very long paper

The Dietary Management of Endometriosis
Sue Cook, July 2010

“Therefore if people pay attention to the five flavors and mix them well, their bones will remain straight, their muscles will remain tender and young, their breath and blood will circulate freely, their pores will be fine in texture, and consequently, their breath and bones will be filled with the essence of life .” The Yellow Emperor’s Divine Classic
Endometriosis is a disorder in which endometrial tissue proliferates outside of the uterus. This tissue most commonly implants within the peritoneal cavity, binding to the surfaces of the organs. It grows and bleeds in response to hormone changes, causing inflammation and scarring. Typical symptoms include dysmenorrhea, dysuria, chronic pelvic pain, pain during intercourse, and infertility. In advanced cases where tissue has implanted outside of the abdominal cavity, there may be nosebleed, coughing of blood, and rectal bleeding. While the etiology is still unknown, the most common theory is that endometrial tissue leaves the uterus through the fallopian tubes in a retrograde form of menstruation and is transported through the body via the lymphatic system. Another theory posits that the tissue develops from peritoneal cells in a type of metaplasia.
Endometriosis is typically diagnosed by a biopsy obtained by laparoscopic surgery. Treatment ranges from NSAIDS for management of inflammation, to the prescription of birth control pills to regulate hormone levels. In extreme cases, an artificial menopause may be induced using GnRH agonists. Surgery to remove endometrial implants is also advised, although the tissue usually regenerates. In very extreme cases hysterectomy may be performed .
New research has correlated endometriosis with high levels of prostaglandin E2 (PGE2), a signaling molecule involved in the regulation of immunity and inflammation. High levels of PGE2 inhibit phagocytosis by macrophages, preventing the destruction of abnormal tissue by the immune system. PGE2 also allows endometriotic cells to synthesis their own estrogen, which in turn stimulates mitosis, producing more aberrant cells. A number of genes that share common markers with tumor angiogenesis are also common to these cells .
Although dietary modification is not a common modality in the biomedical treatment of endometriosis, enriching the diet with natural PGE2 inhibitors and anti-angiogenic foods is a logical step. The Angiogenesis Foundation’s website lists a number of these foods: turmeric, broccoli, cinnamon, green tea, blueberries, pineapple, garlic, ginger, and red wine, to name a few. New research also suggests that eliminating trans-fats and increasing Omega-3 consumption can both reduce risk of developing endometriosis and ameliorate its symptoms. Omega-3 fatty acids are a vital component of prostaglandin E1, which inhibits PGE2. Bromelain, an enzyme found in pineapple, has demonstrated anti-inflammatory and tumor-fighting abilities and may also prove useful . Regular exercise and stress reduction techniques can also help, both by boosting immune response and by modulating pain through endorphin release.
Because of its non-invasive nature, Chinese medicine is becoming more and more well-known for its treatment of chronic diseases. Diagnosis is performed through methodical questioning, careful palpation of the pulse and body, and inspection of the tongue. Diseases are typically categorized according to temperature, location in the body, type of pathogenic influence, and organ system. Treatment is based on the “Four Pillars:” acupuncture, herbal therapy, diet, and exercises such as qi gong and tai ji.
According to Bob Flaws’ book Endometriosis, Infertility, & Traditional Chinese Medicine, modern Chinese medicine divides endometriosis into four main categories according to symptoms: qi stagnation and blood stasis, accumulation of cold causing blood stasis, heat congestion with blood stasis, and qi and blood vacuity with blood stasis.
Qi is an ephemeral substance that powers the body. The functions of qi are to activate, warm, defend, transform, and contain. It provides the force behind the body’s metabolism and growth, sustains the immune system, regulates the production of blood and other bodily substances, and maintains the circulatory system, both by propelling the blood through the body and by restraining the blood within the vessels. When the body’s equilibrium is disturbed, either by external causes such as contagious disease or by internal causes such as emotional turmoil, the qi can become stagnant or weak. Such a disruption inevitably results in disease.
Blood is formed by the interaction of qi and the nutrients received from food, water, and air. It has an interdependent relationship with qi. Qi is the commander of the blood, and blood is the mother of qi. Blood can become static, hot, cold, or deficient, usually in combination.
The body is seen as an equilibrium of yin and yang. If the body is thought of as an machine, yin would be the oil that cools and lubricates the moving parts while yang is the gasoline whose fiery combustion powers the movement of the engine. Qi is primarily yang, blood is primarily yin. Each balances the other and keeps it in check, as well as containing a seed other the other within itself. If the yin and yang become unbalanced, heat or cold can develop within the organs.
