Amenorrhea (bi jing or jing bi)

Course: Acupuncture Treatment of Disease 1 Date: December 1, 2008 Class #: 10 Amenorrhea and Dysmenorrhea Final next week, week 11, NOT week 12! Review ALL case studies and m/c options for final! I need the past case studies I missed. Paper due end of 12 th week. Biomedical perspective Amenorrhea (bi jing or jing bi) The definition of amenorrhea is The absence of menstrual periods. This refers to an absence of periods after the age of puberty, and not during pregnancy, breastfeeding or post-menopause. Amenorrhea can be classified 2 ways: 1. Primary Amenorrhea This is a woman at least 16 years old or older who have never had a 1 st period. Actually, the Nei Jing defines menstruation as typically beginning around the age of 14. Kind of makes sense women s cycles are counted in 7 year increments, so 7x2 = 14 years of age. It should be noted that today, likely because of diet and hormones in the food the average onset of menstruation is 12 13 years of age. That said, for the purposes of the test, it s 16 years of age, which is why I highlighted it above. Dr. Luo said this could be a true/false on the final! The Kidney, it should be noted, is in charge of bringing the first period even though the Liver is then the most important organ on the block in this respect thereafter. 2. Secondary Amenorrhea Secondary amenorrhea applies to women who have had periods already, but the period has stopped for over 3 months. This cessation of the period is a secondary cause due to another disease or special reason. a. Physiological Amenorrhea This encompasses pregnancy and menopause b. Pathological Amenorrhea Always check to see if a woman is pregnant in cases of amenorrhea! i. Accident (Blood stasis in TCM) can cause secondary pathological amenorrhea. ii. Excess weight can also cause this type of amenorrhea iii. An extreme deficiency of body fat/weight (i.e., anorexia nervosa and anorexia athletica), can also result in secondary pathological amenorrhea. Page 1 of 16 1

Other biomedical etiologies for secondary pathological amenorrhea Hypothalamus Pituitary Ovaries Fallopian tubes Uterus Thyroid Adrenal Pancreas Stress Anorexia nervosa Environmental change The highlighted ones are the most likely suspects. Hypothalamus produces GnRH (gonadotropin-releasing hormone) which is needed to begin ovulation cycle. Pituaitary Releases lutenizing hormong and follicle stimulating hormone to promote the development of ovarian follicle containing an egg. Ovaries: Promotes production of estrogen, causing a midcycle surge in LH, stimulating ovulation. Follicle ruptures and an egg is released. Thyroid organ affects menstrual cycle due to the hypothalamus, pituitary connection feedback loop with these glands. Stress can affect glandular production. Treatment depends upon the cause tumor, thyroid, diabetes, etc. Treated with progestin and estrogen. Always rule out preggers first! Page 2 of 16 2

TCM Perspective Menstruation is the monthly accumulation and release of energy. Amenorrhea then is the disruption of the regularity of this bioclock. This bioclock cycle works like this: Period A period is typically 5 7 days long. Blood is lost due to the Qi which builds up between cycles. Heavy bleeding on the other hand is due to 1) Excess Qi causing fire or 2) a Qi xu which then cannot hold the blood and thus heavy bleeding. Bioclock Therapy/Regulation Regulate Qi and Blood Post Period For approximately 7 days after the period you will see signs of blood deficiency. Bioclock Therapy/Regulation Nourish Blood Between Cycle 7 to 10 days after Post Period or 14-17 days after end of period. This is considered to be the between cycle phase in which there is accumulation of blood, yin, and essence. This is a period of conservation and includes ovulation. Bioclock Therapy/Regulation Nourish essence and Yin to support accumulation of Essence and Yin at this time of the month. Before Period One week or so before the start of the next period. The Qi rises as does the Yang. If there is an excess of Qi and Yang one will experience PMS symptoms (Liver). Yang rising may also be tied to migraines at this time in the monthly cycle. Bioclock Therapy/Regulation Soothe the Liver Qi, Protect the Yang, Balance Yin and Yang. Though blood is the most obvious and visible aspect of the monthly period, Qi is the most important component. Work on the Qi before menses, Blood and Qi during menses, and Blood after menses. There are 3 blood chambers involved in menstruation: Page 3 of 16 3

