Instructor: Dr. Daoshing Ni, Yo San University chair of Doctoral program in Women’s Health and Reproductive Medicine
Approved for CEU/PDA by:
NCCAOM Details: Core Competencies: AOM/Biomedicine: 1 PDA
California Acupuncture Board Details: California Category 1: 1 CEU
Welcome back to our integrative Woman’s Health course. Today’s topic it’s going to be on the area of Amenorrhea. Amenorrhea is a situation of the loss of menstrual cycle.
A typical case study from Dr. Fang, He Qian is a 41 year old woman visited him with Amenorrhea for about half a year started after much stress from work.
Now she feels tired. She has dry throat. She couldn’t sleep at night with insomnia and the visit the first visited September 12 2005 and her last menstrual period is March 8th. So it’s about six months that she’s been missing her period. Her tongue appears to be pale and her pulse appears to be thin and slow thready and slow. And she had a pelvic exam as well as physical exam and it seems to be everything seems to be normal.
The definition of Amenorrhea area is lack of menstruation e specially over the age of 16.
When you from the very beginning – when you don’t even have menstruation to begin with – we call that primary Amenorrhea. Or that a person may already have periods but stopped for at least six months or more. We call that secondary Amenorrhea. As early as Huang Di Nei Jing, Su Wen has described how six emotional injuries can cause Amenorrhea and it is true frequently, clinically, when you see Amenorrhea, usually there is a trigger. Usually something precedes it that is very stressful for the body where there is a major loss or emotional stress or travel that’s hard on the body.
And so we need to also in diagnosis we need to make sure that we exclude the obvious lack of menstruation due to pregnancy, lactation postpartum and menopause. And also the situation where a patient has surgery or have lack of certain organs such as the ovaries or uterus can all cause this condition.
So looking at etiology of the pathogenesis there are several different reasons why this condition can occur.
For example when a woman who is 46 years old and has a XY Karyotype instead of Double X Karyotype. This is a situation where you could lose the period earlier. Second you could have anatomical abnormalities where for example the uterus is mal developed and the uterus is quite small and the knighting is not build up properly, for example. Or you can have HypothalamicDefects where the hypothalamus pituitary function becomes abnormal becomes deficient and there is not enough messenger hormones that come down the pipe to tell the ovaries to ovulate properly.
Some of these HypothalamicDefects can all create the problem as well. For example also hyper prolactin anemia sometimes can also stop the period. And in a situation of adenoma in the pituitary can cause prolactin hyper prolactin anemia situation.
Other things such as ovarian failure could have ovary glands that are completely shut down and stop cease to function properly.
Or you can have ovarian dysfunction where that there is massive amount of cysts whether functional or dysfunctional cysts which can also cause and interfere with the ovulation process and in turn obviously in turn interfere with menstruation process. Obesity in a situation of obesity the metabolic picture changes which the insulin level rises. There may be a situation of metabolic dysfunction. Going toward a diabetes situation sometimes can cause a woman to lose her period.
So a lot of time we want to look at a differentiation of internal structure to begin with. In the very beginning in developmental embryology internal structure such as a basic Mullerian or Wolffian duct systems which both develop into female or male internal organs.
Testis secrete androgens that stimulate the Wolffian ducts to develop into a vas deferens seminal vesicles as well as ejaculatory ducts. Testis also secrete Mullerian inhibiting substances that we commonly call MIF’s that costs money we have to retake this one.
We also need to look at differentiation of internal structures. Internal structures such as Mullerian or Wolffian duct systems. Basically these develop into female or male internal organs. In men testis secrete androgens that stimulate the Wolffian ducts to develop into a vas deferens, seminal vesicles and ejaculatory ducts. Testis also secrete Mullerian inhibiting substances – MIS – that cause Mullerian ducts to shrink and disappear in males. In females, the absence of androgen causes Mullerian ducts to develop into fallopian tubes, uterus, inner part of the vagina. And the Wolffian duct system degenerates in a woman’s body.
