Section 4: Endometriosis

Ha Liti believes that the main mechanism of dysmenorrhea is the obstruction of qi and blood circulation in the Chong and Ren meridians and Du meridian, leading to blood stasis in the uterus. Zhang Jianan believes that the occurrence of dysmenorrhea is closely related to the function of the liver. The liver stores blood and governs the free flow of qi; liver qi stagnation, liver fire due to qi stagnation, and liver blood deficiency can all lead to dysmenorrhea. Wang Qingsong believes that dysmenorrhea involves both deficiency and excess, but regardless of whether it is a deficiency or an excess condition, it is always associated with stagnation and blood stasis, and both originate from the kidneys. Sun Weiwei and Zhang Junxue believe that dysmenorrhea is often caused by liver qi stagnation, resulting in qi stagnation and poor blood circulation, or by cold congealing and blood stasis obstructing the flow. Luo Yuanxi believes that dysmenorrhea is essentially either deficiency or excess, or a mixture of both. Among excess conditions, blood heat blockage can lead to dysmenorrhea, but the most common causes are blood stasis, qi stagnation, and cold congealing. Deficiency conditions mainly involve weakness of qi and blood. Wang Caiwen and Deng Haixia believe that dysmenorrhea is primarily caused by obstruction—whether it is cold congealing and qi stagnation, qi stagnation and blood stasis, qi and blood deficiency, or liver and kidney deficiency—all can lead to impaired qi and blood circulation, with blood stasis blocking the Chong and Ren meridians in the uterus, resulting in "obstruction leads to pain." They consider "blood stasis" to be the key pathological mechanism. Xu Jingsheng and Wu Liqin believe that the etiology and pathogenesis of primary dysmenorrhea is blood stasis in the uterus. Due to significant changes in qi and blood during menstruation, women are easily affected by pathogenic factors, leading to impaired qi and blood circulation and subsequent blood stasis. Since women generally have insufficient qi and blood, even though there is blood stasis, it is often accompanied by deficiency. Therefore, the key to its etiology and pathogenesis lies in the combination of blood stasis and deficiency. Wang Yexiu believes that in the early stages of menstruation for young women, when Tian Gui has just arrived, kidney qi is relatively deficient. If health preservation is not done properly or if one is exposed to cold during menstruation, cold-dampness can injure the lower jiao and invade the uterus, causing cold congealing and blood stasis, which results in obstruction and pain. Chu Yuxia believes that dysmenorrhea often occurs because of exposure to cold during menstruation, leading to blood stasis and difficulty in discharge, thus triggering dysmenorrhea. The characteristic of the pathogenesis of dysmenorrhea is that it is fundamentally a deficiency with superficial excess, with kidney deficiency as the root cause and cold congealing and blood stasis as the manifestation. Ma Xiuli believes that the main causes of dysmenorrhea are cold and blood stasis. Cold congealing, impaired qi and blood circulation, or yang deficiency with internal cold, along with disharmony of the Chong and Ren meridians, can all lead to blood blockage in the meridians, resulting in pain due to blockage of the meridians. Alternatively, if women of childbearing age engage in excessive sexual activity or have multiple births, yin blood deficiency may occur, failing to nourish the meridians and causing pain. Section 4: Endometriosis When active endometrial tissue (glands and stroma) appears outside the uterine cavity and myometrium, it is called endometriosis (EMT), which is one of the main causes of pelvic pain and infertility. Ectopic endometrium can invade any part of the body, but the vast majority is located in the pelvis, most commonly in the uterosacral ligaments, rectouterine pouch, and ovaries, followed by the serosa of the uterus, fallopian tubes, sigmoid colon, visceral peritoneum, and vaginal-rectal septum. This disease is most common in women of childbearing age and is related to the cyclical changes of the ovaries, making it a sex hormone-dependent disease. Although this disease is benign, it has the ability to implant, erode, metastasize, and recur like malignant tumors. Approximately 25%–35% of infertile patients have endometriosis.

