic problems and restore tissue health.

Some nutrient chemicals have been found in recent years that can also help protect the body against dysfunctional activity at the estrogen receptors, such as DIM (diindolylemethane) and Lignans. DIM is a chemical created from I3C chemicals in cruciferous vegetables that have been shown to inhibit the aromatase activity and prevent problems with estrogen receptors alpha and beta. While this supplement has not been extensively tested in human trials, much clinical evidence points to its potential efficacy in the treatment protocol for hormone drive tissues such as fibroids, as have certain potent lignans. Lignans are polyphenols, or plant hormonal chemicals, and a number of lipid molecules in foods contain lignan precursors, which may become enterolignans in our bodies via the action of symbiotic bacteria. For instance, flax seeds are a rich source of plant lignan precursors. Certain lignans created in the intestines, enterolactone and enterodiol, have been shown to have weak estrogenic activity, but also exert biological effects via nonestrogenic mechanisms that benefit hormonal balance, and help the body maintain balance of stimulation at the hormonal receptors. Large studies have shown that postmenopausal women with the highest intake of plant lignans and lignan precursors have the lowest risk of endometrial and breast cancers. European researchers have found particularly effective prelignans in a species of spruce trees, and have patented a process for deriving a potent medicine called NuLignan. This product is proven to be protective against breast cancer, beneficial for hormonal regulation, and stimulating of specific antioxidant mechanisms. These two products, DIM and NuLignan are highly recommended in the treatment protocol. These most potent plant lignans are pinoresinol, laricrsinol, matairesinol, and secoisolariciresinol.

Of course, whenever new nutritional and herbal products are researched, conflicting and confusing research is created, much of it driven by market stress and competition, especially competition for the pharmaceutical industry. Initial studies were created to find a potential hazard to lignans and DIM. The way that these studies were designed suggested their outcomes. To date, no health risks have been soundly identified. Research into phytohormones, such as isoflavones and lignans, are plentiful in human diet, and the body has evolved ways to utilized them safely. Bioavailability of these beneficial nutrient chemicals is the key phrase. Presenting the body with the nutrient tools to accomplish the task is the goal. Initial studies that equated not intake, but excretion rates of these isoflavones and lignans weakly with uterine fibroid risk failed to see the big picture of body metabolism and usage of these chemicals. Studies that have looked into the exact biological mechanisms by which they may benefit the reduction of uterine fibroids are more reliable.

IP6 (inositol hexaphosphate) is another potential aid in reducing abnormal tissue growths in the body. IP6 is a nutrient component of many whole grains, legumes and seeds that are high in oil. Strong antioxidant, immune enhancing and cardiovascular benefits are found in this supplement, and it is proven to aid in controlling neovascularization, or angiogenesis, in tumors or other tissues with abnormal growth rates that depend upon a greater supply of blood and growth factors to increase in size. IP6, according to standard health authority websites, such as Memorial Sloan-Kettering Cancer Center's, is a ubiquitous intracellular molecule in mammalian cells obtained from dietary sources used to treat and prevent cancer and heart disease. IP6 may be obtained from the diet or synthesized in the body from inositol, and other inositol nutrient medicines, such as inositol hexacotinate may improve its effectiveness when taken concurrently. IP6 interacts with tyrosine kinase and PCL-growth factor receptors, and contributes to cellular signal transduction and intracellular functions in a positive manner. Studies have shown that it also inhibits proliferation of abnormal growths by chelation of metalloproteins, modulation G-protein signaling, and may inhibit platelet activation with ADP, collagen, and thrombin, inhibiting agonist-induced platelet aggregation and formation of fibrins.

Angiogenesis, or the abnormal formation of new blood vessels in tissue growths, is an important part of the pathology of a variety of diseases and much studied. The growth factor VEGF (vascular endothelial growth factor) drives this angiogenesis. A variety of chemicals are found to potentially enhance VEGF and angiogenesis, and inhibit it. For example, it has been surmised that statin drugs that treat high cholesterol, may enhance VEGF. Some potent inhibitors of VEGF and angiogenesis, besides IP6, are Resveratrol from the Chinese herb Hu zhang, or Polygonum cuspidatum, and Curcumin, from the Chinese herbs Curcuma zedoaria and aromatica (E zhu and Yu jin). Green tea catechols have also been found to be mildly effective. (re: Journal of Physiology and Pharmacology 2995, 56, Suppl 1, 51-69; J. Dulak). These herbs, Hu zhang, E zhu, and Yu jin, have long been used to treat such problems as uterine fibroids. Curcumin increases glutathione metabolism of cellular detoxification, and exerts anti-inflammatory and anti-tumor effects, as well as having a potent antioxidant effect. Curcumin also inhibits platelet aggregation and moderates eicosanoid biosynthesis. In traditional medicine it was used to increase circulation to reduce pain, break up blood stasis, promote the circulation of qi and reduce heat in the cardiovascular system. In modern use in China, it has been found to be clinically effective to treat cervical cancers and leukemia. Curcuma zedoaria has a larger profile of active chemicals, and a relatively high content of essential oil (as much as 2.5%). An alcohol extract may also be effective with this herb due to the essential oil content. E zhu has long been one of the chief herbs in Chinese herbal medicine used to treat cancers. It has been shown to also have a dose related effectiveness to inhibit endometrial growth. Of course, these herbs may have an effect on fertilization and pregnancy, and should only be prescribed by a Licensed herbalis such as a Licensed Acupuncturist.

