Elaine, 38 years old woman, 125 lbs, 5’6”, visited my office at February 11, 2021. Patient had tried to conceive for six years. She was diagnosed with stage 4 endometriosis in last August.  The right ovary and the right tube had been removed with surgery. The ovary cyst was measured 7.2×4.3×3.0 cm. She got pregnant one month after the surgery but miscarriaged in the 9th weeks of pregnancy. The cramping had come back since then. The sharp and  paroxysmal pain occurred before and after period on the pain scale of 8 (if the pain scale from 0 to 10 and the greatest pain is 10) with cold sweating. The pain even happened in between the period. She needed a great amount of pain medication to reduce the pain. It is very disturbed to her normal life and her work. The sonogram showed there was 4.8×4.5cm cyst on the right annex area on January this year. Her doctor suggested another surgery, but she would like to find noninvasive treatment to control the disease since the condition recurred in the short period of time after last surgery.

History of GYN: 14 5/28-30, ovulation on day 14th of the cycle. G2 A2 (Patient has had an abortion in 2015). LMP：02/07/21.

Family history: unclear.

Patient came to visit me and ask to decrease the pain to get back to normal life at first. She also would like to control the endometriosis to avoid the repeated surgery if it is possible. Patient had not believed that she will pregnant again since the endometrioma came back so soon. I told her Chinese medicine not only could help her controlling the endometriosis and decrease the pain, but also was able to absorb or decrease the sizes of endometrioma and she could possibly conceive naturally. I encouraged her try to conceive during the treatment. I suggested she changed her diet with anti inflammatory food, took the herbal supplements daily. came for acupuncture once a week.

Chinese medicine is a holistic approach: it go through all the signs and symptoms (Subjective and Objective), family history, life style, the culture of living area and season (weather) etc. to analysis patient’s condition. Then combining all the information together to figure out（ call differentiation ）a pattern of disease,  then give the treatment according to the pattern. The pattern could reflected the stage of process of disease, or the reaction to the disease from different physique（ including the different epigenetic-see explains below).

Elaine was born in Taiwan, she came over to America, when she was 18 years old.  Foods ( for example, eat more meat than she used to), climate and life style (sleeping patterns, stress etc.) are totally different between two areas. For instance, her body was not get used to the high protein diet, especially when her metabolism was getting lower with the age.  Her immune system and hormone balance had changed through the diversity of bacteria in the guts because of high protein intake and age and stress. These changes were reflected in the pelvic area（uterus, tubes, ovaries and guts) as well as on her tongue color and the coating.

Endometriosis is a benign disease defined by the presence of ectopic endometrial glands and stroma associated with both pelvic pain and infertility(or miscarriage). The ectopic endometrial lining tends to grow in pelvic area such as ovaries, tubes, large intestine and peritoneum etc. These area will induce the bleeding during period. The bleeding is no where to go which making infection ( adhesion, scar tissue etc.) to create great pain and change the structure of the pelvic, especially reproductive organs. These change will interference the oocyte development and early embryogenesis, inhibit or prevents ovum capture after ovulation, reduced endometrial receptivity. Stage 3 and  4 endometriosis presents severe structure changes.

The causes of disease are still not clear and complicated. According to previous studies, the primary mechanism is possible for retrograde menstruation and implantation of viable endometrial tissue. But why does severe disease develop in some women but not in others? Multiple observations suggest that the endometrium in women who develop endometriosis may be inherently abnormal in ways that predispose to ectopic implantation and propagation.

Genes that may predispose to the development of endometriosis might include any of those that direct the molecular processes that survival of detached endometrial cells, their attachment to an invasion of peritoneal surfaces, proliferation, neovascularization, or the inflammatory responds. For instance, europic endometrial cells from women with endometriosis are resistant to apoptosis; in women with endometriosis, secretory endometrial matrix metalloproteinases expression in unusually resistant to progesterone suppression which can confer an invasive potential in shed endometrial cells to the peritoneal surface and subsequent cell proliferation; aromatase, the enzyme that convert androgen to estrogen is abnormally expressed in the eutopic endometrium of women with endometriosis which improve the disease, etc.

Endometriosis also associated with changes in both cell – mediated and humoral immunity, which suggests that an impaired immune response resulting in ineffective removal of reflux Ed menstrual debris may be a causative factor in the development of disease.

Based on the causation, endometriosis not only change the structure of the reproductive organs to decrease the possibility of egg releasing and fertilized, but also affect the oocyst’s quality, early embryonic development and embryo implantation etc. which can’t avoid the infertility and miscarriage. Elaine is one of this case.

Elaine quickly conceived after the surgery but miscarriaged at the 9th weeks. Now surgery should not be an option anymore from the point of fertility preservation. Elaine is going to be 39 this year, the important thing is to protect her fertility preservation. Usually IVF is the option in this point. But the successful rate would be low in the condition that the disease is progressing if the environment of the pelvic and uterus not changed. In the past practices years, I have used Chinese medicine ( including herbal supplements and acupuncture) to help many of the these similar cases whose failed many IVF, IUI or natural pregnancy. According to the studies in China, I believe Chinese medicine from different angles and levels to work on multiples targets to impact the expression of the genes and repair the immune system in order to create the health environment for pregnancy. I suggested she prepared to conceive for three month.  She could consider the IVF if she was not pregnant in three month.

In Chinese medicine, there are serval different patterns for endometriosis. These patterns ( different objective and subjective symptoms) may reflect different expression (different symptoms) of gene in the different body. These expression may be affected by foods, stress, life style, hormones and impaired immune system, etc. call eigenetic. Epigenetics is the study of how your behaviors and environment can cause changes that affect the way your genes work. Unlike genetic changes, epigenetic changes are reversible and do not change your DNA sequence, but they can change how your body reads a DNA sequence.

We suggest the patient change the diet and life style according to the pattern.  Second, the herbal supplements were prescribed for her to get off the symptoms, which I believed it alters the expression of the gene epigenectics. For instance,  the food such as green tea could effect on DNA methylation through to adjust the level of methyltransferase. Most herbal supplements I give to the patient are food grade plants. It indicated the expression has been up or down to reach what they should be if the symptoms were gone. Third, acupuncture helps to decrease stress, anxiety, and balance the munro-immune-endocrine system.

According to Elaine’s signs and symptoms, she could be considered as a pattern of Qi and blood stagnation with damp heat, underlining Qi and Yang deficiency in Chinese medicine. I gave her Chinese herbal supplements daily and acupuncture treatment once a week. Her menstrual cramping decreased to 50% after a month of treatment, 90% after second month. The sonogram showed that the ovary cyst decreased to 2.8 cm from 4.8 cm in January 2021 . She conceived naturally in May 2021.