1. Etiology and Pathology (1) Etiology: The exact mechanism of onset is not yet fully understood. The theory of ectopic implantation is currently the dominant view regarding the etiology of this disease. (2) Pathology: The basic pathological change is that ectopic endometrium undergoes cyclical bleeding in response to ovarian hormones, causing proliferation and adhesion of surrounding fibrous tissue, resulting in purplish-brown spots or small blisters, eventually developing into purple-blue nodules or masses of varying sizes. The lesions can vary depending on the location and extent of involvement.
2. Clinical Manifestations (1) Symptoms vary from person to person and can differ based on the location of the lesion. About 25% of patients experience no obvious discomfort. ① Dysmenorrhea and lower abdominal pain. The main symptom is dysmenorrhea, characterized by secondary dysmenorrhea that progressively worsens. ② Menstrual abnormalities. 15%–30% of patients present with increased menstrual flow, prolonged periods, or spotting before menstruation. Infertility. The incidence rate is 50%. There are many reasons for infertility, including: a. Changes in the pelvic microenvironment affect the fertilization and transport of sperm and egg. b. Immune dysfunction damages endometrial cells, interfering with the fertilization, transport, and implantation of the fertilized egg. c. Endometriosis leads to ovarian dysfunction. d. Extensive adhesions among pelvic organs and tissues affect the transport of the fertilized egg. ④ Pain during intercourse. When the lesion involves the rectouterine pouch or uterosacral ligaments, or when local adhesions cause posterior tilting of the uterus, the cervix may be impacted during intercourse, and the contraction and upward movement of the uterus can cause pain, especially before menstruation. Other symptoms. Intestinal endometriosis can cause abdominal pain, diarrhea, constipation, and even occasional minor hematochezia; in severe cases, intestinal obstruction may occur. If ectopic endometrium invades the urinary system, frequent urination, urgency, and dysuria may appear during menstruation, but these symptoms are often masked by dysmenorrhea. When the lesion compresses or invades the ureter, it can cause ureteral obstruction and hydronephrosis. If both ureters and kidneys are affected, hypertension may occur. Women with scar endometriosis after cesarean section or episiotomy may experience pain at the scar site during menstruation. Pleural and pulmonary endometriosis can cause pneumothorax and hemoptysis during menstruation. In addition, when an ovarian endometriotic cyst ruptures, the fluid inside leaks into the pelvic cavity and irritates the peritoneum, causing sudden severe abdominal pain accompanied by nausea, vomiting, and a feeling of fullness in the anus. The pain usually occurs around the time of menstruation, after menstruation, after intercourse, or when intra-abdominal pressure increases. (2) Physical signs Larger ovarian endometriotic cysts can be palpated during gynecological examination as cystic masses. Rupture of the cyst can cause peritoneal irritation. Typical pelvic endometriosis can be felt during gynecological examination as a mass with posterior tilting of the uterus, tenderness in the rectouterine pouch, uterosacral ligaments, or lower posterior wall of the uterus, as well as cystic, immobile masses in one or both adnexal regions. If the lesion involves the abdominal incision or umbilicus, hard, immobile, poorly defined, tender nodules can be felt in those areas, which enlarge during menstruation. If the lesion affects the rectovaginal septum, purple-blue spots, small nodules, or masses can be felt or seen in the posterior vaginal fornix.
3. Diagnostic Points
4. Medical History Focus on asking about menstrual history, pregnancy history, abortion history, delivery history, family history, and surgical history.
5. Clinical Manifestations If women of childbearing age have secondary, progressively worsening dysmenorrhea, infertility, pain during intercourse, or a history of chronic pelvic pain, and a gynecological examination reveals cystic masses adhered to the uterus or tender nodules in the pelvis, a preliminary diagnosis of endometriosis can be made. However, clinical confirmation still requires laparoscopic examination and biopsy.
