Women’s Health - OB/gyn week 2

Abnormal Uterine Bleeding Amy Love, ND

Lecture Overview

• Types of AUB, diagnosis, treatment • Common causes, management

Abnormal Uterine Bleeding

Abnormal Bleeding (AUB) includes: • Menses that are too frequent (more often than every 26 d) • Heavy periods (esp. if with egg-sized clots) • Any bleeding that occurs at the wrong time, including spotting • Any bleeding lasting longer than 7 days • Extremely light periods or no periods at all

Abnormal Bleeding Patterns

• Menorrhagia: aka hypermenorrhea, prolonged (> 7 days) or excessive bleeding at regular intervals • Metrorrhagia: frequent menses at irregular intervals, the amount being variable • Menometrorrhagia: prolonged bleeding at irregular intervals

Abnormal Bleeding Patterns (continued)

• Oligomenorrhea: infrequent uterine bleeding; intervals between bleeding episodes vary from 35 days to 6 months • Polymenorrhea: occurring at regular intervals of < 21 days • Amenorrhea: lack of menstruation • Dysmenorrhea: painful menstruation AUB considered Dysfunctional Uterine Bleeding (DUB) if no organic cause found

Abnormal Bleeding Etiology

• Reproductive Tract • Abortion (threatened, incomplete, or missed) • Ectopic pregnancy • Malignancies • Endometrial hyperplasia • Cervical lesions (erosions, polyps, cervicitis) • Myomas (uterine fibroid) • Foreign bodies (IUD) • Traumatic vaginal lesions

Abnormal Bleeding Etiology (continued)

• Systemic Disease • Disorders of blood coagulation – von Willebrand’s disease, leukemia, sepsis, Idiopathic thrombocytopenic purpurea • Hypothyroidism > hyperthyroidism • Liver cirrhosis • Iatrogenic causes: – Oral/ injectable hormones or other steroids (birth control pill, HRT) – Tranquilizers/ psychotropic drugs (Always ask about medications)

Abnormal Bleeding

• Ovulatory • Heavy menses in women who ovulate and who do not have a coagulopathy or uterine abnormality • Most commonly occurs after adolescent years and before perimenopausal years • Circulating hormone levels may be the same as in women without AUB • May exhibit decreased prostaglandin synthesis and endometrial prostaglandin receptors • Anovulatory • Continuous estradiol production without corpus luteum formation/ progesterone production • Estrogen stimulates endometrial proliferation; endometrium may outgrow blood supply, necrose, and slough off irregularly

Abnormal Bleeding (cont.)

• Diagnosis – Detailed history (easy bruising/ bleeding, medications, contraceptive methods, symptoms of pregnancy and systemic diseases, pain?) – Labs: hemoglobin, serum iron, serum ferritin, TSH, beta-HCG, liver function, PAP smear, CBC, FSH, LH, STD testing – Imaging: hysteroscopy, pelvic ultrasound – Endometrial biopsy

Abnormal Bleeding (cont.)

• Conventional Management (in general) – Estrogen: causes rapid edometrial growth over denuded and raw endometrium (in high doses stops acute bleeding) – Progesterone: added to estrogen after bleeding has stopped; organizes endometrium so that sloughing process (when hormones are stopped) is less heavy – Birth control pills: long-term management – Mirena: progesterone- releasing IUD – NSAIDs: reduce menstrual blood loss in women who ovulate (inhibit prostaglandins) by 20-50% – Surgical therapy » Dilatation and Curettage » Endometrial Ablation: laser photovaporization of endometrium (may cause scarring, adhesions, uterine contraction) » Hysterectomy (only if AUB severe and persistent)

• Menorrhagia: – Birth control pills: tend to reduce heaviness of flow – If heavy flow may result in anemia; decreasing heaviness may restore normal iron levels – Iron replacement therapy • Pills can cause nausea, upset stomach, constipation • Better absorbed if taken with Vit C (tomato, orange, pepper) • Food-based iron better absorbed and less constipating – Food sources include: molasses, dried figs, meat (esp liver), lentils, dark leafy greens (need to be cooked) – Cooking in an iron skillet increases food iron content, especially acidic foods – Avoid black tea and other tannin sources at mealtimes