There are three main organs involved in gynecological disorders: the Liver, the Spleen, and the Kidneys. The Liver in Chinese medicine is the organ responsible for governing the free flow of qi within the body. It stores the blood and controls the amount of blood released into the vessels. The Spleen regulates digestive function. It transforms food and water into qi and blood and distributes them throughout the body. It is said to hold the organs in place and prevent prolapse. It also prevents the blood from leaving the vessels. The Kidneys are said to store the essential qi that serves as the substrate for all bodily functions as well as to house the ministerial fire that controls the metabolism of water throughout the body.
The first diagnosis, qi stagnation and blood stasis, represents a disruption of Liver function. The Liver is especially susceptible to stress, which causes a sort of internal “traffic jam.” When the qi can’t circulate properly, the blood also becomes sluggish. The blood can also become static from trauma causing obstruction in the vessels or from use of birth control medications, which prevent menstrual blood from being fully discharged. Static blood can in turn cause the qi to back up and become stagnant. Symptoms of stagnant qi and blood are
lower abdominal distention, lower abdominal crampy pain, premenstrual breast distention, a stuffy, tight chest… stabbing, sharp, fixed, and lancinating pain, clots in the menstrual discharge, the relief of dysmenorrhea after the passing of clots… possible palpable lumps or masses, and poking pain with intercourse.
The tongue will have a dark or dusky appearance and the pulse will be wiry or choppy. Treatment will focus on moving the qi and blood. Acupuncture protocols with this aim will select from a combination of points such as: Lv 3, Sp 6, Sp 10, LI 4, Ren 3, Ren 6, St 25, Bl 25.
The second category, cold causing blood stasis, is mainly generated by an external cause. Cold can invade the body during exposure to low temperatures, through excessive consumption of cold and raw foods. However, it can also invade when the ministerial fire of the Kidneys becomes weak, generally from severe illness, aging or prolonged overwork, as well as from a lack of Spleen yang. Symptoms include
cold, fixed pain in the lower abdomen relieved by warmth, a dark, clotty, menstrual discharge, aversion to cold… Lumps or masses may be felt on palpation of the uterus and the patient tends to be chilled.
The period may be late or excessively long and heavy. The tongue will be pale or purple with a wet coating, and the pulse will be deep and tight. If the Spleen is deficient in yang, there will be signs of digestive cold such as excessive mucus, diarrhea, loss of appetite, and vomiting. In this case the tongue coat will be thick and greasy and the pulse may be slippery. If the Kidneys are deficient in heat, there may be low back pain, sore knees, edema in the lower limbs, leukorrhea, and frequent urination. The pulse in this case may be very thin and weak. The treatment strategy is to warm the uterus, dispel cold, and move the blood. The warming functions of the Spleen and Kidney should be strengthened as needed. Acupuncture protocols will use points such as Sp 6, Sp 10, Ren 3, Ren 4, St 28, St 36, Bl 23.
Excessive heat in the body can congeal the blood into stasis. Stagnant qi caused by Liver dysfunction can cause friction, which turns into heat. Heat can also be generated by improper diet or by a lack of cooling yin in the organs. If the heat is a result of depressed Liver function, there will be symptoms like migraine headache, emotional lability, red and painful eyes, itchy vaginal discharge prior to menses, and painful urination. The pulse will be rapid and wiry and the tongue will be red with a yellow coating. If the heat is due to a lack of yin, the patient will experience night sweats, a sensation of heat in the palms, soles and chest, mallar flush, imsomnia, irritability, as well as possible dryness of the mucous membranes. The pulse will be rapid, wiry, and floating and the tongue will be reddish with a dry or very thin coat. The menses may be scant or early and there may be vaginal dryness . The pain will be hot and burning and there may be palpable heat and inflammation in the back and pelvic region. The treatment strategy is either to clear heat and move the blood or to clear heat, nourish yin, and move the blood. In the first case the acupuncture protocol will include a selection from Lv 2/3, LI 4, Sp 6, Sp 10, GB 26, GB 34, GB 41, Ren 3, Ren 6, Bl 18, Bl 19, St 29. For yin deficiency with stasis: Kd 3, Kd 6, Ht 5, Ren 4, Sp 6, Sp 10, St 36.
