Jillian L. Capodice, LAc provides a brief introduction of TCM zang-fu (viscera) theory in gynecology and discusses the most current research for dysmenorrhea and vulvodynia.

by Jillian L. Capodice, LAc

Traditional Chinese Medicine (TCM) has long recognized the specialty of gynecology. The earliest writings on gynecological conditions appear as early as the Shang Dynasty (1500-1000BC)1.  Currently the field of TCM gynecology is growing and there is a great deal of research being done on many conditions such as dysmenorrhea, female pelvic pain, infertility, and symptoms related to menopause. This article will provide a brief introduction of TCM zang-fu (viscera) theory in gynecology and discuss the most current research for dysmenorrhea and vulvodynia (a female pelvic pain condition).

Background TCM

TCM zang-fu theory focuses on the causes of disease and its relationship to the organs. In gynecology, the main organs involved are the uterus, kidney and heart. In TCM, the uterus is not considered one of the main zang-fu organs and is instead classified as an extra organ1. The function of the uterus in Chinese medicine is to store blood, act as a vessel for conception, and provide nourishment. The main related zang organs in gynecology include the heart and kidney. The heart is the commander of blood and the kidneys are the root organs that govern reproduction. The kidneys are also housed in the area of the lower dan tian (a major site of energy storage) and are important when treating gynecologic conditions. 

Based on the principles of TCM, it is clear that all the other organs such as the liver and spleen are also involved when discussing gynecologic disorders.  In zang-fu theory, it is the particular relationship of the organs to one another coupled with the function of the vital substances they coordinate (e.g.: qi, blood, jing) and the flow of qi through the meridians that are important in diagnosis of a gynecologic related condition. Common acupuncture meridians utilized for treatment of gynecologic conditions include the liver (jue yin), spleen (tai yin), stomach (yang ming), and lung (tai yin) main meridians and the extraordinary meridians including the Governing (Du mai), Conception (Ren mai), and Penetrating (Chong mai) vessels.

Pelvic Pain

Background-Biomedicine

There are many conditions that can cause pelvic pain and mechanisms include inflammation, obstruction, blood vessel disturbances, and pain that has origin in the abdomen. Pelvic pain in women can also be due to disorders that cause referred pain in the pelvis. Many pelvic pain disorders can be attributed to gastrointestinal, musculoskeletal, and urinary tract disorders thus making pelvic pain difficult to diagnose. Dysmenorrhea and vulvodynia are two common pain disorders of the female pelvis that are often chronic in nature and may be difficult to treat2.

Dysmenorrhea background-biomedicine

Dysmenorrhea refers to a crampy discomfort in the lower abdomen that can begin prior to menstrual bleeding or at its onset. Symptoms are characterized to gradually decrease with each day following the onset of menses. Symptoms that may accompany dysmenorrhea include fatigue, bloating, headache, nausea, and diarrhea. In general, prevalence is higher in adolescents and decreases following pregnancy23. Finally, there are two classifications of dysmenorrhea, primary and secondary. Primary dysmenorrhea results from increased stores of prostaglandin precursors which cause uterine contractions, increased nerve sensitivity, and pain.  Secondary dysmenorrhea is caused by underlying pelvic pathology such as endometriosis23.

Conventional treatment of dysmenorrhea is varied and can include local application of heat, use of nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g.: ibuprofen, naproxen)4, and use of oral contraceptives5. Complementary, Alternative and Integrative medicine treatments including use of vitamins and minerals such as B1, B6 and magnesium are being investigated6,7.  Physical exercise, yoga and acupuncture are also under investigation for their potential utility in the treatment of dysmenorrhea. 

Current research

Acupuncture for refractory dysmenorrhea

The most recent research in acupuncture for dysmennorhea was published earlier this year by Iorno V et al8. These investigators evaluated acupuncture in subjects with NSAID refractory dysmenorrhea.  They looked at 15 nulliparous women, average age 27 (range 13-35), moderate to severe dysmenorrhea >1 year, and were poor responders to NSAID therapy. Subjects were given 8 treatments of acupuncture over 4 months and a standardized acupuncture point prescription was used. At the end of treatment, substantial reduction in pain and NSAID consumption was observed in 13 of 15 patients (87%). A number of other trends are reflected in this paper, and the authors go into detail about the reduction in pain and NSAID consumption at various time points throughout the study (mid treatment, end of treatment, 3 and 6 months follow-up). While the major limitation of this study is its pilot nature, it is important as it demonstrates that acupuncture may be useful in refractory patients and should be considered as a treatment option.

Other recent research published early this year by Witt CM et al analysed both the effectives and cost-effectiveness of acupuncture treatment in subjects with dysmenorrhea. These investigators conducted a large, multicenter randomized controlled trial of 3 groups, 2 treatment groups and 1 non randomized cohort. The randomized groups were immediate acupuncture treatment for 3 months or delayed acupuncture treatment (delayed 3 months followed by 3 months of treatment).  The control group was a non-randomized cohort.  The entire study period was 6 months. Interestingly, each patient was able to receive a maximum of 15 acupuncture treatments and the number of needles and acupuncture points used were chosen at each doctor’s discretion.  The main outcomes reported was that average pain intensity was lower in the acupuncture group compared to the control group 3.1 (95% CI 2.7, 3.6) versus 5.4 (4.9, 5.9), difference −2.3 (−2.9, −1.6), (P < .001) and these same subjects also had better quality of life scores. Finally, cost effectiveness analysis showed that the cost was increased in the acupuncture group but was still considered cost-effective when estimated by QALYs (cost-benefit analysis)9.