Liver This is the primary congenital organ for women (kidney is primary for men). The Liver stores and holds blood and is in charge of voulation, separation, and discharge of eggs. The Liver also regulates energy and adjusts the endocrine system and the bioclock. Thus, if there is a stagnation of Liver Qi a woman is prone to cysts, fibroids, and blockage of the fallopian tubes. Hormone disorders can be in 3 exciting flavors: o Shi/Excess type Manifests in acne and migraines o Xu/Deficient type Address the Kidney in cases of deficiency o A combination of excess/shi and deficiency/xu Treat both the Liver and Kidney in this case. In western medicine it is also the Liver which helps to regulate the hormone levels. You thus regulate the Liver in order to have a healthy harmonized flow of hormones and thus of the monthly cycle. Chong The Chong Channel is the Sea of the Blood. It originates from uterus just as the Du and Ren channels do. Uterus The uterus is the extraordinary organ from which Chong, Du and Ren emerges. Etiologies: Congenital essence xu This is an essence deficiency, a disorder of the kidney. This is the etiology for primary or secondary amenorrhea. This might be a genetic disorder, absolute lack of uterus, etc. Tian gui is the Chinese phrase meaning hormone system. The Tian gui is in charge of o Growth and maturation of the reproductive system o First menstruation, which per the Nei jing occurs at age 14 (but, again for the test, say 16). Menopause and the cessation of menstruation occurs 2 years after the tian gui stops, which the Nei Jing says is age 49. Thus menstruation stops at around age 51. Emotional disorder This is causes secondary amenorrhea and is the result of stress and/or Liver Qi Stagnation/Yu leading to Liver Fire. This is a Qi level functional disorder further resulting in Blood stasis, a blood level organic disorder. To treat any endocrine disorder: o Excess disorder: Use Liver points plus the basic points detailed in the Differential Diagnosis and Treatment section of this document or of Dr. Luo s handout. o Deficiency disorder: Use Kidney points plus the aforementioned basic points. Page 4 of 16 4

Irregular diet This too causes secondary amenorrhea. An irregular diet leads to dampness then to phlegm retention which blocks the Chong meridian so that Blood cannot move. This causes Blood Xu or Damp-Phlegm. Likewise, malnutrition can cause secondary amenorrhea due to deficiency. Accident Trauma which may damage the Chong meridian causing secondary ameorrhea. Overwork Overwork leads to Qi and Blood deficiency and organ Xu and Yin xu, mostly Kidney. Invasion of cold Cold contracts the meridians and blocks the channels and causes 2ndary amenorrhea. Women should be exposed to wind or cold during menstruation. Wind and cold will directly attack the Kidney and Uterus (Shaoyin channel). Page 5 of 16 5

Differential Diagnoses and Treatments Differentials can be either of excess or due to deficiency. Excess reasons: qi stagnation and blood stasis, cold accumulation, damp/phlegm retention. Deficient reasons can be Qi/blood xu and Kidney xu. I ll say it again, because it s emphasized over and over: Always remember to verify that any patient who comes to you is not pregnant! Here s a fun chart, courtesy of Dr. Wu and Fuyiu Yip detailing the difference between amenorrhea and pregnancy. Symptoms Pulse Gynec Exam Shows: Amenorrhea Chronic and gradual onset. Irregular cycles occur for a long time and with disorder. Symptoms might be similar to menopause. Dysfuncitons may include: o Scanty flow o Heavy flow o Dysmenorrhea followed by amenorrhea No obvious gynecological changes Abdominal cramping Wiry Liver Qi Stagnation/Yu Hesitant/Choppy Liver Blood Yu Deep, weak, thin Blood Xu No changes Pregnancy Sudden onset. Periods just stop suddenly and there may be early signs of pregnancy: o Fatigue o Nausea, vomiting, morning sickness o Craving for sweet/sour foods, etc. History of regular menstruation Gynecological changes such as darkened nipples. No cramping Slippery Note: after 5 months you may be able to tell if it s a boy or girl. A strong floating pulse on the right is a girl, strong on the left is a boy. Best felt at 5-7am. Also good to know the history of your patient s pulses and whether they are usually stronger on one side than other. Obvious changes: o Darker nipple color o Breast distention o Darker lips Pregnancy Test Negative Positive. You must confirm this with multiple tests! Don t promote Blood circulation nor move stasis if you even think your patient is pregnant! Page 6 of 16 6

