Treatment of Benign Ovarian Cysts with Traditional Chinese Medicine

Treatment of Benign Ovarian Cysts with Traditional Chinese Medicine

By Catherine D. (Cat) Calhoun

Fall 2010

Herbal Treatment of Disease 2

Instructor: Dr. He

Table of Contents

Table of Contents 2

Biomedical Overview 3

Functional Ovarian Cysts 3

Abnormal Ovarian Cysts 5

Etiology 7

Symptoms 8

Complications 9

TCM Overview 10

Etiology 10

Pathology 12

Common Syndromes 13

Liver Qi Stagnation 14

Stagnation of Qi and Blood 16

Blood Stasis 18

Kidney Yang Deficiency with Accumulations of Damp and Phlegm 20

Biomedical Interventions and Implications for TCM 23

Summary 24

Reference list 25

Biomedical Overview

An ovarian cyst is any collection of fluid in or on the ovary which is surrounded by a thin-walled sac and is greater than 2cm in diameter. Ovarian cysts are quite common, affecting approximately 97% of premenopausal and 14% of postmenopausal women. Ovarian cysts are also the most common fetal and neonatal tumors, affecting approximately 30% of this population (Valesky). These cysts are categorized as either functional or abnormal in nature.

Functional Ovarian Cysts

Functional ovarian cysts can be part of the normal cycle of menstruation, usually occur only on one side, and result from a slight alteration in the function of the ovarian cycle. Cysts forming in the first half of the menstrual cycle in which an ovum is being prepared for release by the ovary are called follicular cysts or graafian cysts (“Wikipedia: The Free Encyclopedia”). These occur when the follicle forms, but the egg is not released. These types of cysts continue to grow and fill with fluid. Complications of follicular cysts include rupture, hemorrhage of the cyst, and interruption of the menstrual cycle. Rupture can cause severe acute pain on the affected side and affect about 25% of women developing these cysts. Hemorrhage occurs when the cyst bleeds into itself, further enlarging the cyst and causing sharp pain. These types of cysts can interrupt a normal menstrual cycle because follicles are designed to produce estrogen. The cysts also continue estrogen production causing irregular and excessive bleeding. This same hormone release can also trigger hyperplasia of the endometrium or uterine lining, amenorrhea, and fertility problems (Porth). Seventy to eighty percent of follicular cysts will resolve without intervention, however, and are often asymptomatic. Small follicular cysts may even be present in a normal ovary while other follicles are being formed (Stoppler). Ultrasound is the primary diagnostic tool used to detect and diagnose these cysts.

Functional ovarian cysts forming in the second half of the menstrual cycle are “corpus luteum cysts.” During the normal course of menstruation a follicle forms around an egg, the egg is released at Day 14 of the cycle and the follicle becomes known as a corpus luteum, a temporary ovarian gland which remains in the ovary while the egg moves to the fallopian tubes and then to the uterus. The corpus luteum manufacturers progesterone and estrogen after the egg is released in order to prepare the endometrium (the lining of the uterus) to support a fertilized egg. If no fertilization occurs it stops secreting and decays after approximately two weeks. If the corpus luteum does not decay it may fill with blood or fluids and expand into a cyst. These usually only form on one ovary and are often asymptomatic. Corpus luteum cysts can however grow to up to 10cm (about 4 inches in diameter) and can bleed into themselves and/or twist the ovary. Both of these events cause pain in the lower abdomen or pelvis. If a blood filled luteal cyst ruptures internal bleeding results as does acute sharp pain (“Morefocus Media”).

A sub-type of corpus luteum cyst is the theca lutein cyst. These are commonly bilateral and cause dull pelvic pain. These types of cysts are often associated with excessive ovarian stimulation such as in pregnancy, pregnancy with the growth of a large placenta, and diabetes. Theca lutein cysts developing newborns as a result of gonadotropins passed from the mother to the newborn. They can also develop as a result of hypothyroidism due to the similarities between TSH (thyroid stimulating hormone) and human chorionic gonadotropins (Valesky).

