Factors that are Salient in Developing a Traditional Chinese Medicine Nutritional Manual for Women with a History of Endometriosis

By aren !onchae "ordon

# Capstone $ro%ect $resented in partial fulfillment of the re&uirements for the Doctor of #cupuncture and 'riental Medicine Degree

!o San (niversity

)os #ngeles* California #pril +,-.

Approval Signature Page

This Capstone Project has been reviewed and approved by:

Lawrence J. Ryan, PhD., Capstone Advisor

June 10, 2013

Daoshing Ni, PhD., L.Ac. pecia!ty Chair

June 10, 2013

Andrea "#rchison, DA$", L.Ac.

June 10, 2013

% Abstract Endometriosis is a de/ilitating condition characteri0ed /y high recurrence rates1 The etiology and pathogenesis of endometriosis remain unclear1 Typically* endometriosis causes pain and infertility1 This study reviewed the current literature availa/le concerning the use of Chinese her/al medicine and traditional Chinese nutrition including her/s and the integrated use of Chinese nutrition and Western nutrition and medicine to treat women who suffer from Endometriosis1 2t uncovered the strengths* wea3ness* and limitations as well as similarities and differences regarding data gathered from availa/le pu/lished research and other articles* and provided a list of factors that constitute a /asic foundation for a manual that could specifically serve patients with endometriosis1 This study concluded that a Traditional Chinese Medicine nutritional manual specifically created for the treatment of endometriosis could /e developed to aid patients in understanding all aspects of foods* her/s and supplements1 Such a manual could encourage patients to consider dietary changes in con%unction with other healing approaches1 #lso* it could increase awareness of Traditional Chinese Medicine to patients whether or not they have /een e4posed to Traditional Chinese Nutrition1

& Acknowledgements

2 would li3e to than3 my capstone pro%ect advisor* )arry 5yan* for his constant encouragement* support* patience and guidance throughout this capstone pro%ect writing process6 to Carola "ehr3e* for all her support and care in helping us to stay motivated during this program6 Dr1 7ian for her constant positive support* love and dedication to our whole group6 and !o San (niversity li/rarians for their resourcefulness1 2 would also li3e to than3 all my professors* cohort + classmates* my family and friends for all their love and support1

' Table of Contents Chapter -8 2ntroduction999999999999999999999111111111111: 'verview9999999999999999999999999999911: 5esearch "oals999999999999999999999999991: "lossary of 5elevant Terms999999999999999999911; Chapter +8 )iterature 5eview 99999999999999999999991-+ 'verview 999999999999999999911111111111111111111111111111 -+ Description of Endometriosis99999999999999999911-. Diagnosis of Endometriosis999999999999999999911-< Western Drugs for Endometriosis99999999999999991-: The TCM $erspective 5egarding Endometriosis9999999119-; Traditional Chinese Nutrition for Endometriosis999919999++ Common Conditions of Stagnant Blood Causing $ain9999911.$revention and "ood Ha/its99999999999999999991.+ Caffeine and 5eproduction99999999999999999999.+ #lcohol99999999999999999999999999999911.. )iterature 5eview 2ntegration99999999999999999911.= Chapter .8 Method 999999999999999999999991111111111111 2ntroduction9999999999999999999999999999.: Designation of 5esearch Method99999999999999999.: "rounded Theory99999999999999999999999991.; 5esearch Synthesis Method99999999999999999999>, .:

Sampling and Sampling $rocedures 999999999999991111>, 2nstrumentation and Data Collection $rocedure 9999999911>-

Chapter >8 5esults99999999999999999999999999999>> 'verview9999999999999999999999999999991>. Endometriosis Diet9999999999999999999999999>> Endometriosis and Supplements999999999999999999>= Endometriosis and Her/s99999999999999999999911>= Endometriosis Western #pproaches99999999999999991>? Chapter =8 Discussion9999999999999999999999999999>: Summary of Findings9999999999999999999999991>: 2mplications for Theory and $ractice99999999999999991>; Factors for 2nclusion in the Nutritional Manual999911999999=)imitation of the Current Study99999999999999999991=+ 5ecommendations for Future 5esearch9999999999999991=. Conclusion99999999999999999999999999999911=. 5eferences999999999999999999999999999999999911== #ppendices #ppendi4 #8 #rticles (sed for 5esearch Synthesis* )isted in 'rder of Study Num/er999999999991?+ #ppendi4 B8 Characteristics of the 2ncluded Studies 'n Nutrition and Diet999999999999999991?> #ppendi4 C8 Summary of Studies on Nutrition and Diet9999991?? #ppendi4 D8 Summary of Supplements99999999999999911?:

#ppendi4 E8 )isting of Chinese Her/s@Formulas 'nly Studies999<, #ppendi4 F8 Summary of Western Medicine Studies999999991<+

) #ppendi4 "8 Source Data Chart99999999999999999991<> #ppendi4 H8 #rticle #/straction Form999999999999999111<?

List of Tables Ta/le - 8 Signs and Symptoms of Endometriosis999999999999991-= Ta/le +8 Endometriosis in Western and Traditional Chinese Medicine991++ Ta/le .8 Endometriosis in Western and Traditional Chinese Medicine991+> Ta/le >8 Basic Five Element Chart99999999999999999999911+= Ta/le =8 'verview of #rticles99999999999999999999999911>.

Chapter One: Introduction Overview Endometriosis is a reproductive illness affecting an estimated -<? million women and girls around the world AWE5FB1 #ccording to the Cournal of the #merican Medical #ssociation AC#M#B* endometriosis affects appro4imately = to < million #merican women1 Most of the women affected are /etween the ages of ., and >,1 Some women are de/ilitated /y this condition while others may have mild to no symptoms1 2t affects -,D-=E of women of child/earing age in the (1S and is even more common in women of #sian descent* although it affects women of all races1 Endometriosis is the third leading cause of gynecologic hospitali0ation in the (1S A)evett* +,-,B1 Endometriosis is a gynecological disorder in which the cells that form the lining of the uterus or endometrium grow outside the uterus1 2t is a nonD cancerous condition and in Western medicine* the cause is un3nown1 The primary clinical symptom of endometriosis is recurring pelvic pain* often associated with menstrual period1 'ther symptoms are painful se4ual intercourse* rectal /leeding* chronic fatigue* intestinal pain* spotting /etween period* heavy or prolonged menstrual periods and infertility and miscarriage pro/lems ASperoff* +,,=B1 Research Goals The goal of this study is to e4am the relationship of diet and nutrition in treating endometriosis1 This study will specifically e4plore factors that will contri/ute to the construction and composition of a Traditional Chinese Nutrition

+ manual to support patients suffering from endometriosis1 Endometriosis is /ecoming a leading cause of infertility8 .:E of women who are infertile and <,D :,E of women with chronic pain have endometriosis and more than -, million women have endometriosis in the (nited States A)ing* -;;;B1 Furthermore* in the (nited States* annual healthcare costs and costs of productivity loss associated with endometriosis were estimated at F++ /illion in +,,+ ABallweg* +,,>B1 This Study will thoroughly discuss the treatment of endometriosis from the /oth Western and Traditional Chinese Medicine perspectives1 #dditionally* this study will identify and descri/e the factors that need to /e considered in forming a traditional Chinese nutritional manual for endometriosis1 Finally* this study will focus on the usefulness of such a manual1 Glossary of Relevant Terms Abdominal cavity: The cavity within the a/domen* the space /etween the a/dominal wall and the spine1 AMerriam We/sterGs Medical Dictionary* +,,:B Adhesion: The union of two opposing tissue surfaces Aoften in reference to the sides of a woundB1 #lso refers to scar tissue strands that can form in the area of a previous operation* such as within the a/domen after a laparotomy1 AMerriam We/sterGs Medical Dictionary* +,,:B Cyst: # cyst is an a/normal* closed sacDli3e structure within a tissue that contains a li&uid* gaseous* or semisolid su/stance1 # cyst can occur anywhere in the /ody and can vary in si0e1 The outer* or capsular* portion of a cyst is termed the cyst wall1

,AMerriam We/sterGs Medical Dictionary* +,,:B ndometriosis: The presence of tissue that normally grows inside the uterus Awom/B in an a/normal anatomical location1 Endometriosis is very common and may not produce symptoms* or it may lead to painful menstruation1 2t has also /een associated with infertility1 Endometriosis occurs most commonly within the Fallopian tu/es and on the outside of the tu/es and ovaries* the outer surface of the uterus and intestines* and anywhere on the surface of the pelvic cavity1 2t can also /e found* less often* on the surface of the liver* in old surgery scars or* very rarely* in the lung or /rain1 AMerriam We/sterGs Medical Dictionary* +,,:B ndometrium: The uterine lining6 the cells that line the uterus Athe wom/B6 the inner layer of the uterus1 This tissue is shed monthly in response to the hormonal changes of the menstrual period1 The endometrium then grows /ac3 and slowly gets thic3er and thic3er until the ne4t period when it is once again sloughed off1 AMerriam We/sterGs Medical Dictionary* +,,:B strogen: Estrogen is a female hormone produced /y the ovaries1 Estrogen deficiency can lead to osteoporosis1 AMerriam We/sterGs Medical Dictionary* +,,:B Infertility: 2nfertility primarily refers to the /iological ina/ility of a person to contri/ute to conception1 2nfertility may also refer to the

state of a woman who is una/le to carry a pregnancy to full term1 AMerriam We/sterGs Medical Dictionary* +,,:B

,, Laparoscopy: # type of minimally invasive surgery in which a small incision AcutB is made in the a/dominal wall through which an instrument called a laparoscope is inserted to permit structures within the a/domen and pelvis to /e seen1 The a/dominal cavity is distended and made visi/le /y the instillation of a/sor/a/le gas* typically* car/on dio4ide1 # diversity of tu/es can /e pushed through the same incision in the s3in1 $ro/es or other instruments can thus /e introduced through the same opening1 2n this way* a num/er of surgical procedures can /e performed without the need for a large surgical incision1 Most patients receive general anesthesia during the procedure1 AMerriam We/sterGs Medical Dictionary* +,,:B This research study will proceed with a literature review chapter that will e4plicate prior theory and research regarding endometriosis and its treatment1 # methods chapter that will detail the procedures used to carry out the current research study will follow that chapter1 The fourth chapter of this study will include the study results* and will /e followed /y a fifth chapter that will discuss the findings of the current study1

,2

Chapter Two: Literature Review Overview This chapter provides a review of the sources that are the /asis for this literature review synthesis1 First* a /rief description of the literature review process and the resources used in gathering the relevant literature will /e provided1 Topics covered in this review will /e an introduction to /oth Western and Traditional Chinese Medicine approach to understanding and treating endometriosis1 #nd also reviewed will /e the effects of common Western and TCM nutrition* her/s and supplements that are used to support endometriosis treatment1 Final section will /riefly summari0e the studies reviewed1 This research synthesis study will review literature concerning the use of Traditional Chinese Nutrition including her/s and the integrated use of Chinese nutrition and Western nutrition and medicine and supplements to treat women who suffer from Endometriosis1 Material for the )iterature 5eview was gathered /y primarily utili0ing search engines such as "oogle Scholar* Elsevier $u/Med and (C)# )i/rary system1 ey Search words and phrases related to the topic to find

articles and studies applica/le to the study were used such as HEndometriosis I Chinese Medicine@Nutrition@Supplement@DietJ* HEndometriosis I DrugsJ* H Endometriosis her/sJ1

The search resulted in -,: literatures through the $u/Med* +., from "oogle Scholar* += from Elsevier and -+. from the (C)# )i/rary system search*

