Lecture 3 September 13th-amenorrhea

1MEN’S AND WOMEN’S HEALTH – SEPTEMBER 6TH, 2007 AMENORRHEA LECTURE 3 Amenorrhea: the canary in the coalmine, the engine light on the dashboard. It is an important sign that may be the symptom of other pathologies: hormonal imbalance, pituitary tumour, anorexia. Could be pregnancy too. PRIMARY AMENORRHEA Outflow Tract Disorders Mullerian Anomalies: • Transverse vaginal septum: a “wall” across the vagina • Agenesis: no vagina, or atresia, partial development. Could be blind sac • Imperforate hymen: most females have a hole in the hymen that ruptures with intercourse, horseback-riding Cryptomenorrhea: • Have monthly symptoms of getting a period, but there is no period. • May see signs on physical examination (ie. Not speculum, bimanual exam.) • In cryptomenorrhea, menses produced, but can’t leave the body due to imperforate hymen. Can distend vagina (hematocolpos), uterus (hematometra), enter abdominal cavity through fallopian tubes (hematosalpinx). Can cause scarring and infertility. Disorders of the ovary: Turner’s Syndrome: • Streak ovaries: vestigial ovaries that are underdeveloped • Physical symptoms may be subtle! • Cubitus valgus, at rest, forearms appear slightly abducted Resistant Ovary Syndrome • Ovaries are resistant to FSH, LH. Not producing progesterone, estrogen in response to pituitary hormones. • Will see growth problems, secondary sexual characteristics. Testicular Feminization Syndrome Genetically male, “look like women” Disorders of the Anterior Pituitary Pituitary Tumour: • Have usually had a period, and then it stops, although kids do get tumours too. Congenital adrenal hyperplasia: • No period, ever. • 21 hydroxylase deficiency: in progesterone pathway, some progesterone goes to Aldosterone and cortisol via 21hydroxylase. In 21 hydroxylase deficiency, all progesterone becomes adrenal androgens (testosterone), bypassing the other parts of the pathway. Disorders of the CNS (Hypothalamus) DeMorsier Syndrome: • Can’t smell or taste. This may not bring patient in. Lack of senses of smell/taste, with amenorrhea, think of this syndrome. Craniopharyngioma: • Tumour between hypothalamus and pituitary (anterior). Benign.

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Low body weight, exercise-induced amenorrhea and stress induced amenorrhea: • Drop in body weight for any reason (exercise, anorexia, cancer) could cause this. If body is below certain weight, can’t support fetus, menses, ovulation suppressed. • Stress response: you won’t get pregnant while running away from the sabre-toothed tiger of the fight/flight response. • Trying to slow people down: major challenge. • • •

Under stress? Hypothalamic suppression via cortisol. Short luteal phase: your cycles are disrupted. Might end up with more periods… Can help patient assess this with basal body temperature measurement (track morning body temperature before getting out of bed). Will see spike at ovulation. Be careful when you put patients on diets. They may end up restricting their food intake as a result.

MANDATORY CLASS NEXT THURSDAY: BRING GYNECOLOGICAL MANUAL, AND WOMEN’S ABUSE PROTOCOL • • • • •

22% body fat needed to sustain menstruation. 17% needed to initiate menstruation. Sustaining menstruation: basic marker of health in a woman. Sign of returning menstruation, sign of health returning. Loss of 10-15% drop in weight is loss of 1/3 body fat, will result in drop below 22% line. Stress and exercise AND loss in % body fat are independent factors that suppress the hypothalamus. Excess cortisol directly suppresses GnRH. Cortisol is general signal to hypothalamus to shut down, sufficiently high levels of cortisol can suppress all hypothalamic hormones SECONDARY AMENORRHEA