Other herbal constituents and nutrient chemicals that have been proven effective to inhibit VEGF and angiogenesis include various isoflavones, luteolin, genistein, apigenin, Ponicidin and Oridinin from Rabdosia rubescens, Ginseng, polysaccharopeptides in Coriolus versicolor (Turkeytail mushroom), and polyacetylenes in Bidens pilosa, as well as the much studied Baicalein, Berberine, epicatechin, and acteoside in the Chinese herbs Berberis, Coptis chinensis, and Phellodendron (Huang lian, Huang qin, and Huang bai), as well as Epimedium sagitatum (Yin yang huo), Trichosanthes kirilowii (Guo lou and Tian hua fen), and Dalbergia odorifera. These herbs are found in various Chinese herbal formulas that often are used to treat endometriosis, uterine fibroids and ovarian cysts, established centuries ago, and demonstrate scientifically the efficacy of these herbal strategies. Milk thistle, or sylamarin, has also been heavily researched and found to exert potent anti-angiogenic activity, inhibition of IGF signaling, and proapoptotic effects. (Current Medicinal Chemistry, Vol.14, no.3, Feb 2007;315-338). The Licensed Acupuncturist and herbalist can devise a treatment protocol that is safe and effective, and over time comprehensive to not only reduce and alleviate the problems of endometriosis, uterine fibroids and ovarian cysts, but also to treat the underlying health problems that have caused them.

Research in the last ten years has identified a specific local defect in the insulin receptor function that links insulin resistance to polycystic ovary syndrome and has created a novel nutrient therapy to correct it, D-chiro insitol supplementation

Research into the specific mechanisms of the insulin receptor has uncovered that two chemicals on the cell surface are cleaved when the insulin receptor is activated, and these chemicals are then able to enter the cells and stimulate glucose utilization and testosterone production. The two chemicals, D-chiro inositol (DCI), and myoinositol, attach to phosphoglycans, form chemical complexes called inositol phosphoglycans (IPGs), inside fat, muscle and ovarian follicle cells, and are transported to the cell membrane where they await release, or activation by the insulin receptor. Insulin is a hormone that guides the glucose utilization and other energy needs inside the cell. Like all hormone receptors, the insulin receptors are varied, and may be stimulated by other hormones than the target insulin, as well. With all hormone stimulation, a number of local hormones and hormone-like chemicals act in a quantum field to insure proper regulation and modulation of the cellular responses so that unwanted cellular responses and growths do not occur. This is part of our complex homeostatic mechanism that maintains healthy function in the body. These two inositol complexes must be maintained in a balanced, or paired, relationship to insure that cellular energy usage and adjunct hormonal signals are normalized.

These two cellular signaling molecules, DCI-IPG, and Myo-IPG, are kept in balance and released via the action of signaling enzymes. When the insulin hormone attaches to an insulin receptor, an enzyme cleaves the DCI-IPG, which stimulates glucose energy usage and storage, and Myo-IPG, which releases adjunct hormones, especially testosterone. In polycystic ovary syndrome, excess testosterone release is often a substantial part of the problem, and excess Myo-inositol stimulation combined with deficient D-chiro inositol is an explanation for this phenomena. A number of factors may inhibit the enzymes that maintain the balance of DCI and Myoinositol, including environmental toxins, drug chemicals, and advanced glycation endproducts. Normally, if enough DCI is not obtained from the diet, myoinositol may be converted to DCI, but if various factors are present, a deficiency of DCI will drive the excess stimulation of myoinositol, and the excess production of testosterone. If DIC-IGP is not stimulating the use and storage of glucose in the cell, a feedback mechanism that stops insulin stimulation will not readily occur, and insulin will continue to stimulate more and more Myo-IPG, overproducing local cellular testosterone. Supplementation with D-chiro inositol has been proven effective as an adjunct therapy in the treatment of polycystic ovary syndrome.