Then you have a situation where a woman with a 46, XY Karyotype. This is a situation where there is a sexually undifferentiated male fetal testis which secretes Mullerian inhibiting factor and testosterone. And this MIF, Mullerian inhibiting factor, promotes regression of all Mullerian structures: the uterine tube, as well as the uterus, and the upper two-thirds of the vagina. So in this situation you could have a situation where the ovary and the uterus gets completely shut down.
In looking at conventional western medicine etiology, Amenorrhea can be divided into anovulatory or ovulatory Amenorrhea.
Basically it is whether or not you ovulate or do not ovulate. So let’s take a look at AnovulatoryAmenorrhea first. This is a situation the body does not ovulate for whatever reason. The first reason could be a hypothalamic dysfuncton, particularlyfunctional hypothalamic anovulation, where the messengers of hormones, such as FSH and LH, is not present for example. Or at a very low level, where it doesn’t stimulate the ovaries to actually grow the follicles. And the second could be pituitary dysfunction where pituitary can create or grow tumors can grow adenomas, will cause secretion – hyper secretion – of prolactin for example. And that can shut down the other female sexual hormones.
The third could be a premature ovarian failure where the ovary just gets shut down and doesn’t ovulate at all. And a fourth is that it could be endocrine disorders that cause androgen excess, particularly what we see in polycystic ovarian syndrome.
So now let’s take a look at the Ovulatory Amenorrhea. A lot of time there a situation where you are ovulating, but you still don’t get your period. And a big part of this could be a congenital, congenital genital abnormalities.
First is cervical stenosis, where the cervix is completely shut tight, and that’s rare. Number two it could be an imperforate hymen where the hymend membrane is completely shut in the vagina. That’s number two. Number three. You may have a situation of a pseudohermaphroditism and that can also create this issue. And number four, you could have transverse vaginal septum which is actually a divider in the vagina where that it shuts everything, or retains everything. Number five. You could also have vaginal or uterine aplasia here which sometimes we call a Mullerian agenesis.
Or you could have a whole category of acquired uterine abnormalities. Where you could have Asherman syndrome which frequently occurs after a DNC situation or miscarriage situation.
You could also see a situation of endometrial tuberculosis which can also attack the uterus and cause the uterus to completely shut down. You could also see this in obstructive fibroids and polyps. Normally you still get your period with fibroid polyps but there are particularly unique situations where the fibroid is so obstructive, where the polyp is so obstructive, that the uterus just doesn’t have any chance to develop membranes.
And in Chinese medicine the etiology really has five major areas. One we believe is a form of qi and blood deficiency. Number two is kidney qi deficiency. And number three yin deficiency with blood dryness. And number four is qi stasis and blood stagnation. Number five is phlegm damp accumulation.
So let’s take a look at qi and blood deficiency first. This can be a situation where a woman have constitutional weakness where their qi and blood are already deficient to begin with. Or that they’ve been suffering from chronic or major illnesses. Because as we know when you have a chronic or major illness this can consume and damage qi and blood. In a constitutional weakness situation combined especially with excessive worrying. When a woman who worries a lot, thinks a lot, they sometimes could have irregular food intake, where their appetite is decreased, they’re not as hungry. And when that occurs they’re taking in of nutrients is much reduced, and that can cause spleen deficiency, which now they are unable to transform the food essence into energy for the body.
And when that occurs the nutrient of blood becomes deficient. And when that occurs you have both qi and nutritive blood deficiency in this situation.
Now when you have chronic or major illnesses this of course consumes the qi in blood as well. And when that occurs the body starts to take away the blood from the sea of blood, the Chong channel for example. And that sea of blood becomes empty. And when that’s empty you have a very good situation of qi and blood deficiency. So both constitutional weakness and chronic or major illnesses can be a big etiology for the Amenorrhea situation.
The next one is Kidney Qi deficiency. Kidney Qi deficiency can occur because of constitutional kidney deficiency. This is where the essence, both essence and qi is deficient. And where the Tian Gui is lacking where the Tian Gui or secreetion of Tian Gui is weak and that is a kidney qi deficiency situation causing the loss of period. Or you could have excessive labor, miscarriages, abortions, sexually activities, which can cause damage to the kidney qi. And that in turn can cause damage to Chong and Ren function. Chong and Ren function. And when that occurs, when you have a dysfunction of Chong and Ren, then you’re going to start losing your period. And hence kidney qi deficiency can cause the Amenorrhea situation.