These are women that have had an initial period, but at some point, it has stopped. Disorders of the CNS Low body weight (see above) Medications: • Can increase prolactin levels (block dopamine, prevents prolactin secretion from being inhibited. This can cause prolactin levels to rise) • BCP: Estrogen. Fools body into thinking it is pregnant. Not a “real period”, shedding a lining, but it is not a fertile lining, couldn’t support a fetus. Period is “breakthrough bleeding” from estrogen withdrawal. Will have irregular cycles after getting off pill. Taking exogenous estrogen will interrupt the whole cascade. Estrogen inhibits LH, FSH, GnRH. • Discussion about pills that prevent menstruation altogether. Athletes and others that take pill continuously. Is this healthy? Function of menstruation? • MAO inhibitors, antihypertensives, psychotropic agents, tranquilizers, anti-depressants, narcotics, marijuana (blocks GnRh) Infections: • Post inflammatory encephalitis/meningitis: headaches, dizziness, fever Disorders of the Anterior Pituitary Pituitary Tumours: • Consider if you can express milk from nipple • Are they on Synthroid? Overmedication might result in symptoms of hyperthyroidism, DDX tumour. Hypothyroidism • Hypothyroidism pocket in Kitchener-Waterloo Disorders of the Ovary PCOS: • Patients are unhappy because they have acne, facial hair, not ovulating, not losing weight • Dx: ultrasound looking for cysts. Don’t always have cysts on ovaries. • Will see this in practice if we treat women of reproductive age. • Infertility is a big reason to bring patients in. • Increased risk of breast cancer due to unopposed estrogen. MEN’S AND WOMEN’S HEALTH SEPTEMBER 13TH 2007 – PAGE 2

Chemotherapy: • Chemo may result in gonadal failure. Some women will harvest eggs and store them before chemo. Premature ovarian failure: • Links with other auto-immune disorders Asherman’s syndrome: • Adhesions due to surgical scarring. Hormones are fine, but walls of endometrium are compromised. • Will see symptoms following surgery TREATMENT OF AMENORRHEA Real need for NDs to understand endocrine system thoroughly. Many presentations have their source here. Nutrition • Cholesterol: precursor to steroid hormones. Have to ensure that they have sufficient levels to produce hormones they need. • Calcium and Vitamin D required to produce oocytes • Elevated plasma carotenes could indicate eating disorder. Botanicals: • MANY that can help, we will go through some that are general suggestions. Solution will depend on patient. • Vitex: Increases LH production. • Most therapies need to be used over a period of time (3-4 months) to assess whether it is working. • Cimicifuga: often “prescribed” to women at health-food stores. May not be appropriate. • Hops: estrogenic properties. Drink too much beer, get breasts! TCM: • Amenorrhea is due to excess or deficiency. 2 general problems. • Spleen deficiency: Spleen makes blood. If Spleen Qi is deficient, you aren’t making blood. We all have some degree of Spleen Qi deficiency. • Excess Liver Qi, Liver Qi stagnation. If there is stagnation, Liver is not moving the blood. Bloating, frustration, anger, crampy, achy, PMS, temporal headaches, red eyes, purple tongue, scalloped tongue (because LV invades SP) • Book: Obstetrics and Gynecology in Chinese Medicine (Machioccia) • Read handout on E-college. Condition-specific treatment notes: Hypergonadotropic hypogonadism (eg. Premature ovarian failure): • If there is a serious deficiency, we may not be able to impact it with natural medicine (eg. Pharmaceuticals) • Can distinguish estrogen dominance from progesterone dominance via blood test. Different clinical presentation too: Dr. Hillier will post something on e-college for us. • Chemo causes blood stagnation. • Example protocol: there are many approaches to this presentation. • Anorexia: not a disorder related to food. Control at root of condition. Normogonadotropic anovulation: • PCOS: start by treating insulin resistance! Address stress which may be compounding the problem. • NOTE: measurements for protein and carbs should be GRAMS • PCOS: give healthy source of EFA: will help with food cravings. Exercise: get outside! Sunlight is important for sleep/wake cycle, can help regulate other hormones. • Address glucose dysregulation. Treat as you would diabetics: chromium

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