Obstetrics and Gynecology	Fu Ke Yi xue
Huang di Nei ing	women and womb
Zhang Zhong-jing: shang Han Za Bing Lun
Shang Han Lun (cold diseases)
Jin gui Yao Lue (Golden Prescriptions)	Pregnancy and post partum
Sun Si-Miao	Women are 10x more difficult to treat due to pregnancy, childbirth, and vaginal bleeding, they need
	special formulas.
	Bei Ji Qian Jin Yao Fang: nurturing life- preserve and prolong. Women and pediatrics first in book.
Chen Zi-ming	First regulate the menstruation. If not regular, illnesses will ensue.
	Movement of qi, blood, Yin, and yang govern women’s health, along with changes in nutrition
	emotions, lifestyle, and weather. Imbalances manifest a menstrual irregularities, infertility, and problems.
Fu Qing-Zhu	1827: Book of Gynecology and a book on Men’s diseases.
Huang di nei jng- Stages of life
Nei jng Wu Wen chapt. 1 Women	7- Kd Qi abounds, teeth and hair grow
	14- Tian Gui arrives, Ren and Chong are full
	21- Kd qi stabilizes, growth reaches apogee
	28- Kd qi strong, muscles and bones firm and strong
	35- Sp and kd function waning
	42- Kd qi weaken, surplus declines
	49- Kd and Tian Gui exhausted, menopause ensues.
Nei jng Wu Wen chapt. 1 Men	8- Kd qi is replete, hair and teeth grow in
	16- Kd qi abounds and Tian Gui arrives
	24- Kd Qi stabilized, growth reaches apogee
	32- Kd Qi is strong muscles and bones firm and strong
	40- Kd Qi weakens, hair and teeth wither
	48- Yang Qi weakens, face dries, hair shows white
	56- Kd qi exhausted, jing exhausted
	64- teeth and hair go, 5 depots weak, sinews exhausted
Reproductive Years	Gynecology was established to classify and thoroughly treat these illnesses. Study the classic formulas
	pulse diagnosis, and other essentials. Subtleties can be mastered with this book:
	Golden Mirror of Orthodox medicine vol. 44-49 Qing dynasty. In a heart approach to Gynecology
Classic 4 divisions of OB/GYN	Menstruation
	Obstetrics and Post partum
	Abnormal Vaginal Discharge
	Miscellaneous: Prolapse, fertility, Zheng-Jia
Femals are different	They have a Uterus
	Menstruate
	Bear Children
Uterus	Zi Gong/Bao Gong: Baby Palace. Connotes protection and connection
	Heart wrapper pericardium
	A place where something is treasured and concealed Extraordinary organ
	Bao Luo: intimate connections from the KD that nourish the uterus (Bao Gong)
	Bao Mai: vital circulatory network vessels that feed Qi and blood from the Heart.
	Bao Zhong: central place inside all genders where the Ren, Du, and Chong begin, the potential for life.
Blood vs Menstrual blood	Blood is the pure part of food and water, transformed by spleen, it nourishes organs, sinews, mother of Qi.
	Menstrual: Jing-Shui (menstrual water) evolves after being transformed by Tian-Gui and transported
	via Chong and Ren and to the Bao Gong Uterus along the kidney pathways of the Bao Luo
	Menstrual blood is discharged monthly by the uterus.
Tian gui: heavenly dew	A yin fluid material substance, with no special function until the HT, SP, and KD transform it to Jing-Shui.
	Tian gui connotes fertility as the impulse from heaven present in all genders at puberty.
	Arrives when there is a surplus to overflow.
	In females, it goes down (yin) as monthly menses. In males, it goes up (Yang) as facial hair.
Menarche/Puberty	Post natal source is 7 years in female, and 8 year in male
	Surplus Qi and Blood can now be stored as acquired essence
	when acquired essence is sufficient to make a surplus and tian gui arrives at 14 menses commence.
	Jng flows at 16 in boys.
Infertility (bu Yun Zheng)	Primary is unable to conceive after one year
	Secondary is unable to conceive after successful previous conception
	Under 35: one year of regular intercourse with contraception
	Over 35: six months
	15% or 1/6 of the U.S. population is considered infertile
	Decline in women starts at 32 and worse after 40.
Menstrual Cycle	Hypothalamic-pituitary-Gonadal Axis
	Women: Hypothalamus releases GnRH to Pituitary gland- LH and FSH to Ovaries- Estrogen and Inhibin
	Men: Hypothalamus releases GnRH to Pituitary gland- LH and FSH to gonas- leading cells- testosterone,
	Sertoli cells- release androgen binding globulin and inhibin.
	So many things have to go right. Cervical mucus, cervical height
Infertility causes	Male 30%
	Female 30%
	Combined 10%
	Unexplained 25%
	Other 5%
Female infertility	Unexplained
10% each	Endocrine disturbances
	Anomalies of Uterus
	Endometriosis
	Ovulatory Failure
	Tubal Damage
	Immunological Factors
	Urogenital Infection
	Acquired Factors
	Congenital anomalies
Male Infertility	Unexplained 34%
	other causes 8%
	Imune system factors 5%
	Hypogonadism 10%
	Varicocele 17%
	Systemic disease 3%
	Sexual Factors 6%
	Urogenital infection 9%
	Undescended testicles 8%
Ovarian Cycle
Ovarian follicle	SMALL FLUID-FILLED SAC THAT CONTAINS 1 PRIMARY OOCYTE
	Granulose cells inside the follicle surround the oocyte and secrete hormones estrogen and progesterone
	ovarian follicles start as a primordial follicles and develop into mature follicles
Oogenesis	Primary oocytes are stuck in meiotic arrest and complete meiosis 1 just before ovulation
	Secondary oocytes are released during ovulation, do not develop into mature ovum until after fertilization occurs
	Many follicles (10 to 20) with eggs develop during a single ovulation cycle, but typically only 1 survives
	and releases its egg (ovulates) and the rest degenerate (via atresia).
Uterine Cycle (3 phases)	Proliferative: thickening, proliferative (growth of endometrium): estrogen thickens endometrium rapidly
	Secretory: vascularization, secretory phase influenced by progesterone, lining vascular and edematous.
	Menstruation, the sloughing of endometrial lining. Menses. day 28.
Menstrual Cycle (3 phases)	Changes to ovaries, uterus, and whole body through 28 day cycle.
