Integrative Woman’s Health Course DAOSHING NI

Inter-Menstrual Bleeding 經間期出血

Clinical Case Dr Cai, Xiao Sun 蔡小蓀  28yo,single.FirstVisit5-12-2005 Intermenstrualbleedingfor5years.Menarcheage14,7/30,LMP4-21,slightfaFgue,coaFngthinyellow,Fpandsidered,pulsethin.

 Diagnosedasovulatorybleeding(Intermenstrualbleeding)

Definitions Intermenstrual Bleeding (IMB)  Intermenstrualbleeding(IMB)referstovaginalbleedingatanyFmeduringthemenstrualcycleotherthanduringnormalmenstruaFon.

 ItcansomeFmesbedifficulttodifferenFatetrueIMBbleedingfrommetrorrhagia(irregularlyfrequentperiods).

 Postcoitalbleeding(PCB)isnon-menstrualbleedingthatoccursimmediatelyaRersexualintercourse.

 BreakthroughbleedingisirregularbleedingassociatedwithhormonalcontracepFon.

Midcycle Spotting or Bleeding  OvulaFonbleedingormid-cyclespoVngisatermusedtodescribemildbleedingorspoVngthatoccursataroundtheFmeofovulaFon.Inmostcases,thisbleedingoccursapproximately14to16daysaRerthelastmensesinanormal28-daycycle.

 AtovulaFon,estrogenlevelsdiptemporarily,whichisoRenenoughtocausesomespoVng.AnovulaFonisthemostcommoncauseofabnormalbleedinginpremenopausalwomen.

IMB and PCB  IMBandPCBarebothsymptoms,ratherthandiagnoses,andwarrantfurtherassessment.

 Theyoccurcommonlyandareemphasizedinreferralguidelinesforsuspectedgynecologicalcancers.

 Genitaltractmalignancyisanuncommoncauseofbleedingandararecauseinyoungwomen,itmustbeconsideredinallpaFents.

Epidemiology  Around14%ofpremenopausalwomenexperienceirregularorexcessivelyheavymenstrualbleeding.(UKpopulaFon)

 IthasbeenesFmatedthatinthosewomenwhopresenttoprimarycarewithmenstrualproblems,aroundonethirdwillhaveIMBorPCBinaddiFontoheavymenstrualloss.

 Thetwo-yearcumulaFveincidenceofIMBhasbeenshowntobe24%andthatofPCBwasaround8%inastudyofperimenopausalwomen.

 UnscheduledbleedingcausesanxietyandconcernbecauseitcanbeapresenFngsymptomforgynecologicalcancer,parFcularlycervicalandendometrialcancer.

Etiology  ThecausesofIntermenstrualbleedingtypicallyvarywithage

 Amalignantcauseisveryuncommoninyoungerwomen.

 InaddiFon,thelikelihoodofuterinepolypsandfibroidsincreaseswithage. Ifitisaregularoccurrenceduringmid-cycle,thismightbeduetoovulatorybleeding.

 ManywomenwillpresentwithacombinaFonofPCBandIMB.

Causes of postcoital bleeding (PCB)  InfecFon. Cervicalectropion(turnoutofcervix)-especiallyinthosewomentakingthecombinedoralcontracepFvepill(COCP).

 Cervicalorendometrialpolyps.

 Vaginalcancer.

 Cervicalcancer-usuallyapparentonspeculumexaminaFon.

 Trauma.

The Cervix ThecervixispartofthefemalereproducFvesystem.

Around2–3cenFmeters(0.8–1.2in)inlength.

Thecervixisthelowerpartoftheuterussituatedbetweentheexternalos(externalorifice)andinternalos(internalorifice).

Thecervicalcanalconnectstheinteriorofthevaginaandthecavityofthebodyofuterus.

Cervical Erosion (Ectropion)

Cervical Polyp  Acommonbenignpolyportumoronthesurfaceofthecervicalcanal.

 TheycancauseirregularmenstrualbleedingbutoRenshownosymptoms.

 Treatmentconsistsofsimpleremovalofthepolypandprognosisisgenerallygood.

 About1%ofcervicalpolypswillshowneoplasFcchangewhichmayleadtocancer.

 Theyaremostcommoninpost-menarche,pre-menopausalwomenwhohavebeenpregnant.

Vaginal Cancer Vaginalcancerisadiseaseinwhichmalignant(cancer)cellsforminthevagina.

AgeandbeingexposedtothedrugDES(diethylsFlbestrol)beforebirthaffectawoman'sriskofvaginalcancer.

Signsandsymptomsofvaginalcancerincludepainorabnormalvaginalbleeding.

