GYNECOLOGY July 22nd: Chapter 5: Miscellaneous Diseases Continued: ENDOMETRIOSIS: Definition: Refers to the presence of the functioning endometrial tissue outside of its normal situation, usually in the pelvis, so it is also called pelvic emdometriosis. When this tissue is found in the myometrium, it is called adenomyosis. More than 50% complicated with fibroids. This is a common disease in gynecology and the incidence apprears to be on the rise. It is more common in upper middle class professional women. Delayed or infrequent pregnancy may contribute to this condition. Age group from 30 to 40 years old. LOCATION: The location can be anywhere, even behind eyes!!!! But mostly in the pelvis. The most common locations are: 1) Ovaries (80% one ovary only) 2) uterosacral ligaments 3) recto-uterine pouch (between uterus and rectum) (aka Douglas pouch) 4) Uterovesical peritoneum 5) Rectvaginal pouch Adenomyosis is more evenly in the uterine smooth muscle, and usually with an enlarged uterus. WESTERN ETIOLOGY: Unknown, but there are theories. 1) Theory of implantation This is the most commonly accepted theory. During the period the menstrual blood can go into the pelvic cavity through the tube. That blood is like a seed that can implant. Deqpuamated menstural endometrium is viable and can grow intrateritoneal. Also congenital narrowing of cervix and women with a narrow vaginal opening are more likely to retain blood, and more likely to have this disease. This disease can be found in the episiotomy site (cutting to help baby out during delivery), so that also supports this theory. Endometrial tissue can also be found in c – section site. This theory cannot explain endometriosis in arms and legs, etc. 2) Transport theory Endometrium can be found in pelvic lymphatic channels and pelvic veins, and also very far away from pelvis. So there is a theory that the tissue can circulate in the blood vessels. This is not a common form, most endometriosis is in the pelvic area. 3) Coelomic metaplasia theory Ovarian epithelium and pelvic peritoneal mesothelium are capable of differentiating into endometruim by certain stimuli. No strong clinical lab suppost. 4) Auto immune theory Most women have menstrual blood in the pelvis, but very few women develop endometriosis. Also this disease seems to have a genetic tendency. The patients who have this disease have Lupis 2x as often as those without this disease. Key concept is hormonal factors are central importance. See handout. 2) ovaries out, endometriosis gone. 3) Rarely in those with amenhorria, but common in women with uninterrupted cycle for 5 years. 4) Improves during pregnancy. 5) Frequent pregnancy in early reproductive life will prevent this disease. SYMPTOMS: Symptoms vary individual by individual, and 20% have no symptoms at all. The first symptom is dysmenhorrea, and constant lower abdominal pain. The pain is mostly in the lower abdomen and the lumbo sacral region, and it can radiate the the vagina, perinum, anus. Pain will start 1-2 days before period, and the first day of the period is the worst, and the pain usually is gone after the period. The pain will gradually get worse year after year, and some patients will have constant lower abdominal pain that is worse with menses. Second symptom is irregular menstruation. 15% have heavy period and longer duration menses. Next symptom is deep pain upon intercourse. Especially if the location is the recto uerine pouch, and the pain will get worse before the period. Infertility is the next symptom. 40% of women with endometriosis have this problem. If in the ovary, or could change the tube or something else. There can be leaking of a chocolate liquid that causes pain in the pelvis and can also cause inftertility. Painful defication can also be a sign of endometriosis. Some patients will have diarrhea, constipation or even infrequent urination during their menstrual cycle. PREVENTION AND TREATMENT: For prevention, if you have narrow cervix or smaller vaginal opening then there may be surgical intervention. During the period, NO gynecological exam!!! NO SEX during the menses either (condom cannot protect against this disease, it is from the pressure). Use care with operation, especially not to put the needle in the endometrial layer. Western Treatment: One treatment is called pseudo pregnancy therapy. This is the birth control pill with more progesterone and less estrogen. This can relive the symptoms. Pseudo menopause therapy is also common now, and this is Danazol, which has mild androgen function, (hair and gain weight, lower voice, breast reduction, as side effects). This will cause you to have no period. You take for 6 months, and then period will return in 3-4 months. Then period regular for 2 months, and then try to get pregnant. After this therapy, 50-70% of patients can become pregnant. Androgen therapy is most common, where