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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)

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Women s health ob gyn week 2

Women’s Health - OB/gynweek 2

Abnormal Uterine Bleeding

Amy Love, ND

Lecture overview
Lecture Overview

  • Types of AUB, diagnosis, treatment

  • Common causes, management

Abnormal uterine bleeding
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
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
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
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
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
    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
    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 cont1
    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)

    Women s health ob gyn week 2

    • 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

    Women s health ob gyn week 2

    • 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

    Women s health ob gyn week 2

    • 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

    Women s health ob gyn week 2

    • 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
    (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


    • 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
    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 amenorrhea1
    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)

    Women s health ob gyn week 2

    • 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

    Women s health ob gyn week 2

    • 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

    Women s health ob gyn week 2

    • 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
    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
    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
    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
    CAM treatment of Amenorrhea

    • Treat the underlying cause

      - Hypothyroid

      - Stress

      - Eating disorder

      - Genetic

      - Tumors

      - Systemic diseases

    Premature ovarian failure
    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
    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

    Women s health ob gyn week 2

    • 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
    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
    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
    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
    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
    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


    • What is “normal menstruation”?

    • What are some types of AUB?

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