Ovarian/mentrual phases:	Follicular phase: low estrogen- pituitary release FSH- estrogen rises developing follicle. Day 1 to 14.
	Ovulatory phase: Luteinizing hormone releases the egg in ovulation. Day 14
	Luteal phase: Progesterone, corpus luteum and corpus albicans. Day 14 to 28.
Summary:	Uterine cycle: Menses- Proliferative- Secretory phases of Uterine Cycle.
	Ovarian cycle: Follicular phase- 1 to 14 days, ovulation of ovum, (day 14), and Luteal phase 14-28 days.
Regulating the menstrual cycle (Priority)	Daily cycle: day and night, Seasonal cycle- spring, summer, fall, winter, Life cycel: birth, child, adult, old age, death.
Reproductive cycle: women	age 25: 130k eggs, 80% pregnancy per year
	age 30: 12% eggs remain, 63% chance pregnancy per year
	age 35: advanced maternal age, 52% chance of pregnancy per year, infertility rises to 15%
	age 40: 3% of eggs remain, egg quality reduced, 36% chance of pregnancy per year, 32% infertility rate
	age 45: 1% chance of live birth
	age 50: onset of menopause
Menstrual cycle	28 days- ovulation as the peak (high noon/peak).
Seeing in Two	Lower burner: Neijing understanding of body: fire water. Fire under the kidneys.
	Middle burner: qi and blood
	Upper burner- Ying and wei connection
Seeing in four:
Blood phase: nourish and move blood	Blood phase: Menses/end shead of blood/endometrium. Cleaning out, clots
Yin: Nourish Yin: tonify KD, move blood	Yin Phase: growth of estrogen. Peak is ovulation. Like sunrise/spring. Ovulation- mid day. 7-14 days
	Yin phase: blood, yin, Chong and ren are empty and need replenish. Turn on the burner (yang) cervical fluid.
	Ovulation: 11-16 days, Yin so full it transforms to yang, move qi, boost yang, downbear yang if excess
Yang phase: Tonify KD yang	Yang phase: secretive phase, yang , juicy , potential for baby, Sunset.
	Yang phase: increase of warmth, qi and blood increase, chong and ren fill,
Qi phase: Regulate Qi	Qi phase: gathering for baby, or sloth off and restart. PMS. Mid-night
	Qi Phase: PMS, (like fall), potential for stagnation, blood deficiency, Liver def.
	Go with patients level of normal 26 to 30 days range
	4-7 days bleeding
	No more than 2 heavy days.
#1 is Ovulation. Confirm ovulation	1. Cervical mucus. Hospitable mucus is clear and sticky, spinmarkus .
	2. Basal Body temperature
	3. Progesterone blood test
Treat what you see in the patient.
Seeing in 5: zhang and Fu	summer/heart- ovulation, Fall/Lung- gathering refining, storage, spring/liver- growth of follicle/estrogen,
	Winter/kidney- storage, restart of cycle.
	Heart- involvement
	Spleen- yang qi vacuity and dampness
	Kidney- yin or yang def. or both, anovulation and small uterus
	Liver- Qi stagnation, blood stasis/vacuity, blocked tube or irrgular menses.
Dr. Qui Xiao-Mei
On how to become pregnant	Principally related to the exuberance of Kidney qi , abundance of yang qi, ren mai penetrating, chong mai
	all working in a timely way, the two shen wrestling together, a woman will get pregnant.
	Kidney qi absorbs jing, if KD qi is weak , jing and blood are not exuberant, chong and ren lose nourishemnt
	uterus is empty and no ability to absorb jing and get pregnant.
Fertility as farming	planting seeds in land for crops to thrive, access, quantity, quality, dissemination, enviromnemental
	seeds good? Dry or weak, is the land fertile or wasted, etc.
Kidney: fundamental to fertility	Full sotehouse at birth, declines with age
	dependent on pre-natal and post-natal support
	Keeps chong and ren fully functional
	If jing insufficient at birth this can cause problems like late tian-gui (period)
	Life stresses and poor diet can deplete the storehouse, hasten decline of Kd qi and aging.
Kidney pathologies: deficient	Kidney yang vacuity: cold and stasis, when healthy it holds, warms and moves.
	Kidney Yin vacutiy: creats heat and dryness, when healthy nourishes, builds and cools.
	Kidney Jing vacuity: growth delay and infertility, when healthy supports development.
	Kidney Qi Vacuity: insecure leaky lower yin, when healthy contains and holds leakage.
	Yang xu is like planting seeds in a tundra, cold, stasis, delayed cycles, infertilty, miscarriage.
	P: deep weak, slow, T: pale, white fur, A: cool, flabby below navel.
	Yin Xu- planting seed in a desert, dryness, delayed cycle, light bleeding, PMS, amenorrhea, infertility
	P: weak thin, T: small thin, dry cracked, A: dry, thin, tight
	Jing xu- no seeds, underdeveloped seeds, soil damaged, menarch delay, sperm abnormal, infertility
	Qi xu- leaky, inability to hold and support, dribbling menses, miscariage, prolapsed utuerus, leukorrhea
Dr. Xia Gui-Cheng and infertility
	Many cases with Kidney, Kd yang def. cold womb. Enrich yin to benefit yang assist with blood and Liver qi.
	the blood yin and yang are thought of together which means Kidney yang.
Liver qi stagnation	qi mechansm not in sync there is a ascending and descending problem causing inner zang issue.
	When liver is open fully qi can move the blood, menstruation normal and pregnancy easy.
	If lever qi is depressed and knotted qi is stagnant and blood congealed, abnormality and infertility.
	Liver is the mster of orderly reaching, it regulates all cycles of the body
	Liver maintains smooth flow of all transitions, stres blood and builds between cycles.
Liver pathologies
Excess (garden blocked)	Qi stagnation- qi not smooth, irregular menses, PMS, amenorrhea, clots, stop/start bleeding, infertility
	T: red, esp. sides, depressive spots, P: tense/wiry, fast. A: tense subcostais.
	Blood stasis- brick wall, enometriosis, past etopic or abortion, infection w/adhesions, scars, fibroids, trauma
	T: purple, dark. P: choppy. A: hard around navel, + Oketsu.