Basic points Notes on points listed above: Kidney 8 Very important (maybe most important) point for amenorrhea. This point is especially for menses as well as endocrine diseases. Also used for infertility. Note, not KI 10. This is the He Sea point and nourishes Ki and Ki yin. If you see a question re KI 10 or KI 8 for amenorrhea, pick KI 8! Ren 5 Can induce menses and do not needle this point during menses! Also note that deep needling Ren 5 may damage the Chong channel and create a state of secondary amenorrhea! Needle 0.5 1 cun for Ren 5, though you can needle Ren 4 and 6 to a depth of between ½ - 2 cun. Ren 6 Sea of Qi. Good for Qi stagnation and Qi deficiencies. Zigong Uterus point or Fetal Palace. 3 cun lateral to Ren 3. ST 28 Treats water passage problems and promotes Qi flow. It is also called the Gate of the Uterus on the left side and Children s door on the right. Use it for reproductive problems. Sp 6 Nourishes the 3 yin channels of the legs, treating Yin, Blood, dampness and reproductive problems. Never use it with LI-4 during pregnancy, as it is said to cause abortion of the fetus. Lots more stuff than this in Zheng Zeng s notes. Click here and scroll to page 6 if you care to read about it. You may also need to use some of the 8 Confluent Points (also referred to as Completion Points ). Ren channel is opened by LU 7, for instance, while SP 4 is used to open the Chong channel. For deficiencies, use these points alone to tonify Ren and Chong. Page 7 of 16 7

For excesses, however, combine them: LU 7 + KI 6. KI 6 opens the Yin Qiao channel combine the 2 together for throat, lung, chest and for excess type amenorrhea. SP 4 and PC 6. PC 6 opens the Yin Wei vessel and treats Heart, Chest, and Stomach disorders. The combination of the two opens the Chong and the Yin Wei, treating excess type amenorrhea. Note the # s on the Basic Points chart in the Xu and Excess sections. This refers to a cross insertion technique. You begin on the right side since as Dr. Wu says, Women are always right. 1st Right 2nd Left 3rd Right 4th Left Open Ren LU 7 KI 6 LU 7 KI 6 Open Chong SP 4 PC 6 SP 4 PC 6 (To open the Ren or Chong for men you can also use the cross insertion technique, just begin on the left instead of on the right.) Kidney deficiency Symptoms in patients over 16 or 18 years old will be amenorrhea plus primarily Ki Xu symptoms. Look for lower back and knee weakness and pain, heel pain, mental and intelligence deficiencies, tinnitus, etc. In the case of KI yin xu, look for the yin xu signs. If Qi xu, look for the back/knee problems, weakness. Very special for Kidney essence: GB 30, 39. GB 39 is the confluent of marrow. Open the Ren channel to tonify. Can also use Sp 4 to nourish. This is a deficiency type, so use the Ren and Chong opening points without their combinations. Page 8 of 16 8

Qi and Blood Deficiency Note the differences in Qi and Blood xu above. Tonify the Qi and Blood points in this case. Ren 6, ST 36, SP 6. Again, be sure you have ruled out preggers! UB 20/21 = nourish middle jiao so more qi/blood generated. Qi Stagnation, Blood Stasis Blood stasis question on the final! If stasis affecting skin, will be darker and scaly. Look for T/F questions on the final. Scaly skin and dark = blood stasis/stagnation. Might also be scaly dry. Patient might also have pain in lower ab (most likely) and will be fixed, worse at night. Pulse should be choppy/hesitant/uneven. SP 10 and UB 17 are the key points. Page 9 of 16 9

Accumulation of Cold in the Uterus This pain will be alleveiated by warmth. If excess cold, won t like touch. If deficient will want it. Moxa is a key treatment here! Phlegm/Damp Retention How would you know this? Slippery pulse, greasy coating, nausea/vomiting, poor appetite especially in really humid weather. SP 9 and ST 40 are very important. Look for T/F question on amenorrhea indicating you should rule out preggers first! Page 10 of 16 10