The last pattern, vacuity of qi and blood with stasis, is a particularly common and self-perpetuating cycle. The blood and qi becomes weak due to blood loss itself, poor diet, overwork, stress, or external disease; when there is not enough blood or qi for the qi to flow evenly through the vessels it causes a concurrent stasis of blood and qi, which in turn prevents the generation of more qi and blood. This pattern may be differentiated by whether the qi or the blood is more deficient. If the blood is more deficient, the period will be short and scanty or may stop altogether. The cramps will not be improved as the cycle progresses. The patient may have restless fatigue, insomnia, poor memory, heart palpitations, dry skin, hair and nails, and vertigo. If the qi is more deficient, there will be a dragging sensation in the uterus as the cycle progresses, profound fatigue, and pain made worse by activity. Both types may be accompanied by Spleen cold symptoms such as diarrhea, lack of appetite, abdominal pain during digestion, bloating, and feeling chilled. The treatment strategy is to strengthen qi, generate new blood, and move the static blood. Acupuncture should be accompanied by moxibustion, a modality in which the dried form of the herb mugwort is burned over acupuncture points to supplement the qi and blood. Sample points are St 36, Sp 6, Lv 3, Lv 8, Ren 4, Bl 18, Bl 20.
While Chinese herbal therapy has proven extremely useful in treating endometriosis, many patients may resist taking herbs, often for financial reasons. Dietary modification is extremely useful in these cases. It also allows the patient to recover a sense of control over their body, which can relieve the antipathy many chronic pain patients feel toward themselves.
Chinese herbal and dietary therapy are both based upon the five flavors: pungent/acrid/spicy, sour, sweet, bitter, and salty. Each flavor corresponds to one of the five elements: pungent is the flavor of metal, the element of the Lung; sour is the flavor of wood, which is the element of the Liver; bitter is the flavor of fire and the Heart; sweet is earth and the Spleen; salty is water and the Kidney. The elements follow a specific cycle in which one generates the next: wood, fire, earth, metal, water. Each element also restrains another: wood, earth, water, fire, metal. Each flavor also has an action: acrid promotes motion, sour preserves and contains, bitter drains, sweet nourishes, and salty dissolves. Herbs and foods also have a corresponding temperature, either hot, warm, neutral, cool, or cold. Therefore for a condition of heat from deficient yin and blood with concurrent static blood, the herbs and foods used should be sweet to nourish yin and blood, acrid to move the blood, and a balance of cooling and neutral. When using sweet foods, it is important to include ingredients that boost the digestion, primarily those that are bitter and acrid.
Foods that are said to move the blood include adzuki beans, black beans, peaches (both the fruit and the kernel within the pit), hawthorn berries, chestnuts, chives and green onions, eggplant, chili peppers, brown sugar, cinnamon, wine, acrid spices like cumin, coriander, and turmeric, and vinegar. Foods that move stagnant qi and soothe the Liver include oranges, carrots, plums, greens, celery, and vinegar. Herbs and seasonings that move Liver qi include onions, basil, bay leaf, cardamom, cumin, rosemary mint, and lemon balm. Raw and sprouted foots can also restore function to a stagnant Liver, especially when there are heat signs present. Foods that strengthen qi, yin and blood are miso, oats, rice, grapes, raspberries, longan fruit, lychee, goji berries, peanuts, beets, broccoli, spinach, sweet potatoes and yams, molasses, seaweed, kale. Animal products such as dairy, eggs, and meat all build blood as well, but their temperature must be carefully considered. Red meat like beef and lamb are hot in nature, while duck is cool. Pork and most seafood is neutral. In cases with pronounced cold, hot and warm natured foods like garlic, black pepper, cloves, cinnamon, ginger, lamb, and walnuts should be favored. Conversely, they should be avoided in cases with heat, and cooling foods such as watery fruits and vegetables, mung beans, barley, wheat, and seaweeds should be consumed. Dairy, sugar, and white flours as well as excessively bitter/spicy foods are particularly taxing to the Spleen and tend to contribute to digestive complains as well as damp conditions such as yeast infections and chronic phlegm and should be avoided.
It is often overwhelming for a patient to look at a list of foods and try to come up with something to prepare, especially if they are overworked and tired or have little background in cooking. Sample recipes such as those that follow at the end of this essay can relieve this stress as well as giving the patient a sense of responsibility for their own recovery.
