Treating Heavy Menses Due to Fibroids - Naturopathic Approach

Fibroids affect between 5 and 21% of the population and can present with noncyclical pelvic pain, abdominal bloating, constipation, increased urinary frequency, fatigue, dyspareunia (pain during intercourse), and menorrhagia (very heavy menstrual flow).^[1] The menorrhagia may be quite severe and described as “gushing.” Fibroids can also be asymptomatic. Chronically heavy flow takes a toll on the body in both physiological and energetic terms. Blood loss can result in iron loss, leading to iron deficiency and anemia. From a Chinese medicine perspective, loss of blood can result in liver or heart blood deficiency, which can progress into heart or blood yin deficiencies. The symptoms of these two pathologies include heart palpitations, night sweats, dizziness, floats, blurry vision, restlessness, and insomnia, to name a few.

Potential Causes ^[2]

While the etiology of uterine fibroids remains unknown, there are a few leading theories or hypotheses. The first is the hormone disruption. Both estrogen and progesterone promote the growth of fibroids, and women with fibroids have a higher amount of estrogen within the uterine tissue (not in circulation). Additionally, the aromatase enzyme that converts testosterone to estrogen appears to be up-regulated, and thus may be responsible for the elevated tissue estrogen. In fact, going through menopause, which is characterized by the drop in estrogen and progesterone, has been shown to reduce the size of the fibroids. Xenoestrogens are exogenous estrogen ligands, meaning that they can bind to the estrogen receptor and either stimulate or suppress its activity. Organochlorine pesticides are an example of xenoestrogens that may bind to receptors on the uterus and promote its growth.^[3] Another xenoestrogen is a compound called bisphenol A, which concentrates in the uterine cells and that can induce proliferation of the smooth muscles.^[4] However, this has not been confirmed in clinical trials; only in animal and in vitro research. Other endocrine disruptors include industrial solvents and lubricants, dioxins, plasticizers such as phthalates, fungicides (vinclozolin), pesticides (e.g. dichlorodiphenyltrichloroethane [DDT]), and polychlorinated bisphenyls. However, their effect on fibroids is yet to be explored. Another prominent hypothesis proposes that the fibroids are due to a disorder of wound healing. Damage to the myometrium causes activation of various growth factors that stimulate cellular proliferation, increase extracellular matrix, and prevent cell programmed death (apoptosis). This can result in the thickening of the myometrium and can give rise to the fibroid tumour. Lastly, genetic predisposition may contribute to the pathogenesis, though more research is needed to uncover specific genes responsible for this condition.

Treatment Options

Phytoestrogens

Phytoestrogens are compounds that can have a mild estrogenic or antiestrogenic effect on the body. In a way, they buffer the reproductive hormone system by binding to the estrogen receptors and out-competing the natural estrogen produced by the body. This earns phytoestrogens the term “selective estrogen receptor modulator.” In the case of fibroids, this results in an overall mild antiestrogenic effect, and thus reduced stimulation of the uterine lining and the myometrium. This may not shrink the fibroid, but it may stop the fibroid from growing. The well-known phytoestrogens include foods like soybeans, flaxseeds, and tempeh. However, phytoestrogens can also be found in fruits—like plums, pears, apples, and grapes—as well as vegetables—like beans, sprouts, cabbage, garlic, hops, and spinach. Even grains can have small amounts of phytoestrogens.^[5] While large systematic reviews have cleared phytoestrogens—soy in particular—from its bad reputation with breast cancer,^[6] there is still a lingering unease surrounding the use of soy in autoimmune hypothyroid conditions. However, this is largely based on animal and preclinical studies, which demonstrate soy’s ability to interfere with the thyroperoxidase enzyme.^[7] This enzyme is responsible for adding iodine ions to the tyrosine residues of the thyroglobulin protein and forming thyroid hormones, thyroxine (T4) and triiodothyronine (T3). Clinical trials did not find any negative association between soy and thyroid hormone production, when supplementing at 2 mg of isoflavone per day per kilogram of body weight.^[8] For a 70 kg weight (154 lb), this would mean 140 mg of isoflavones per day. The table (right) shows what that would look like in terms of soy and soy products. However, while phytoestrogens may provide treatment to the underlining hormone imbalance contributing to the menorrhagia due to fibroids, they do not address the immediate problem of excessive bleeding. Thus, a more acute solution is still needed.