Cervical Cancer Incident Rate  TheAmericanCancerSociety'sesFmatesforcervicalcancerintheUnitedStatesfor2016are:

 About12,990newcasesofinvasivecervicalcancerwillbediagnosed.

 About4,120womenwilldiefromcervicalcancer.

 Cervicalpre-cancersarediagnosedfarmoreoRenthaninvasivecervicalcancer.

Cervical Cancer Incident Rate  CervicalcancerwasonceoneofthemostcommoncausesofcancerdeathforAmericanwomen.

 Butoverthelast40years,thecervicalcancerdeathratehasgonedownbymorethan50%.

 ThemainreasonforthischangewastheincreaseduseofthePaptest.

 Thisscreeningprocedurecanfindchangesinthecervixbeforecancerdevelops.Itcanalsofindcervicalcancerearly−initsmostcurablestage.

Cervical Cancer Screening  Cervicalcancertendstooccurinmidlife.

 Mostcasesarefoundinwomenyoungerthan50.

 Itrarelydevelopsinwomenyoungerthan20.

 ManyolderwomendonotrealizethattheriskofdevelopingcervicalcancerissFllpresentastheyage.

 Morethan15%ofcasesofcervicalcancerarefoundinwomenover65.HoweverthesecancersrarelyoccurinwomenwhohavebeengeVngregularteststoscreenforcervicalcancerbeforetheywere65.

Cervical Cancer Staging  Stage0(Tis,N0,M0):Thecancercellsareonlyinthecellsonthesurfaceofthecervix(thelayerofcellsliningthecervix),withoutgrowinginto(invading)deeperFssuesofthecervix.Thisstageisalsocalledcarcinomainsitu(CIS)whichispartofcervicalintraepithelialneoplasiagrade3(CIN3).Stage0isnotincludedintheFIGOsystem.

 StageI(T1,N0,M0):Inthisstagethecancerhasgrowninto(invaded)thecervix,butitisnotgrowingoutsidetheuterus.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

Stage I - The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0).  StageIA1(T1a1,N0,M0):Thecancerislessthan3mm(about1/8-inch)deepandlessthan7mm(about1/4-inch)wide.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 StageIA2(T1a2,N0,M0):Thecancerisbetween3mmand5mm(about1/5-inch)deepandlessthan7mm(about1/4-inch)wide.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IB(T1b,N0,M0):ThisincludesstageIcancersthatcanbeseenwithoutamicroscopeaswellascancersthatcanonlybeseenwithamicroscopeiftheyhavespreaddeeperthan5mm(about1/5inch)intoconnecFveFssueofthecervixorarewiderthan7mm.Thesecancershavenotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IB1(T1b1,N0,M0):Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IB2(T1b2,N0,M0):Thecancercanbeseenandislargerthan4cm.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

Stage II  StageII(T2,N0,M0):Inthisstage,thecancerhasgrownbeyondthecervixanduterus,buthasn'tspreadtothewallsofthepelvisorthelowerpartofthevagina.

 StageIIA(T2a,N0,M0):ThecancerhasnotspreadintotheFssuesnexttothecervix(calledtheparametria).Thecancermayhavegrownintotheupperpartofthevagina.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IIA1(T2a1,N0,M0):Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IIA2(T2a2,N0,M0):Thecancercanbeseenandislargerthan4cm.

 IIB(T2b,N0,M0):ThecancerhasspreadintotheFssuesnexttothecervix(theparametria).

Stage III  StageIII(T3,N0,M0):Thecancerhasspreadtothelowerpartofthevaginaorthewallsofthepelvis.Thecancermaybeblockingtheureters(tubesthatcarryurinefromthekidneystothebladder).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IIIA(T3a,N0,M0):Thecancerhasspreadtothelowerthirdofthevaginabutnottothewallsofthepelvis.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IIIB(T3b,N0,M0;ORT1-T3,N1,M0):either:

 cancerhasgrownintothewallsofthepelvisand/orhasblockedoneorbothureters(acondiFoncalledhydronephrosis),

 OR

 cancerhasspreadtolymphnodesinthepelvis(N1)butnottodistantsites(M0).Thetumorcanbeanysizeandmayhavespreadtothelowerpartofthevaginaorwallsofthepelvis(T1toT3).

Stage IV  StageIV:Thisisthemostadvancedstageofcervicalcancer.Thecancerhasspreadtonearbyorgansorotherpartsofthebody.

 IVA(T4,N0,M0):Thecancerhasspreadtothebladderorrectum,whichareorgansclosetothecervix(T4).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).

 IVB(anyT,anyN,M1):Thecancerhasspreadtodistantorgansbeyondthepelvicarea,suchasthelungsorliver.