The third etiology is Yin Deficiency with Blood Dryness. You could have a case of constitutional yin and blood deficiency where there may be blood loss which can cause damage to the yin and the blood. And that in turn can see the rise of deficient heat fire dry condition and where the fire can dry up the water element. So here you have a loss of menstruation because of it.
Or you could have chronic or major illnesses where there’s damage to the nutritive in the yin situation where it consumes the blood, causing the blood to be dry. And this again creates the rising of deficient heat and the fire dries up the water situation.
Number four Qi Stasis and Blood Stagnation can be your etiology as well. Especially when there is a chronic or typical liver stasis. For example, anger, resentment. In this situation this qi stasis can cause blood stagnation. And as we know when it’s accumulated long enough the stagnant blood can start to block channels. When it blocks channels, qi and blood, and blood stagnation becomes the diagnosis, and then the blood flow ceases.
Or you could be having a cold invasion during menstruation. When there is a cold pathogen invasion it causes contracture of the blood due to cold. And when that occurs, the stagnancy occurs in the blocking of the Chong and Ren occurs.
And this in turn creates this etiology of qi stasis and bood stagnation causing Amenorrhea.
The next one is phlegm damp. Well, when there is a typical chronic spleen deficiency unable to transform food, it’s also unable to transform damp. So when that, when that situation occurrs dampness will accumulate and it will produce phlegm.
So that’s one situation and the other situation. It could be the person is typically a phlegm damp constitution. So in both of these situations phlegm dmp blocks that’s Chong and Ren channels. Or formation of phlegm nodules causing blockages of the blood flow. For example you might be somebody who has very large uterine fibroids or polyps two due to, and there might be a phlegm damp situation. Lacking, for example cause the stoppage of the menstruation.
Now let’s take a look at pathology. The location of this pathology is in Chong and Ren channels. In Western medicine, the location of this pathology could be in different places. Could be in the uterus could be in the ovaries. Could be a pituitary hypothalamus situation. Could be in many different places.
Now there are two main scenarios. One: there there’s no blood to bleed. So where there is a deficiency in blood. Number two is that the blood is blocked so we cannot bleed. Or a combination. So you have a situation of deficiency and the excess condition and you could also have both combined together. So we need to learn how to differentiate between deficiency excess, heat and cold. But mostly deficient condition trumps out the excess condition. You’ll see a lot more deficiency condition in Amenorrhea compared to excess conditions.
So clinically to arrive at the diagnosis. There’s several examinations that we deploy. First of all you can do a BBT: basal body temperature. This is where you can see whether or not the patient is actually ovulating or not. Number two you can do a vaginal culture and take a look at if there’s any bacteria. Take a look at if the hormone level is sufficient to create a period. Number three you can also use an ultrasound to actually measure the actual thickness of the uterine lining. To actually look at the ovarian activity, see if the ovaries are functioning at all.So that’s ultrasound.
Or if you want to be more precise. You can always go to an MRI situation where you can actually be more precise in a measurement of follicles and the lining as well. Or you can do a hysteroscopy, where through the vagina you can send up a skope and take a look at the uterine formation, the contour of the uterus, and see if there’s any blockages obstructions, or uterine fibroids, polyp situations. Or you can do a diagnostic D&C, where you can go in and scrape the lining, and try to stimulate the uterine lining to build up again. and then can kind of “jumpstart” this process. Or you can also take the tests of serum FSH, E2, prolactin the thyroid stimulating hormone or testosterone.
These are some hormones I will give you some guidance on what to do. And then, not the least, take a look at the mother’s Karyotype type. Or take a look at a woman’s Karyotype. If the Karyotype is XY, then you know this is going to be an issue.
So in qi and blood deficiency we can see symptoms of missing period, or delayed period, usually scanty pale thin flow, combined with fatigue, decreased libido, vaginal dryness or atrophy.