6. Laboratory and Other Examinations (1) Imaging Examinations B-mode ultrasound can determine the location, size, and shape of ovarian endometriotic cysts. The cyst walls are thick and rough, with tiny speckled echoes inside, particularly adhering to the uterus. However, this echo image is not specific and cannot be used alone to confirm the diagnosis. Pelvic CT and MRI are useful for diagnosing and evaluating deep pelvic endometriosis. (2) Laparoscopy Currently, laparoscopy is the best method for diagnosing endometriosis, especially for those who have negative findings on pelvic examination and B-mode ultrasound but exhibit typical endometriosis symptoms. A biopsy under laparoscopy can confirm the diagnosis and determine the clinical stage. (3) CA125 Level Measurement Serum CA125 levels may rise, but generally do not exceed 100 U/L. CA125 measurement can also be used to monitor the activity of ectopic endometrial lesions, assess treatment efficacy, and detect recurrence. However, CA125 specificity is limited. (4) Cystoscopy or Colonoscopy If bladder or intestinal endometriosis is suspected, cystoscopy or colonoscopy with biopsy can be performed to rule out other organ diseases, with a diagnostic probability of 10%–15%.
7. Western Medical Treatment
8. Pharmacological Treatment Applied to cases with a basic confirmed diagnosis; long-term "trial treatment" is not recommended. The purpose of treatment is to suppress ovarian function, reduce the activity of endometrial lesions and the formation of adhesions, and prevent the progression of endometriosis. Currently, there is no standardized protocol; when selecting medications, side effects, patient preferences, and financial capacity should be fully considered. Commonly used drugs include: (1) Nonsteroidal Anti-inflammatory Drugs Indomethacin, naproxen, ibuprofen, etc., used as needed. The main side effect is gastrointestinal reaction; long-term use requires vigilance for gastric ulcers. (2) Contraceptive Pills Commonly used low-dose, high-potency progestin and ethinyl estradiol combination preparations. Long-term continuous use can cause artificial amenorrhea similar to pregnancy, known as pseudo-pregnancy therapy. Take one pill daily for 6–9 months, suitable for patients with mild endometriosis. (3) Progestins Methylprogesterone can be taken at 20–30 mg daily, or norethisterone at 5 mg daily, continuously for 6 months. Menstruation resumes several months after stopping medication. Side effects include irregular spotting, nausea, water retention, and liver function abnormalities. (4) Gestrinone A 19-nortestosterone derivative that antagonizes estrogen and progesterone, lowers sex hormone-binding protein levels, raises free testosterone levels, suppresses FSH and LH peaks, reduces average LH levels, thereby lowering estrogen levels, causing ectopic endometrium to atrophy and be absorbed. (5) Gonadotropin-Releasing Hormone Agonists (GnRHa) Artificially synthesized peptide compounds that mimic the action of GnRHa in the body, depleting GnRHa receptors, reducing Gn secretion, and causing temporary menopause.
9. Surgical Treatment The goal is to remove the lesion and restore anatomy, applicable to cases where symptoms do not improve after drug treatment, lesions worsen, or reproductive function is not restored, as well as to patients with large ovarian endometriotic cysts who urgently wish to conceive. Laparoscopic surgery is preferred. (1) Conservative Surgery That is, lesion excision, suitable for young patients or those who desire fertility, with laparoscopic surgery being the first choice. The surgery aims to completely remove or destroy visible ectopic endometrial lesions, excise endometriotic cysts, and separate adhesions. (2) Hysterectomy Complete removal of the uterus, preserving the ovaries, suitable for patients without fertility desires, with severe symptoms, or whose condition does not improve after conservative surgery or drug treatment, but who are relatively young and wish to preserve ovarian function. (3) Hysterectomy with Bilateral Adnexectomy Removal and clearance of the uterus, bilateral adnexa, and all visible lesions. Suitable for older patients, those without fertility desires, with severe symptoms, or whose condition does not improve after conservative surgery and drug treatment.