,% limited to reviews on the topic of Traditional Chinese her/s* nutrition and supplements used to support endometriosis1 # total of .. articles@monograph entries e4amining the use of Chinese her/al medicine and traditional Chinese nutrition including her/s and the integrated use of Chinese nutrition and Western nutrition and supplements and drugs to treat women who suffer from Endometriosis satisfied the criteria for inclusion in this literature review synthesis1 'f these articles* eighteen e4amined the use of Chinese her/s and nutrition with /oth Western nutrition and supplement suggestions and ten mainly e4amined Western nutritional and supplements without the use of Chinese Medicine6 seven compared the Western nutrition and supplements mostly and eight compared the effectiveness of Chinese nutrition and her/s alone versus Western medicine treatment modalities1 This study will serve to uncover the strengths* wea3ness* and limitations as well as similarities and differences among the availa/le pu/lished research and other articles* and provide a /asic foundation for a manual that could specifically serve patients with Endometriosis1 !escription of ndometriosis Endometriosis is a very common de/ilitating disease that occurs in ? to -,E of general female population6 in women with pain* infertility* or /oth* the fre&uency is .=D=,E A"iudice K ao* +,,>B1 #/out += to =,E of infertile women have endometriosis* and ., to =,E of women with endometriosis are infertile AHummelsho% et al* +,,?B1 Endometriosis is a disorder in which the cells that form the lining of the uterus or endometrium grow outside the uterus1 2t is a nonDcancerous condition

,& and in Western medicine* the cause is un3nown1 Theories as to what causes it a/ound in Western medical te4ts1 The cause of endometriosis is unclear in conventional medicine and there are many theories including three ma%or perspectives1 The first theory is that small /its of menstrual tissue flow /ac3ward into the fallopian tu/es and out into the a/dominal cavity where they seed with hormonal stimulation and /egin to grow1 The second theory is that cells from the uterine lining may /e transported through the /loodstream into other locations where they seed and grow1 The third theory is that cells outside the uterus may change into uterine cells with hormonal stimulation in those who are genetically predisposed1 Each month the endometrium /uilds up in the uterus then /rea3s down and sheds off* resulting in vaginal /leeding or menstruation1 2t is speculated that this same cycle occurs with the endometrial tissue located outside the uterus1 However* endometrial tissue outside the uterus that sheds off and /leeds is trapped inside the /ody and is slowly a/sor/ed1 This process can create pain and inflammation and may lead to the development of local lesions* masses* and larger amounts of endometriosis1 Common locations for the growth of this a/normal endometrial tissue are the ovaries and ligaments that support the uterus1 )ess common locations are the outer surface of the colon and small intestines* the ureters* /ladder* vagina* pleura of the lungs* and pericardium ASperoff* +,,=B1 The symptoms of endometriosis depend on where the tissue is growing1 $elvic pain is the most common symptom followed /y heavy menstrual /leeding* dyspareunia* and pain with /owel movements1 5ectal /leeding is not unusual as a result of this condition* as is pain with urination1 #lso women with endometriosis are often una/le to conceive1 Women with endometriosis may e4perience pelvic

,'

Common "igns#"ymptoms

"evere "igns#"ymptoms

$imic other health conditions

D$ain /efore and during periods D$ain with intercourse D"eneral* chronic pelvic pain throughout the month D)ow /ac3 pain DHeavy and@or irregular periods D$ainful /owel movements* especially during menstruation D$ainful urination during menstruation DFatigue D2nfertility DDiarrhea or constipation

DHeadaches D)ow grade fevers DDepression DHypoglycaemia Alow /lood sugarB D#n4iety DSuscepti/ility to infections* allergies

D'varian cysts DEctopic pregnancy D$elvic 2nflammatory Disease D2rrita/le /owel syndrome D'varian cancer

pain =D< days /efore menstruation* during menstruation or with ovulation1 Many women e4perience low /ac3 pain with periods* nausea* vomiting* intestinal upsets* fatigue* pain with se4ual intercourse* and pain with urination or /owel movements A)evett* +,-,B1 Endometriosis classically presents with severe dysmenorrhea* pelvic pain* dyspareunia* menstrual irregularities* and infertility1 Systemic symptoms may also occur* such as fatigue* increased incidence of allergies* and

autoimmune diseases ABallweg* +,,>B1 Table %: "igns and "ymptoms of ndometriosis

Definitive diagnosis is usually made through laparoscopic investigation although recent research suggests that nonDinvasive symptom evaluation may have a greater positive prediction value1 The $recise prevalence of endometriosis is unclear /ut there us a /road consensus that /etween =E to -=E of the female

,( population will have signs and symptoms of the disease during their reproductive years Aage -= to =, yearsB AFlower* )iu* )ewith* )ittle K )i* +,-+B1 Endometriosis is increasingly regarded as a comple4* multiDfactorial condition of uncertain etiology where immunological* genic* environmental* and possi/ly even psychological factors com/ine to create a fullD/lown diseases ABallweg* +,,>B1 2t is estimated that ., to >, percent of women who report infertility pro/lems have endometriosis1 The most common symptoms of Endometriosis are pain /efore and during periods* pain with intercourse* general* chronic pelvic pain throughout the month* low /ac3 pain* heavy and@or irregular periods* painful /owel movements* especially during menstruation* painful urination during menstruation* fatigue* infertility* diarrhea or constipation1 'ther symptoms include headaches* lowDgrade fevers* depression* hypoglycemia Alow /lood sugarB* an4iety and suscepti/ility to infections and allergies ABallweg* +,,>B1 'ne of the /iggest pro/lems regarding endometriosis is that the signs of this disease in the early stages appear to /e the normal /odily changes that ta3e place with the menstrual cycle1 2t is only as time goes /y that a woman /egins to suspect that what is happening* and the symptoms she feels* are not normal1 The pain of her menstrual cycle gradually and steadily /ecomes worse and worse as the months go /y1 These symptoms are only the /eginning of what will /ecome a gradual decline in a womanGs general health* as well as the health of her reproductive system1 However* there are odd instances where some women do actually have endometriosis* /ut they are nearly free of any symptoms1 These women will only /e diagnosed /y default* for e4ample when they have surgery for

,) other issues* and only then is endometriosis found1 That is what ma3es this disease so enigmatic* difficult to interpret or understand1 Endometriosis does not follow any distinct pattern* which is why it is difficult for the medical profession to 3now that a woman has the disease1 Some of the symptoms will mimic those of other health pro/lems* including ovarian cysts* ectopic pregnancy* pelvic 2nflammatory disease* irrita/le /owel syndrome* ovarian cancer* fi/roid tumors* colon cancer and appendicitis ASperoff* +,,=B1 !iagnosis of ndometriosis Endometriosis is diagnosed through a laparoscopy1 This procedure allows the surgeon to see inside the a/dominal cavity through a tinyDlighted optical tu/e that is inserted through a small incision in the navel1 $art of the pro/lem that causes the delay in diagnosis of endometriosis is that many people in the medical profession are not fully aware of the e4tent of this disease today1 There are a variety of methods that can /e used to assess whether a woman has endometriosis* /ut laparoscopy is the only relia/le way to confirm the presence of the disease is /y visually inspecting the a/dominal organs1 Before a laparoscopy is done a full gynecological evaluation should /e done covering the patientGs medical history1 Diagnosis methods of endometriosis can include physical e4amination and a pelvic e4amination1 These e4aminations involve the physician feeling and loo3ing for a/normalities that are associated with endometriosis1 $hysical findings depend on the severity and location of the disease1 There may /e palpa/le nodules or tenderness in the pelvic region* enlarged ovaries* a tippedD/ac3 AretroDdisplacedB uterus* or lesions on the vagina or on surgical scars1 Dana0ol Aderivative of the synthetic steroid ethisteronB is

,* ta3en for ? wee3s prior to an operation to shrin3 the endometrial growths and ease the surgical removal1 Following surgical removal of endometrial tissue* /irth control pills may /e prescri/ed that contain /oth estrogen and progesterone* to /e ta3en continuously for up to nine months1 This procedure will induce a pseudoD pregnancy* with the aim to allow the /ody time to rest and heal ASperoff* +,,=B1 &estern !rugs for ndometriosis

'ral contraceptives or /irth control pills regulate the growth of the tissue that lines the uterus and often decrease the amount of menstrual flow1 2n general* the therapy contains two hormones* estrogen and progestin1 2t often wor3s as long as you ta3e the pills1 'nce you stop the treatment* your a/ility to get pregnant returns* and your symptoms of endometriosis may also return1 Some women ta3e /irth control pills continuously* without using the sugar pills that signal the /ody to go through menstruation1 When /irth control pills are ta3en in this way* the menstrual period may stop altogether* which can reduce pain or get rid of it entirely ASperoff* +,,=B1 Some /irth control pills contain only progestin* a progesteroneDli3e hormone1 Women who canGt ta3e estrogen use these pills to reduce menstrual flow1 Some women may not have pain for several years after stopping treatment1 $rogesterone and progestin improve symptoms /y reducing a womanGs period or stopping it completely1 #s a pill ta3en daily* these hormones will reduce menstrual flow without causing the lining of the uterus to grow1 "n5H agonist is used daily in a nose spray* or as an in%ection given once a month or every three months1 Most health care providers recommend that patients stay on the "n5H agonist for a/out si4 months1 #fter that time* the /ody

,+ will come out of the menopausal state1 #fter women stop ta3ing "n5H agonists for si4 months* a/out =, percent have some return of their endometriosis symptoms1 These medications also have side effects* including hot flashes* tiredness* pro/lems sleeping* headaches* depression* /one loss* and vaginal dryness A'live et al* +,,>B1 Current research is e4ploring the use of other hormones in treating endometriosis and pain related to endometriosis1 Some of these include "n5H antagonists* selective progesterone receptor modifiers* and selective estrogen receptor modulators* also 3nown as SE5Ms1 Some women also have less pain from endometriosis after pregnancy* /ut the reason for this is unclear1 5esearchers are trying to determine whether it is /ecause the hormones released /y the /ody during pregnancy also lessen the growth of endometriosis* or if pregnancy causes changes in the uterus or endometrium that lessen the growth of endometriosis A'live et al* +,,>B1 The TC$ 'erspective Regarding ndometriosis 2n China* endometriosis is called Neiyi* meaning internal lump descri/ing Western term endo1 2n TCM it is called Lheng Cia* meaning a/dominal mass and the incidence of endometriosis in China* li3e that in the (nited States* is reported increasing ADharmananda* +,,+B1 2n Traditional Chinese medicine* endometriosis is understood /ased on the differentiated clinical manifestations associated with each individual1 2t is important in TCM to diagnose the patient according to his or her own specific pattern1 Each individual has a pattern that mar3s the foundation and progression of the disorder1 Traditional Chinese medicine ATCMB* including acupuncture and

2her/s has /een used successfully in treating a wide range of female health disorders including endometriosis1 The primary aim of the TCM doctor in the treatment of endometriosis has always /een to remove /lood stagnation1 Endometriosis is a Western medical la/el and not a TCM term1 However* the scientific medical understanding of this diseases has contri/uted to the notion that this is a diseases characteri0ed /y /lood /eing where it shouldnGt and una/le to escape the /ody1 Symptoms such as severe sta//ing period pain* clotty menstrual flow and palpa/le nodules or masses in the a/domen appear to verify the diagnosis of stagnation /lood A)yttleton* +,,>B1 2n China* doctors found that more pregnancies resulted if treatment of women with endometriosis targeted the 3idney for endometriosis lesions that can produce secretions which clog up the system Aphlegm damp in TCMB also /oosting idney !ang is generally rather effective at clearing such phlegm damp1 2n TCM* more attention is paid to moving /lood* clearing stasis and /rea3ing up masses during the period and fortifying the idney !ang and moving /lood at ovulation1 2f there is such severe stagnation that a pregnancy is impossi/le* then treatment will focus on the stagnation during the entire cycle1 We 3now that menstrual /lood travels not only downwards from the uterus and out through the cervi4 /ut also upwards through the fallopian tu/es and out into the peritoneal cavity1 This small &uantity of /lood carries with it /its of discarded endometrium1 Women with strong uterine cramps due to )iver 7i Stagnation are more li3ely to close more menstrual flow upwards through the tu/es A)yttleton* +,,>B1