women are given testosterone, which will relieve dismenhorria, but will NOT stop the ovulation. You can still become pregnant here, so this is not a method of birth control. If the period is overdue, you have to stop this treatment immediately. Operation: Lazer can cauterize the endometriosis. Sometimes we have to cut the ovary, but you only cut the diseased part. Sometimes you take the uterus and the ovaries, it just depends on the severity and the age (over 45 no desire for pregnancy). Pregnancy is not a cure, but each pregnancy will reduce the symptoms of the disease. Adenomyosis: This is usually seen between 30-50 year old women, who have had a delivery. During the delivery there may be damage to the endometrium layer, so if you have never delivered a baby then it is not common, and it is more common in natural delivery than C – section. Treatment in Western medicine for this is non-existant. This is more injury than hormonal. Usually the patient has heavy period with a long duration, and enlarged uterus. If severe symptoms, then can remove the uterus. TCM and ENDOMETRIOSIS: Treatment principle is promote blood circulation and eliminate blood stasis. The tissue outside of the local area is considered blood stasis in TCM. In Clinic you still see syndromes. QI STAGNATION AND BLOOD STASIS: Symptoms like severe pain in lower abdomen before and during menstruation, or sometimes heavy period with clotting and bearing down sensation in the lower abdomen. Breast tenderness and PMS are common. Tx: Promote qi and blood circulation and remove blood stasis. Fx: Tong Jing Fang: Dang Gui, chuan xiong, dan shen, chaun Niu xi, Xhi shao yao, gui zhi, xiang fu, yuan hu, san Len, e zhu. San Len and E zhu you take out during the menses. You cannot use the same formula all the time for this condition. During period you cannot take the blood movers if you have heavy period. KIDNEY DEFICIENCY WITH BLOOD STASIS: Symptoms like pain during intercourse, heavy menstruation, and KD deficiency like tinnitus and dizziness and frequent urination and infertility and black eye bags. Tx: Tonify KD and promtoe blood circulation and remove blood stasis. Fx: Gui Zhi Fu Ling Wan + Gui Shen Wan BLOOS STASIS D/T ACCUMULATION OF COLD: This is cold pain in the lower abdomen, before during or even after menses, and cold can be relieved by warmth. Scanty period, and can be dark color with clots. Pale tongue deep thready pulse. Tx: Promote blood circulation remove blood stasis, warm meridian and disperse cold. Fx: Shao Fu Zhu Yu Tang In clinic can be qi deficiency with blood stasis BOTH, then you combine formulas. Gui Zhi Fu Ling Wan with ju Yuan Jian or Bu Zhong Yi Qi Tang, etc. MODIFICATIONS: If dismenhorria is severe use xiang fu, yuan huo, pu huang, and san qi. Heavy period or longer duration: Pu huang, san qi, and yi mu cao. (stop bleeding and promote blood circulation) Infertility: usually add tu si zi, lu jiao jiao, yin yang huo, chuan duan (xu duan) to promote the ovulation. DURING THE PERIOD NO BLOOD MOVERS!!!!!! FORMULA FOR EXTERNAL USE: Du huang 60 Huang Bai 30 Ze Lan 30 Che Bai Ye 60 Bo He 30 Raw herbs ground into powder and then water and honey to make it like plaster, and place it in the lower abdomen one time per day. Do not use during the period. You can put this powder in a bag as well, then in microwave to warm it and it is better. You can use it until you stop being able to smell the herbs. PROLAPSE OF THE UTERUS Uterus slips out of the normal place or the vaginal wall expands out. In TCM this is called Yin Ting (yin means vaginal wall, ting means expand out.) In clinic this is seen in three stages by severity. Stage one is the mildest, and stage three the most severe. Stage one means the external os of the cervix is below the ischial spine, the distance between the externals of the cervix and the hymen is less than 4 cm. Stage 2 the cervix or part of the uterine body slips out of the vaginal orifice. Stage 3 thw whole uterus is out of the vaginal uterus. ETIOLOGY: 1) Injury from labor and early overwork after childbirth can cause this condition. The muscles and lignaments and tendons in the pelvis are overexpanded during pregnancy. Sometimes there can be tearing during delivery (if second stage of labor is long you will see overexpanded or torn. If the baby is too big and comes too fast this can also cause problems. 2) Long term increase of abdominal pressure, like prolonged cough, constipation from narrow rectum, abdominal tumor, or ascites (LR problem) gives too much pressure and makes the uterus go down. 3) Congenital maldevelopment of the pelvic floor can also cause this, and it can even happen in virgins or without delivery. 