Women’s Health - OB/gynweek 2

Abnormal Uterine Bleeding

Amy Love, ND

Lecture Overview

• Types of AUB, diagnosis, treatment

• Common causes, management

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

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: 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 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

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 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

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?