2, The /lood and the tissue will either /e rea/sor/ed or will remain and esta/lish itself somewhere in the pelvic cavity1 2f idney !ang is strong* then movement of 7i in the pelvis will mo/ili0e the menstrual de/ris* which shouldnGt /e there and it will /e rea/sor/ed1 So Wea3ness of idney !ang will allow the accumulation of /lood and tissue* which creates stagnation1 The pattern that suggests endometriosis is when temperature does not drop very much when the period comes* or if it does drop it may start to go up again after -D+days1 These patterns indicate that the switch to !in from !ang has not /een on time or complete1 These patterns all indicate inade&uate idney !ang function A)yttleton* +,,>B1 #ccording to the )yttletonGs HTreatment of 2nfertility with Chinese MedicineJ* the treatments would /e divided into three phases* postDmenstruation* ovulation and post ovulation1 During postDmenstruation* /uild /lood and reinforce the !in1 For a/dominal masses with strong patient with no desire for conception* clear )M 7i Stagnation with Damp and treat S$ 7i Deficiency A)yttleton* +,,>B1 Diet changes can help reduce the symptoms of endometriosis1 #ccording to H Endometriosis DietJ /y )evett* Carolyn* increasing omegaD. fatty acids* fi/er and avoiding meat* dairy products* wheat and sugar* modulate estrogen1 #lso avoid caffeine and alcohol* refined foods* additives* minimi0e or avoid soy products seem to help patients with Endometriosis1 #d%usting eating ha/its could have many positive physical and meta/olic changes A)evett* +,-,B1

22

Types of lesion

Action

Treatment

* (on)pigment ** * *l esions *

* 'igmented ** * *l esions *

D$roduce secretion which may clog the fim/rial end of fallopian tu/e DCauses possi/le infertility DCauses pain and /leeding in pelvic cavity

Boost D !ang and invigorate S$ 72 to remove $hlegmDDamp 5esolve Blood stagnation with BloodDregulating her/s and /oost D !ang to $romote dispersal of stagnant Blood 5esolve Blood stagnation with BloodD/rea3ing her/s and /oost D !ang to promote dispersal of stagnation

* Cysts+ ** * *n odules ** * *a nd * masses

DCauses pain and possi/le infertility due to distortion of tu/es or ovaries

Ta/le +8 Endometriosis in Western and Traditional Chinese Medicine

Traditional Chinese (utrition for ndometriosis #ccording to The Tao Of Nutrition /y Maoshing Ni and Cathy McNease* ancient people were much more aware of the environment and how their /odies reacted to their surroundings1 The system of Chinese Nutrition is a healing system of its own and it adapts to every individualGs needs /y treating the whole person instead of the disease1 Chinese Nutrition differs from the modern Western nutrition in that it does not rely on analy0ing the chemical constiruents of each food6 rather* it determines the properties of energies of each food and com/ination* ta3ing consideration of season* method of preparation and

geographical location* and utili0es the information according to the natural principle of life and /alance ANi K McNease* +,,>B1

2% Chinese Nutrition differs from Western Nutrition in that it does not tal3 a/out the /iochemical nature of food /ut it deals on an energetic level where /alance is the 3ey1 Foods are selected according to their energetic &ualities such as warming* cooling* drying* or lu/ricating1 Thus* Chinese Nutrition would see3 to warm the coldness* cool the heat* dry the dampness* and lu/ricate the dryness1 By carefully studying the individualGs im/alances* one would choose the appropriate foods to /ring a/out a /alanced state of health1 For e4ample* for an e4cessive individual who is e4hi/iting conditions of heat in the /ody* cooling food would /e appropriate1 For a deficient individual who tends toward coldness* warming foods would /e chosen1 This is way health is achieved1 Foods all have specific &ualities inherent within* determined /y the effect the food has on the /ody1 Then the method of preparation either enhances or neutrali0es the foods1 "enerally spea3ing* warming raise meta/olism and cooling food lower meta/olism1 Balance in the diet is essential for good health1 #ccording to the Chinese point of view* the /ody is loo3ed at as a whole* wor3ing together in harmony ANi K McNease* +,,>B1

2& Types of lesion Action Treatment

* (on)pigment ** * *l esions *

* 'igmented ** * *l esions *

D$roduce secretion which may clog the fim/rial end of fallopian tu/e DCauses possi/le infertility DCauses pain and /leeding in pelvic cavity

Boost D !ang and invigorate S$ 72 to remove $hlegmDDamp 5esolve Blood stagnation with BloodDregulating her/s and /oost D !ang to $romote dispersal of stagnant Blood 5esolve Blood stagnation with BloodD/rea3ing her/s and /oost D !ang to promote dispersal of stagnation

* Cysts+ ** * *n odules ** * *a nd * masses

DCauses pain and possi/le infertility due to distortion of tu/es or ovaries

Table ,: ndometriosis in &estern and Traditional Chinese $edicine

#ccording to Traditional Chinese Medicine ATCMB* the human /eing is an intricate whole* made up of these essential components8 Chi Avital energy* life force* /odyGs networ3* pathway and also called meridiansB* /lood* /ody fluids* Cing Afound in the sperms* eggs* /one marrow and the /rainB and Shen ASpirtB1 TCM views the /ody organ as couples consisting of a !in organ and !ang organ1 Each pair of organs is associated with one of five energies called the Five Elements8 Wood* Fire* Earth* Metal and Water1

2' &ood /lavers 0ang Organ#1in /u Organ#1ang "all Bladder "enses Organ Eye Tongue Mouth Nose S1 2ntestine Stomach )1 2ntestine (rinary Bladder Ear Sour )iver /ire Bitter Heart arth Sweet Spleen $etal $ungent )ung &ater Salty idney

Table -: .asic /ive lement Chart

#ccording to The Tao of Nutrition /y Ni and McNease* premenstrual symptoms resem/ling endometriosis symptoms may /e characteri0ed /y a/dominal cramps* /loating* /ac3ache* irrita/ility* low energy and mood swings1 This is partially due to the large consumption of cold foods and drin3s in this country that in turn cause the /lood to stagnate1 2n Chinese terminology* premenstrual symptoms A$MSB is a condition of disharmony in the /lood D stagnant /lood* not enough /lood* or heat in the /lood6 and stagnation of Chi1 #cupuncture* acupressure* her/s* diet* and Chi A7iB "ong e4ercises are all very /eneficial for relieving the symptoms and correcting the disharmony1 The /oo3 suggests ginger* green onions* fennel* orange peel* spinach* walnuts* hawthorn /erries* cinnamon* and /lac3 pepper* Chinese date* Dang "ui A#ngelica sinensisB to /e used a wee3 /efore the menstruation1 #nd cold foods* raw foods* e4cessive consumption of fruit* vinegar* all shellfish* coffee* stimulants* sugar* dairy

products* and smo3ing should /e avoided ANi K McNease* +,,>B1

2( #ccording to Chinese Natural Cures /y Henry )u* female infertility pro/lems such as endometriosis and dysmenorrhea could /e treated /y addressing spleen deficiency* 3idneys yang deficiency* deficiency of energy A7iB and /lood* 3idneys yang deficiency* yin deficiency* cold and deficient wom/* hot /lood* liver energy A7iB congestion AstagnationB and dampnessDsputum1 )u states that for treating spleen deficiency with chronic diarrhea* chronic dysentery* lac3 of firm erection* poor appetite* prolapsed of any internal organ* prolapsed of anus and shortness of /reath* apply treatment principle to tone energy and strengthen the spleen /y using the formula Bu Lhong !i 7i Tang1 Dietary recommendations for food cure included fish* apple cucum/er* gold carp* carrot* chestnut* cornco/* %o/GsDtears* 2rish potato* rice* royal %elly* string /ean* yam* /eef and red and /lac3 date A)u* +,,=B1 For 3idneys yang deficiency with cold feet* cold loins and legs or cold sensation in the genitals* diarrhea /efore dawn* diarrhea with stic3y muddy stool* di00iness* edema* e4cessive perspiration* fatigue* fre&uent urination at night* panting* perspiration on the forehead* retention of urine* ringing in ears* scant urine* seminal emission and shortness of /reath* apply treatment principle to warm the 3idneys and reinforce 3idneys yang energy /y using formula !ou "ui Wan mainly1 Food cure recommendations are 3idney /eans* lo/ster* sardine* shrimp* sparrow* clove* dill seed* fennel* pistachio nut* sparrow egg* cra/ apple* rasp/erry and walnuts A)u* +,,=B1 For energy and /lood deficiency with symptoms of /leeding of various 3inds with /lood in light color* often seen in consumptive diseases* di00iness* fatigue* flying o/%ects seen in front of the eyes* insomnia* irregular menstruation*

2) low energy* low voice* menstrual flow in light red color* mentally depressed* regular menstruation /ut with very scant flow lasting for one or two days only* num/ness of lim/s* pale comple4ion and lips* pale nails* palpitation apply treatment principle to tone the energy and the /lood simultaneously and to tone the 3idneys /y using formula called Ba Lhen !i Mu Wan1 Food cure recommendations for this condition included a/alone* asparagus* cuttlefish* chic3en egg* duc3 egg* white fungus* /eef liver* grape* mandarin fish* oyster* mil3* /eef* cherry* clam* maltose* 2rish potato* sweet rice* apple cucum/er* /og /ean* gold carp* carrot* chestnut* ham* horse /ean* hyacinth /ean* Co/GsDtears* 5oyal %elly* string /ean* whitefish* yam* red and /lac3 date* mutton* s&uash* and roc3 sugar A)u* +,,=B1 For yin deficiency symptoms with /leeding from gums* constipation* di00iness* dry and scant stools* dry sensation in the mouth or dry throat* fatigue* headache in the afternoon* low fever in the afternoon* menstrual flow in dar3 color* night sweat* nose/leed* pain in the throat also red and swollen* palms of hands and soles of feet are /oth hot* palpitations with insecure feeling* regular menstruation with scant flow lasting for half day or one day* short and reddish streams of urine* sleeplessness* swallowing difficulty* toothache* underweight* vomiting of /lood or nose/leed during menstrual periods apply treatment principle to nourishAwaterB the yin and clear the heat and to nourish the /lood and regulate the menstruation /y using the formula !ang Cing Lhong !u Tang* 7ing "u Li Shen Tang or 7ing Nue !ang !in Tang1 Food Cures recommendation included /ird nest* cheese* 3idney /ean* a/alone* asparagus* chic3en egg* cuttlefish* duc3* duc3 egg* white fungus* oyster* por3 and royal %elly A)u* +,,=B1