The tongue is usually pale and the pulse is usually slow, or weak. And so this is a typical Chong and Ren Qi and Blood deficiency, sea of blood is empty. So we want to tonify qi, and we’re going to try to regulate the blood. OK.
So the formula that we use a lot in this situation is Ren Shen Yang Rong Tang. Ren Shen Yang Rong Tang is typical, very nice, very strong strengthening qi and blood formula. So it’s a combination of Ren Shen,HuangQi,BaiZhu,FuLing, ChePi, GanCao, ShuDi, Dang Gui,BaiShao,WuWeiZi, Yuan Zhi, Rou Gui.
And with this as a base you can add Zi He Che, LuJiao Shuang, Lu Rongfor Jing deficiency. So you can add some these additional herbs into the mix.
The next etiology and syndrome is a Kidney Qi Deficiency. We tend to see this in primary Amenorrhea or a delayed menarche situation. This can be a gradual onset of amenorrhea. There is fatigue, is poor development of physique, poor secondary sex characteristics development, poor development. You can see tongue is pale. The coating is dark coating, with thin white, and the pulse is deep and thready, deep and thready. So in this situation we want to tonify kidney, benefit qi and regulate Chong and Ren.
So the formulation that we have basically selected is modified. Modified Cong Rong TuSi Zi Tang. Modified Cong Rong Tu Si Zi Tang. OK. This is a very famous formula that comes from a wonderful professor. Doctor Dr Zhuo, Yu Nong from Sichuan province. And it’s a combination of Rou Cong Rong, Tu Si Zi, Fu Pen Zi, Gou Qi Zi, Sang Ji Sheng, Shu Di, Dang Gui, Ai Ye. And you should add Zi He Che, and Xian Ling Pi into the mix. OK. A wonderful formula that’s used for kidney qi deficiency amenorrhe.
Now let’s go to Yin Deficiency Blood Dryness. This is a situation where there’s Amenorrhea with delayed menstruation. There’s prior history with scanty red thick flow. Gradual onset set of Amenorrhea. Tongue is red, coating is lacking and the pulse is thin and rapid. So here we need to nourish yin, clear the heat and regulate Chong and Ren. So the formula that we have selected is Yi Yin Jian. Yi Yin Jian. Yi Yin Jian is a combination of Sheng Di, Bai Shao, Mai Dong, Dan Shen, Shu Di, Niu Xi, and Gan Cao. OK so this is the herb that’s used for yin deficiency and blood dryness.
So let’s go to the next one. Qi Stasis Blood Stagnation. This is a situation you’re going to be seen losing a period. The tongue is purple dark with stagnancy spots, pulse is deep wiry and sluggish. So we need to regulate qi, activate blood to get rid of stagnancy, to regulate menstruation. So the formula we use is a typical formula of blood activating herb. It’s Xue Fu Zhu Yu Tang. Xue Fu Zhu Yu Tang is the five Zhu Yu Tang, one of the Zhu Yu Tang that focuses on the abdomen area. This is a combination of, a combination of Dang Gui, Sheng Di, Tao Ren, Hong Hua, Zhi Ke, Chi Shao, Chai Hu, Gan Cao, Jie Geng, Chuan Xiong, and Niu Xi.
So the next etiology is Phlegm Damp Blockage. This is a situation you are losing your period. There is a prior history of delayed menstruation with scanty flow, pale sticky flow. There’s a gradual onset to kack of a period and losing period. There’s also some gradual onset of weight gain. Greasy coding, and the pulse tends to be slippery. This is a situational Phlegm Damp blocking of Chong Ren. So the treatment principle would be to strengthen spleen dry, up the dampness, and dissolve phlegm. So the formula that we would use is a combination of Si Jun Zi Tang plus Cang Fu Dao Tan Tang as well as Dang Gui into the mix.
So this is a combination of Dang Shen, Fu Ling, Bai Zhu, Fu Ling plus Cang Zhu, Xiang Fu, Ban Xia, Chen Pi, Dan Nan Xin, and you have Sheng Jiang, Shen Qu, Dang Gui, and Chuan Xiong.