• Metrorrhagia: – If menses too frequent but regular, ovarian production of progesterone may be insufficient – If menses are inconsistent, may be anovulatory • birth control pill used to establish regularity – If menses irregular (unpredictable intervals) but otherwise “normal” • low-dose birth control pill helps establish regularity – If spotting in between regular menses, suspect a mechanical problem such as fibroids or polyps • Ultrasound or sonohysterography (fluid-enchanced U/S) • Copper IUD may be responsible for spotting – Screen for PCOS, thyroid disease

• Natural management approaches • Tissue tonification– bleeding may be sign of poor tissue tone of mucus membranes, uterus • Stress reduction– endocrine system adversely affected by stress, inappropriately timed release of hormones • Reduce inflammation– omega-3 fatty acids • Correct nutritional deficiencies: Vitamins A, B complex, C, K, bioflavonoids

• Botanical Considerations • Chaste tree/

Vitex agnus castus

: balances estrogen progesterone ratio to normalize and regulate cycle • Ginger/

Zingiber officinale

menstrual flow : anti-inflamatory (inhibits prostaglandin and leukotriene synth), helps reduce • Astringent herbs: Sheperd’s purse/

Capsella bursa pastoris

, Yarrow/

Achillea millefolium

• Botanical uterine tonics: Dong quai/

Angelica sinensis

, Raspberry leaves/

Rubus idaeus

• Uterine stimulants: Vitex, Achillea,

Mitchella repens

, Blue cohosh/

Caulophyllum thalictroides

• Stop semi-acute blood loss: Cinnamon, Fleabane/

Erigeron spp

., Shepherd’s purse

(TCM info from Dr. Fritz)

• Acupoints to regulate bleeding – Sp-1: strengthens Sp function of keeping blood in vessels; esp. good for uterine bleeding – BL-17, Sp-10, K-8, Lr-1 • Herbs to stop bleeding?

– Pao Jiang (fried ginger), Ai ye – San qi, Qian cao gen, Pu huang – Da ji, Xiao ji

Amenorrhea

• No menstrual flow for at least 6 months • Physiologic: during pregnancy or post-partum (eg during lactation) • Pathologic: due to endocrine, genetic, and/or anatomic disorders – Failure to menstruate is a symptom of these disorders; amenorrhea is therefore not a final diagnosis. If a woman is not pregnant or breastfeeding (or menopausal), amenorrhea is not normal and must be investigated.

• Can be Primary or Secondary

Primary Amenorrhea

Absence of menses in a woman who has never menstruated by the age of 16.5 years • Primary – No secondary sex characteristics • Genetic disorders, enzyme deficiencies • If uterus not present, may also have congenital kidney and cardiac defects – Secondary sex characteristics • Anatomic abnormalities, thyroid dz, hyperprolactinemia

Primary Amenorrhea …

• Breasts Absent/ Uterus Present – Gonadal Failure: • Most common cause of primary amenorrhea – Chromosomal disorders: • Two X chromosomes needed for ovarian development – Turner syndrome (45,X) – 46,X, abnormal X – Mosaicism (X/ XX; X/XX/XXX)

…

– Hypothalamic failure secondary to inadequate GnRH release • Neurotransmitter defect: not enough GnRH is secreted • Kallman syndrome: not enough GnRH is synthesized • Congenital anatomic defect in CNS • CNS neoplasm – Pituitary Failure • Isolated gonadotrophin insufficiency (thalassemia major, retinitis pigmentosa) • Pituitary neoplasia • Mumps, encephalitis • Newborn kernicterus • Prepubertal hypothyroidism

…

• Breast development/ Uterus absent – Androgen resistance (testicular feminization) • Genetically transmitted disorder • Absence of androgen receptor synthesis or action • XY karyotype; normally functioning male gonads, normal levels of testosterone • Lack of receptors on target organs so there is a lack of male differentiation of external and internal genitalia • Normal female external genitalia; no male nor female internal organs • Gonads need to be removed around age 18 due to their high malignant potential – Congenital absence of the uterus • Second most frequent cause of primary amenorrhea • Occurs in 1 in 4000-5000 female births • Also may have congenital kidney and cardiac defects

…

• Absent Breast and Uterine development • Rare • Male karyotype • Due to enzyme deficiencies • Breast development/ Uterus present – Second largest category (approx. 1/3) – Due to problems in: • Hypothalamus • Pituitary • Ovaries • Uterus • Diagnosis: • Labs: estradiol, FSH, progesterone, serum prolactin • Chromosomal testing • Imaging: cranial CT scan or MRI

Primary Amenorrhea (continued)

• Likely already diagnosed and worked up by the time they get to your office • Ask your clinic instructors if they have had any experience with this patient population • Cannot have menses without uterus!