Tumor Extent (T)  Tis:Thecancercellsareonlyfoundonthesurfaceofthecervix(inthelayerofcellsliningthecervix),withoutgrowingintodeeperFssues.(TisisnotincludedintheFIGOsystem)

 T1:ThecancercellshavegrownfromthesurfacelayerofthecervixintodeeperFssuesofthecervix.Thecancermayalsobegrowingintothebodyoftheuterus,butithasnotgrownoutsidetheuterus.

 T1a:Thereisaverysmallamountofcancer,anditcanbeseenonlyunderamicroscope.

 T1a1:Theareaofcancerislessthan3mm(about1/8-inch)deepandlessthan7mm(about1/4-inch)wide.

 T1a2:Theareaofcancerinvasionisbetween3mmand5mm(about1/5-inch)deepandlessthan7mm(about1/4-inch)wide.

Tumor Extent (T)  T1b:ThisstageincludesstageIcancersthatcanbeseenwithoutamicroscope.Thisstagealsoincludescancersthatcanonlybeseenwithamicroscopeiftheyhavespreaddeeperthan5mm(about1/5inch)intoconnecFveFssueofthecervixorarewiderthan7mm.

 T1b1:Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).

 T1b2:Thecancercanbeseenandislargerthan4cm.

Tumor Extent (T) T2  T2:Inthisstage,thecancerhasgrownbeyondthecervixanduterus,buthasn'tspreadtothewallsofthepelvisorthelowerpartofthevagina.Thecancermayhavegrownintotheupperpartofthevagina.

 T2a:ThecancerhasnotspreadintotheFssuesnexttothecervix(calledtheparametria).

 T2a1:Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).

 T2a2:Thecancercanbeseenandislargerthan4cm.

 T2b:ThecancerhasspreadintotheFssuesnexttothecervix(theparametria)

Tumor Extent (T) T3 and T4  T3:Thecancerhasspreadtothelowerpartofthevaginaorthewallsofthepelvis.Thecancermaybeblockingtheureters(tubesthatcarryurinefromthekidneystothebladder).

 T3a:Thecancerhasspreadtothelowerthirdofthevaginabutnottothewallsofthepelvis. T3b:Thecancerhasgrownintothewallsofthepelvisand/orisblockingoneorbothureters(thisiscalledhydronephrosis).

 T4:Thecancerhasspreadtothebladderorrectumoritisgrowingoutofthepelvis

Lymph Node Spread and Metastasis  Lymphnodespread(N)

 NX:Thenearbylymphnodescannotbeassessed

 N0:Nospreadtonearbylymphnodes

 N1:Thecancerhasspreadtonearbylymphnodes

 Distantspread(M)

 M0:Thecancerhasnotspreadtodistantlymphnodes,organs,orFssues

 M1:Thecancerhasspreadtodistantorgans(suchasthelungsorliver),tolymphnodesinthechestorneck,and/ortotheperitoneum(theFssuecoaFngtheinsideoftheabdomen).

Cervical Cancer - Staging

Causes of inter-menstrual bleeding (IMB) - 1  Pregnancy-related,includingectopicpregnancyandgestaFonaltrophoblasFcdisease. Physiological:◦ 1-2%spotaroundovulaFon.◦ HormonalfluctuaFonduringtheperimenopause(thisshouldbeadiagnosisofexclusion).

 Vaginalcauses:◦ Adenosis.◦ VaginiFs(bleedinguncommonbeforethemenopause).◦ Tumors.

Causes of inter-menstrual bleeding (IMB) - 2  Cervicalcauses:◦  InfecFon-chlamydia,gonorrhea.

◦ Cancer(butbleedingismostoRenpostcoital).◦ Cervicalpolyps.◦ Cervicalectropion.◦ Condylomataacuminataofthecervix.

Causes of inter-menstrual bleeding (IMB) - 3  Uterinecauses:◦ Fibroids(occurinover25%ofwomenofreproducFveage).

◦ Endometrialpolyps.◦ Cancer(endometrialadenocarcinoma,adenosarcomaandleiomyosarcoma).◦ Adenomyosis(usuallyonlysymptomaFcinlaterreproducFveyears).

◦ EndometriFs.◦ Estrogen-secreFngovariancancers.

Causes of inter-menstrual bleeding (IMB) - 4  Iatrogeniccauses:◦ Tamoxifenuse.

◦ Followingsmearortreatmenttothecervix.◦ MissedoralcontracepFvepills.◦ DrugsalteringcloVngparameters-eg,anFcoagulants,selecFveserotoninreuptakeinhibitors(SSRIs),corFcosteroids.◦ AlternaFveremedieswhentakenwithhormonalcontracepFves-eg,ginseng,ginkgo,soysupplements,andStJohn'swort.