	Heat- congested heat, early/heavy bleeding, meno/metrorrhagia, can be toxic
	Damp-heat- heavy cycle, pelvic infections, yellow discharge
Vacuity	Blood vacuity- unwaterd garden, pallor, dizzy, floaters, early grey hair, short period
	P: thin. T: pale, especially sides “ginger-orange” color
	Yin vacuity- vacuous heat, hot flashes
Mixed	Yin or blood vacuity with Yang rising with or without wind- twitching, spasms, dizziness, shaky tongue
Spleen	Like a sponge to absorb all the good nutrition. It can get bogged down with too much. Make healthy fluids.
	Root of post heaven qi
	Engenders Qi and blood
	Controls the blood vessels
	When weak from damp and phelgm, cannot absorb
	Can get too dry and not absorb or too wet and absorbed too much.
Spleen pathologies (flooded garden)	spleen qi /Yang vacuity: damp-phlegm accumulation, weakness, apllor, cold, damp, bloating, PMS
	Loose stool, poor appetitue prolapse, miscarriage, vacuous bleeding “Beng luo”, lukorrhea, morning sick
	pale puffy tongue with slippery pulse. A: soft or hard
Heart
	Creates mentruat blood with Tian gui and Kidney
	Direct connection to Uterus via Bao Mai and Chong.
	Circulates and governs blood flow.
	Manifests health via the Shen
Heart pathologies	The erratic garden, Quakes.
	The undernourished heart cannot nourish the shen. Shen can be disturbed like the surface of a lake.
	patients tend to be emotional, anxiious, difficult sleep, fidgety and talkative.
	Heart connect to uterus through Bao mai and Chong mai, sends it blood
	usually afftected as a result of disharmony in other organs and channels
	Always consider in fertility
Perfected spirit qi	Pregnancy results from the union of yin and yang under optimal conditions
	KD jing + SP qi + Liv/HT blood with Full and unobstructed Ren and Chong +
	and a nourished and clear Bao Gong (uterus) will engender and support Tai (Fetus).
	Pregnancy is a miracle every time.
Seeing in Six	The great turnings
	Life: constantly taking in storing and expressing out, to enable birth, growth, maturation, and decline of
	menstrual cycle or pregnancy.
Yang ming (ST/Li)	the downward path for fire in the west. Open/clear/energetic
	sx: red face, dry mouth, constipation, pulse strong, odor, feel hot, sweaty
	Excess and hot
Shao yang (GB/TB)	The pivot that gets fire rooted in west to east. Helps Yang ming transform
	Sx: pms, periodic issues, comes and goes presentations
	Periodic
Tai yin (SP/Lu)	The sponge that absorbs and steams in the center
	sx: abdominal issues, poor appetite, gas, bowel, digestive
	Dry if not absorbing, Damp into tissues or outside body
Shao Yin (Ht/Kd)	ministerial fire that holds fire and water in the north
	Sx: anxiety, insomnia, hot flashes, agitation, bladder issue, cold uterus,
	fire flares up (unrooted) or too Weak (cold) or leaky
Jue Yin (Liv/PC)	Union of fire and Water as Blood in the east
	sx: blood deficiency, blood stasis, pallor, pain
	Poor blood quality
Tai yang (UB/Si)	Outward expression of harmonized Ying and Wei from north to south
	Sx: sweating, fevers
	Yin and Yang separate into heat and damp
flow of the 6 conformations	Imperial fire becomes minster fire when brought below the kidneys
	shao yin- path fom heart to the kidney. Uterus is present- and ovarian and uterus cycles
	Yang ming helps bring the fire down, shao yang transforms the things brought in to be transformed in center
	Tai yin- then absorbs and transforms into steam in the pot, Lungs rain down clear fluids
	Jue yin: all this nourishment becomes blood for health and reproduction, stores blood
	Tai Yang: express out the external world. How this all works helps with ovulation and reproduction.
	So many issues can go wrong- like weak fire, strong fire, etc., anywhere along the 6 flows.
mentrual cycle and 6 conformations	Shao yin mentrual bleeding, jue yin, Tai yang follical growing in restart, estrogen growing, lining growing- yin is juicy
	Ovulation- either pregnant with sperm or gathering and decline (yang ming)- back to shao yang then shao yin.
	tai yin in center-makes everything go round and round.
	Tai yang- can be blocked or leaky if ying-wei are not harmonized
	Yang ming- blocked – excess and hot
	Shao yang- pivot stuck- periodic sysmtpoms, exces
	Shao yin- cold and deficient, unrooted, flaring up, or leaking down
	Tai yin- not absorbing damp or dry, def, leaking middle
	Jue yin- blood creation and movement, dry/deficient/stuck
10 lessons in treating fertility
assumptions and mistakes	1. Red herring- avoid distractions, false leads, jumping to conclusions without seeing whole picture
	and incorrect diagnosis.
	2. Over focus on disease- current and past diseases.
	3. Deep dive: details, what is patient coming to you for, 10 quesitons. Different treatment , different disease.
	same treatment , different disease. Disease protocols are hit-or-miss.
	treat patient but not the disease.
	4. Looking for patient in books. Book only help fine tune what you are thinking. Patients are not in books.
	Maciocias book has 63 infertility formulas for:
	Empty types like: kd yin xu, kd yang xu, blood xu
	Full types: cold uterus, damp in lower, blood heat, Qi stagnation, blood stasis
	5. Overestimating Tonics: how deficient is your patient> tired is not necessary need tonic
	6. Boundaries. Emotional/psyche supprt.  Focus can be easily detrailed by:
	Needy patients need to be gently supported and empathy/be present, Non topical information how to focus
	Counseling/Translating is it appropriate?, Scope of practice/malpractice,
	Time management, Inappriopriate Pt behavior/firing a patient
	7. patient participation- managing expercations. Over vs underestimate Pt commitment to health
	will they come regularly? Will they cook and take herbs? Change their diet and lifestyle? Use an enema?
	will they commit to the course of treatment?
	8. the Blame game: if patients condition does not improve. Slef doubt, questioning the medicine,
	patient not following the advice.
	9. Treatment expectations: course of treatment, women: 3 cycles , can be shorter or longer (years)
	10. K.I.S.S.: keep it simple silly. Tried and true are mainstay of my practice, don’t need to do everything
	or always try new things if you have what works. Branch out when it doesn’t.
Common Fertility Treatments to not do	1. don’t always focus on the kidneys
	2. don’t rotate strickly with the cycle: yin tonics in yin phase, yang tonic in yang phase not always necessary
	3. Don’t rely to heavy on the BBT basal body temp for info
	4. don’t use protocols for the disease rather than the patient
	5. do not fear moving qi or blood in luteal phase
	6. do not avoid resolving phlegm: the potient embryo is not a phlegm ball.
