women’s health - ob/gyn week 2 abnormal uterine bleeding amy love, nd
TRANSCRIPT
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Women’s Health - OB/gynweek 2
Abnormal Uterine Bleeding
Amy Love, ND
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Lecture Overview
• Types of AUB, diagnosis, treatment
• Common causes, management
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Abnormal Uterine BleedingAbnormal 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
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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
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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
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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
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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)
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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
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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
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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)
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• 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
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• 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
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• 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
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• 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
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(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
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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
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Primary AmenorrheaAbsence 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
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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)
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…– 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
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…• 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
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…• 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
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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!
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Secondary AmenorrheaAbsence 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
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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
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CAM treatment of Amenorrhea
• Treat the underlying cause
- Hypothyroid
- Stress
- Eating disorder
- Genetic
- Tumors
- Systemic diseases
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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)
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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
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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
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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
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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
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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…
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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
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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
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Review• What is “normal menstruation”?
• What are some types of AUB?
• What’s the difference between primary and secondary amenorrhea?