2* For cold and deficient wom/ with symptoms of cold pain or cold sensation in the lower a/domen or genitals* dar3 /lac3ish menstrual flow* failure of the fetus to grow* fetus motion* fre&uent miscarriage* functional distur/ances of the ovary* ha/itual miscarriage* pale comple4ion* poor appetite* thin and watery menstrual flow in light color and underdevelopment of the wom/* treatment principle is to warm the wom/ /y using fomula #i Fu Nuan "ong Wan1 Food cure recommendations include cinnamon* 3idneys* lo/ster* sheep mil3* sardine* shrimp* star anise* red and /lac3 dates A)u* +,,=B1 For hot /lood Aheat in the /loodB with symptoms of a/dominal pain that occurs at onset of menstrual periods* deep red or violet menstrual flow* discharge of /lood from anus /efore periods* fever after child/irth* irregularity of menstrual periods* menstrual flow somewhat heavy* menstrual flow with a /ad smell* nose/leed* plentiful menstrual flow* premature menstrual periods which may /e more than -, days early or two periods within one month* red and plentiful menstrual flow* s3in ulcers* vaginal /leeding* vomiting of /lood or nose/leed during menstrual periods* treatment principle is to clear heat in the /lood /y using formula 7ing Cing Tang1 Food cures include /lac3 fungus* salt* spinach* straw/erry* /anana* cucum/er and licorice A)u* +,,=B1 For liver energy A7iB congestionAstagnationB with a/dominal pain* convulsion* irregularity of menstrual periods* menstrual pain* morning sic3ness* num/ness* pain in the upper a/domen* premature periods or overdue periods* shortage of mil3 secretion after child/irth* stomachache* su/%ective sensation of o/%ects in the throat* vomiting of /lood and whitish vaginal discharge apply treatment principle to rela4 the liver and disperse energy congestion /y using

2+ Niao !ao San or De Sheng Dan1 Food cures for this condition are /rown sugar* garlic* turmeric* 3um&uat* /eef* cherry* /ird nest* /utterfish* chic3en* coconut meat* date* tofu* mustard seed* sweet rice* goose meat* mutton* %ac3fruit* s&uash* sweet potato* red and /lac3 date* rice* roc3 sugar* caraway seed* spearmint* common /utton mushroom* oregano* red /ean* am/ergris* dill seed* sweet /asil and saffron A)u* +,,=B1 For dampnessDe4cess of sputum with discharge of sputum that can /e coughed out easily or discharge of white watery sputum* di00iness* e4cessive whitish vaginal discharge* fre&uent cough during pregnancy that are prolonged and cause motion of fetus* headache* hiccups* light red menstrual flow* menstrual periods overdue fre&uently* morning sic3ness* tur/id and stic3y menstrual flow* pain in the chest* panting* plentiful menstrual flow* prolonged di00iness* sleep a lot or sleeplessness* suscepti/le to morning sic3ness during pregnancy* suppression of menses* vomiting and white sliding sputum that can /e cleared from throat easily apply treatment principle to strengthen the spleen and dry up dampness and use 7i "ong Wan1 Food cures for this condition are ad0u3i /ean* am/ergris* /arley* common carp* cucum/er* mung /ean* seaweed* shepherdGs purse* star fruit* /am/oo shoot* crown daisy* date* fresh ginger* leaf or /rown mustard* /lac3 and white pepper* white or yellow mustard seed* asparagus and pear A)u* +,,=B1 Healing with Whole Foods /y $aul $itchford e4plains that main cause of womenGs diseases such as endometriosis is due to stagnant /lood1 #ccording to $itchford* stagnant /lood is a /lood that coagulates or congeals* and is /rought a/out either /y in%uries to the tissue of the /ody or /y &i energy insufficient to

%push the /lood through the vessels1 Signs of stagnant /lood include sta//ing pain that is fi4ed in one place* fre&uent /leeding* /leeding with dar3 purple clots* dar3 purple tongue with red spots* and unnaturally dar3 comple4ion1 When /lood is stagnant* clots tend to develop6 chronic stagnation generates tumors* cysts* nodules* and hard immo/ile lumps1 Women are often afflicted with stagnant /lood* particularly in the lower a/dominal AreproductiveB area1 2n fact* a large portion of all gynecological pro/lems* especially those of a painful nature are related to stagnant /lood1 E4amples of womenGs diseases commonly caused /y stagnant /lood are amenorrhea Aa/sence of menstruationB* dysmenorrhea Apainful menstruationB* uterine hemorrhage* uterine tumors* fi/roids* cancer* and ovarian cysts A$itchford* +,,+B1 Clearing stagnant /lood is easiest in the early stages* /efore masses form1 2n all cases* one must improve the circulation of &i energy6 when the liver is the cause of stagnation* the remedies outlined earlier for stagnant liver &i are appropriate1 #nother approach to treating stagnant /lood involves improving the &uality of the /lood itself1 Blood filled with to4ins* waste matter* and fat is much more li3ely to /ecome stagnant and congealed1 For healthy* vital /lood* the spleenDpancreas must /e maintained at pea3 performance* since its function has a great effect on /lood formation A$itchford* +,,+B1 2n the West* dampness and mucus are the two main factors which wea3en digestion and the spleenDpancreas* there/y causing tur/id /lood6 in damp@mucus conditions* one should restrict the cold Ain temperatureB* very sweet* and highly mucusDforming foods including meat* dairy* eggs* and ice cream1 2n every case of stagnant /lood* regardless of its cause* proper eating ha/its such as thorough

%, chewing and preparation of simple meals are essential1 Furthermore* those foods and spices which disperse stagnant /lood should /e added to the diet1 #dding one such item to each meal is an effective dietary aid in con%unction with her/al* acupuncture* or other treatments1 For milder conditions* these dietary remedies may /e sufficient /y themselves A$itchford* +,,+B1 Each food and spice in the following are warming* with the e4ception of eggplant AcoolingB* white pepper AcoolingB* adu3i /ean AneutralB* and peach seed AneutralB1 The warming remedies* particularly garlic and ginger* should /e used carefully* if at all* in cases mar3ed /y signs of heat Aaversion to heat* sensation of feeling too hot* flushed face* /loodshot eyes* deep red tongue with possi/le yellow coating* and @or great thirst for cold fluidsB or signs of deficient yin Atidal fever* hot palms and soles* fresh red chee3s and tongue* fre&uent light thirst* and@or night sweatB1 Eggplant specifically relieves stagnant /lood conditions of the uterus* /ut may wea3en the uterus when /lood is not stagnant A$itchford* +,,+B1 Common Conditions of "tagnant .lood Causing 'ain When the condition includes pain* the pain is invaria/ly fi4ed in one place6 pain that moves around is not caused /y stagnant /lood1 Blac3 fungus Awood earB and seaweeds are also especially helpful for dissolving fi/roid and other uterine tumors* and these can /e added to the diet for this purpose1 Chives and cayenne are additional e4cellent remedies for in%uries with signs of /lood stagnation1 They wor3 internally when added generously to the diet1 For e4ternal use* chive greens and@or roots are cut finely* then %uiced /y wringing the pulp through muslin or similar cloth* or /y e4pressing with a %uicer1 The %uice can then /e soa3ed into cotton cloth and applied as a compress* or ru//ed on directly as a liniment1

%2 # cayenneDvinegar liniment is also very effective1 To prepare* simmer one ta/lespoon cayenne pepper in - pint appleDcider or riceDwine vinegar for -, minutes in a covered container6 /ottle hot and unstrained1 #pply on the in%ured site without ru//ing too much1 This liniment is also useful for lung congestion* and for pain of arthritis and rheumatism1 'revention and Good 2abits Women who eat a /alanced diet* get ade&uate e4ercise and sunshine* and wor3 toward emotional clarity seldom have menstrual pro/lems1 #t the time of menstruation* the deeper hormonal@emotional &ualities surface* while their physical corollary is discharged O the heatD/earing /lood that results from a natural purification1 This is a fragile state O surfacing aspects from the interior* yin* hormonal parts of the /eing are delicate and sensitive* and need protection from the yin climates Acold and dampB and physical and emotional e4tremes1 During the menses* it is therefore important to avoid heavy physical wor3* emotional stress* and overe4posure to cold and damp conditions6 for e4ample* 3eep the legs and feet warm* 3eep covered when in cold places and during the cool seasons* and avoid wor3ing with the hands in cold water1 #lso avoid constipation* get plenty of rest* and a/stain from se4 during menstruation AChavarro K Willett* +,,;B1 Caffeine and Reproduction #ccording to The Fertility Diet /y Chavarro K Willett A+,,;B* the process of meta/oli0ing caffeine changes throughout her menstrual cycle1 There is a mar3ed slowdown during the luteal phase* which /egins the day after ovulation that may lead to higher levels of caffeine in the /ody during the period of fertili0ation*

%% implantation* and early em/ryonic development1 #nother pro/lem may /e genetic O some women /rea3 down caffeine faster than others and so may /e less prone to any possi/le negative effects1 # cup of coffee delivers mostly water1 Ta3en /lac3 without sugar* it is nearly calorie free1 2t is /rimming with antio4idants and other /iologically active su/stances* including caffeine1 Several longDterm studies have shown that coffee drin3ers are less li3ely to develop type + dia/etes* gallstones and 3idney stones* and possi/ly colon cancer1 The main downsides of coffee drin3ing are caffeine addiction and the fats and calories that come with the sugar* cream* whipped cream* caramel* and other toppings and flavoring now put in and on coffee1 Chavarro K WillettGs A+,,;B findings e4plained that almost half of the women in the NursesG Health Study say they drin3 coffee every day1 2n the fertility study* the coffee drin3ers werenGt any more or less li3ely to have had trou/le getting pregnant than women who didnGt drin3 coffee1 'vulationDrelated infertility was similar across the spectrum of coffee drin3ing* as was infertility due to other causes* such as endometriosis or tu/al pro/lems1 However* pro/lems with study design ma3e it impossi/le to 3now if this is a true causeDandDeffect relationship AChavarro K Willett* +,,;B1 Alcohol Heavy drin3ing is indisputa/ly harmful O for general health* mental health* relationships* and reproduction1 2t can halt menstrual periods* stop ovulation* throw off the hormone cycles needed for conception and the implantation of a fertili0ed egg* end a pregnancy with miscarriage* and trigger early menopause1 #lcohol a/use can endanger a new life from the moment of conception until after /irth1 Do0ens of study have loo3ed at the impact of moderate drin3ing on fertility

%& and fetal development1 AChavarro K Willett* +,,;B1 The results are all over the map1 Some show that women who are moderate drin3ers ta3e longer to get pregnant than nonDdrin3ers1 2n a study conducted among women undergoing 2MF* those who dran3 alcohol in the month /efore the 2MF cycle produced fewer eggs and had lower pregnancy rates1 2n another study* moderate drin3ing did not affect fertility among women under age .,* /ut did get in the way of pregnancy for older women1 2n a Danish study* women who were moderate drin3ers averaging a drin3 a day got pregnant faster than teetotalers1 2n another study* women who dran3 wine got pregnant faster than nonDdrin3ers or those who dran3 /eer or spirits AChavarro K Willett* +,,;B1 5esults from the NursesG Health Study provide another piece of the pu00le* /ut only for very moderate drin3ing* up to one drin3 a day1 2nfertility due to pro/lems with ovulation was no more common among nurses who had a drin3 a day than it was among those who did not drin3 alcohol at all1 The same was true for infertility due to endometriosis* /loc3ed fallopian tu/es* and other causes1 2t did not matter what 3ind of alcoholic /everages the women preferred1 # daily glass of wine* /eer* or spirits did not seem to help or hinder getting pregnant1 Heavy drin3ing can derail pregnancy with a miscarriage or a still/irth1 2t can also harm a fetus in several ways1 #lcohol passes &uic3ly through the placenta1 #n un/orn /a/y /rea3s down alcohol much more slowly than its mother* so the alcohol level in its /lood can reach high levels even when the motherGs is still o31 This can lead to fetal alcohol syndrome* a condition that causes lifelong physical and mental disa/ilities1 Heavy drin3ing can also lead to more su/tle pro/lems

