Welcome back to our integrated 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. OK. OK. All right let’s take a break for a
moment I think. Clem them. OK. Let’s continue to need to take
a break. I thought I might need to drink a lot of. Regional face so I can see your glasses. All right. Let’s go to Slide 22. On the top
3 2 1 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 Dr. Fang has diagnosed this patient as
having Liver Stasis, Spleen Deficiency. And this is what he suggests: that let us regulate
liver and spleen. Tonify Qi and Nourish Blood for this patient. So he used a modified formula
called Modified He Gan Tang. He Gan Tang. If you look at He Gan Tang carefully it’s
a composition of Dang Gui, Bai Shao , Dang Shen, Chai Hu, Fu Ling, Xiang Fu, Bai Zhu,
Su Geng, Da Zao, um, Bo He, Zhi Gan Cao. These are some the herbs that’s in this formula.
And the formulation used on this patient was using that base, and add Sheng Di and Shu
Di as well so Ze Lan and Dan Shen into the mix and that’s it for now. Oh the next one case they apologize. At a
top of twenty seven at the top of twenty seven. No no I’m sorry. I’m sorry. Top of twenty eight twenty not top of twenty
six cover twenty six was the last slide. You said you said that’s it. Oh no. OK let’s let’s go back from the beginning.
Well just give me the last. Topic I think is. Where. I think to Heaven an law school I’m in this
line. OK here we go. OK so this is slow snow. Twenty four staff on the top of state 24. 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.