ENDOMETRIOSIS AND THE ANTERIOR COCCYX: OBSERVATIONS ON FIVE CASES
Endometriosis and the Anterior Coccyx: Observations on Five Cases
This section is compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
PCC Research Forum 1985 (Summer); 1 (4): 120–122 ~ FULL TEXT
Aldred G. Robinson, D.C., Louis J. Freedman, M.S., D.C.
(Dr. Aldred G. Robinson is in private practice in Grenada, Mississippi. Dr. Louis J. Freedman is an instructor in the Physiology/Chemistry department of Palmer College of Chiropractic.)
Observations on five patients presenting endometriosis are given. Relief of symptoms is effected by adjusting the anteriorally displaced coccyx. The author suggests a relationship between the displaced coccyx and endometriosis and counsels upon the recognition of same.
Epdometriosis, the presence of actively functioning endometrial tissue in ectopic locations, has been the subject of two recent reviews. [ 1, 2 ] This endometrial tissue responds to the same hormonal influences as normal endometrium. During folliculogenesis, estrogen stimulates growth and proliferation and after ovulation progesterone from the corpus luteum induces secretion of the epithelial endometrium and decidual reaction in the stroma. [ 1 ] How the lesion arises is a subject of controversy but three major theories are most popular. The oldest and still the most widely accepted is Sampson's theory of retrograde trans tubal flow of endometrial tissue shed at menstruation. [ 3 ] This theory cannot explain certain sites of the lesion or the presence of the lesion in women with bilateral tubal block. A second theory suggests a vascular and or a lymphatic route of delivery to the ectopic site from the basal endometrium. [ 4 ] A third theory suggests a mechanism of metaplasia, that is given the proper hormonal environment and possibly other poorly understood factors of neural influences, the coelomic epithelium differentiates into endometrial like tissue, [ 5 ] Genetic predisposition has also been suggested. [ 6 ]
The ectopic sites of endometrial tissue are many. The most common site is the ovary. Other frequent sites are the Pouch of Douglas, uterine ligaments, pelvic peritoneum, broad ligaments, uterosacral ligaments, serosa surface of the uterus, and rectovaginal septum. Sites encountered less ftequently include the appendix, terminal ileum, cervix, perineum, abdominal scars, umbilicus, inguinal region, and ureter. Rarely lesions have been found in the diaphragm, skin, skeletal muscle, lungs, kidney, pleura, stomach, heart, spleen, gall bladder, lymph nodes and bone. [ 1, 2 ]
It has been estimated that 25 percent of all women in their thirties and forties have endometriosis to some degree. [ 7 ] Another estimate of the incidence is 18 percent of all women undergoing gynecological laparotomy are found to have endometriosis. [ 8 ]
The ectopic location is a problem with this tissue cyclically proliferating and regressing. The most common complaints are infertility, dyspareunia, dysmenorrhea, pelvic pain and other menstrual problems. [ 9 ] Medical treatment falls into three categories: surgery which may range from resection of lesions to entire hysterectomy along with resection of lesions; hormonally induced "pseudopregnancy" using exogenous progesterone-estrogen combinations; pseudomenopause induced by danazol, a derivative of testosterone which possesses weak androgenic and anabolic activity. The treatments may be used alone or in combination [ 9 ] and considerations include age of the patient, degree of symptoms and whether later pregnancy is desired. [ 1 ]
The etiology of endometriosis is still widely debated and poorly understood. [ 10 ] We hypothesize an association between a structural malposition, possibly causing an irritation or insult to the sympathetic nervous system (SNS) creating a neurochemical imbalance which may be involved with the development and perpetuation of endometriosis. Correction of the hypothesized malposition might cure endometriosis. No currently accepted treatment offers such obvious advantages of complete cure without invasive treatment or major side effects.