%' with thin3ing s3ills and /ehavior1 No one really 3nows if moderate* responsi/le drin3ing has similar effects on pregnancy and the development of a new life1 Timing is one issue1 2t is possi/le* though not proven* that alcohol prevents nerves from ma3ing essential connections in the growing /rain at certain critical moments of fetal development /ut has little or no effect at other times1 # motherGs meta/olism is another un3nown1 Women whose /odies /rea3 down alcohol &uic3ly may /e a/le to drin3 safely throughout pregnancy* while those who meta/oli0e it more slowly may need to a/stain1 Some studies have reported that women with endometriosis tend to drin3 more alcohol than those without the disease A"rodstein et al1* -;;>6 Missmer and Cramer* +,,.B1 Literature Review Integration #/out ., percent to >, percent of women with endometriosis are infertile* ma3ing it one of the top three causes of female infertility1 Some women donGt find out that they have endometriosis until they have trou/le getting pregnant AN2H* +,,+6 Speroff* +,,=B1 Endometriosis treatment using hormonal therapies is most often not a permanent solution and often unsatisfactory* and surgical removal or aspiration of endometrial cysts usually provides only temporary /enefits and may cause secondary pro/lems* including persistent a/dominal pain due to adhesions and infertility ACottreaual et al1* +,,?B1 Many studies suggest that higher inta3e of green vegeta/les Aall typesB and fresh fruit Aall typesB can lower the ris3 of endometriosis1 Conversely* inta3e of /eef or red meat and ham can increase the ris3 A$ara00ini et al1* +,,>B1 # study conducted in the (1S1 on ovarian endometrioid cysts reported elevated ris3s of endometrioisis for higher inta3es of polyunsaturated and vegeta/le fats* /ut no

%( reduction in ris3 for high inta3e of vegeta/les and fruits ABritton et al1* +,,,B1 There are however* some indications that a diet poor in vegeta/les and fruits and rich in fat increases the ris3 of endometrial cancer A#rmstrong* -;<;B and fi/roids AChiaffarino et al1* -;;;B* two diseases 3nown to /e associated with estrogens* and of ovarian /enign and malignant epithelial diseases A5isch et al1* -;;>B1 For e4ample* for endometrial and ovarian cancer and fi/roids* there was a direct association with the fre&uency of consumption of meat and ham in this 2talian population* whereas high inta3e of vegeta/les and fruits conferred some protection ABritton et al1* +,,,B1 2n /iological terms* it may influence prostaglandin concentrations* which may affect ovarian function ASmith* -;:?B1 There were foods that overlapped /ut also grouped in apposing ways1 5eviewing the studies also revealed that hormonal factors are a potential lin3 /etween diet and endometriosis* since the ris3 may /e increased /y e4posure to unopposed estrogens* and a diet rich in fat increases circulating unopposed estrogens A#rmstrong et al1* -;:-6 "oldin et al1* -;:+6 "or/ach and "oldin* -;:<B1 # diet rich in green vegeta/les and fruits includes high levels of vitamin C* carotenoids* folic acid and lycopene* micronutrients which may help to protect against cell proliferation ABosetti et al1* +,,+B1 Some studies have reported that women with endometriosis tend to drin3 more alcohol than those without the disease A"rodstein et al1* -;;>6 Missmer and Cramer* +,,.B1 Healthy Living Pointers for Better Health- Nutrition and Dietary uidelines! "phrodite Women#s Health

A+,,>B reported the incidence of endometriosis is >,E less among females who consumed more fresh fruit and green vegeta/le1 Females with a high inta3e of /eef* ham or other red meat* increased their ris3 of endometriosis /y :,D-,,E1

%) 2n most of the nutrition and diet studies showed connection /etween diet and endometriosis1 2n many studies* proper attention was given to research comparing the effectiveness of Western medicine treatment alone versus a com/ination of nutrition and Chinese her/al medicine and Western medicine* and Chinese her/s alone versus Western medicine alone1 2n most of the studies using Western medicine* Dana0ol or analogs of "n5H such as )upron* Synarel* or Lolade4 were the treatment choice followed /y omegaD. supplementation1 )astly* many of the her/s overlapped and common Chinese formulas emerged among the studies1 Chinese formula* "ui Lhi Fu )ing Wan was most effective treatment modality in improving overall cases of endometriosis1 There were foods that overlapped in many of studies as well1 While there has /een a good deal of writing and research that pertains to nutritional recommendations for women suffering from endometriosis* there have /een no studies which have /rought the findings of research and theory into a single user manual to assist endometriosis sufferers in ma3ing nutritional choices that will facilitate the remediation of their conditions1 #s a result there e4ists a gap or H/lind spotJ in the current literature1 2t will /e the purpose of the current study to /egin to fill that gap /y assem/ling the most salient nutritional factors that should /e incorporated into a manual specifically designed for women who suffer from endometriosis1

%*

* Chapter ** * *T hree: ** * *$ ethod * Introduction The Method section will provide information pertaining to the research design* selection of data sources* procedures and rationale of data collection* data instruments and data analysis* and finally methodological limitations of this literature review synthesis1 This study will review the current literature availa/le concerning the use of Chinese her/al medicine and traditional Chinese nutrition including her/s and the integrated use of Chinese nutrition and Western nutrition and medicine to treat women who suffer from Endometriosis1 2t will serve to uncover the strengths* wea3ness* and limitations as well as similarities and differences among the availa/le pu/lished research and other articles* and provide a /asic foundation for a manual that could specifically serve patients with endometriosis1 !esignation of Research $ethod This retrospective study used a &ualitative literature synthesis research method to review* analy0e* compare and generate appropriate and emerging themes and ideas from the availa/le literature A#ronson* -;;>B1 The researcher discerned that the thematic style of analysis was appropriate for this literature review synthesis /ecause this style helped to /etter identify themes and patterns within all of the ., studies that were collected for this research1 This study engaged the methods of grounded theory and literature synthesis to achieve its stated research o/%ective1 #s a &ualitative research method* grounded theory is

%+ effective in uncovering potential connections and identifying factors that may /e followed up /y additional and more controlled research studies ABowen* +,,?B1 Grounded Theory "rounded theory is a &ualitative and systematic research method that results in the generation of theory from the synthesis of many sources of data1 2t is an inductive approach that proceeds from specific data to result in generali0ed theory1 # grounded theory is generated /y themes* the themes emerge from the data during analysis* capturing the essence of the meaning or e4perience drawn from varied situation and conte4t and the progress is toward saturation until the variation is e4hausted ABowen* +,,?B1 The grounded theory method of research provides a systematic means for information analysis and has /een used e4tensively in the social and nursing research arenas AChiovitti K $iran* +,,.6 Weed* +,,=6 $andit* -;;?B1 "rounded theory emerged as a research method in the last few decades* and has gained respect as a method for &yalitative research1 #n area of in&uiry is put forth and data gathered via various methods generally including /oo3s* research studies* interviews and email e4changes1 The data collection and coding of what is found performed to group ideas and themes that emerge in the process1 This process is continued until all new avenues or leads are e4hausted1 These data groups are further coded into themes* and those themes into larger categories1 The names of these types of codes are open coding Athe la/eling and categori0ing of data elementsB* a4ial coding Athe development of main categories and their su/categoriesB and selective coding Athe integration of the categories developed from the previous coding eventsB A$andit* -;;?B1

&Research "ynthesis $ethod 5esearch synthesis method is the process through which two or more research studies are assessed with the o/%ective of summari0ing the evidence relating to a particular &uestion1 This method is retrospective study /y using &ualitative research method to review* analy0e* and generate appropriate and emerging theme and ideas relating to the availa/le literature A#ronson* -;;>B1 "ample and "ampling 'rocedures The source of data for this study includes research articles that have /een e4tracted from a num/er of traditional Chinese medicine and Western medicine literatures* te4ts* %ournals and articles1 The online research data/ases $u/Med* "oogle Scholar* EBSC' host and the (C)# online %ournal data/ase were used to search for research articles and collect data pertaining to my capstone topic1 The search was done in the principal investigatorGs house* at the (C)# Biomed li/rary* or at the !osan (niversity )i/rary1 # com/ination of following 3ey words was used in the search8 endometriosis* Chinese her/s* diet* nutrition* supplement* and Traditional Chinese Medicine and TCM nutrition1 "rounded theory research method of systematically categori0ing* assessing* collecting data and developing a theory or conclusion from availa/le data will /e used in the literature review synthesis A"lasser and Strauss* -;?<B1 #rticle a/straction forms were used to e4tract and summari0e information pertaining to each article1 The sources of data for this study included research articles that were accessed from a num/er of Traditional Chinese Medicine* Western medicine %ournals and other literature1 2n total* not less than ., research articles* %ournals and other literature sources were analy0ed1

&, This research synthesis was &ualitative in nature1 # summary and overall comparison of the results and findings among and /etween different research studies was engaged* and common themes and patterns found among the various studies emergee during the research process1 This research loo3ed for various influences that different foods* supplements and her/al medicines have on endometriosis1 These common themes were identified and analy0ed to assist in developing a Traditional Chinese Nutritional manual for endometriosis1 The validity and relia/ility of the research articles used in my research synthesis pro%ect varied depending on the study design and methodology of each individual study1 Instrumentation and !ata Collection 'rocedure Ta/les and charts were used to organi0e* e4tract and summari0e information pertaining to each article selected1 The information o/tained from these ta/les and charts was used to esta/lish themes that were analy0ed to arrive at the conclusions that formed are detailed in the final 5esults and Discussion sections of this paper1 Throughout the process* ta/les were used for trac3ing and reviewing the ., articles selected and analy0ed to constitute the &ualitative data for this study1 This process modified the ta/les and as a result other chart* ta/les and categories of information was also created1 This procedure was repeated as needed and a final review of the articles* data analysis ta/les* and result findings were conducted for consistency1 2n order to affirm the validity and trustworthiness of my data analysis techni&ue* a sample of the studies were reviewed and researched /y my supervisor1 Ta/les were constructed to assist in the organi0ation and analysis of the data collected for this study1

&2 #n article a/straction form was used to assess and summari0e each research article that will /e used for this research synthesis1 # copy of the article a/straction form used in this study is included in #ppendi4 H of this document1 The form contained the following sections to /e discerned /y the researcher8 title of study authors source o/%ective research design language@setting participants participant selection method treatment interventions outcome measures procedures results conclusion1

The conclusions section includes comments or o/servations made /y the researcher regarding main points* 3ey ideas* as well as gaps and strengths of the study1 The article a/straction form assisted in identifying the ma%or themes* categories of information* and conclusions that are descri/ed in the 5esults and Discussion sections of the Capstone $ro%ect paper1 The fourth chapter of this study includes the study results* and is followed /y a fifth chapter that discusses the findings of the current study1

&%

Types of "tudies

"tudies

Total (umber of "tudies

ndometriosis !iet

-* +* .* >* <* ;* -,* -<* -:* -;* +,* -? +-* ++* +>* +=* +?

ndometriosis and "upplements ndometriosis and 2erbs ndometriosis &estern approach

=* :* -+* -.* +; ?* ->* -=* -?* ., --* +.* +<* +:

= = >

Chapter /our: Results Overview This chapter will summari0e the findings of the current studies on treatment options for endometriosis including* nutrition* Chinese her/s and Western medicine1 The coding process was a naturally thematic analysis in style1 The research articles collected for this study were categori0ed according to the themes that emerged and coded into thematic categories previously descri/ed in the Methods section for grounded theory analysis1 #ppendi4 B refers to appendices that show the initial categori0ation of articles according to general emergent themes of each article that have /een found1 #ppendi4 C further categori0es in /roader in nature with the thematic groups1 #ppendi4 D* E* F and " were formed to support this study also /y using selective coding into further related themes1 Data collected were analy0ed using thematic content analysis* such as finding themes within the data* categori0ing the varia/les* and finding and discussing similarities and differences1

