Irregular Menstruation for 2 years

Date of first visit: 11/10/2011                                      Name: Merry

Gender: Female                                                         Date of birth: 12/10/1972

Chief complains:  Irregular Menstruation for 2 years

Descriptions (4 diagnostic methods)

A: Asking

Present illness complains: Kay has a busy life. The menstruation became irregular about 2 years ago. There was plenty of bleeding in the beginning even though the timing was not regular. Now the timing is not regular and the bleeding is scanty and dark. There are some clots in the blood. Feel fatigue and sleepy all the time. Always feel cold, prefer warm drink. Urination and defecation are normal. Sore waist. 

Past history: Nothing abnormal detected

Lifestyle: working in a stressful environment

Family history: no

Menstruation, marital & obstetrical history: Single, no child,

The first period started at 12 years old.

B: Inspection

General: Lack of vitality, pale complexion

Others:

Tongue: pale and tender tongue body with thin white tongue coating

C: Auscultation/Olfaction

Sound: weak

Odours: nothing abnormal detected

D: Palpation

Body areas: cold in lower abdominal area

Pulse: weak and thready

Case Summary

Diagnosis: Irregular Menstruation

Syndrome Differentiation: Cold in Blood and blood deficiency

Explanation: She always feels cold, tired and sleepy, sometimes dizziness. Her pulse is weak, deep, and thready. Because of her busy life, she always goes to bed after mid-night, which is the important time for generating blood. Long term blood deficiency leads to dizziness and scanty menses. The blood circulation becomes slow and weak due to the deficiency of blood. Cold was accumulated gradually in the blood and due to the deficiency.       

Treatment principles: Points of the thoroughfare Vessel and Spleen Meridian are mainly prescribed. Acupuncture with even technique is appropriate to predated menstruation while needling and moxibustion are both recommended to the postdated menstruation and irregular menstrual cycle.

Points and Therapies: Qihai (CV6), and Sanyinjiao(SP6), Xueihai(SP10), and Guilai(ST29)

Explanations:

The points in this prescription are mainly for regulating Thoroughfare Vessel and Conception Vessel and activating the circulation of Qi and blood, as Conception Vessel is responsible for the conception and the vigorousness of Qi in Conception Vessel is essential to the normal menstruation. Qihai benefits the source of the whole body, therefore the abundant Qi is able to control blood, for Qi is the commander of blood, spleen and stomach form the foundation of generating blood, so Sanyinjiao is elected to build up spleen so that the blood is under control. Xuehai, Guilai, and Qihai are punctured with reducing technique to animate the circulation of Qi and blood for the postdated menstruation resulting from blood stagnation while the performance of reinforcing technique and Moxibustion in these points warms meridians and nourishes blood for blood deficiency.

Life style advice:

1. Raw, cold, or spicy food is prohibited,
2. Excessive physical labour or exercise should be reduced.
3. Have less stress life style
4. Have healthy diet and regular life style (i.e. go to bed before 10:30 pm)

 

TCM Etiology and Pathology:  

      Definition:  Irregular menstruation refers to the disorder of menses in their circle and is often accompanied by the morbid changes of the colour, amount, and the quality of menses blood. The menses is sometimes preceded and sometimes delayed. The common conditions of irregular menstruation are predated and postdated menstruation and irregular menstrual cycle. It is often found in menstrual disorders due to hypophyseal or ovarian dysfunction.  

          1.  Predated Menstruation :

               It is mainly caused by fire transformed from long-standing Qi stagnation due to mental           depression or worrying, or by the accumulation of heat in uterus so that the fire 

               or heat  makes the blood unsettles, thus the antedated cycle results. 

         2. Postdated Menstruation

              It resules chiefly from retention of pathogenic cold  in the uterus, or from feebleness

              of Yang and deficiency of blood which inactivate the flow in Thoroughfare Vessel 

              and  Conception Vessel, so the menstrual bleeding fails to come on due time.  

         3. Irregular Menstrual Cycle

  Multiparity, too much sex, chronic haemorrhagic, diseases, and constitutional

  weakness  of spleen and stomach undermining the liver and kidney, cause

  dysfunction  of Thoroughfare and Conception Vessels,  therefore, the menstrual

   flow is disordered and the cycle certainly become irregular.

Differentiation

1. Predated Menstruation

Blood Heat

Main Manifestations: Predated menstruation with large amount of sticky, condensed and purplish-red blood, irritability, stuffiness in chest, short and dark urine, red tongue and yellow coating, and rapid forceful pulse.

Qi Defficiency

Main Manifestation

Antedated menstruation which is thin, light red and in large quantity is associated with lassitude, palpitation, shortness of breath, feeling of emptiness and dragging-down in the lower abdomen, pale tongue, thin coating, and weak pulse.