A small number of patients have presented at the Robinson Chiropractic Clinic with endometriosis as part of their case history. In the cases reported, the condition was diagnosed by a gynecologist. The diagnosis of endometriosis was based on laproscopic examination, biopsy from dilation and curettage, or complete pelvic and rectal examination. These patients had sought care at the Robinson Chiropractic Clinic for other conditions, usually complicated with low back or leg pain. From the nerve charts, endometriosis was thought to be due to a subluxation at or above L3. [ 11 ] And, some cases were apparently corrected by adjustments at or above the level of the sacrum. Occasionally, after correction of an anteriorly displaced coccyx, patients would report a bruising appearance in the pelvic and upper thigh regions, for which no cause was known. Their recovery from endometriosis was thought to be from corrections of the third lumbar and above and not from correction of the coccyx.
In succession, three patients with endometriosis came in with the coccyx as their major complaint. Each had apparent rectal endometrial involvement (palpable nodules). Four to six weeks after correction of the coccyx, by inserting a finger into the rectum and gently pulling the palpable coccyx posterior, they were free of the rectal involvement and reported that vaginal and low abdominal pain were also gone. They reported the bruising phenomonen at about the third week following the coccyx correction, but it was of short duration (approximately one week) and disappeared as the nodules disappeared from the rectal area.
More recently two women, one married and one single, presented with endometriosis as part of their case histories. Each was in the first month of medical treatment for endometriosis, having had their menses stopped by hormonal treatment. Each had a tender coccyx. It was agreed that each would receive chiropractic care for five months except the coccyx would not be adjusted. They continued medical treatment, with visits to the Robinson Chiropractic Clinic as their other conditions indicated. At each visit the coccyx was lightly touched to assess its tenderness.
At the end of five months each still had low abdominal discomfort and tenderness in the coccygeal area. The married patient reported that sex was painful. In these patients, under medical care with various steroids, and under chiropractic care correcting all subluxations, with the exception of the anteriorly displaced coccyx, endometriosis persisted.
When the coccyx was corrected in each patient as described above, a similar response was observed. Within 5-10 minutes the abdominal discomfort was gone. In about three weeks the bruising effect of the lower abdominal area and upper thigh area was observed. One week later the nodules in the rectal area, presumably intestinal endometriosis, had diminished. In the married patient the tender nodular formations were gone and sex was not as painful. One area of small nodes persisted at four weeks in the single patient, but that was gone at six weeks. At the end of six weeks the married patient stated that sex was no longer painful.
This preliminary data suggests that by correcting the anteriorly displaced coccyx, the endometriosis was cured. The theory we propose is that the anteriorly displaced coccyx could compress the ganglion of Impar. This ganglion represents the distal end of both sides of the sympathetic chain ganglia, and in most cases is located midline and immediately anterior to the coccyx. [ 12 ] This compression may cause a neurochemical imbalance in the sympathetic nervous system. This in turn, may be involved with a metaplasia of epithelial cells to the glandular endometrial tissue. This is the view first put forth by Meyer [ 5 ] concerning the etiology of endometriosis and it has received support . [ 13, 14, 15 ] Once initiated, perhaps, continual imbalance in the SNS is important for the perpetuation of this ectopic endometrial type tissue. Therefore, removal of this neurochemical imbalance could cause the ectopic sites to regress and ultimately disappear, as occurred in the cases reported above.
The exact nature of this neurochemical imbalance, if present, is unknown at this time. Possibilities include hyperactivity of the SNS as a result of this irritation or hormonal imbalance. Certainly it has been well documented that the SNS stimulates glandular secretion [ 11 ] and hyperactivity of the SNS has been implicated as a critical factor in many diverse clinical syndromes. [ 16 ] Recently, many neuropeptides have been isolated in both the gut and the brain and the role of these in neurophysiology is poorly understood. [ 17 ] Perhaps an imbalance in these neuropeptides (peptidergic influence) is involved.
Since some cases of endometriosis have responded when adjustments were given above the level of the sacrum, insult to the SNS causing endometriosis may occur from other levels. The coccyx, however, is often overlooked and may be a major contributor. A sensitive state of the coccyx can be found with a sacral rotation. If the sensitive state persists at the coccyx after the sacrum and/ or ilia have been corrected, then it is possible that the coccyx is also in need of correction.
It is our hope that this study will stimulate further research and also aid in giving relief to many suffering women. In the majority of cases treated to date, the results have been positive. The treatment is noninvasive, requires no steroids with their potential side effects, and offers the hope of a complete cure.