10. Professor Pei Zhengxue’s Clinical Experience Professor Pei Zhengxue believes that the main cause of this disease is related to innate constitution and external pathogenic factors experienced before and after menstruation, or to damage to the uterus caused by excessive sexual activity, cesarean section, or induced abortion. The main pathogenesis is “blood that has left the meridians,” which does not follow the normal pathway, stagnating in the Chong and Ren meridians and the uterus, forming blood stasis. Based on typical symptoms and physical signs, combined with tongue and pulse characteristics, he believes that the basic pathogenesis of endometriosis is blood stasis obstructing the flow. The "Complete Works of Jing Yue" records: “Stagnant blood forms lumps, only women experience this; the cause is either menstruation or postpartum, whether internal injury from cold or external wind-cold, or emotional distress such as anger and frustration, which causes qi to reverse and blood to stagnate, or worries and overthinking that weaken the spleen, causing qi to be weak and blood to stagnate, or accumulated fatigue and weakness that make qi unable to move freely. In short, whenever blood is moving, some residual blood remains, and once something goes wrong, it accumulates and eventually forms a lump.” This explains the process of blood stasis formation: if one is careless during menstruation or postpartum, experiences the six pathogenic factors, has congenital deficiencies, weak kidney qi, or emotional imbalance, causing the uterus’s storage and drainage functions to malfunction, all of these can lead to blood stasis. Stagnant blood is harmful because it blocks the meridians; when the meridians are blocked, pain occurs, which is why dysmenorrhea is seen. Moreover, if blood stasis persists for a long time, qi and blood functions become disordered, leading to tumor formation. If blood stasis is left unaddressed for too long, it blocks the lower jiao, obstructs the Chong and Ren meridians, and impairs the uterus’s storage and drainage functions, resulting in menstrual irregularities. If the Chong meridian is damaged and the Ren meridian is blocked, and the Du meridian loses its warming function, the two essences cannot interact, leading to infertility. Professor Pei Zhengxue believes that activating blood circulation and removing blood stasis is the fundamental treatment for endometriosis. The "Plain Questions" states: “Unblock the qi and blood, allowing them to circulate smoothly,” which forms the basis of the principle of activating blood circulation and removing blood stasis. The circulation of qi and blood, as well as human physiological functions, are all related to the abundance of kidney qi. If kidney qi is deficient due to illness, chronic disease, or excessive sexual activity, qi and blood become deficient, causing blood to fail to flow through the meridians, backflow to the lower abdomen, and triggering pain. “Kidney deficiency” is the root cause of endometriosis; kidney qi deficiency can also lead to blood stasis, which obstructs the circulation of qi and blood, weakening righteous qi and ultimately leading to kidney deficiency. “Kidney deficiency” and “blood stasis” interact and influence each other, forming a vicious cycle that makes the disease persistent, recurrent, and difficult to treat. The "Plain Questions" says: “The north is cold,” so most patients live in the northwest, easily exposed to cold pathogens, and most clinical manifestations include cold extremities, aversion to cold and preference for warmth, relief of pain with warmth, or cold pain in the lower abdomen during menstruation. The "Comprehensive Good Prescriptions for Women" says: “Cold qi invades the blood chamber, causing blood to stagnate and not flow... therefore pain occurs.” The "Discussions on the Origins and Causes of Various Diseases" says: “Women who experience abdominal pain during menstruation... are exposed to wind and cold... wind and cold collide with qi and blood, causing pain.” Yang deficiency makes it easy for cold pathogens to invade, causing cold congealing in the liver meridians, leading to constriction of the meridians, damage to the Chong and Ren meridians, poor circulation, obstruction in the uterus, “pain because of cold,” resulting in dysmenorrhea.