Abnormal Ovarian Cysts

Abnormal ovarian cysts are those which result from abnormal cell growth, most of which are benign growths. These cysts are cystadenomas, endometrial cysts, and dermoid cysts. Some women develop large numbers of cysts in the ovaries and suffer from polycystic ovary syndrome, or PCOS.

Cystadenomas are cysts which develop on the other surface of the ovary. They are either serous or mucinous in nature and are the most common type of benign ovarian growths (Porth). They can be attached to the outside of the ovary by a stem. While they are usually asymptomatic, there is a danger that they can twist on the stem which leads to rupture and acute severe pain on the affected side (Glenville). They can also become quite large, up to 12 inches or more in diameter, and interfere with the function of other organs or vascular structures (Slater).

Endometrial cysts occur secondary to the condition of endometriosis (Porth). Endometriosis is a condition in which the lining of the womb grows in parts of the body other than the uterus. Endometrial cysts form when endometrial tissue grows on the ovaries. Because endometrial tissue, regardless of location, responds to menstrual hormonal changes these cysts will fill with blood which becomes a dark, reddish brown color, prompting the nickname “chocolate cysts.” Because there is no outflow for the endometrial tissue that grows monthly in these cysts they tend to get larger and larger, pushing on surrounding tissues and eventually rupturing (Glenville). Endometrioid cysts may range in size from three quarters of an inch to eight inches in diameter (Stoppler).

Teratomas or dermoid cysts are also classified as tumors. They derive from germ cells and per Porth are “composed of a combination of ectodermal, mesodermal, and endodermal elements.” They also often contain bits of fatty tissue, hair, skin, fluids, glandular tissue and teeth. They grow very slowly and generally are asymptomatic until they grow large enough to infringe upon other tissues or until they rupture, causing severe acute pain. The larger the dermoid cyst, the more likely the risk for rupture, which spills the contents of the cyst into the peritoneal cavity resulting in adhesion and severe pain. Most women have them on only one ovary but about 10-15 % of women will have them on both ovaries. While many types of ovarian cysts will spontaneously resolve these will not and surgical removal is advised by most western health professionals. CT or MRI scans are required to detect the presence of dermoid cysts (“Morefocus Media”).

PCOS or Polycystic Ovarian Syndrome is a condition in which there is not one, but a number of small egg follicles which are classified as cysts. PCOS is fairly common, affecting 4-7% of reproductive aged women. Women suffering from PCOS will have enlarged ovaries, often twice the normal size, with thickened linings along the outer capsule of the ovary. Multiple cysts within the ovary are only one of the facets of PCOS (Slater). Western medicine often regards this as an endocrine or hormonal imbalance disorder. Other manifestations are infertility and lack of ovulation as well as secondary male sex characteristics such as hirsutism, acne, weight gain, deepened voice and depression. These result from the androgens, normally produced in small amount in normal ovaries, but produced in higher amounts in polycystic ovaries. A further complication is the link between PCOS and insulin resistance. The associated insulin resistance causes an increased risk for type 2 diabetes and hypertension. PCOS is further associated with an increased risk of endometrial cancer (Stoppler).

Etiology

Valesky cites the following reasons as causes or possible causes for ovarian cyst disorders:

r  Disorders that increase ovarian stimulation. These can include:

o  Gestational trophoblastic disease (GTD).
This is a tumor disorder with tumors forming from the layer of cells normally surrounding the embryo. These are predominantly benign, yet stimulate hormone production and increase the likelihood of ovarian cysts.

o  Multiple gestational pregnancies.
Twins are the most common form of multiple gestational pregnancies.

o  Exogenous ovarian stimulation.
Hormone and fertility therapies, ovarian stimulation prior to in vitro fertilization and embryo transfer, and glandular disorders causing elevated levels of gonadotropins are among the most common examples.

r  Pregnancy.
Ovarian cysts form most often in the second trimester of pregnancy when β-hCG levels peak in the body. β-hCG is also referred to as beta-HCG, HCG, and serum HCG. This is human chorionic gonadotropin, a hormone secreted by an embryo which stimulates production of estrogen and progesterone. (This is the hormone which is detected in home pregnancy tests in the event of a positive result.)

r  Hypothyroidism.
A component of thyroid stimulating hormone, the alpha subunit, is very similar in structure to β-hCG. Because TSH levels increase in hypothyroidism this hormone is thought to stimulate the formulation of ovarian cysts.

r  Maternal gonadotropins.
These hormones can stimulate the development of neonatal and fetal ovarian cysts.

r  Cigarette smoking and increased Body Mass Index (BMI).
There is a higher risk of ovarian cysts among women who smoke cigarettes and have a higher than average BMI.

r  Tubal ligation sterilization.
This can increase the frequency of functional cysts.