Causes of breakthrough bleeding - 1  UnscheduledvaginalbleedingiscommonwhenanewcontracepFvemethodisstartedandoRenselleswithoutintervenFon.ItisimportanttoexcludepregnancyandalsoanyunderlyinginfecFon.

 Bleedingproblemsaremorecommonwithprogestogen-onlymethods.Smokersactuallyhaveagreaterriskofbreakthroughbleeding.

 COCP:◦ PreparaFonscontaining20microgramsethinylestradiolaremorelikelytobeassociatedwithbreakthroughbleedingthanthosecontaining30-35micrograms.◦  IncombinaFonwithanenzyme-inducingdrug-eg,rifampicin.

Causes of breakthrough bleeding - 2  Progestogen-onlycontracepFvepill(POCP). ContracepFvedepotinjecFons.

 Intrauterinesystem(IUS)orimplant.

 EmergencyhormonalcontracepFon.

TCM Etiology

KidneyYinDeficiency

BloodStagnaFon

DampHeat

TCM Etiology Kidney Yin Deficiency

ConsFtuFonalWeakness

ExcessiveLaborandSex

ExcessiveWorrying

AbundanceofStagnantFire

KidneyYinbecomingdeficient

DeficientFirestruggleswith

YangQi

DamagingYinLuo,ChongRenDysfuncFon

DeficientFireconsumesEssence

TCM Etiology Damp Heat

LiverQiStasisAlackingSP/ST

YangQiInternalMovement

iniFaFngDampHeat

WaterDampnessformed

internally.Accumulatedtotransformedto

Heat

HeatDisturbingUterus

TCM Etiology Blood Stagnation

ConsFtuFonalWeakness

EmoFonalInjury

QiStasisatChongRen

StagnantBloodAccumulaFon

InternalMovementof

YangQiStrugglingwith

BloodStagnaFon

MenstrualandGestaFonal

AccumulaFons

TCM Pathology  DisorderLocaFon:ChongRenChannels Pathology:dysfuncFoninYin-YangtransiFonduringovulaFonperiod,damagingChongRen,CausingdysfuncFonofSeaofBloodinstoringandcontrolling

TCM Pathology EFology• KidneyYinDeficiency• DampHeatRetenFon• StagnancyBlockingBaoLuo

DuringOvulaFon,YangQiInternalMovement,DysfuncFonofYin-YangTransiFon

DamageofYinLuo,ChongRen

DysfuncFonofStoringfuncFonofSeaof

BloodExtravasaFonofBloodIntermenstrual

Bleeding

Diagnosis  MainSymptoms:IntermenstrualBleedingoccurringaroundCD12-16for2-3dayswithspoVngorlightflowfortwoormoreconsecuFvecycles.

 SecondarySymptoms:Itcancombinewithlumbago,pelvictendernessunilaterallyorbilaterally,breasttenderness,leukorrheaeitherclearorwhite

Exams  BBTconfirmaFon

 Serumestrogenlevel

Differential diagnosis IntermenstrualBleeding

EarlyMenstruaLon

ScantyMenstrualFlow

RedVaginalDischarge(ChiDai)

Similarity VaginalBleeding

Difference MostlyaroundovulaFonFme,lastsaround2-3days,mostlylightorspoVng

MostlyearlierthanregularcycleFme,lastslikearegularmenstrualflowandcorrespondtoBBT

CycleisnormalbuttheflowquanFtyisreducedorjustspoVng

TendstobespoVngwithmucus,canoccuranyFmebetweenperiodsandhaveahistoryofcervicaldisease

TCM Etiology

KidneyYinDeficiency

BloodStagnaFon

DampHeat

Kidney Yin Deficiency  Intermenstrualbrightredflow,slightlysFcky,canbelessormoreflow

 Dizziness,lumbago,insomnia,fivesolerestlessheat,consFpaFon,yellowurinaFon.

 TongueRed,slendertongue,pulsethinrapid NourishKidneyYin,StrengthenChongandStopBleeding

 LianDiTang+ErZhiWan兩地湯 ＋ 二至丸

Liang Di Tang + Er Zhi Wan 兩地湯 ＋ 二至丸  LiangDiTang:ShengDi,DiGuPi,XuanShen,MaiDong,AJiao,BaiShao.生地，地骨皮，麥冬，玄參， 阿膠，白芍。

 ErZhiWan:NvZhenZi,HanLianCao.女貞子，旱蓮草。

 Ifprofuseflowwithpaleflow,noclots,faFgue,useDaBuYuanJian大補元煎.