Western terminology	Communicate effictively with what patients bring to us
	communicate effictively with our patients and other providers
	Understanding our limits and when we need to refer
	More knowldege gives you more credibility
Uteri	Anteverted uterus- normal (forward leaning uterus)
	Retroverted uterus (more vertical)
	Uterus in retroversoflexion (leans backward toward spine/rectum
	Unicornutate- one sided uterus
	Bicornuate- double sided, double uterus
	Didelphys- split in two uterus
	Septate- split in the middle
	Arcuate- top of the uterus in indented.
Endometrium*	most important layerm vascular lining, shed in menses, creates palcenta in pregnancy
Myometrium*	middle layer, smooth muscles
Perimetrium*	outer layer, equivalent to the peritoneum
	*myomas and fibroids can be at any layer with varying levels of consequence.
Uterine tubes/Fallopian tubes	aka Salpinges- greek for trumpet
	Fimbriae- finger-like projections at the end of uterine tube that catch the egg.
	can get blocked, swollen/infected (hydrosalpinx).
	blockage can be tubal infertility
	Implanted embryo is Ectopic pregnancy in the tube.
Ovaries	produce the eggs inside ovarian follicles, normally cycling montly
	primordial follicles develop into mature follicles which release a secondary oocyte (egg/ovum)
	Remaining follicle becomes the corpus luteum
Pelvic floor or pelvic diaphragm	muscles, ligaments and connective tissue that support the bladder, uterus, and intestines holding them up
	also important for urinary and fecal incontinence
	dysfunction may play a part in chronic pain conditions vulvodynia, dysparenia
Hyothalamic pituitary ovarian Axis (HPO)	hypothalamus releases GnRH to anterior pituitary- FSH- granulosa cells- inhibin. LH to Theca ceels- andro/estrogens
	influende adrenals and thyroid hormones.
Ovarian cycle	estrogen- oocyte, oogenesis- one survives.
Uterine Cycle (3 phases)	menstruation (menses) proliferative phase (growth of endometrium), secretory phase (vascularization).
Mentrual cycle,	encompasses changes in ovaries, uterus, and whole body in 28 days.
	Ovarian and menstral cycle have same phases: follicular, ovulatory, and luteal phases.
Normal according to ACOG	21 to 35 days and last up to 7 days
	longer cycles can be ovulation issue.
follicular phase- shorted or longer	support of ovulation. Different length of cycles. Short cycle- ovulatin early, late cycle- ovulated later.
BBT- basal body temperature	97f, follicular phase 98f. taken first thing in morning. 98f in luteal phase as release of progesterone after ovulation.
	juicy yin phase to warmer yang phase. Ovulation 3 days elevated temp.
	Fertile with the “egg white cervical mucous” wet clear vaginal lube, spotting, mittelschmerz (painful ovulation)
Common BioMed Labs
Papanicolaou test- cervical cancer	Looks at cells under microscope. High risk HPV most common cause of cervical cancer.
“PAP”	HPV primary test as well.
	Screening may be HPV primary every 5 years, PAP every 3 years or PAP and HPV every 5 years.
Other:	Colposcopy looks at cervix after abnormal PAP. Cervical biopsy.
	cervical biopsy- punch biopsy, cone biopsy, endocervical curettage.
	LEEP- loop electrosurgical excision procedure. Small electrical wires removes cells.
	CIN: cervical Intreepithelial Neoplasia aka Dysplasia.
Common procedures	Hysteroscopy- viewing the uterus with a scope for abnormal bleeding, remove foreign object, confirm abnormal findings
	D&C (Dilation and Curettage) /D&E (Evacuation)- diagonositc. Medical abortion.
Imaging	TVUS- trans vaginal ultrasound- of the pelvis using a transducer in the vagina.
	diagnostic for pelvic pain, abnormal bleeding, guide for ART procedures like IUI/IVF, establish pregnancy
	HSG- Hysterosalpingography- injection of radiopaque dye into uterus via catheter and then
	flouroscopy (real time x-ray). For infertility anomalies.
	Laparoscopy– thin viewing tube is passed through small incision in abdomen to externally view uterus, ovaries, tubes.
	good for Pelvic inflammatory disease, ectopic pregnancy, hysterectomy, tubal ligation.
Hysterectomy	Partial- only body and fundus
	total/Complete- body, fundus, and cervix
	Radical- entire utuerus, cervix, uterine tubes, overaries and proximal vagina.
	surgical types- abdomina, vaginal, total laparoscopic hysterectomy
	cause: PCOS, Fibroids, Cancer.
Menstrual terminology
Amenorrhea	absence of menses
	Primary- absence by age 16
	Secondary- absence of menses for 3+ months, who had period before
	Post OCP- failure to resume ovulation 6 months after discontinuing hormonal contraception
	Gonadotrophic amenorrhea- pituitary hormones
	Hypergonadotrophic hypogonadism- high FSH low estrogen, no period. Menopause.
	Hyporgonadotrophic hypogonadism- low FSH , low estrogen, follicals not stimulated
	Normogonadotropic anovulation- seen in PCOS, normal FSH, LH but cycle Is disrupted, low progesterone.
	refer out: Consitiutional delay of growth and puberty (CDGP), DSD’s disorder of sexual development: turner syndrome,
	Mullerian agenesis, Androgren Insensitivty Syndrome (AIS), Kallman syndrome.
	Hyperprolactinemia- breast feeding, thyroid meds.
Prolactin	Anterior pituitary gland hormone for breastfeeding.