Dysmenorrhea This is, per biomedical angle, dysmenorrhea is pelvic pain during the period. Etiology is of 2 flavors: Primary Related to a Prostaglandin level that is too high. This causes uterine contraction, less blood supply and more sensitivity to pain. Usually happens prior to the age of 20. Secondary Generally happens in women over the age of 20 and is related to organic problems such as: o Endometriosis o Fibroids o Pelvic infection o Pelvic congestion syndrome Pain occurs a few days prior to menstruation and within a day of the period pain may be more severe. Typical symptoms of dysmenorrhea can include lower abdominal pain, lower back and leg pain, headache, nausea, constipation, diarrhea, urinary changes and irritability. Treatment depends upon cause and consists of non-steroidal anti-inflammatory drugs such as NSAIDs like ibuprofen and aspirin, antiemetics, rest, sleep, exercise. You need to be able to tell the difference between this and say appendicitis, cholitis, etc. TCM perspective Tong jing is the Chinese term for dysmenorrhea. Tong = pain, jing = menses. In concept this is 2 fold: 1. Pain and blockage syndrome resulting from a blocked release of monthly accumulations of energy. Refer to the previous discussion of the bioclock on page 3 of this document. 2. Pain and blockage due to a large mass or tumor. If less than 1 cm in size acupuncture can help to shrink the mass. If larger, surgery may be necessary. Mechanism Pain is due to only 2 reasons: Blockage blood stasis, qi stagnation for instance. Cold will also contract the meridian. Phlegm and damp will also cause blockage. Bu tong ze tong This is blockage of the Ren and Chong due to Qi Stagnation (yu), damp, Blood (xue) Stasis Symptoms can include pain that comes at the beginning of the period when the Qi rises and is in excess. This is a sharp excruciating pain with aversion to touch. Malnutrition qi and blood xu or liver/ki xu. Bu rong ze tong not nourished then pain. This is malnutrition of the Ren and Chong from overwork. Symptoms include dull generalized Page 11 of 16 11

pain coming at the end of the period with a desire for touch. This is due to an existing deficiency of Blood exacerbated by the blood xu that comes at the end of the period. Same as amenorrhea, but different expression! Etiology There are 5 possible etiologies for Dysmenorrhea Emotional disorder This stems from Qi Stagnation. Qi stagnation is a process leading to Blood stagnation and finally to Blood stasis. o Blood Stagnation (Xue Yu) This is a process showing the body s condition at that moment and is not visible. o Blood Stasis (Yu Xue) Visible dead blood in the form of menstrual clots, bruise with mass, etc. This is a pathogenic factor and the result of Blood stagnation. Irregular diet Irregular diet leads to dampness and then to phlegm. Turbid phlegm blocks the meridians. Fibroids, for example, are a combination of phlegm with Qi and Blood Stagnation. Trauma/Accident This can directly cause blood stasis Wind-Cold invasion Can occur before or during menses when resistance is decreased. Wind cold can directly attack to the Shaoyin level. Blockage of meridians Refers to blockage in the Ren, Chong and Du, all of which originate from the uterus. Liver and Kidney are also affected. Overwork Affects the Liver, Kidney, and can cause Spleen Qi Xu leading to malnutrition of the Ren and Chong. Page 12 of 16 12

Differential Diagnoses and Treatments Can be reasons of deficiency (usually at the end and after periods) or excess (prior to period and during period). Deficient reasons: Qi and Blood Xu, Liver and Kidney Xu. Excess reasons: Qi Yu and Blood stasis and accumulation of Cold. Some of these points are the same as for amenorrhea. Why ST 29 rather than ST 28 as in amenorrhea? ST 28 is water passage and will dredge blockage. ST 29 is more for qi and phlegm blockage as well as for malnutrition. Some points are local around the umbilicus. Can open ren/du/chong channels as in the previous section. Qi Yu and Blood Stasis Qi stasis will move more than blood stasis. Pulse will be wiry, choppy, uneven, hesitant. 4 Gates are primary, UB 17 and SP 10 are important points. Can also open the Ren and Chong. Opening the Chong will help more with blood related problems. Page 13 of 16 13

Retention of Turbid Phlegm Can also use back shu s for spleen/stomach. Accumulation of Cold in the Uterus Especially cold in the lower ab, get cold and then problems get worse, touch cold water and gets worse. Menstruation will be less because cold contracts. Moxa at Ren and Du 4 are the first choice. Baliao UB 32 for moxa is excellent. Also the San Jiao Ju the triangle on the belly would be a good choice for moxa. Page 14 of 16 14

Qi and Xue Xu Tired, not sleeping well, etc tells the Qi xu. With blood xu will be less blood. Qi xu more likely to be more blood because body cannot hold it. BL 17 very helpful. Use Liv 8 to nourish the blood of the Liver. Liver and Kidney Xu Lower back and knees will hurt a lot. Tinnitus. Long term concentration will suffer. Look for yin xu signs night sweat, hot flashes, etc. Kidney 8 again. Ki 3 will nourish the KI. Timing of Treatments Excess types: Treat before and during menses. Deficiency types: Treat at end or after menses. Before menses focus on the Qi. Afterward focus on Blood Page 15 of 16 15

During, harmonize and regulate both Qi and Blood Always pay attention to eight extra meridians o Chong sea of blood o Ren - Sea of Qi and Yin o Du Sea of Yang Treat every week for a while then go to 1ce per month about 2-3 days before period for excess and at end for deficiency. Page 16 of 16 16