11. Analysis of Professor Pei Zhengxue’s Formulas Professor Pei Zhengxue often uses Shaofu Zhuyu Tang before and during menstruation to remove blood stasis, and Guizhi Fuling Wan plus Jin Gui Shenqi Wan after menstruation. He often combines Sanleng, Ezhushi, seaweed, kelp, Xiangfu, Yanhusuo, Chuanlianzǐ, Han Sanqi, leech, and other herbs. Shaofu Zhuyu Tang is detailed in the explanation of the dysmenorrhea formula. Guizhi Fuling Wan originates from the "Jin Gui Yao Lue," composed of guizhi, fuling, danpi, taoren, and chishao. Taoren has a bitter-sweet taste and neutral nature, clearing blood stasis and dispersing it; the ancient text "Ben Cao Jing Shu" says: “Taoren has a good effect on breaking up blood clots, dispersing rather than collecting, promoting excretion without replenishing…” Pharmacological studies show that its extract can reduce vascular resistance, promote blood flow dynamics, and even stimulate uterine contractions. The decoction has analgesic and antibacterial effects; fuling has a sweet and bland taste, good at “tonifying the spleen and removing dampness… facilitating urination to help drain water,” and can also promote blood circulation between the waist and navel, working together with taoren to activate blood circulation and remove blood stasis, while also benefiting from the moist and blood aspects to assist guizhi. Research shows that fuling has diuretic, immune-enhancing, anti-tumor, anti-inflammatory, and antiviral effects. Chishao has a bitter and slightly cold taste, clearing heat and cooling blood, dispersing blood stasis and relieving pain. The "Shennong Ben Cao Jing" says: “For abdominal pain caused by evil qi… break up stubborn accumulations… relieve pain, promote urination.” This product contains paeoniflorin, which has good sedative, anti-inflammatory, and analgesic effects; danpi has a bitter and spicy taste, cool blood without leaving stasis, activates blood without causing clotting, and its contained peony phenols have analgesic and spasmolytic effects, also inhibiting platelet aggregation. Danpi and chishao, combined with the aforementioned guizhi, taoren, and fuling, enhance the effect of removing blood stasis and also nourish blood and cool blood. The formulas are simple and focused, working together to achieve the effect of activating blood circulation and removing blood stasis, while also slowing down tumor growth. Additionally, sanleng and ezhushi are added to break up blood stasis and activate qi, clearing blood stasis and relieving pain; the former is good at breaking up blood within the blood, while the latter is good at breaking up qi within the blood. These two herbs work together, applying both qi and blood, commonly used clinically, first appearing in the "Good Prescriptions for Experience" as sanleng pills, used to treat abdominal pain during menstruation and other conditions. Modern research shows that sanleng and ezhushi can increase blood flow and decrease blood viscosity, inhibiting platelet aggregation. Yanhusuo is a good medicine for activating blood circulation and relieving pain, with predecessors saying it can “clear qi stagnation in the blood, blood stagnation in the qi, thus specializing in treating all kinds of pain throughout the body.” Leech is a medicine for activating blood circulation and removing blood stasis, as well as preventing platelet aggregation, with effects similar to Western medicines like urokinase and heparin. Jin Gui Shenqi Wan, also known as Shenqi Wan or Ba Wei Di Huang Wan, is a dual-tonic supplement for both yin and yang, used to tonify yang deficiency. Using Jin Gui Shenqi Wan after menstruation achieves the purpose of warming yang and tonifying qi to relieve pain. Modern pharmacological research shows that Guifu Di Huang Wan can increase the level of estradiol in rats, potentially affecting microcirculation and sex hormone-like changes. The main ingredients of Jin Gui Shenqi Wan are effective in improving yang deficiency.
12. Case Example Patient, 28 years old, first visit on May 20, 2017. Chief complaint: Lower abdominal distension and pain during menstruation for 10 years, progressively worsening. Past medical history: The patient has had lower abdominal distension and pain during menstruation for 10 years, with symptoms gradually worsening, and menstrual flow has also decreased compared to before. No systematic treatment has been received during this period. Seeking detailed diagnosis and treatment, she came to Professor Pei Zhengxue’s clinic. Physical examination: Lower abdominal distension and pain, refusal to press, pain relieved upon pressing the mass, accompanied by fear of cold, poor appetite, normal sleep and urination, but loose stools, once a day. Marital and reproductive history: Never married, denies sexual activity. Menstrual history: First menstruation at age 12, cycle length of 28 days.