	Normal range- 25ng/mL
	Returns to 25ng/mL by 6 weeks of post partum. 25-40 mildly elevated. Highly elevated can cause amenohea
	Evelavate: galactorrhea, unusual periods. Sx of low estrogen, low libido, infertility,
Functional Hypothalamic Amenorrhea
(FHA)	Weight loss related, stress related, exercise related. Low estrogen and insulin, elevated cortisol
Normogonadotrophic Hypogonadism	hyperandrogenic anovulation- PCOS, androgen secreting tumor, cushing’s disease, Congenital adrenal Hyperplasia (CAH)
	hypothyroidism
	Outflow tract obstruction- Asherman’s syndrome (Uterus adheres to itself), Cervical stenosis
PCOS (20%)
Polycystic Ovarian Syndrome	SX: menstual dysfunction, anovulation, follicles that have not released, elevated androgens (hair on face)
	diabetes, sleep issues,FSH weaker with LH much stronger. Can have PCOS w/o polycystic ovaries
Abnormal Vaginal Bleeding
excessive or irregular	Average is 35-40 ml blood (double espresso cup)
	Heavy is >80 ml blood. Mot heavy is 80-200 ml blood per period.
causes	Structural: polyp, adenomyosis, leiomyoma, Malignancy
	Non-strucutral: coagulopathy, ovulatory, Endometrial, Iatrogenic, Non: IUD
	Menorrhagia: >7 days at regular intervals 24-35 days. Excessive >80ml, change menstural products every 1-2 hours, clots
	Metrorrhagia: bleeding that occurs at irregular frequent intervals especialy between periods
	Menometrorrhagia: bloth heavy bleeding and irregular frequent intervals
	Oligomenorrhea: bleeding that occurs at intervals >35 days, “infrequent period 4-8/year
	Polymenorrhea: menstrual cycle that is less than 21 days.
	ovulation bleeding: spotting between cycles at time of ovulation
	Dysfunctional Uterine Bleeding (DUB): abnormal uterine bleeding not due to structural or systemic disease.
Ovulatory vs Anovulatory abnormal bleeding	Ovulatory abnormal bleeding: regualr cycle with PMS symptoms, ex: menorrhagia
	Anovulatory abnormal bleeding: irregular or infrequent periods with variable flow,
	No ovulation is No corpus luteum si no progesterone causeing prolonged estrogenic stimulation of the endometrium
	excessive proliferation, enometrial instability, and erratic bleeding. Ex. Oligomenorrhea,
	, and perimenopause.
	Ovulatory- BBT sustained rise, Luteal progesterone >3 Ng/ML, cleary sticky vaginal mucous,
Vaginal Bleeding in Pregnancy DDX	Normal: Implantation, hormone changes, sex, light bleeding, discuss with OB/Midwife
	Ectopic pregnancy: implantation outside the uterus, cramping, sharp pain, sx: 4-8 weeks after period. Rupture, shock.
	Gestational Trophoblastic disease (GTD): Abnormal tumors mode of trophoblastic (pre-pacenta) cells.
	Several different diseases, the most common is hydatidiform mole (‘nolar pregnancy”) causing miscarriage.
	Red flag- ectopic pregnancy- can cause sepsis and shock, death.
	Pacenta Previa- Placenta partially or completely covers the cervix could separate from uterine wall with cervical dilation.
	Spontaneuous abortion: miscarriage, noninduced embryonic or fetal death or passage of products of conception
	before 20 weeks gestation. Sx: crampy pelvic pain, bleeding, expulsion of tissue.
	Still birth aka Fetal Demise– fetal death after 20 weeks gestation. Sx: crampy pelvic pain, bleeding, expulsion of tissue.
	natural labor within 2 weeks or may require induction.
	Retained products of conception (RPOC) retained palcental and/or fetal tissue after Sab, induced abortion,
	vaginal delivery or cesarea delivery. Sx; postpartum pelvic pain, vaginal discharge, bleeding, possibly fever.
	Can cause life-threatening infection and or hemorrhage.
Benign lesions:	Cervical polyps- irregular bleeding, spotting, heavy period.
	Uterine polyps, fibroids, adenomyosis, endometrial hyperplasia, irregular bleeding, heavy periods
	Endometriosis- endometrium outside fo uterus, large lesions can disrupt ovaria function. Sx: severe pain
Malignant lesions	Cervical cancer, endometrial cancer can cause irregular bleeding, spotting, heavy periods
Infection	Cervicitis or endometritis can cause vaginal bleeding between periods and be asymptomatic
Trauma	Vaginal tearing after sex or childbirth, IUD perforation
Endometrial Hyperplasia (thickening)	Common sign of Hyperplasia is abnormal uterine bleeding (ex: new onset menorrhagia, bleeding after menopause)
	Cause: excessive estrogen without progesterone. (No ovulation is No progesterone means lining not shed.)
	Comon in perimenopause, PCOS and other Anovulatory conditions. Not cancer but has a high risk of becoming cancer.
Endometrial Cancer	Sx: abnormal vaginal bleeding, change in period or bleeding between period or after menopause.
	10% of cases discharge associated with the cancer is not bloody. Pain in pelvis, feeing a mass/tumor, losing weight.
	Hysterectomy is tx.
Cervical Cancer	Frequently diagnosed in women age 35 to 44.
	no symptoms with early or pre-cancercervical cancers, symptoms arise when tumor invades other tissue
	Abnormal vaginal bleeding, after sex, bleeding after monopause, bleeding between periods, long and heavier period.
	Unusual discharge from vagina, may contain some blood and may occur between period or after menopause.
	Dyspareunia- pain during sex
Other systemic diseases with bleeding
Coagulopathies that cause menorrhagia	vonWillebrand disease- type of hemophilia caused by missing or defective vonwillebrand factore (VWF) clot protein.
	Thrombocytopenia– low platelets. Ex. Low B12, leukemia, liver failure, Immune Thrombocytppenic Purpura (ITP)
	Auto immune disease, disseminated Intravascular ocagulation (DIC), chemotherapy, Lyme disease.
	Leukemia- common in patients with AML and ACL. Blood cancers.
Iatrogenic/medications cause of bleeding	Anticoagulant therapy- warfarin, Eliquis, Xarelto, does not cause but can worsen
	Intrauterine device (IUD): Hormonal (Mirena, Sykla) amenorrhea, spotting, copper (para-guard Menorrhagia, cramps
	Hormonal therapy: oral contaception pill (OCP) to regulate period, cause spotting.
	Estrogen replacement therapy- can cause vagnal bleeding
	SERMs: Selective Estrogen Receptor Modulators: used in ER-postive breast cancer, infertility, osteoporosis (Tamoxifen)
Psychotropic agents	such as valproic acid, aripiprazole, haloperidol, chlorpromazine, risperidone can cause Hyperprolactinemia
Dysfunctional Uterine bleeding (DUB)	aka Abnormal uterine bleeding in the absence of recognizable pelvic pathology, general medical disease, or pregnancy
	considered a diagnosis of exclusion, must rule out other causes.
Western management of abnormal bleeding	Medical: Irregular periods: oral contraception
	Menorrhagia: OCP, Tranexamic acid (Lysteda): antifibrinolytic med. Hormonal IUD.