Inositol is an oxygenated carbohydrate alcohol that is widely occurring in nature and plays an important role in the human nervous system. Inositol and choline are necessary components of our nervous system, and increased nervous stress may place an unusual demand for inositol. This is an explanation for how nervous stress and autonomic nervous dysfunction contributes to polycystic ovary syndrome. Myo-inositol plays an important role in a number of cellular processes throughout the body as a second messenger, or signaling molecule. Myo-inositol is produced in the body from glucose, and imbalances in glucose metabolism may contribute to myo-inositol and DCI imbalances. This creates a potential cycle of dysfunction. A number of lipid hormone-like substances are built on the backbone of myoinositol, including inositol phosphates, phosphatidylinositol, and phosphatidylinositol phosphate, and these chemical are related in functions to such nutrients as P5P (active Vitamin B6), phosphatidylcholine (active lecithin), and inositol hexacotinate (active niacin, or Vitamin B3). Inositol and inositol phosphate is found in cantaloupe and fresh oranges or tangerines, and are derived from phytates found in the bran of true whole grains, as well as beans, legumes and fresh nuts and seeds (phytic acid will be degraded in overly produced foods or foods that are stored improperly). This explains how a modern diet contributes to the pathology of insulin resistance and polycystic ovary syndrome, as well as obesity. While such research produces overly complex explanations that are hard for patients to deal with, it also elucidates mysteries and associations that can be confusing, and tells us why a recommended holistic treatment, diet and lifestyle protocol is needed to correct our health problems.