Table 3 : Overview of Articles

&&

ndometriosis !iet Many studies suggest that higher inta3e of green vegeta/les Aall typesB and fresh fruit Aall typesB can lower the ris3 of endometriosis1 Conversely* inta3e of /eef or red meat and ham can increase the ris3 A$ara00ini et al1* +,,>B1 # study conducted in the (1S1 on ovarian endometrioid cysts reported elevated ris3s of endometrioisis for higher inta3es of polyunsaturated and vegeta/le fats* /ut no reduction in ris3 for high inta3e of vegeta/les and fruits ABritton et al1* +,,,B1 There are however* some indications that a diet poor in vegeta/les and fruits and rich in fat increases the ris3 of endometrial cancer A#rmstrong* -;<;B and fi/roids AChiaffarino et al1* -;;;B* two diseases 3nown to /e associated with estrogens* and of ovarian /enign and malignant epithelial diseases A5isch et al1* -;;>B1 For e4ample* for endometrial and ovarian cancer and fi/roids* there was a direct association with the fre&uency of consumption of meat and ham in this 2talian population* whereas high inta3e of vegeta/les and fruits conferred some protection ABritton et al1* +,,,B1 2n /iological terms* it may influence prostaglandin concentrations* which may affect ovarian function ASmith* -;:?B1 Hormonal factors are a potential lin3 /etween diet and endometriosis* since the ris3 may /e increased /y e4posure to unopposed estrogens* and a diet rich in fat increases circulating unopposed estrogens A#rmstrong et al1* -;:-6 "oldin et al1* -;:+6 "or/ach and "oldin* -;:<B1 # diet rich in green vegeta/les and fruits includes high levels of vitamin C* carotenoids* folic acid and lycopene* micronutrients which may help to protect against cell proliferation ABosetti et al1* +,,+B1 Some studies have reported that

&' women with endometriosis tend to drin3 more alcohol than those without the disease A"rodstein et al1* -;;>6 Missmer and Cramer* +,,.B1 ndometriosis and "upplements New studies including the studies pu/lished in the %ournal Human $eprodu%tion* seem to suggest that paying attention to what we eat and put on our /odies could significantly reduce the ris3 of developing endometriosis1 2n a study loo3ing at endometriosis and the types of fat women eat* while total fat consumption was not associated with endometriosis ris3* the women who ate the most omegaD. fatty acids were ++Eless li3ely to /e diagnosed with endometriosis when compared to the group that ate the lowest amount1 The unhealthy fats such as trans fats increased the ris3 of developing endometriosis /y nearly =,E percent1 Most of the study reviewed had findings were similar in that women with the lowest fifth of longDchain omegaD. fatty acid consumption were less li3ely to /e diagnosed with endometriosis1 2n addition* those in the highest &uintile of transDunsaturated fat inta3e were more li3ely to /e diagnosed with endometriosis1 #lso many studies indicate that fish@nD.Doil might have positive influence on pain1 ndometriosis and 2erbs # total of . formulas and her/s included in these formulas were used across many studies to treat endometriosis1 The formula which used with greatest fre&uency was "ui Lhi Fu )ing Wan and others included Tao He Cheng 7i Tang and Shao Fu Lhu !u Tang with similar positive outcome1 2n study ? ADong et al* +,,.B o/served that "ui Lhi Fu )ing Capsules plays an important role in the regression of endometriotic implants /y immunological

&( regulation in the rat model1 2n this study* they used the rat model of surgically induced endometriosis to test the effect of the immunological regulation of "ui Lhi Fu )ing Capsules1 This formula has /een used clinically for the therapy of endometriosis for a long time and the clinical date has shown the protective effects on women endometriosis as well1 2n this study* the volume of endometriosis was significantly reduced in "ui Lhi Fu )ing Capsule treatment group1 ndometriosis 4&estern Approaches Medical treatment of endometriosis relies on drugs that suppress ovarian steroids and induce hypoestrogenic state that causes atrophy of ectopic endometrium1 "onadotrophinDreleasing hormone A"n5HB anaolgues* Dana0ol* $rogestogens and estrogenDprogestin com/ination have all proven effective in relieving pain and reducing the e4tent of endometriotic implants1 However* symptoms often recur after discontinuation of therapy and hypoestrogenismD related side effects limit longDterm use of most medications1 Furthermore* these therapies are of limited value in patients with a desire to /ecome pregnant /ecause they inhi/it ovulation1 Study -- AHarel* +,,+B compared the effectiveness of nonsteroidal antiD inflammatory drugs ANS#2DsB and oral contraceptive pills com/ined with estrogen and progestin to treat dysmenorrhea which is most commonly lin3ed with endometriosis1 This study suggested that most common pharmacologic treatment for dysmenorrhea is dose of NS#2Ds and it should /e used Atypically twice the regular doseB as initial treatment for dysmenorrhea in adolescents followed /y a regular dose until symptoms a/ate1 #dolescents with symptoms that do not respond to treatment with NS#2Ds for three menstrual periods should /e offered com/ined

&) estrogen@ progestin oral contraceptive pills for three menstrual cycles1 #dolescents with dysmenorrhea who do not respond to this treatment should /e evaluated for secondary causes of dysmenorrhea1 Study +< ASeli et al* +,,.B and study +: AMinatier et al* +,,-B /oth found that a/normal e4pression of aromatase $>=, Aestrogen synthetaseB in the endometrium of women with the endometriosis and impaired inactivation of estrogen may lead to elevated local estrogen concentrations which leads to endometriosis1

&* Chapter 3: !iscussion "ummary of /indings This study was a retrospective literature review synthesis* which reviewed Western and Traditional Chinese Medicine approach to understanding and treating endometriosis1 #nd also reviewed the effects of common Western and TCM nutrition* her/s and supplements that are used to support endometriosis treatment1 Many studies suggested that changing the foods and following a diet for endometriosis could /e proved to /e on the /est ways to reduce the symptoms of the disease and most recommendations were natural and healthy treatment option1 The improvement in symptoms can include a reduction in pain and inflammation1 #lso reducing estrogen in the /ody seemed to reduce the opportunity of the disease to grow further1 Many studies showed that diet changes could help reduce the symptoms of endometriosis and recommended increasing omegaD. fatty acids* fi/er and avoiding meat* dairy products* wheat and sugar* modulate estrogen not only can improve endometriosis /ut also these findings can /e used as a preventive measure1 #lso avoiding caffeine and alcohol* refined foods* additives* minimi0e or avoiding not fermented soy products seem to help patients with Endometriosis1 Studies have shown that ad%usting eating ha/its could have many positive physical and meta/olic changes1 #lso understanding nutrition not only from Western perspective /ut also from TCM approach would provide more comprehensive way in dealing with symptoms of endometriosis1 Many studies showed that diets which decreased estrogen levels and sta/ili0e hormones*

&+ increase energy* alleviating painful cramps and sta/ili0ing emotions have had positive results in treating endometriosis1 Implications for Theory and 'ractice This study reviewed total of ., research studies regarding treatment options for endometriosis highlighting nutrition and natural treatment1 Studies have shown that endometriosis is on the most devastation and misunderstood diseases in the world today1 2t is estimated that there are over :, million women and girls who suffer from the disease worldwide1 This num/er is growing all the time1 2t is now more common than /reast cancer1 Despite the huge num/ers of women who suffer from this disease* few people have actually heard of endometriosis /ut studies have shown that this is gradually changing1 #s the disease develops a womenGs immune system tends to /ecome more impaired and this could lead to further health pro/lems1 Due to increased research* as well as surveys of patients* it is now /ecoming clear that women with endometriosis can /e suscepti/le to other health pro/lems which mostly relate to an impaired immune system and this study uncovered that natural treatments for endometriosis are o/taining more positive results in actively assisting the healing of the diseases for many suffers1 Nutrition* healthy diet* supplements and Chinese her/s could /e a 3ey element in /oosting the immune system and this study has found many studies lin3ing endometriosis with diet and how change in diet as well as ta3ing certain supplements and Chinese her/s could effectively reduce or prevent endometriosis as well as the symptoms1 Many studies suggest that higher inta3e of green vegeta/les Aall typesB and fresh fruit Aall typesB can lower the ris3 of endometriosis1 Conversely* inta3e of

'/eef or red meat and ham can increase the ris3 A$ara00ini et al1* +,,>B1 # study conducted in the (1S1 on ovarian endometrioid cysts reported elevated ris3s of endometrioisis for higher inta3es of polyunsaturated and vegeta/le fats* /ut no reduction in ris3 for high inta3e of vegeta/les and fruits ABritton et al1* +,,,B1 There are however* some indications that a diet poor in vegeta/les and fruits and rich in fat increases the ris3 of endometrial cancer A#rmstrong* -;<;B and fi/roids AChiaffarino et al1* -;;;B* two diseases 3nown to /e associated with estrogens* and of ovarian /enign and malignant epithelial diseases A5isch et al1* -;;>B1 The methods of detecting and diagnosing endometriosis are improving1 However6 more women need to ta3e their pelvic pain and period pain seriously /y pursuing answers from the medical profession1 5ecent studies are /eginning to indicate that women with the disease are at greater ris3 of other health pro/lems such as infertility and even cancer1 Many women suffering from endometriosis may have surgical procedures or ta3e drugs /ut studies have shown that these options were largely unsatisfactory however this study discovered that there are more doctors who are /eginning to speciali0e in the disease and new surgical techni&ues* drugs and diets are /eing developed today1 This study supports many women who are see3ing ways to ta3e care of their own health with regard to dealing with this disease and information gathered and the summary of charts with /eneficial food suggestions* supplementation* Chinese her/s as well as Western treatment options could provide a /asic foundation for a manual that could specifically serve patients with Endometriosis1 The inclusion cfactors for the TCM nutritional manual are as /elow1

', /actors for Inclusion in the (utritional $anual The current study resulted in the identification of the following factors that the researcher discerned as /eing salient and important for inclusion in a traditional Chinese nutrition manual that will provide support and information for patients suffering from endometrioisis8 E4planation on Endometriosis and symptoms E4planation of /asic TCM Theory including Five Element Theory TCM Diagnosis of Endometriosis TCM Treatment options with pros and cons Western Diagnosis of Endometriosis Western Treatment 'ptions with pro and cons Western Drugs E4planation with pros and cons E4planation of TCM Nutrition Beneficial food groups for each TCM diagnosis with /oth TCM and Western e4planation )ist food groups into warming* cooling* /lood nourishing* /lood moving* fluid generating and 3idney strengthening Awith e4planationB )ist of foods to avoid Awith e4planationB Supplement recommendation Awith e4planationB )ist of Menu with coo3ing instruction using recommended foods Awith e4planationB 'ther recommendations Ae4ercise* &i gong* tai chi* mediations and yogaB Support groups information

'2 Limitations of the Current "tudy The primary limitation of current study is in the nature of the study itself1 The face that a literature review is a secondary analysis of studies which have previously /een conducted /y others1 This limits the choice of the studies and varia/les involved in this research synthesis1 #s a conse&uence of this limitation* the data generated in this study in many ways were not associated with the original research o/%ective1 This was true in many studies where the study mainly focused on one formula or on particular food or drug* while others loo3ed at various food* drugs and Chinese her/s1 While all of the studies had to do with endometriosis in one way or the other /ut difference in varia/le used made it difficult to analy0e the data for this study1 There was also lac3 of articles availa/le for analysis regarding my su/%ect matter that also matched my inclusion criteria re&uiring that study include nutrition* diet change and Chinese her/s1 The lac3 of articles that com/ined TCM* nutrition and Western medicine treatment for endometriosis made it difficult compare the treatment options however there were significant num/er of article for each modality which made it possi/le to form a general /ut understanda/le summary1 While effect was made to /e as o/%ective as possi/le in assessing the &uality and relevance of the research methodology and design of the articles selected for this study* the possi/ility of my own /ias was present1 Because a single rater did the data analysis* there was an increased possi/ility of inaccurate recording and misinterpretation of data1