	Surgical: Hysterectomy, endometrial ablation, surgery to remove fibroids.
Reproductive Tract Disorders
Uterus	Adenomyosis– growth of enometrium inside the myometrium. 20-30% of uteri-containin population
	risk factor: middle age, multiparous status, hisotry of gynec. Surgery. Diagnoses in 40-50’s.
	presentaiton: dysmenorrhea, menorrhagia, chronic pelvic pain, underdiagnosed, dyspareunia
	cause menorrhagia more than endometriosis.
	Physical exam: may be normal, diffusely tender, boggy, spongy, squishy, suggestive of adenomyosis.
	Adenomyosis is in myometrium and endometriosis is found outside
	the uterine cavity causing inflammation, adhesions and cysts.
	Endometriosis- 25-30 yo, endometrial mucosa abnormally implanted in locations other than uterine cavity.
	Responds to cyclic hormonal fluctuations. Arbitray- can be minor or severe. Affects uterus, ovaries, pelvic peritoneum.
	Stage 1: minimal and superfical adhesion.  Stage II- mild above and deep leisons.
	Stage III: moderate- ovary and elsewhere. Stage IV: severe and large endometromas infilrate other organs
	sx: involving uterus, ovaries, posterior pertonieum, dysmenorrhea, dyspareunia, low back, bloating, nausea, inguinal pain
	Uterine Fibroids- Leiomyoma which is benign, overgrowth of smooth muscles and connective tissue. 70-80% develop this.
	5-20% are problematic. Classified as submucosal, intromural, subserosal, pedunculated.
	presentation: aymptomatic, menorrhagia, prolonged period, pelvic pressure, frequent urination
	main complications- blood loss, anemia, constipation,urinary retention. TX complications- scarring, adhesions, infertility.
	Uterine Cancer
Uterine Tubes	Ectopic pregnancy
Cervix	HPV/abnormal PAP
	Cervical Dysplasia
	Cervical Cancer
Ovaries	Ovarian cysts– common, type I- follicular cycst from unruptured follicle. Type II: Dermoid cyst, Cystadenoma
	asympomatic, usually found on transvaginal sonogram. Any stage in life. Sx: pain lower ab, unilateral pain from rupture.
	PCOS
	Benign ovarian tumors
	Ovarian/Adnexal Torsion
	Ovarian Cancer
Fertility Case review	What to do first?
	Look at symptoms and call it for what it is without jumping to a diagnosis
Avoid:	going from Symptom to diagnosis or worse,
	going from a disease to a diagnosis.
Assessment Pt signs and Sx: menses	Prolonged bleeding x 10 d. | excess blood loss -> blood vacuity, dryness
	Spot thick brown x6    |   blood stasis
	Heavy red painfuly clotty x2     |  blood stasis
	spot x2
	PMS fatigue, headache, breast/pelvic pain px    | menstual movement disorder: Qi stagnation and blood stasis and heat
	Cystic Acne
	Night sweats PMS and OV time   | leakage during cycle transitions
	Occ pink spot mid cycle
10 questions	cold hands and feet: qi stagnation in the center or cold?
	Sweaty palms with anxiety: heart heat steaming fluds or yang Qi xu?
	Chronic Sinusitis: damp phlem accumulation in upper
	Frequent head colds: weakness on the exterior
	Bloat with certain foods: Qi stagnation in center
	Chronic constipation: Heat/Dry? Stagnation?
	BM anal/vagina px: excess in lower jiao
	Frequent urination, burning: excess DH in the lower
	T: pale, red tip, puffy, scalloped , wet white frothy: vacuity, heat above GB/Liv, Damp accum in SP, Damp accum in lower jiao.
	P: forceful, wiry: heat, stagnation
	Ab: distened and form: excess stagnaiton
Excess v Deficient
Hot v Cold
Wet v Dry
Which Zhang fu?	Liver: qi, blood movement and nourishment (pain, pallor). Stasis (bloat, Cold) -> heat (red tongue, burning urine
	Spleen: absorption transform/transport of body fluids _> damp. Stasis-> damp accumulation -> Damp heat in Lower qi/blood stasis
	5 elements: Sp- Liv line.
	6 conformations: Yang ming and Shao yang blocked
	Excess patterns need to be treated first.
Treatment principles	Clear heat, drain damp in lower jiao, Regulate qi and blood
acupuncture:	Li11 to clear heat, SP9 GB34 to drain damp, Li4, Liv3 and St25 to regulate qi, Sp10, 6, St29 to regulate blood.
Formula	Zhu ling Tang + Da Cha hu tang +tao ren. Raw 2 monts with modification.
	Patient was pregnant in 5 months.
Common GYN presentations in Infertility	Always start with Menstrual cycle: bleeding, not bleeding, irregular cycles, pre-menstrual syndrome, dysmenorrhea
Blood Phase: what could go wrong?	Too much, prolonged, Starts then stops then starts again, No blood, Pain.
Bleeding disorders: Abnormal uterine bleeding	1. Dysfuntional Uterine Bleeding (DUB) No anatomicla or malignant case
	2. Menorrhagia: heavy bleeding more than 2 days of cycle during menses
	3. Flood ing and Spotting (Beng-Luo): heavy and spotting bleeding.
	4. Metrorrhagia: breakthrough bleeding between menstrual cycles
diseases of abnormal bleedingL	infections (PID)Trauma, fibroid/polyp/Myoma, Blood clot disorder, PCOS, hormonal disorder, Peri-menopause, Cancer,
	bleeding after sex, IUD/OCP, pregnancy, miscarriage, Ectopic
Refer out Uterine bledding	Post-coital: rule out cervical cancer, polyps, infection
	Post menopausal: rule out endometrical/cervical cancer
	In pregnancy: confirm viability of fetus with OB or Midwife
Healthy bleeding:	7 day period, bleed heavy 2 days or 7 days total is too much blood loss.
Heavy flow:	35-40 ml blood (double expresso cup.)
	Heavy: losing >80 ml blood. Some as much as 200 ml
Palm-Coein: causes of heavy menstrual bleeding	Structural causes: polyp, adenomyosis, Leiomyoma (fibroid), malignancy.
	Non-strucutral: coagulopathy, ovulatory, Endometrial, Iatrogenic, Non: IUD
Stages of treatiing bleeding	1. During bleeding , “When acute, treat the branch” to avoid hemorrhage.