In Healing with Whole Foods, Paul Pitchford recommends a number of supplements for blood deficiency: vitamins A, E, and the B complex, iron and zinc, as well as Omega 3 and 6, chlorophyll and spirulina. Dietary supplements can sometimes be more appealing to patients than herbal which need to be taken several times a day and which often require purchasing a bottle per week. In this case taking a single-herb supplement like turmeric extract should also be suggested.
It is interesting to note the overlap between the list of anti-angiogenic foods provided earlier and the list of foods that build and move blood. The Angiogenesis Foundation website also notes the anti-cancer properties of several mushrooms, namely shiitake, wood ear, and Ganoderma, which are said in Chinese medicine to boost the defensive qi, which corresponds to the immune system. Consumption of these mushrooms, either in extract or as food, may also help promote the destruction of abnormal endometrial tissue by white blood cells.
A diagnosis of endometriosis from a gynecologist can feel like a life sentence. To be forced to choose between sometimes crippling pain and hormonal treatments with unpleasant side effects, exploratory abdominal surgery followed by excision and cauterization, or even hysterectomy is the harsh reality that often faces these women. In contrast, Chinese medical modalities such as acupuncture, herbs, and dietary therapy can provide both temporary and long-term care in a gentle, self-empowering way. By using the “five flavors,” women with endometriosis can find not just relief, but actual recovery.

Sample Recipes:
Curried Sweet Potato and Lentils
ingredients:
2 T organic butter or vegan butter substitute (preferably the flax-based type)
1 large purple onion, diced
2-3 cloves garlic, pounded to a paste or minced
2 inch piece fresh ginger, grated or 1 tsp dried ginger powder
2 large unbroken bay leaves
1 tsp each cumin and fenugreek seeds, powdered
1 tsp turmeric root, powdered
1 large sweet potato or yam, diced
2 cups dried red lentils
water to cover
1 large ripe tomato, chopped
salt or Bragg’s Liquid Aminos to taste
directions: Heat a heavy-bottomed pot, using a pressure cooker if available over a medium flame and melt the butter. Add the onions and bay leaves, stirring frequently until the onion begins to brown, then add the garlic, ginger, and spices, stirring to prevent sticking, and cook for 2 minutes. Add the sweet potato and lentils and pour in sufficient water to cover by at least one inch. Bring to a low boil, then reduce the heat to a simmer and cover. Simmer for approximately one hour until the lentils are soft. Puree if desired. If using a pressure cooker, close the lid and allow to boil until the pressure sensor goes off, then lower heat and cook for 20 minutes. top with fresh tomatoes. Makes approximately 4 2-cup servings.
Analysis:
onions, garlic, cumin, turmeric and bay are warm and acrid and move Liver qi and blood; they also prevent gas during digestion of the legumes. butter is warm and sweet and also reduces stagnant blood. ginger and fenugreek are warm and strengthen the yang of the kidneys and spleen and stop abdominal pain. lentils are sweet and neutral and strengthen the essential qi of the kidney, and are rich in iron and B vitamins. sweet potato is sweet and strengthens the qi overall, especially of the spleen, as well as the yin of the kidneys. they balance estrogen levels and are rich in vitamin A. tomatoes are sweet, sour, and cooling. they nourish yin and generate stomach fluids and purify the liver; they are rich in lycopene which is a powerful antioxidant.
this recipe would be helpful for cold-type blood stasis, i.e. for the woman who feels freezing cold all the time and has painful stabbing cramps relieved by a heating pad, and who also tends to have diarrhea during her period. it is warming and strengthening without being too drying. in cases of severe cold the tomatoes may be removed.

Roasted Duck with Blueberry Sauce and Shiitake Wild Rice
ingredients:
1 fresh duck
3 T brown sugar
1 tsp minced fresh rosemary
one pint blueberries
1 cup thinly sliced shiitake mushrooms
1 shallot, minced
1 cup brown/wild rice mix
3 cups water
1 tsp turmeric powder
2 T corn starch
sea salt
directions: preheat the oven to 350. rub the duck with the brown sugar, rosemary, and a pinch of sea salt mixed together, then place in a roasting pan. bake for about 40 minutes covered with foil, then remove the foil. at this time spoon off a few tablespoons of the fat into a saucepan and cook another 20 minutes until the skin is crispy and the temperature of the meat of the thigh is 170 degrees. remove from the oven and pour off the fat into a jar. remove the duck and let it rest. scrape the brown drippings from the pan into a small saucepan.
after removing the foil from the duck and spooning the fat into a saucepan, heat the pan over a medium flame. add the shiitakes and shallot, stirring frequently until brown. add the rice and stir to coat evenly with the fat, then add the water and bring to a boil. cover, reduce to a simmer, and cook until all the water is absorbed, approximately 35-40 minutes.
while the rice is cooking, prepare the sauce: dissolve 2 T corn starch in 2 cups of water, then whisk into saucepan with the drippings, the blueberries and about 2 T of the duck fat. reserve the rest of the duck fat in a tightly lidded jar for a sad and gloomy day. let the sauce simmer until thickened. mash the blueberries against the side of the pan. salt to taste.