    
     2. Postdated Menstruation

Blood Deficiency

Main Manifestation: Postdated menses is scanty, light red and accompanied by empty pain in the lower abdomen, emaciation, sallow complexion, lustreless skin, dizziness blurred vision, palpitation, insomnia, light red tongue with little coating, and weak, thready pulse.

Cold in Blood

Main Manifestation: Delayed menstruation in dark colour and small quantity is associated with colic in lower abdomen which is alleviated by warmth, cold extremities, aversion to cold, thin white tongue coating and deep, slow pulse.

Qi Stagnation

Main Manifestation: Postdated menstruation with dark and scanty coatingis accompanied by fullness and distending pain in lower abdomen, emotional depression, stuffiness in chest which is eased by eructation, distention in the costal region and breasts, thin and white tongue coating and wiry pulse.

     
     3.  Irregular Menstrual Cycle

Liver Qi Stagnation

Main Manifestation: Variance of menstrual cycle with sticky, thick and purplish bleeding which is impeded and in varying quantity, distention in costal region and breast, distending pain in lower abdomen, mental depression, frequent sighing, thin and white tongue coating and wiry pulse.

Kidney Deficiency

Main Manifestations: Irregular cycle with scanty, thin and light red blood flow, dizziness, tinnitus, soreness in lower back, weakness of knee, nocturia, loose stools, pale tongue with thin coating, and deep, weak pulse.

WMS:

Definition

The menstrual cycle is not the same for every woman. On average, menstrual flow occurs every 28 days (with most women having cycles between 24 and 34 days), and lasts about 4 days. However, there is wide variation in timing and duration that is still considered normal, especially if your periods began within the last few years.

If you soak through a sanitary pad or tampon every hour for 6 consecutive hours, this is considered a very heavy period. A prolonged period is one that lasts longer than 7 days.

A small percentage of women have periods more often than every 21 days or less often than every 35 days. These variations may be normal.

Causes

Causes of the metrorrhagia irregular menses pattern are unknown or are more likely related to stresses and ingested medications or substances that disrupt corpus luteum function or even act as anticoagulant blood thinners. Caffeine may act this way and disrupt corpus luteum function. Heavy caffeine consumers tend to have twice the risk of short cycle length (less than 24 days). Their cycles are not heavier but they are often more frequent.

Cigarette smoking is another agent that can shorten menstrual cycles. Cigarettes seem to shorten the follicular phase but heavier smoking also may shorten the luteal phase. Both heavy smoking and even smoking just 10 cigarettes or more a day may cause menstrual cycles to be shorter in length, as well as more variable in their lengths than nonsmokers.

Acute or excessive alcohol ingestion, getting drunk on occasion, is also known to alter menstrual patterns. Sometimes it shortens cycles while at other times it can cause a delay of menses. The alcohol is thought to affect the liver's ability to properly metabolize estrogen and progesterone.

Stress or eating disorders is also the most common cause. Recreational running does not seem to change menstrual cycle length, but strenuous endurance running can disturb cycle length, and make a woman anovulatory. Long distance runners and other strenuous sports have been well known to cause anovulation of the low estrogen type.

While the most common cause of irregular delayed menses is due to stress type hypothalamic amenorrhea, the next most frequent type is due to polycystic ovarian syndrome. This is a complex condition of the ovaries in which follicles seem to grow and produce estrogen but the egg does not get released. This results in a high estrogen condition but infrequent menses. When the period does start, it often can be a very heavy one that persists for days or even weeks. The continuous, high estrogens cause the uterine lining to grow and proliferate and eventually it gets too thick and then sloughs off causing a menstrual like bleed. Because of the chronic and continuous estrogen stimulation, most doctors feel that a menstrual period should be induced with hormones (progesterone/progestin) so that a woman is not at risk for endometrial cancer.

Women who have polycystic ovarian syndrome (PCOS) will frequently have abnormal carbohydrate metabolism called insulin resistance or even develop diabetes. Additionally, excess hair growth due to extra testosterone occurs in many women with PCOS.

Treatment

What is the best non-prescription treatment to make menses more regular?

For a metrorrhagia type of irregular menstrual pattern, it is important to give up tobacco, alcohol and cut caffeine servings down to 2 or less per day. Try to minimize any medications that you do not have to take. If menses are mildly irregular and you are trying to time conception, taking a phytoestrogen supplement on a daily basis may help stabilize the menstrual cycle length.

For a low estrogen, irregular menstrual problem, the key treatments are:

• stress reduction and/or relaxation techniques
• elimination of overly strenuous physical exercise
• eliminate any eating disorders such as purging, bulimia, or anorexia
• take supplemental, measured estrogens such as phytoestrogens in soy or clover products

For a high estrogen irregular menses pattern such as that found in PCOS, weight reduction using a low carbohydrate diet is essential. Even a 10% weight loss will help restore normal menstrual patterns in obese women who are anovulatory.