	2. When bleeding has stopped: clear residual stasis if spotty, stop/start
	3. Confirm patients pattern and constitution to determine the treatments:
	a. cool if hot
	b. warm if cold
	c. Drain excess
	d. Supplement vacuity
	4. Regulate and supplement the vacuity that remains: must replensih.
TCM abnormal bleeding	Blood stasis, Heat in Blood, or Yang Qi vacuity
	1. Blood stasis- is always a branch. The blood leaves vessels ude to blockage in normal pathway.
	Sx: pain, cramping, sharp and fixed. Clumpy blood with hard clots.
	Purple , dark, red, brown or black blood.
	Purple on tongue, blood spots, SLV
Blood stasis causes	Dark and dry scanty complexin and skin
	Deficiency: to weak to move, must tonify
	Cold: slows, freezes: must warm
	Heat: simmers and thickens: must cool
	any stasis: blocks movement, must move
what is a blockage:	Bleeding: leave abandoned blood
	Qi is the commander of the blood, If Qi regulated, bleeding should be normal. If Qi stagnant, blood does not move smoothly- stasis.
	Stasis causes Heat. TX: clear out obstruction so blood returns to normal pathways and improve quality of blood.
	5 element: SP/ST and Liv/GB are primary
	in 6: Yang ming and Shao yang: yang conformations will regulate Zang counterpart.
Treatment of bleeding, excess blood stasis,	Acupuncture: Li11, ST25, ST29, SP10, SP6, Liv2, Liv5
and heat in blood (Yang ming)	Tao he Cheng Qi Tang: tao ren, da huang, Gui zhi, Mang xiao, Zhi gan cao
Treating Bleeding due to excess blood stasis	Acupuncture: SJ5/GB41, GB34, Liv2, 5, SP10,6.
and heat in blood (Shao yang)	Dan Zhi Xiao yao San
Treating Bleeding due to excess blood stasis	Acupuncture: SJ5/GB41, GB34, Liv2, 5, SP10,6.bleed- liv1, PC3, and UB40
and FIRE in blood (Shao yang)	Long dan Xie Gan Tang
Bleeding with Stasis with qi stagnation PMS	sx: breat pain, bloat, irritable, stress.
	regulate qi to harmonize blo0d: Liv3, Li4, PC6, SP4
Formulas for blood stasis	Tao Hong Si Wu tang
	Shi Xiao San
modifications due to heat	Excess heat: di yu, Bai moa gen, Zhi zi, Chi Shao
	Damp heat: Qu mai, Bian Xu, Mu tong
	Charred herbs for heat: Huang Qin Tan, Huang bai tan. Jing jie Tan, Shen di huang tan, Ce bai ye tan
acupuncture bleeding due to heat	Clear heat and cool blood: Liv2, liv5, liv8, Pc3, UB40, SP10, Kd2, LI11
	Protect Yin: Kd3, KD6, SP6, Liv8, Ren4
	Restrain Bleeding: xi-cleft points KD8, SP8, Liv6, Du20
	excess blood stasis: 4 gates, Sp6, Sp10, ST29 right side only for these points makes it stronger
Bleeding due to Vacuity
key signs for bleeding due to blood vacuity	Pale, watery gushy blood (Beng-luo), possible mushy clots
	Pale tongue, lavender or puffy
	pale complexion
	Lax muscles, skin
	Generalize fatigue and weakness
	5 Zhang fu- Kd, SP, Liv
	In 6: Tai yin, shao Yin affecting jue yin
Blood coming out with it should not:	Leakage in the East: Jiao Ai Tang
	Acupuncture: Du 20, si shen cong, SP 1,3,4, ST36, Ren 4,6
Bleeding from Stasis with vacuity	If Qi/blood vacuity: Dang Gui Bu xue Tang  sx: fatigue, worse with exertion, weak pulse, pallor
	If kidney vacuity (low back weak, poor libido, cold) mu li and long gu. Moxa
Deficient cold blood stasis causing bleeding	Leak in the east: Wen Jing Tang
	Acu: du20, KD 12.13, SP 1,3,4, ST36, Ren 4,6 and moxa. Must warm to tonfiy to contain.
Acupuncture and vacuity bleeding	Can needle left side to support, moxa. SP4/PC6 chong combo, Du 20, Ren4, St36, SP6, SP1
what does prolonged bleeding tell you?	Blood is coming out when it shouldn’t for too long.
	Do differentioan diagnosis: Excess or deficient? Blockage or leakage? Hot or Cold?
course of treatment	Most should have rapid response to stop bleeding treatment during bleed if diagnosis is correct
	Vacutity cases may take 3 cycels, but should have improvement progressively
	Treating the pattern is essential to preventing recurrence.
What does start/stop bleeding tell you?	Blood is not moving smoothly. Treat as blood stasis but find the root cause.
	At the end of bleeding, harmonize blood to break up residual blood stasis and allow for new blood
	After bleeding, Nourish the blood only if needed to improve absorption capacity and Sp and KD.
No Bleeding: Amenorrhea
Primary Amenorhea	absence of menses by age 16 in the presence of otherwise normal secondary sexual characteristics
	or by age 14 if secondary sexual development has not occurred.
	Causes: congenital, or outflow tract obstructions
Seconday Amenorrhea	absence of menses 3+ months in a person who has had periods before.
	common causes: Pregnancy, Menopause, PCOS, and FHA (functional hypothalmic amenorrhea)
	Causes: pregnancy, prolactin, FHA, PCOS, POI/POF, Menopause
Post OCP amenorrhea	Failure to resume ovulation 5 months after discontinuing hormonal contraceptive.
FHA (functional hypothalmic amenorrhea	Hypothalmus not releasing rhe GnRH gonadotrophins affecting the FSH and LH secretions.
	3 types: weight loss-elated, stress-related, exercise-related.
	Resltins in low estrogen and insulin and eleveated cortisol (stress hormone) which can lead to
	osteopenia, osteoporosis, cardiac events, mental health issues.
Hyperprolactimemia/Prolactinoma	Begnin tumor (adenoma) of pituitary gland
	Autopsy found 25% of population has a pituitary tumor, 40% prolactin secreting.
	Cliniclaly significant ademons effect 1/7000 causing amonorrhea, impotence, and infertility.
	Elevates prolactin which suppresses ovulation and promotes lactation
	WM tx: dopamine agonsits or surgery
prolactin	hormone made by anterior pituitary for milk production
	normal serum range <25ng/mL
	usually returns to less than 25ng/mL by week 6 postpartum even with breast feeding.