So coming back to this case of Dr. Fang, He Qian. 41 years old, first visit is September 12 2005. Amenorrhea for half year, started after much stress with work. Now feeling tired, dry throat, insomnia. Last period is March 8th. And the tongue is pale pulse is thin and slow. And had a physical exam. Everything, everything seems to be normal.
So this patient has been diagnosed of having Liver Stasis Spleen Deficiency.
So the treatment principle is to Regulate Liver and Spleen, Tonify Qi and Nourish Blood. And so he uses the Modified He Gan Tang. Modifying He Gan Tang. He Gan Tang is an experiential formula of Dr. Fang. And the composition is Dang Gui, Bai Shao , Dang Shen, Chai Hu, Fu Ling, Xiang Fu, Bai Zhu, Su Geng, Da Zao, Bo He, Zhi Gan Cao. And the formula that was used in this particular patient was this formula and of Dang Gui, Bai Shao, Dang Shen, Chai Hu, Fu Ling, Xiang Fu , Bai Zhu. And Su Geng he did not use in this situation, Da Zao, Bo He, Zhi Gan Cao, and he also got rid of Sheng Jian. In this situation he added Sheng Di, and Ze Lan , and Dan Shen. Prescribed about ten bags for the patient, she would be to drink for two days, stop one day. Drink two days, stop one day. A very unique way of drinking. A unique way of decoction in taking this medicine.
So on the second visit which is October 24 2005. The patient comes back and has reported that her energy has improved – but no period yet. There is some pelvic discomfort, which we like, with increased vaginal discharge. The bowel movement is normal. Tongue is still pale, and the pulse is even and slow.
So Dr. Fang decided, we’ll stay with the same previous formula. But we’re going to do a little tweaking. So he uses the same previous formula. So now he adds Shan Zhu Yu, six grams, he adds Mai Dong, 10 grams and about 10 packs of tea to drink every other day.
And the next visit is basically two months later. December 15 2005 which is the third visit. The period actually returned on December 11. Absolutely great. Though, scanty flow for two days. Dark color, pulse even and slow, tongue is pale. Now this is a Qi and Blood Deficiency therefore the menstrual bleeding is light. So we need to tonify Qi and Blood more in this situation.
So he decided to use a modified Zi Bu Tang. Modified Zi Bu Tang. Again this is an experiential formula for Dr. Fang.
So Zi Bu Tang. It’s a composition of Dang Shen, Bai Zhu, Fu Ling, Zhi Gan Cao, Shu Di, Bai Shao, Dang Gui, Gui Zhi, Chen Pi, Mu Xiang, and Da Zao out into the mix. So this is Zi Bu Tang formula it’s a very nice formula to be used to tonify blood to tonify qi at the same time.
So the formula that is used in this particular situation it’s Dang Shen, Bai Zhu, Fu Ling , Zhi Gan Cao, Shu Di, Bai Shao, Dang Gui, Gui Zhi, Chen Pi, Mu Xiang, Da Zao. And are we going to add extra a few extra herbs adding Shu Di, Gou QI Zi, Mai Dong , and Zhi Juang Qi , 12 bags, and drink every other day. Drink every other day. Okay.
So Dr. Fang, He Qian was born in 1923 and he was one of the chief physicians in Chao Yang hospital in Beijing. Famous for difficult cases of pulmonary heart diseases and hepatic disorders. He is a student of one, He is a student of one of the last imperial physicians. Dr. Zhao, Yun Qing. Dr. Zhao, Yun Qing.
So as a few last words I want to leave with you is that the cause, we need to really focus on the liver, spleen, and kidney. These are the three organs that really are at the cause of this Amenorrhea situation and the leader of it is always a kidney deficiency.
And so currently the there are three types of approaches of treatment to treat this. One. It’s just to do a syndrome treatment – which is what we just did. Or a second we’re going to do phasic treatment. Take a look at what phases the patients are in. And the third is that you can do both integrative Western medicine where you can bring some medication and as well as a combination of TCM treatments. And I think the third part, it’s going to work so much better for people who have been missing their period for quite a while. For quite a while.
So thank you so much for the opportunity for me to share this knowledge with you and I hope this has been enjoyable for you and looking forward to seeing you next time. Take good care.