Download Women`s Health - OB/gyn week 2

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 estrogenprogesterone 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
(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 hypoestrogen 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?