Secondary Amenorrhea

Absence of menses for longer than 6-12 mo, in a woman who has menstruated previously • Secondary – Thyroid dz, hyperprolactinemia, anatomic causes (low weight, uterine adhesions), medications – Normal estrogen, normal FSH • Chronic anovulation, ovarian neoplasm, congenital adrenal hyperplasia, PCOS, Cushing’s dz, high stress – Low estrogen, normal FSH • Hypothalamic, functional, chronic dz, Addison’s dz, pituitary-hypothalamic lesions – Low estrogen, high FSH • Ovarian failure

Conventional Treatment of Amenorrhea

• Primary – Surgery and/or radiation for operable tumors and anatomic abnormalities – Cyclic estrogen/progestin • To initiate and maintain secondary sex characteristics • Osteoporosis protection • Secondary – Surgery for tumors – Psychotherapy for functional – Cyclic hormones for anovulation

CAM treatment of Amenorrhea

• Treat the underlying cause - Hypothyroid - Stress - Eating disorder - Genetic - Tumors - Systemic diseases

Premature Ovarian Failure

• Low estrogen, high FSH • Managing Estrogen deficiency symptoms – Osteoporosis – Surveillance- DEXA – Calcium/Magnesium/D/K/trace minerals – Exercise-weight bearing – Age related dose – OCP’s or bio-identical HRT – Libido, vaginal atrophy – may benefit from Testosterone – General mind/body support – Traditional emmenagogues – Mitchella repens, Achillea millefolium (yarrow), Vitex agnus castus (chaste tree), Caulophyllum (blue cohosh)

Polycystic Ovarian Syndrome (PCOS)

• Diagnosis – Symptoms • Oligo or amenorrhea • Obesity • Infertility • Metabolic syndrome • Hirsutism – Signs • Bilateral polycystic ovaries • Elevated LH and LH to FSH ratio • Elevated free testosterone and DHEAs • Abnormal gonadotrophin secretion • Glucose intolerance and elevated insulin

PCOS

• Is a diagnosis of exclusion • Must document the following: – Oligo or amenorrhea – Clinical evidence of hyperandrogenism, or biochemical evidence of hyperandrogenemia – Exclusion of other disorders that can cause menstrual irregularity and hyperandrogenism • May also exhibit: – Alopecia – Skin tags – Acanthosis nigra (brown skin patches) – Exhaustion – Lack of mental alertness – Decreased libido – Thyroid disorders – Anxiety/ depression

Conventional Txt of PCOS

• Metformin – helps promote ovulation and improve metabolic derangements • Diet and exercise for weight management and insulin resistance • OCP’s, GnRH agonists, spironolactone and other agents for hirsutism

CAM txt of PCOS



Strategies

 Treat insulin resistance, hyperinsulinemia  Address androgen excess problems   Provide hormone support Address fertility issues, obesity  Address long term amenorrhea complications   Osteoporosis Heart disease

CAM txt of PCOS (cont)

    Increase SHBG:  soy, flax, nettles, green tea Improve insulin resistance:  vitamin C, Cr  High protein, low Carbs Reduce testosterine activity  Saw palmetto (serenoa repens) - 5-alpha-reductase inhib Hormone support  Vitex  Progesterone  TCM you tell me…

More CAM txt for PCOS

• Reduce inflammation – Turmeric/

Curcuma longa

/ Yu Jin (cools blood, moves qi, breaks stasis) – Ginger • Balance cholesterol – HDL/LDL ratio better predictor of risk factors than total cholesterol – Krill oil and other omega-3 fatty acids • Decrease stress – Tai chi, qi gong, yoga, meditation. laughter

Risks of Amenorrhea

• Anovulatory amenorrhea is associated with increased risk of endometrial hyperplasia and cancer of the uterus due to an “unopposed estrogen state” – Progesterone is produced by corpus luteum, which is formed after ovulation • Majority of amenorrheic women are in hypo estrogen state – Later risk of osteoporosis, fractures – Rising lipid levels – Higher risk of cardiovascular disease

Review

• What is “normal menstruation”?

• What are some types of AUB?

• What’s the difference between primary and secondary amenorrhea?