 DaBuYuanJian:RenShen,ShanYao,ShuDi,DuZhong,DangGui,ShanZhuYu,GouQiZi,ZhiGanCao

Damp Heat  Intermenstrualdeepredflow,sFcky,tendstobeheavierflow

 Leukorrhea,coloryellow,faFgue,bodyache,bilermouth,drythroat,chestdistenFon,restlessness,poorappeFte,abdominaldistenFon,urineshortandred.

 TongueRed,coaFnggreasyyellow,pulsethreadywiryorwiryslippery

 ClearDampHeat,StrengthenChongStopBleeding

 QingGanZhiLinTangridofAJiao,HongZao,AddXiaoJiandFuLing.清肝止淋湯去阿膠，紅棗加小薊茯苓。

Qi Gan Zhi Lin Tang rid of A Jiao, Hong Zao, Add Xiao Ji and Fu Ling 清肝止淋湯去阿膠，紅棗加小薊茯苓  <FuQingZhuNvKe>(DrFu,QingZhu’sGynecology)傅青主女科

 BaiShao,DangGui,ShengDi,AJiao,DanPi,HuangBo,NiuXi,XiangFu,HongZao,smallblackbeans

 NourishBloodClearLiver

 Womanblooddeficiencywithfirecausingincessantredleukorrhea.

Stagnant Blood  Intermenstrualpurpleblackflow,cloly,tendstohavefluctuaFngflowamount

 Pelvictendernessorpain,aversiontopressure,chestdistenFon,restlessness

 Tonguepurpleorwithstagnantspots,pulsethreadywiry DissolveStagnaFon,StopBleeding

 ZhuYuZhiXueTang逐瘀止血湯

Zhu Yu Zhi Xue Tang 逐瘀止血湯  <FuQingZhuNvKe>(DrFu,QingZhu’sGynecology),傅青主女科

 ShengDi,DaHuang,ChiShao,DanPi,GuiWei,ZhiKe,GuiBan,TaoRen.生地，大黃，赤芍，丹皮，歸尾，枳殼，龜板，桃仁。

 Ifbleedexcessively,ridofChiShaoandGuiWei,addShiXiaoSan失笑散(PuHuang+WuLingZhi)

Clinical Case Dr Cai, Xiao Sun 蔡小蓀  28yo,single.FirstVisit5-12-2005 Intermenstrualbleedingfor5years.Menarcheage14,7/30,LMP4-21,slightfaFgue,coaFngthinyellow,Fpandsidered,pulsethin.

 Diagnosedasovulatorybleeding(Intermenstrualbleeding)

Clinical Case Dr Cai, Xiao Sun 蔡小蓀  YingYindeficiency NourishKidneyYin,RegulateChongRen

 FuLing12,ShengDi10,ShiHu10,LuLuTong10,JiangXiang3,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ChiBaiShao10each.TobedrunkaRerperiodhasstopped.7bags

Clinical Case Dr Cai, Xiao Sun 蔡小蓀  SecondVisit LMP5-21,PMP4-21

 Currentlyapproachmidcyle

 FuLing12,ShengDi10,ShuDi10,ShiHu10,XiangFu10,LuJiaoShuang10,LuLuTong10,JiangXiang3,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ChiBaiShao10each,ZeXie10.12bags

Clinical Case Dr Cai, Xiao Sun 蔡小蓀  ThirdVisit ARerdrinking12bagsofherbs,nointermenstrualbleeding.CurrentlymenstruaFngwithscantyflow,slightlumbago,faFgue,pulseslightlythin,coaFngthinyellow,tonguesideFpred.

 DangShen10,HuangJin12,DangGui10,FuLing12,ShengDi10,ShuDi10,HuaNiuXi10,ChuanXiong10,BaiShao10,DuZhong10,ChuanDuan10,XiangFu10,LuJiaoShuang10,,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ZeXie10.7bags

Cycle Analysis TheEnFreCyclewehavefocusedonNourishingtheYin,buttherearesomesubtlenuancesduringthe

enFrecycle

DuringOvulaFon,NourishYinheavilyandremoveallmovingherbs

Menstrually,addspleentonificaFonherbsto

strengthenQiandBloodtostrengthenChong

Ren

Dr Cai, Xiao Sun 蔡小蓀  1923- 7thgeneraFonCaiFamilyOBGYNLineageinShanghai.

 ChiefTCMOBGYNphysicianinShanghaiCityFirstPeople’sHospital.

 WellversedinallOBGYNcases

 EspeciallyfocusedontheimportanceofSpleenandStomachinOBGYNcare