Women’s Health - OB/gyn week 2

1. Women’s Health - OB/gynweek 2 Abnormal Uterine Bleeding Amy Love, ND

2. Lecture Overview • Types of AUB, diagnosis, treatment • Common causes, management

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. Botanical Considerations • Chaste tree/ Vitex agnus castus: balances estrogen-progesterone ratio to normalize and regulate cycle • Ginger/ Zingiber officinale: anti-inflamatory (inhibits prostaglandin and leukotriene synth), helps reduce menstrual flow • 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

15. (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

16. 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

17. 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

18. 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)

19. … • 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

20. … • 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

21. … • 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

22. 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!

23. 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

24. 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

25. CAM treatment of Amenorrhea • Treat the underlying cause - Hypothyroid - Stress - Eating disorder - Genetic - Tumors - Systemic diseases

26. 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)

27. 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

28. 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

29. 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

30. 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

31. 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…

32. 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

33. 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

34. Review • What is “normal menstruation”? • What are some types of AUB? • What’s the difference between primary and secondary amenorrhea?