Information Resources

1. Research in 2006 by the University of North Carolina revealed that hormonal imbalance is integral to the pathology of endometriosis, with progesterone insensitivity causing an abnormal expression of cell membrane estrogen receptor alpha during the mid-luteal phase, promoting endometrial cellular dysfunction. While allopathic medicine seeks to use pharmaceutical hormonal inhibiting drugs to treat such imbalance, Complementary Medicine seeks to correct problems with hormonal homeostasis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1679803/
2. Endometriosis presents a twofold risk of developing ovarian cancer later in life, and a fourfold increase in this risk for endometriosis patients with fertility problems, as revealed in this meta-analysis of research in 2010 by the Odense University Hospital in Denmark: http://www.ncbi.nlm.nih.gov/pubmed/21118664
3. Endometriosis was linked to malignant ovarian cancer by examining tissue biopsy histology at Harvard Medical School as early as 1996: http://www.ncbi.nlm.nih.gov/pubmed/8631545
4. Endometriosis and malignant, as well as some benign ovarian cancer, was linked to hepatocyte nuclear factor-1beta (HNF-1beta) and the progression of clear cell carcinoma from endometrial tissues to ovaries. HNF-1beta is a human gene that has a liver specific factor, and acts in the body to activate or inhibit target genes in other cells: http://www.ncbi.nlm.nih.gov/pubmed/16258507
5. Endometriosis migrating to the ovaries is a common finding, and is treated with laparoscopic surgery to remove the ovarian cyst or tumor. Recurrence rates of this endometrial cancer in the ovaries after this surgical intervention is high. Standard use of hormone suppression with drugs has been shown to be ineffective in reducing this recurrence. Use of Complementary Medicine may be a more sensible approach to integrate: http://www.ncbi.nlm.nih.gov/pubmed/19665279
6. A 2009 mega-analysis of randomized controlled human trials with Chinese herbal medicine (CHM) for the treatment of endometriosis and related disorders, at Southampton University in Sussex, England, found that CHM outcomes compared favorably to standard pharmaceutical treatment with fewer side effects: http://www.ncbi.nlm.nih.gov/pubmed/19588398
7. Endometriosis and Irritable Bowel Syndrome may be linked in many cases, as this simple explanation by Dr. Donnica L. Moore MD reveals: http://www.drdonnica.com/faqs/00005150.htm
8. Endometriosis is linked to a variety of underlying health problems, including IBS, fibromyalgia, hypthyroidism, and autoimmune disorder, as revealed on this website: http://www.endo-resolved.com/symptoms.html
9. Harvard Medical School found in 1995 that a combination of factors seemed to ineract to create the dysfunctions that lead to uterine fibroids, or leiomyomas, including estrogen-progesterone balance, progesterone receptor imbalances, and even synthetic progestins: http://www.ncbi.nlm.nih.gov/pubmed/7847524
10. A 2004 study at Kobe University Graduate School of Medicine in Kobe, Japan, found that progesterone plays both a stimulatory and inhibitory role in formation of uterine fibroids, affecting growth factors locally, and that the interaction between estrogen receptors and progesterone receptors in the cells may be involved in modulatory gene regulation. This complex cross-talk between hormones and growth factors not only make this pathology difficult to understand, but makes utilization of a single allopathic synthetic hormone, or other pharmaceutical medicine unlikely to have as positive effect as restoration of the homeostatic balance in the cellular environment: http://www.ncbi.nlm.nih.gov/pubmed/15140868
11. A study at the University of Goettingen, in Germany, in 1999, found that synthetic progestins may play an important role in the multifactorial cause of uterine fibroids, modulating growth factors at their receptors: http://www.ncbi.nlm.nih.gov/pubmed/12227898
12. Further study at Kobe University in Japan in 2004 found that uterine fibroid, or leiomyoma, growth is tied to interactions between estrogen and progesterone receptors, and that a healthy estrogen progesterone balance modulates the growth factors, EGF and IGF (epidermal growth factor and insulin-like growth factor), which are responsible for this fibroid growth. This also explains why pregancy does not stimulate increased fibroid growth, as a balance of estrogen and progesterone, despite large increases, is maintained in pregnancy: http://www.ncbi.nlm.nih.gov/pubmed/15140868
13. A 2000 study at New York University School of Medicine found that altered expression of IGFs (Insulin-like growth factors) and the downstream protein signaling molecules, or kinases, such as pAKT, were seen in tissue samples of about a third of fibroids, with much higher levels seen in larger fibroids, implying that these growth factors may play a significant part in the growth of larger fibroids: http://www.ncbi.nlm.nih.gov/pubmed/18439583?dopt=Citation
14. A 2005 study at Dongguk University School of Oriental Medicine in South Korea found that a commonly used Chinese herb, Scutellaria barbata (Ban zhi lian), reduced uterine fibroid tumor size and induced the rate of cell death in the fibroid (apoptosis) by acting on the modulation of growth factors. Clinical evidence of effectiveness of other common Chinese herbs in this capacity, also containing the active chemicals resveratrol, baicalin, berberine, besides the chemicals studies, apigenin and luteolin, two bioflavonoids, have yet to be evidenced in study: http://www.ncbi.nlm.nih.gov/pubmed/15922007
15. Studies in 2010 reveal that polycystic ovary syndrome is associated with various hormone and metabolic imbalances, and autoimmune disorder as well: http://www.ncbi.nlm.nih.gov/pubmed/20578591
16. A 2006 review of scientific research of polycystic ovary syndrome by the University of Bologna, in Italy, found that there is an association with metabolic syndrome, insulin resistance, excess androgen production, and irregular menstruation, and that a combination of these hormonal and metabolic factors is probably responsible for the disease : http://www.ncbi.nlm.nih.gov/pubmed/17308142
17. A 2004 review of scientific studies at the University Alma Mater Studiorum in Italy, found that there is a 5 to 10 fold higher risk of insulin resistance, glucose intolerance (chronic inflammatory changes to the beta cells of the pancreas), and metabolic syndrome for patients experiencing polycystic ovary syndrome, regardless of ethnicity: http://www.ncbi.nlm.nih.gov/pubmed/14973409