4) Atrophy and retrogression of pelvic floor in old women. Usually this is only if there has been a problem before, and then in old age the condition gets worse. WESTERN TREATMENT: Prevention during delivery (midwife, etc.) After childbirth rest, especially for the first three months. In old days use 100% alcohol to inject ligament and cause scarring to shorten, not used anymore. Now Vaginal Pessary, put in in the morning, and take out at night, then every day like this. This is uncomfortable, but this is usually for stage 3 patients, since then can have infection all the time. Don’t use during the menses. This just covers the cervix. Operation: Shorten the ligaments in an operation, or cut the cervix or part of the uteral body off. For severe conditions for people who have kids, they may remove the whole uterus. With this condition you should avoid heavy labor. TCM TREATMENT: Traditionally this is SP qi deficiency, but the KD can be involved too. QI DEFICIENCY: Prolapse of uterus, with general symptoms like SP qi deficiency, bearing down sensation, etc. Tx: Tonify the qi and elevate the uterus. Fx: Bu Zhong Yi Qi Tang + Chuan Duan, Jin Ying Zi, Zhi Qiao 30-60 g. huang qi to ascend. Not as much sheng ma 6-10 g (sheng ma more guide herb, huang qi actually ascends) New research shows zhi qiao has the function of inducing the contraction of smooth muscle of uterus, but must be more than 30 g. Small dose promotes qi. NOT gui pi tang. Jin Ying Zi is astringenet, chaun duan tonify the KD. KIDNEY DEFICIENCY: Tinnitus, low back, frequent urination, etc. Tx: Tonify KD and elevate the uterus. Fx: Da Bu Yuan Jian + Jin Ying Zi, Lu Jiao Jiao, Sheng Ma, Zhi Qiao In clinic BZYQT and then ADD KD tonics, zhi qiao, and large dose of huang qi (30-60g) ACUPUNCTURE: Wei bao Xue (6 cun lateral from guan yuan – Ren 4) Strong stimulation. Some patients will be able to feel contraction of the uterus. Zi Gong Xue – Uterus point. Du 20, Zhong Qi (ren 3), Zu San Li (st 36) , San Yin Jiao (SP 6) and add moxa. Or Ren 2. Once a day 10 days then stop for 5 with moxa. Zhi Qiao 30 g. every day can also be used on its own. In China may use herbs in vagina, as well as herbs and acupuncture, then if stage one or two, then you have 90% success. Stage 3 hard to recover. After delivery, DON’T breast feed after 2 years, even 1 year is good enough, and even 8 months is OK. BREAST LUMPS In TCm this is Ru Pi, Ru means breast and Pi means nodule. This is benign tumors of the breast. Breast cancer is called Ru Yan, and Yan means rock, because the rock is very hard. Malignant tumors are more often harder, and tied to the underlying tissue (not movable) and the margin is not clearly defined. If there is cancer, personally Ling suggests operation. If you are on the pill, and period is scanty, then STOP the pill, TCM can’t help. Fibrocystic disease (breast cyst) is the first most common benign condition of the breast and 50% of women have it. Most common in 40 –60 years old patients. Cysts are usually multiple, and more common in the last decade (maybe food). Usually kind of hard and tender, and they may hurt with pressure. Only a few cases will have malignant change, but it is monitored every year. nd 2 : Fibroadinoma is the second most common benign breast tumor, and it is more common in young women 20-25. The cyst is slow growing, and it can finally shrink. Usually this is a single lesion in the upper right quadrant (patient’s right) usually very soft and no tenderness. There is usually no malignant change at all. Regular breast exam, inverted nipple, or milk or blood from the nipple is cause for alarm. TCM: This is qi stagnation, or qi stagnation and phlegm. Tumors themselves are blood stasis, qi stagnation and phlegm, but this disease (breast cyst) there is not usually blood stasis. This is more qi stagnation and phlegm. (Liver) QI STAGNATION: LR qi stagnation with gynecological like tumor in breast, size can change with period or emotions. Usually with tenderness of the breast, PMS, dismenhorria, or even infertility. General like LR qi stagnation. Tx: Soothe the LR and move the qi and promote blood circulation and dissipate nodues. Fx: Xiao Yao San + Yu Jin, Ju He, Ji Nei Jin, Xia Ku Cao You have to modify here, to promote the qi and soften the hardness. QI STAGNATION WITH PHLEGM This is usually seen in fibroadenoma. No tenderness or change with period or emotion, and more often seen in young women, probably with irregular menstruation. General symptoms of phlegm with mucus, dizziness, fullness in chest, greasy coat and slippery pulse. Tx: Soothe the LR and strengthen the SP and resolve the phlegm and dissipate the nodules. Fx: Xiao yao San + Gua Lou Xie Bai Ban Xia Tang (add one or two blood herbs like dan shen) Qi stagnation and phlegm: Hai Zao Ju Yu Tang (more for plum pit qi???) NEED at least 3 months to see a change in the lumps. Acupuncture and TCM are good treatment for this condition, but you should get regular check ups as well. LIVER QI STAGNATION WITH KD DEFICIENCY: Women during menopause. Add KD tonics like Liu Wei Di Huang Wan or Zhi Bai Di Huang Wan.