'% Source /ias was also possi/le limitation of this study* for many of the articles were pu/lished in %ournal which only pu/lish articles in favor or the use of nutrition* Chinese her/al medicine or Western medicine only1 #lso it was difficult to trac3 all the foods* Chinese her/s and supplementation suggestions in the studies with amounts and dosages* as some did not list the dosage or amount at all in the study1 Recommendations for /uture Research For future study* randomi0ed and controlled trials regarding this topic can /e carried out with more specific food groups as well as assessing the effectiveness of com/ined integrative approach /y applying nutrition* Chinese medicine as well as Western treatment options for endometriosis could /e done1 More focused approach that e4amines %ust one or two varia/les could help /etter understand the effectiveness of specific treatment protocol1 #lso* there seemed to /e more new and advance Chinese studies regarding various treatment options /ut there seemed not enough present studies in the Western studies for new and advanced treatment options for endometriosis1 Conclusion The goal of this study was to e4amine the relationship of diet and nutrition in treating endometriosis1 This study specifically e4plored factors that will contri/ute to the construction and composition of a Traditional Chinese Nutrition manual to support patients suffering from endometriosis1 Endometriosis is /ecoming a leading cause of infertility8 .:E of women who are infertile and <,D :,E of women with chronic pain have endometriosis and more than -, million women have endometriosis in the (nited States A)ing* -;;;B1 Furthermore* in

'& the (nited States* annual healthcare costs and costs of productivity loss associated with endometriosis were estimated at F++ /illion in +,,+ ABallweg* +,,>B This Study discussed the num/er of treatment options for endometriosis from the /oth Western and Traditional Chinese Medicine perspectives1 This study identified and descri/e the factors that need to /e considered in forming a traditional Chinese nutritional manual for endometriosis /y summari0ing findings into ta/les to show different foods* Chinese her/s* supplements and Western medicine1 2n conclusion* despite its limitations* this study suggests that there is some lin3 /etween diet and ris3 of endometriosis1 These findings suggest the need for a proper summari0ation of studies to form a manual to aid patients as well as medical practitioner in treating endometriosis1 This study uncovered that Traditional Chinese Medicine nutritional manual specifically created for the treatment of endometriosis could /e developed to aid patients in understanding all aspects of foods* her/s and supplements1 Such a manual could encourage patients to consider dietary changes in con%unction with other healing approaches1 #lso* it could increase awareness of Traditional Chinese Medicine to patients whether or not they have /een e4posed to Traditional Chinese Nutrition1

''

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(2

Appendi5 A: Articles 6sed for Research "ynthesis+ Listed in Order of "tudy (umber

(%

(u Author#s mb
+ . > = ? < : ; -, --+ -. -> -= #l/ertson* +,,; Bal/i et al* +,,, Barnard et al* +,,, Britton et al* +,,, Coven et al* -;:: Dong et al* +,,. Deutch* -;;= Deutch et al* +,,, F%er/ae3@ nudsen* +,,? "rodstein et al* -;;. Harel* +,,+ Harel et al* -;;? Hass* +,,. Huang et al* +,,< Ci et al* +,--

(u Author#s mb
-? -< -: -; +, +++ +. +> += +? +< +: +; ., Cing@Cing* +,-)evett* +,-, )ittman* +,,Masa3i* et al +,,< Mears* -;;< Missmer* +,-, Ni@McNease* +,,> 'live et al* +,,> $ara00ini* et al* +,,> $itchford* +,,+ 7ing et al* +,,: Seli et al* +,,. Minatier et al* +,,Wieser et al* +,,< Lhang et al* +,,.

Appendix A: Articles Used for Research Synthesis, Listed in Order of Study Number

(&

Appendi5 .: Characteristics of the Included "tudies on (utrition and !iet

('

Authors .albi et al+ 8999 Women

"ample

Age -+D+.=?

(o7

Intervention

.arnard et al+ 8999

Women with moderate to severe a/dominal pain during menstruation

++D>:

..

#8 )ow fat vegetarian diet for + menstrual cycles with normal diet and place/o supplement

Outcome measurement Menstrual pain intensity* locali0ation and duration Fre&uency of consumed foods from a set list Severity of Menstrual $ain Menstrual pain assessment

Result # lower inta3e of fruit* fish and egg is associated with dysmenorrhea

)ow far vegetarian diet reduces dysmenorrhea duration and pain intensity and increases the concentration of se4 hormone /iding glo/ulin Megeta/les and polyunsaturated fat can increase the ris3 of /eing diagnosed with a /enign ovarian tumor1 5esults for the endometrioid su/type are similar )ow fat inta3e and high car/ohydrate and fi/er inta3e has a negative effect on dysmenorrhea1 High n.@n? ratio inta3e reduces pain )ow far vegetarian diet reduces dysmenorrhea and endometriosis Dietary soy isoflavones may affect the ris3 of endometriosis

.ritton et al+ 8999

!eutch+ %::3

Cases8 Women diagnosed with a /enign ovarian tumor Aincluding endometrioidB1 Controls8 Women identified using a method of random digit dialing Acommunity controlB Women

-:D<>

?<.@.=A+:, of cases

were endometrioidB

!early consumption of food items form -+? item food fre&uency &uestionnaire

+,D>=

-:-

"eneral dietary ha/its assessed /y dietary self recording

/;erbaek#<nudsen+ 899= $asaki+ et al+ 899>

)iteratures concerning the effect of diet on endometriosis and dysmenorrhea Women diagnosed with endometriosis laparoscopically1

-?

+,D>=

-.:

They measured urinary levels of genistein and daid0ein as mar3ers for dietary inta3e of soy isoflavones* and genotyped ES5+ gene 5sal polymorphisms1 Wee3ly consumption of selected dietary items

'ara??ini+ et al+ 899-

Women with confirmed endometriosis

+,D?=

=,>

# reduction in ris3 for high inta3e of green vegeta/le and fruit and an increased ris3 for inta3e of ham* /eef and other red meat1 No association with inta3e of alcohol* coffee* fish and mil3

Appendi5 .: Characteristics of the included studies on nutrition and diet

((

Appendi5 C: "ummary of "tudies on (utrition and !iet

()
Authors
#l/ertson* +,,;

eneficial
.resh .r#it, /reen vegetab!es high in antio0idants 12ita3ins A, C, 4 and bio5!avonoids !i6e carrots, ya3s, spinach, 6a!e, brocco!i, ca#!i5!ower, sweet potatoes, green and red peppers7, high 5iber diet, who!e grains, green 5oods 1wheat grass, ch!ore!!a, spir#!ina7 c!ean, no#rish, 3ove b!ood and create circ#!ation. .or Pain: to3atoes, !e3ons, !i3es, apricots, grapes, beets, ce!ery, strawberries, b!#eberries, b!ac6berries, 6e!p, seaweed, gar!ic, sca!!ions and onions /a33a ino!enic acid 8o3ega (9P#3p6in seeds, o!ive oi!, 5!a0seed and pri3rose $3ega % 5atty acids9 5ish or !inseed oi! .or co!d condition9 eat foods with properties that are neutral or warm in nature A/eans* lee3s* onions* carrots* garlic* ginger* wheat /ran* millet* venison* /eef* tur3ey* chic3en* mangos* papaya* pineapple* figs* sweet potatoes* yams* red and green ca//ages1B The /ody seems to wor3 /est on a diet high in al3aineDforming foods1 Those foods which give al3aline elements when /ro3en down /y the digestion1 # diet which contains <,ED:,E al3alineDforming foods is ideal for healthful living1 MucusDless Diet8 #l3aline diets The /ody is normally slightly al3aline* the /lood pH /eing <1>-1 Mucus is considered to /e related to acidDforming foods* also called mucusDforming foods1 We need some mucus for /ody function1 However* if a diet too high in acid Oforming foods is eaten* the /ody can /e medium conducive for the growth of /acteria and viruses1 E4cess mucus can create congestion* the cause so many illnesses1 The pro/lem lies more in the diet1 #l3aline Food8 #pple* Bananas* Citrus fruits* Dates* "rapes Cherries* peaches* pears* plums* papaya* mangoes** pineapple* rasp/erries* /lac3/erries* elder/erries* huc3le/erries* /oysen/erries* persimmons* apricots* olives* coconut* figs* raisins* melon* millet* /uc3wheat* corn* sprouted grains* nonDfat mil3* almonds* /ra0il nuts* olive oil* soy* sesame* sunflower* corn* safflower* cottonseed* margarine* soy/eans* limas* sprouted /eans* honey #ll vegeta/les are al3aline Aincludes starchy vegeta/les li3e potatoes and s&uash as well as seaweedB Caffeine inta3e is associated with an increased ris3 of endometriosis

Not eneficial
:ee5, ha3 or other red 3eat 9Ca55eine, a!coho!, sa!t 9Ani3a! 5ats 9Re5ined and hydrogenated oi!s D#voiding animal products treated with steroids and anti/iotics1 #cid forming foods8 Fruits8 Cran/erries* pomegranates* straw/erries* sour fruits "rains8 Brown rice* /arley* wheat* oats* rye* /reads Nuts8 Cashew* walnuts* fil/erts* peanuts* pecans* macadamia nuts Sugars8 Brown sugar* white sugar* cane sugar* mil3 sugar* cane syrup* malt syrup* maple syrup* molasses 'ils8 Nut oils* /utter* cream Beans and $eas8 )entils* navy* ad0u3i* 3idney Seeds8 $ump3in* sesame* sunflower* Chia* Fla4 Meats and Dairy $roducts8 #ll meat* fish* fowl* eggs* cheese* mil3* yogurt* /utter #void Caffeine inta3e