18. A 2006 review by this same medical university in Italy makes clear that polycystic ovary syndrome is largely dependent on metabolic changes and physiological obesity, with insulin resistance and metabolic problems even in patients that are not overweight, and that polycystic ovary syndrome is one of the most commone causes of infertility due to anovulation: http://www.ncbi.nlm.nih.gov/pubmed/16827825
19. A 2006 review of polycystic ovarian changes in the premenopausal woman at the Erciyes University Medical School in Turkey, found that polycystic ovary disease, but not polycystic ovarian syndromes, were common to premenopausal women with a diagnosis of type 2 diabetes, or Metabolic Syndrome, implying that the metabolic disorder may be more closely tied to the formation of ovarian cysts when the endocrine axis, particulary Luetininzing Hormone (LH) is suppressed in the premenpausal state: http://www.ncbi.nlm.nih.gov/pubmed/16762349
20. A 2010 study at the University of Gothenburg, Sweden, found that low frequency electroacupuncture increases insulin sensitivity in laboratory animals with polycystic ovary syndrome (PCOS) induced with DHT, exerting systemic and local effects that could benefit treatment of PCOS: http://www.ncbi.nlm.nih.gov/pubmed/20663984
21. A 2009 study at the University of Gothenburg, Sweden, demonstrated how electroacupuncture could benefit patients with polycystic ovary syndrome (PCOS) by reducing elevated hypthalamic gonadotropin releasing hormone (GnRH) and androgen receptor (AR) expression levels without altering GNrH receptor functions or corticotropin releasing hormone (CRH) expression, reducing the effects of excess androgens that drive PCOS pathology: http://www.ncbi.nlm.nih.gov/pubmed/19680559
22. A 2009 study at the University of Gothenburg, Sweden, also demonstrated how low-frequency electroacupuncture combined with appropriate exercise could reduce sympathetic nervous excess that drives the pathology of polycystic ovary syndrome: http:/www.ncbi.nlm.nih.gov/pubmed/19158405
23. A 2011 article in the medical journal Human Reproduction, authored by experts at the University of Milan, in Italy, called for less surgical treatment of endometriosis, and the integration of more complementary therapies, such as hormonal therapy, as a commonsense approach to these female health problems. An even more commonsense approach, considering the wealth of research that ties synthetic progestin therapy to cancer and other health problems, is to integrate Complementary Medicine and natural bioidentical hormone therapies, combined with acupuncture and herbal and nutrient medicine: http://www.ncbi.nlm.nih.gov/pubmed/21071490
24. A 2009 analysis at King's College London concluded that Traditional Chinese Medicine (TCM) had significant advantages of standard medicine in treating gynaecological disorders, including endometriosis, uterine fibroids, polycystic ovarian syndrome, and a host of other disorders, with the combination of acupuncture and Chinese Herbal Medicine: http://www.ncbi.nlm.nih.gov/pubmed/20606770
25. A 2007 study at the University of Southamptom, United Kingdom, found that such medical treatment guideline strategies as the Delphi process, was creating treatment guidelines for endometriosis from Chinese and Western databases that medical experts agreed was comparable to consensus good practice evidence-based guidelines in standard pharmaceutical practice: http://www.ncbi.nlm.nih.gov/pubmed/18047443
26. A 2009 study at the University of Southamptom, United Kingdom, found that Chinese Herbal Medicine (CHM) for post-surgical treatment of endometriosis compared favorably to standard drug therapy but with less side effects: http://www.ncbi.nlm.nih.gov/pubmed/19588398
27. A 2007 study at the University of Vienna found that herbal medicine presented evidence of efficacy for the treatment of endometriosis, although more published research was needed in the West. Nonetheless, these experts encouraged present use and developments of herbal and nutrient medicines, herbal analogues, and establishment of simplified registration of herbal medicines, particularly those with a long history of safe use, such as in Chinese Herbal Medicine and the TCM acupuncture profession, for the treatment of endometriosis: http://www.ncbi.nlm.nih.gov/pubmed/17575287
28. A 2009 study at Greenville Hospital System in South Carolina found that the Chinese herb Prunella vulgaris (Xia ku cao) displayed estrogen modulating activity that made it useful as an adjunct for the treatment of estrogen-dependent disease processes such as endometriosis and uterine and breast cancers: http://www.ncbi.nlm.nih.gov/pubmed/18923163
29. A 2010 study at Shanghai University found that acupuncture combined with acupoint sticking therapy was proven to be very effective in the treatment of dysmenorrhea associated with endometriosis in a randomized controlled study with comparison to standard pharmaceutical therapy: http://www.ncbi.nlm.nih.gov/pubmed/20886791
30. A 2010 study at the Johannes Bischko Institute in Vienna, Austria, found that acupuncture therapy for endometrosis-related pain appeared to be very effective in a randomised controlled human clinical trial: http://www.ncbi.nlm.nih.gov/pubmed/20728977
31. A 2008 study the Shanghai Research Institute found that integrating acupuncture with standard medicine produced significant therapeutic benefits on downregulatin endometriosis tissues and MMP-2 expression (a type of collagen enzyme matrix metalloproteinase associated with the spread of endometriosis tissues) to inhibit the spread of endometriosis tissue and reduce the ectopic endometriosis tissue, effecting cure. The points used in the study were SP10, SP6, and Ren4, which are just the traditional base points used in individualized treatment: http://www.ncbi.nlm.nih.gov/pubmed/18822986
32. A 2009 review of TCM and Chinese Herbal Medicine by The Centres for Natural Medicines Research, King’s College London, found significant evidence of effectiveness of TCM herbal formulary in the treatment of endometriosis, infertility and other gynecological problems: http:/www.bioline.org.br/request?tc09040

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