Finally, the most recent Cochrane review on acupuncture for dysmenorrhea was published in 2002.  This review by Proctor ML looked at the use of both Transcutaneous electrical nerve stimulation (TENS) and acupuncture for the treatment of dysmenorrhea. The data analyzed included data from 7 TENS trials, 1 acupuncture trial and 1 mixed (TENS and acupuncture) trial. The authors conclusions confirmed that high frequency TENS was effective for treatment of dysmenorrhea but low frequency TENS and acupuncture had insufficient evidence to determine effectiveness10.  It is hoped that updated systematic reviews can pool more recent data in the next couple of years.

In conclusion, recent clinical trials have demonstrated the potential utility of acupuncture for the treatment of dysmenorrhea and the most recent German study demonstrates the cost-effectiveness of acupuncture. It is hoped that continued investigation into the mechanism, efficacy and utility of acupuncture for dysmenorrhea in real-time clinical practice will ensue.

Vulvodynia background-biomedicine

Vulvodynia (VVD) is poorly understood in etiology and treatment strategies and lifetime prevalence rates range from 2% to as high as ~15% in the United States11-13. VVD is commonly encountered in both the urologic and gynecologic settings due to overlap in symptoms such as pelvic pain, urinary, and sexual complaints11-15. Potential etiological factors of VVD include neurological, genetic, hormonal, and inflammatory aspects though no single feature is thought to be an absolute cause121415

Diagnosis of VVD is complex since there are no laboratory tests employed and diagnosis is often one of exclusion. Numerous diseases that present with similar symptoms include >25 differential diagnoses such as endometriosis, pelvic inflammatory disorder, chronic urinary tract infection, interstitial cystitis, inflammatory bowel syndrome, lumbar vertebrae compression, shingles, and neurological dysfunction14,15. Diagnosis of VVD is often made after these abovementioned diagnoses have been ruled out. Standard treatment for VVD pain includes vulvar care measures, topical analgesics, oral analgesics, antidepressants, anticonvulsants, physical therapy, surgery, and psychotherapy121415. Recently, it has been suggested that a variety of CAM therapies be utilized for VVD based on its presumed etiology and clinical presentation.  However, at this point only a number of acupuncture trials loosely related to VVD have been performed. These include one trial testing acupuncture for overactive bladder, and a number of trials focusing on treatment for dysmenorrhea as abovementioned1819. While more studies need to be done, other research shows that pelvic floor physical therapy may be useful for VVD and in general, many clinicians are advocating for an integrative approach for the woman diagnosed with VVD.

Conclusions

Female pelvic pain disorders compromise a large number of conditions such as dysmenorrhea and vulvodynia. Traditional Chinese Medicine texts have long recognized gynecologic and pelvic pain disorders and new research is being done on both acupuncture and Chinese herbal medicine for these conditions.


References

1. Giovanni Maciocia , Obstetrics & Gynecology in Chinese Medicine Churchill Livingstone, 1998.

2. Harrison’s Principles of Internal Medicine.  16th Edition, McGraw Hill, 2004

3. The Merck Manual, 17th Edition.  Merck Research Laboratories, 1999.

4. Clayton AH. Symptoms related to the menstrual cycle: diagnosis, prevalence, and treatment. J Psychiatr Pract. 2008 Jan;14(1):13-21.

5. Harel Z.Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006 Dec;19(6):363-71..

6. Proctor ML, Murphy PA. Herbal and dietary therapies for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2001;(3):CD002124.

7. Dennehy CE.The use of herbs and dietary supplements in gynecology: an evidence-based review. J Midwifery Womens Health. 2006 Nov-Dec;51(6):402-9..

8. Iorno V, Burani R, Bianchini B, Minelli E, Martinelli F, Ciatto S. Acupuncture Treatment of Dysmenorrhea Resistant to Conventional Medical Treatment. Evid Based Complement Alternat Med. 2008 Jun;5(2):227-230.  9.  Witt CM, Reinhold T, Brinkhaus B, Roll S, Jena S, Willich SN. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8. 

10. Proctor ML, Smith CA, Farquhar CM, Stones RW. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev. 2002;(1):CD002123.

11. Sand PK. Chronic pain syndromes of gynecologic origin. J Reprod Med. 2004 Mar;49(3 Suppl):230-4.

12. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis. 2005 Jan;9(1):40-51.

13. Goetsch MF. Vulvar vestibulitis: prevalence and historic features in a general gynecologic practice population. Am J Obstet Gynecol. 1991;164:1609-1614; discussion 1614-1616.

14. Updike GM, Wiesenfeld HC. Insight into the treatment of vulvar pain: a survey of clinicians. Am J Obstet Gynecol. 2005 Oct;193(4):1404-9.

15. Goldstein AT, Marinoff SC, Haefner HK. Vulvodynia: strategies for treatment. Clin Obstet Gynecol. 2005 Dec;48(4):769-85.

16. Smart OC, MacLean AB. Vulvodynia.Curr Opin Obstet Gynecol. 2003 Dec;15(6):497-500.

17. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003 Mar;101(3):594-611.

18. Emmons SL, Otto L.  Acupuncture for overactive bladder: a randomized controlled trial. Obstet Gynecol. 2005 Jul;106(1):138-43. 

19. Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea.. . J Adv Nurs. 2004 Nov;48(4):380-7.


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