Symptoms

Ovarian cysts can be asymptomatic but often share some commonalities in symptoms regardless of classification. Dull unilateral pain and/or heaviness in the lower abdomen or pelvis that may stop or start are common signs. Pain may be sharp, sudden and severe, especially after strenuous exercise or sexual intercourse. Many women suffering from ovarian cysts will also find sexual intercourse to be painful or uncomfortable. Tenesmus is another common symptom reported by patients with ovarian cysts as is pain or pressure felt when urinating or defecating. Heavy or prolonged menstrual bleeding, vaginal pain, and intermittent spotting are also reported. Sudden, sharp, and unilateral pelvic pain is common upon rupture of a cyst and may spontaneously resolve. Nausea and vomiting are an occasionally reported symptoms.

Complications

The possible complications of ovarian cysts are ovarian torsion, rupture, and malignancy. Ovarian torsion is a danger with any ovarian cyst, but especially those on the right side of the body and those that are greater than 4cm in diameter. The sigmoid colon on the left side of the body tends to obstruct movement of the ovary on that side and torsion is thus a lesser danger. Ovarian torsion occurs when the weight of the cyst twists or rotates the ovarian pedicle. This leads to obstruction of the blood vessels nourishing the ovary. The venous structures are obstructed first, then the arterial flow. This can cause necrosis in the tissues of the ovary. Torsion is most commonly seen in cases of PCOS and dermoid cysts (Valesky).

Rupture can cause blood spillage into the peritoneum, peritonitis and a drop in blood pressure. Ruptures are most often associated with corpus luteum cysts and involve the right ovary about two-thirds of the time. Ruptures of this type tend to occur in the final week of the menstrual cycle prior to the beginning of the next monthly period. The greatest dangers associated with rupture are that of hemorrhage and shock, but may also include tachycardia and hypotension if more severe. Some patients will also experience orthostatic hypotension (Valesky).

Malignancy of cystic tissues is rare, especially in premenopausal women and girls. Pregnancy patients with simple cysts less than 6 cm in diameter for instance have an only 1% risk of malignancy. When a cyst is unilocar (contains only one cavity) they are rarely malignant. Multiloculated cysts however carry a 36% risk of malignancy. Those that are diagnosed as malignant there is a 70% chance that there is regional or distant spread. Only 25% of these cases are limited to stage 1 cancer.

TCM Overview

Ovarian cysts in Chinese medicine are considered to be abdominal masses. Maciocia quotes the Spiritual Axis stating that this could be the oldest pathology that seems to resemble an ovarian cyst. The Spiritual Axis calls this “Intestines Deep Mass.”

External Cold engages in a fight with the Defensive Qi, Qi cannot flourish and accumulations develop inside forming a nodule: a perverse Qi rises and decayed flesh forms. In the beginning the lump is the size of an egg; gradually it increases in size until it becomes the same size as the abdomen of a woman at full term’s pregnancy. After some years the lump feels hard on pressure but it is moveable; it fluctuates with the menstrual periods.

Fratkin says that TCM defines an ovarian cyst as an enlarged ovary.

Etiology

Maciocia cites the following etiologies for abdominal masses in general which includes ovarian cysts.

r  Emotion
Specifically, emotional strain. Anger is the most important of the emotions in regard to the formation of abdominal masses/ovarian cysts, especially in the form of repressed rage, frustration, resentment or hatred. All of these strongly impact the Liver and it’s Qi. Stagnation of Liver Qi and the resulting stasis of Liver blood impact the Liver channel rendering it less able to move the Qi of the lower abdomen and the circulation of Liver Blood.