2ass+ 8998

Grodstein et al+ %::, Levett+ 89%9

Whole grains* /eans* vegeta/le* fruits* oatmeal* mustard greens* dar3 greens* /roccoli* ca//age* onions* garlic* carrots* live yoghurt* rhu/ar/* seeds and spouted seeds* ginger* green tea* /erries* parsley* fennel* cauliflower* nuts* seeds and celery MitaminsD magnesium* 0inc* calcium* iron* B vitamins* Mitamin C* #* E and selenium $rogression of endometriosis is considered estrogenDdependent1 Dietary soy isoflavones may affect the ris3 of endometriosis* and polymorphisms in estrogen receptor genes may modify this association1 They e4amined associations among soy isoflavone inta3e estrogen receptor + AES5+B gene polymorphisms and ris3 of endometriosis1 4at p!enty o5 vegetab!es and 5resh 5r#it. 4at as 3any who!e 5oods as possib!e, s#ch as who!e grain cerea!s. ;here possib!e, gri!!, stea3 or stew 5oods rather than 5ry the3. 4at 3ore 5oods rich in essentia! 5atty acids, s#ch as seeds, n#ts and grains. Coo6 in oi! rather than 5at. 4at !ow95at versions o5 dairy prod#cts 15or e0a3p!e, non9 or !ow95at 3i!67. C#t down on s#gar 1and re3e3ber that s#gar is added to 3ost processed 5oods, inc!#ding 5ro<en dinners and snac6 5oods= read !abe!s care5#!!y7. Red#ce yo#r inta6e o5 sa!t and ani3a! 5ats. Choose white 3eats, s#ch as chic6en, rather than red 3eat. Drin6 !ess co55ee, tea and carbonated drin6s. Drin6 at !east si0 g!asses o5 water a day. !he Natural "strogen #iet: o3e researchers be!ieve that by eating 5oods containing wea6 p!ant estrogens 1iso5!avonoids7, yo# 3ay act#a!!y be ab!e to red#ce the a3o#nt o5 estrogen in yo#r own body. >owever, the idea is very controversia! and the bene5its have not yet been 5#!!y s#bstantiated. .oods that are a rich so#rce o5 these inc!#de: Dried 5r#its, Cabbages and t#rnips, :erries, peas and !eg#3es, :eans, n#ts and seeds, ?nre5ined grain prod#cts, s#ch as rye prod#cts, oy prod#cts s#ch as to5# and soy 3i!6 @t is not advisab!e to change yo#r diet radica!!y witho#t detai!ed advice and s#pervision 5ro3 a physician, a!ternative practitioner or n#tritionist. Reco33endations: At !east one wee6 prior to the #s#a! onset ti3e o5 P.". . cons#3e so3e o5 the 5o!!owing: ginger, green onions, 5enne!, sy3pto3s, orange pee!, spinach, wa!n#ts, hawthorn berries, cinna3on, and b!ac6 pepper, Chinese date, Dang /#i 1Ange!ica sinensis7. Summary $oods and Spices %hich #isperse Stagnant lood: & t#r3eric, chives, gar!ic, vinegar, basi!, peach seed, sca!!ion, !ee6, ginger, chestn#t, rose3ary, cayenne, n#t3eg, 6oh!rabi, eggp!ant, white pepper, ad#6i bean, sweet rice, spear3int, b#tter

$asaki+ et al+ 899>

Wheat* red meat* refined and concentrated car/ohydrates* refined sugars and honey* caffeine* chocolate* dairy produce* eggs* fried foods* saturated fats and oil* soy products* convenience foods* additives* preservatives and alcohol Dietary isoflavones may reduce the ris3 of endometriosis among Capanese women1

$ears+ %::>

DonAt ta6e iso!ated vita3ins or 3inera!s witho#t the advice o5 a B#a!i5ied practitioner. /enera!!y, it is best to ta6e s#pp!e3ents with 3ea!s beca#se they are 3ore easi!y absorbed. >owever, there are so3e e0ceptions, s#ch as <inc, which is tho#ght to be absorbed better at night on an e3pty sto3ach. ;hen b#ying a 3#!tivita3in s#pp!e3ent, do opt 5or one with a wide and ba!anced variety o5 3inera!s and vita3ins. DonAt be te3pted to ta6e s#pp!e3ents instead o5 eating ba!anced 3ea!s. DonAt ta6e h#ge doses o5 vita3ins and s#pp!e3ents

(i#$c(ease+ 899'itchford+ 8998

Avoid: co!d 5oods, raw 5oods, e0cessive cons#3ption o5 5r#it, vinegar, a!! she!!5ish, co55ee, sti3#!ants, s#gar, dairy prod#cts, and s3o6ing Alcohol, tobacco, coffee, cold-temperature foods, refined sugar, hydrogenated fats such as shortening and most margarines, polyunsaturated cooking oils (see Oils and Fats, Chapter 10 for options), and o erconsumption of fruit or ra! food" Fluoridated !ater suppresses thyroid acti ity, !hich upsets the hormonal system in general# chlorinated !ater destroys itamin $, an essential nutrient for menstrual ease" Commercial red meats and poultry ha e residues of steroids composed of female animal se% hormones, !hich interfere !ith human menstruation"

Appendi5 C: "ummary of studies on (utrition and !iet

(*

Appendi5 !7 "ummary of "upplements

(+
Authors "ummary

Covens et al* -;::

Deutch et al* +,,,

Harel et al* -;;?

Sample8 5a//its No7: .: 2ntervention8 Fish 'il 'utcome measurement8 $"E+ and $"F+S concentration and endometroitic implant si0e Result: $eritoneal fluid $"E+ and $"F+S concentration were significantly lower in the fish oil group1 Diameter of implants was significantly lower in the test group Sample8 Women regularly suffering from dysmenorrhea #ge8 -?D.; No18 <: #8 $lace/o B8 Seal oil C8 Fish oil D8 Fish oil I Mit B-+ 2ntervention8 (se of analgesics* Blood )i&uid concentration* "luteal 5ecord* Menstrual pain assessment Result: Marine oil reduces dysmenorrhea1 The effect of fish oil and Mitamin B-+ was more than =,E Sample8 !oung women who reported dysmenorrhea #ge8 -=D-: No18 .< #8 Fish oil for + months B8 $lace/o for + months Followed /y crossover #8 $lace/o 'utcome Measurement8 Fre&uency and severity of symptoms associated with dysmenorrhea1 Result: Fish oil lowered dysmenorrhea symptoms
Result: Women with the lowest fifth of longDchain omegaD. fatty acid consumption were less li3ely to /e diagnosed with endometriosis1 2n addition* those in the highest &uintile of transDunsaturated fat inta3e were more li3ely to /e diagnosed with endometriosis1 Result: The literature on diet and endometriosis is sparse and inconsistent1 Diet and dysmenorrhea have more /een in focus* and the studies indicate that fish@nD.Doil might have positive influence on pain1 For all other food items* results are diverse1 This review reveals that no clear recommendation on what diet to eat or refrain from to reduce the symptoms of endometriosis can /e given* whereas a few studies indicates that fish oil can reduce dysmenorrhea1 Further research is recommended on /oth su/%ects1

Missmer et al* +,-, Wieser et al +,,<

Appendi5 !: "ummary of "upplements

)-

Appendi5 : Listing of Chinese 2erbs#/ormulas Only "tudies

),
Authors Dong et al* +,,. Huang et al* +,,< Ci et al* +,-Cing et al* +,,> Lhang et al* +,,. /ormulas used "ui Lhi Fu )ing Capsule Tao He Cheng 7i Tang "ui Lhi Fu )ing Wan Shao Fu Lhu !u Tang "ui Lhi Fu )ing Wan

Appendi5 : Listing of Chinese 2erbs#/ormulas Only "tudies

)2

Appendi5 /: "ummary of &estern $edicine "tudies

)%
Authors "ummary Nonsteroidal antiDinflammatory drugs ANS#2DsB are the most common pharmacologic treatment for dysmenorrhea1 # loading dose of NS#2Ds Atypically twice the regular doseB should /e used as initial treatment for dysmenorrhea in adolescents followed /y a regular dose until symptoms a/ate1 #dolescents with symptoms that do not respond to treatment with NS#2Ds for three menstrual periods should /e offered com/ined estrogen@ progestin oral contraceptive pills for three menstrual cycles1 #dolescents with dysmenorrhea who do not respond to this treatment should /e evaluated for secondary causes of dysmenorrhea1 #dolescent care providers have the important roles of educating adolescent girls a/out menstruationDassociated symptoms* as well as evaluating and effectively treating patients with dysmenorrhea1 The medical treatment of endometriosis has /een centered upon producing a hypoestrogenic environment /y producing pituitary suppression or progestinDdominant environment1 However* as more is uncovered regarding pathogenesis and pathology of this diseases* more targeted therapies can /e developed1 Current research has focused upon medications designed to attac3 specific aspects of the development and maintenance of endometriosis1 These include progesterone receptor modulators* gonadotropin releasing hormone A"n5HB antagonists* matri4 metalloproteinase inhi/itors* pento4ifylline Aand other general immune modulatorsB* and estrogen receptor /eta agonists1 2t is hoped that new wave of medications will improve the response to medical therapy for this disorder1 The medical treatment of endometriosis has long /een played a ma%or role in the therapeutic approach to this disorder1 However* the approach to the design of medical therapeutics for endometriosis is evolving scientifically* as new strategies are aiding in the attac3 upon this disease1 What once was an armamentarium of a handful of ovulation suppression agents is fast /ecoming a diverse array of finely directed treatment options1 The original development of medication to treat endometriosis was /uilt upon several o/servations1 First* endometriosis is infre&uently encounter in the parous women and is much more often in the nulliparous female* suggesting a protective effect of the hormonal milieu of pregnancy1 Second* endometrium is 3nown to /e estrogen dependent1 Finally* endometriosis tends to occur nearly e4clusively in menstruating women of reproductive age* again suggesting hormonal dependence1 These findings suggested the potential /enefits of hormonal therapy to alter the normal menstrual cyclicity of the reproductive years* the mainstay of medical treatment for endometriosis1 However* the approach has changed1 There e4ist a much greater depth of understanding of the pathogenesis* growth and maintenance of ectopic endometrium* particularly at the molecular level1 This has provided drug developers with new* precise molecular targets for treatment of the disease1 5eviewed new e4perimental approaches to the medical treatment of endometriosis and its symptoms1 Selective progesterone receptor modulators "onadotropin releasing horomone antagonists #romatase inhi/itors Tumor necrosis factorD#lpha inhi/itors #ngiogenesis inhi/itors Matri4 Metalloprteinase inhi/itors $ento4ifylline and other immunomodulators Estrogen receptor /eta agonists The use of accepta/ility of medical therapy in the treatment of endometriosis has wa4ed and waned over the years1 'riginally* the disease was felt to /e /est treated surgically /ut the pendulum has /een swinging relentlessly towards medical options as the comple4ity and chronicity of endometriosis has /een recogni0ed1 With a wide variety of investigational medications in the development pipeline* it is li3ely that the role of medication for this disease will e4pand in the future with fewer sideDeffects1

Harel* +,,+

'live et al* +,,>

Seli et al* +,,. Minatier et al* +,,-

Estrogen upregulates the formation of prostaglandin which is the most potent stimulator of aromatase $>=,* and a positive feed/ac3 loop is esta/lished* where continuous estrogen and prostaglandin release can favour the inflammatory and proDliferatory nature of the disease1 #/normal e4pression of aromatase $>=, in the endometrium of women with the endometriosis and impaired inactivation of estrogen may lead to elevated local estrogen concentrations1

Appendi5 /: "ummary of &estern $edicine "tudies

)&

Appendi5 G: "ource !ata Chart

)'
"ource !ata Chart @uestion#Aariable
#1 What is endometriosisR -1 Western definition* pathophysiology and diagnosis +1 TCM definition and diagnosis B1 What are the Western medicine treatment modalities for endometriosisR -1 Western Drugs +1 .1 >1 =1 ?1 <1 Nutritional Supplements Nutritional Diet@Foods Traditional Chinese Her/s@Formulas Her/s@Spices for Endometriosis Traditional Chinese nutrition 'ther

Bournals#Articles AMostly found onlineB C C

Te5tbook Aonline or printB 5 5

5 C C C C C C 5 5 5 5 5 5 5 C 5 5 C 5

What is Traditional Chinese NutritionR How are Chinese Her/s used to treat endometriosisR Commonly used her/al formulas and individual her/ for EndometriosisR Side effects of her/s Side effects of Formulas Side effects of foods Side effects of drugs@supplements

C C C C

5 5 5 5

)(

Appendi5 2: Article Abstraction /orm

)) * Article ** * *A bstraction ** * */ orm *

5eviewer8 aren "ordon Title8 #uthors8 Date8

Source8 '/%ective8

5esearch Design8 )anguage@Setting8

$articipants@$articipant Selection Methods8

Treatment 2nterventions8

'utcome Measures8

$rocedures8

5esults8

Conclusions AThemes@Main $oints@ ey 2deas@"aps in Study@Strengths of studyB8