Serve the duck over the rice topped with the sauce. This can feed two people for several meals or a group of 4-6 once.
Analysis: duck is sweet and cool and nourishes kidney yin and essential qi. blueberries are sweet, cold, and nourish kidney yin; they are also anti-angiogenic and full of antioxidants and fight cancer. brown sugar moves and tonifies blood; it contains B vitamins. rosemary is warm and acrid and moves qi; it is also anti-angiogenic and anti-inflammatory. shiitakes are sweet and neutral and strengthen the lungs and stomach; they are anti-angiogenic and boost white blood cell counts and fight cancer. shallots are sweet, acrid, and neutral. they strengthen the qi of the lung and stomach and help to break down the fats in the meal. turmeric is warm and acrid and moves liver qi and breaks up static blood. wild rice is cool, bitter and sweet, brown rice is sweet and neutral. they strengthen qi overall and contain B vitamins to build blood and strengthen the nervous system.
this recipe is well suited for a woman with a mixture of yin/blood/qi deficiency. she would feel hot, irritable, restless and exhausted before, during, and after her period. this would be a particularly suitable meal for winter months as it is extremely nourishing. if she has difficulty digesting heavy foods, orange or tangerine zest may be added to the sauce to help break down the fats and prevent stagnant qi in the belly.


Endnotes didn't seem to work so I am cutting and pasting them. I will re-edit this post later to make sure they show up: I sure don't want to be thought to plagiarize.

Veith, Ilsa, trans. The Yellow Emperor’s Classic of Internal Medicine Los Angeles: University of California Press, 1973. (109).
Beers, Mark H. et al, Eds. The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck & Co. Inc. 2009. (2089-92)
Wu, Meng-Hsing et al. “Prostaglandin E2: the Master of Endometriosis?” Experimental Biology and Medicine, Vol 235, number 6. 2010. (668-677. ) Retrieved from http://ebm.rsmjournals.com/cgi/content/full/235/6/668

Angiogenesis Foundation Website, online at http://angio.org/news.php
Missmer, Stacy A. et al. “A Prospective Study of Dietary Fat Consumption and Endometriosis Risk.” Human Reproduction, Vol 25, number 6. 2010. (1528-1535). Retrieved from http://humrep.oxfordjournals.org/cgi/content/full/deq044
Mynott, Tracey et al. “Bromelain, from Pineapple Stems, Proteolytically Blocks Activation of Extracellular Regulated Kinase-2 in T Cells.” Journal of Immunology, vol. 163. 1999. (2568-2575). Retrieved from http://www.jimmunol.org/cgi/content/full/163/5/2568
Flaws, Bob. Endometriosis, Infertility, & Traditional Chinese Medicine: a laywoman’s guide. Boulder: Blue Poppy Press, 1989. (28)
Wiseman, Nigel and Andrew Ellis, translators. Fundamentals of Chinese Medicine. Brookline: Paradigm Publications, 1996. (19-20)
Wiseman, 22.
Wiseman, 64-67.
Wiseman, 59-60.
Wiseman, 68-70.
All acupuncture protocols are cited from: Flaws, Bob. A Handbook of Menstrual Diseases in Chinese Medicine. Boulder: Blue Poppy Press, 1997. (543-544).
Endometriosis, 32-33.
Endometriosis, 34-35.
Endometriosis, 36-37.
see Subhuti Dharmananda’s excellent summary of recent research in China, available online at http://www.itmonline.org/journal/arts/endometriosis.htm
Wiseman, 7-14.
Pitchford, Paul. Healing with Whole Foods: Asian traditions and modern nutrition. Berkeley: North Atlantic Books, 2002. (327)
Mattson, Brendan, DAOM. "TCM Dietary Guideline Reference Table." Eastern Nutrition class lecture handout, Pacific College of Oriental Medicine, Chicago. Spring term, 2010.
Pitchford, 388.