Herbal Medicine

The primary treatment goal when approaching fibroids with heavy menses is first to stop the heavy flow. The second component is the balancing of reproductive hormones with the hope to reduce growth, and then to promote the shrinkage of the fibroid. Hemostatic herbs often contain tannins as well as diverse milieu of other flavonoids and compounds. Tannins are astringent and such favour vasoconstriction.^[10] The function of many other compounds present in hemostatic herbs is largely unknown. In vitro studies cite evidence for wound healing, while others demonstrate increased activation of coagulation factors. Some of the herbs that are included in this category include Geranium maculatum, Achillea millefolium (yarrow), Alchemilla vulgaris (lady’s mantle), Myrica cerifera (bayberry bark), Urtica dioica, Capsella bursa-pastoris (shepherd’s purse), and Vitex agnus-castus (chasteberry). Hamamelius virginiana (witch hazel) and Quercus alba (oak) are also known hemostatic herbs; however, their primary targets are hemorrhoids and dysentery, and the effect on the uterine lining is minimal. A herbal product called Ankaferd demonstrates hemostatic activity in gastrointestinal bleeds as well as topical wounds, and contains the herb Glycyrrhiza glabra (licorice) along with several others.^[11] What is interesting is that Glycyrrhiza has been shown to have antithrombin effects, thus making it a possible treatment to consider in venous thrombosis, but one which would likely promote bleeding rather than reduce it. This speaks of the importance of examining herbal preparations as a complex of herbs working synergistically, rather than evaluating a signal herb on its ability to promote or reduce bleeding. The other herbs in Ankaferd include Urtica dioica, Vitis vinifera, Alipinia officinarum, and Thymus vulgaris.

Acupuncture

According to Chinese medicine, pathologies result from excess or deficiency of energy flow. This may be due to blockages in the body or due to exposure to particular foods, environmental challenges, and stresses. There can be a genetic predisposition to a particular state as well. The insertion of needles used in acupuncture opens up the passage for the energy “qi” to flow, thus either moving it away from excess or moving it towards a deficient organ. In either case, the symptoms are improved.

Several case reports provide evidence for the efficacy of acupuncture in regulating increased uterine bleeding. One case reports a 50% reduction in bleeding in a single treatment in 33-year old female. Needles were inserted into points SP 6 and CV 4, and retained for 30 minutes.^[12] Within three days of treatment, the bleeding stopped. Prior to this, the bleeding was profuse for 10 days, with no evidence of subsiding. Another case reports acupuncture treatment combined with electrostimulation in a 48-year-old female with six months of menorrhagia.^[13] The treatment involved points ST 29 and SP 6. The electrostimulation provided 80 Hz frequency and 3–4.5 mA of intensity of current for 30 minutes. Using a Doppler ultrasound, the team was able to visualize the uterine artery before and during the treatment. The ultrasound demonstrated a reduction in blood flow through the uterine artery within 15 minutes of treatment. The treatment was carried out for 30 minutes per day for six days, resulting in a lessening of the menstrual flow, though not a complete stop. Thus from the theoretical perspective, the reduction in blood flow through the uterine artery would suggest that the excessive hemorrhage in this case was due to excess “qi” being directed to the organs. However, from a different perspective, it may be that the acupuncture strengthened or tonified the spleen organ (with stimulation of SP 6), allowing it to properly contain blood within the vasculature and minimize bleeding. Regardless of the mechanisms, these case reports illustrate the potential of acupuncture as acute therapy in the management of excessive uterine bleeding due to fibroids.

Conclusion

While the cause of uterine fibroids remains unknown, it is likely due to the combination of genetic predisposition coupled with hormone imbalance and wound-healing dysfunction. Hormone imbalances may be due to increased exposure to xenoestrogens and/or due to increased activity of the aromatase enzyme. Dietary recommendations may address the hormone imbalance, but more acute treatment is needed to target the menorrhagia. Herbal treatments include combinations of hemostatic herbs that may promote local vasoconstriction of the uterine arteries and production of clotting factors. These herbs likely work synergistically, thus the same herbs may be prothrombic or antithrombic depending on the herbs they are combined with, as seen in the case of Glycyrrhiza glabra. Acupuncture with or without electrical stimulation may provide acute symptomatic relief, possibly by reducing the blood flow through the uterine artery. This review does not address the treatments required for patients with bleeding disorders or uterine hemorrhage due to nonfibroid related causes.