The supplements recommended below have been studied in clinical trials and have been found to be effective in connection with irregular periods. For best results you should take them over a period of three months, at the end of which you should be reassessed in order to monitor improvements and changes and then adjust the supplement programme according to your new condition.

Multivitamin and Mineral
A good quality multivitamin and mineral would form the foundation of your supplement programme to make sure that you are getting a 'little bit of everything'. You then add in those nutrients in slightly higher amounts which are known to be helpful for irregular periods.

B Vitamins
These are often called the 'stress' vitamins because they can help you to cope with the pressures of everyday life. As stress can be such an important factor in causing irregular periods it is important that you have some help in dealing with it. Vitamins B2, B3 and B6 are also necessary for thyroid hormone production and B5 (pantothenic acid) is essential for optimum adrenal function. Both imbalances in thyroid function and stress can affect your cycle.

The easiest way to make sure you are getting a good supply of these vitamins is to take them in the form of a good B-complex tablet. B vitamins are synergistic, which means that they work together.

Antioxidants
Antioxidants are particularly relevant with irregular periods. It is believed that antioxidants have the ability to prevent cells from mutating. In other words, they prevent cells from becoming 'abnormal'. This is extremely important if you have been diagnosed with thickening of the womb lining (endometrial hyperplasia) because you don't want the cells to mutate. Antioxidants include vitamins A, C and E and the mineral selenium. Their effects have been proven: women with womb tumours have been shown to have less of both selenium and vitamin E than women without them so make sure you are getting enough of these valuable nutrients.

Magnesium
This mineral has been classed as 'nature's tranquilliser', so it is an essential inclusion in the diet of anyone suffering from irregular periods. In fact, anyone in today's hectic society will benefit from a magnesium supplement. Stress is often a factor in period irregularity, and this mineral will help to redress the balance of a stressful lifestyle.

Essential Fatty Acids (EFAs)
Linseeds, which are an excellent form of both Omega-3 and Omega-6 fatty acids, have been proven to encourage regularity of the cycle among other things. Even if hormonal imbalance is not at the root of your condition, it is worth adding these fatty acids to your diet. There are many factors that are now known to affect the way fatty acids are used by our bodies, including high adrenaline levels (in the case of stress), high alcohol consumption, and high levels of cholesterol. If your body is NOT getting or using enough of the fatty acids consumed, your cycle can be affected. You can't lose by adding these supplements to your diet.

What are the best prescription treatments for menstrual irregularities?

Oral contraceptives (OCPs) are the most commonly used hormonal treatment for irregular menses. They do not correct the underlying problem that causes the irregularity but they will regulate the pattern very precisely to the same day of the week each cycle. In general, oral contraceptives are very safe and will not cause an alteration in the body even after taking for a very long time. Some women cannot take birth control pills, however, so other treatments are also used.

Women with irregular menses due to hypothalamic factors can take a sequential hormone regimen. In this regimen, estrogen is given each day and then progesterone is given for 10-14 days each month in order to induce a withdrawal bleed. This regimen will not protect against pregnancy should ovulation occur so if a pregnancy is desired, this may be the best regimen.

For polycystic ovarian syndrome most physicians will prescribe oral progestins or progesterone to take for 10 days every two months if there has not been a spontaneous menses. This is thought to protect against the development of endometrial cancer or hyperplasia from the long term elevation of estrogens.

Carbohydrate metabolism abnormalities are often successfully treated with a combination of diet and medications, and the menstrual irregularities may disappear. Metformin, a drug which reduces high insulin levels has been shown to make women with PCOS resume normal menses in almost 90% of cases . This is a dramatic breakthrough in treatment and one worth seeing your physician about if you have PCOS.

 

 

Follow up consultation

 

 

Patient Name: Merry                                                              Treatment Number:2

TCM Disease: Irregular Menstruation                                     Date: 18 / 10 /  2011

Current condition/ changes:

The patient feels more energetic, but the MC still not comes yet. She still feel cold, but not as cold as before.

Treatment Principle:

Expel the cold and promote the circulation of QI and Blood

Prescription:

Keep the same needling points: Qihai (CV6), and Sanyinjiao(SP6), Xueihai(SP10), and Guilai(ST29)
Moxa the above points after needling
 
Use ear acupuncture on the points related to Intertragus, Ovary, Uterus, Kidney, and Liver.

Explanation (if any adjustment):

The patient can only come once a week. Use ear acupuncture can help the performance of treatment.

Lifestyle Advice (if any adjustment):

Same with the first visit.

Case Conclusion

This is a chronic disease. It takes time to rebuilt a healthy constitution with energetic Qi and Blood. Some tonic herbs might be helpful to strengthen the QI and Blood of the patient and improve the effect of treatment.