	Mildly elevates to 25-40ng/mL
	High prolactin can supress GnRH causing amenorrhea , prolactinoma
Premature Ovarian Failure (POF)
Premature Ovarian Insufficiency (POI)	POF/POI also called early menopause (FSH>25)
	Meanses cease prior to age 40 (U.S. avg. is 51)
	Approx. 200,000 women diagnosed per year.
	Irregular cycles stop and estrogem depletion causes menopause symptoms: hot flash/ night sweats, dryness.
TCM: “Bi Jing” (blocked period)	1. Uterus blocked from discharing blood
	Yang ming Dryness
	Blood stasis or Phelgm obstruction
	2. Not enough blood to bleed
	Insuffienct/depleted SP/KD, Chong/Ren
Tx:	Yang Ming/Shao yang: Tao he Cheng qi Tang, Xiao Chai Hu tang, Xue Fu Zhu yu tang
	Gui zhi fu ling wan
	Acupuncture: Ren 3,4, ST25,29, SP6,8, Liv2,3, Li4
“Opening throutgh” down and out of body	Lack of opening thorugh can cause amenorrhea, dysmenorrhea, PMS, uneven flow, miscarriage, infertility
	Unbloking in a vertical way between upper and lower jiao
	Improves connection between the heart and uterus, stasis that blocks Ren and Chong mai
what are we opening through:	digstion- bowel, bladder, or blood stasis
	Breast/chest: painful PMS
	Spirit: manic and agitation PMS
	menstruation: blockage in blood, Ren mai cannot open, no bleeding, scanty or painful bleeding
When do we open thorugh?	Fullness, pain, stagnation, rebellious, lacking a flow, no bleeding.
	Open just before Menses if having a period.
Deficieny causes no bleeding	warm and invigorate. Wen Jing tang, Dang gui si ni tang
	acupuncture: ren 4,6, St 25, 36, KD3, 13, SP6 , UB17,18,19,20, 23, Du20
Shao Yin Weakness	Yang def./cold:Jin Gui shen qi Wan add KD points and moxa.
	Ba zi ren wan: connects HT and uterus. Add PC6/SP6, ht7
Tai Yin deficiency no bleeding	Spleen: Dry and def. , dry mouth, lips, GI weakness. Dang gui Jian zhong Tang, Ren 4,6,12, ST36, SP4,6, KD6,13, UB17,19, 20
	Too damp: accumulation can thicken into phlegm and block. Dang gui Shao yao san (enrich and regulare blood and fluids)
	Cang Fu Dao Tan Tang (regulate Qi and blood, resolve damp and phlegm)
	SP9,ST36, ST40, Ren9
Jue Yin weakness no blood	Si wu tang
	Dang gui Si Ni tang
	Wen jing tang
	Dang gui shao yao san
Tai yang not resolving, no blood	Gui zhi tang, cold types, easily tired,pale, anxious.
(Poor or no ovulation) PCOS	Ma huang tang: cold, dry, rough skin
Treating not Bleeding: two stategies
Defieicnet not bleeding enough	Def: Warm shao yin, steam tai yin, to fill jue yin and harmonize blood
Excess	Open through yang ming, open shao yang pivot
Acupuncture of Amenorrhea	Stasis must be cleared first. Vacuity must be moved very gently to not drain the pond to catch the fish
	SP6 main regulator
	Stasis Qi and Blood: Li4, Liv 2/3, St29, Sp8, 10, GB41
	Stasis of Damp-phlegm: St36/40, Sp9, St28, Rn9, GB34
	Support ST/SP: St36, Sp4/PC6, Du20, UB220/21, Ren 4,6
	Support KD: Kd3, 6,7, UB23, Du4, Ren 3,4
Very weak patients: may need moxa	ST36, Du20, UB 17,19,20, lower ren. Eval for primary or secondary amenorhea to manage expectations.
Amenorrhea- what is seen the most	Primary: no menarch by 17, not pregnant
	Secondary- menses stop 3 months, not pregnant
	Most common causes: PCOS, FHA  hypothalamic, Hypthyroidism, Post OCP
	Less common: POF, Anatomical, Hyperprolactinemia
Yang Phase and PMS	Unsmooth movment and suspended yang: getting hot, agitation, acne, liver gets tight.
	Wood element: PMS is a wood problem. Liver and GB so can be jue yin or shao yang.
	Wood governs smooth movement, and in an orderly way. Requires smooth flow of qi and blood.
PMS Phase emotional symptoms	Yang ming excess: hot temper, irrational behavior. LI11
	Shao yang Excess: grumpy, sad that comes and goes.
	Tai Yin: digestive distress, bloating, constipation, diarrhea, GI upset.
	Shao Yin: deficiency cold from unroot yang: deficency sweating
	Jue yin deficiency: blood not nourished, pale, vulnerable, anxious, insecure
	Tai Yang: not resolved “coming down with something” like a cold before period. Ying-wei need harmonization
Chai Hu frmulas to open up the west.	Si Ni san for Blood def.
	Xiao yao san for SP def and Blood def.
	Xiao Chai Hu tang for excess heat and SP def.
	chai Hu Gui Zhi tang- SP def and unresolved Tai Yang
	Da Chai Hu tang for excess in the middle and flanks
	Chai Hu long Gu Mu li tang for Damp, Upsurge/Yang rising and shen disturbance
	Xue Fu Zhu Yu Tang: blood stasis
Acupuncture	Excess stagnant Liver qi and Hyper yang Liver: Ren 6,17, Liv 2,3, Li4, Li11, Liv 14, PC6, SP6, GB20
	Deficicent and weak yang qi and Liver blood: UB17, 18,20, 23, ST36, SP6, Li4, Liv3
Pain with Bleeding- Dysmenorrhea	“Tong Zhi Bu tong, Bu tong Zhi tong” “If there is free flow, there is no pain, if there is pain, there is lack of free flow”. HDNJ
	Abdominal pain is one of the leading reasons people seek medical care. Especially women.
Chronic and Cyclic pelvic pain	Primary Dysmenorrhea- occures in the absence of a pelvic pathology
	Secondary Dysmenorrhea- results from identifiable organic disease.
	Mittelscherz (ovulation pain)
	Endometriosis
Primary Dysmenorrhea	Onset shortly after menarch < 6 months
	Usual duration of 48-72 hours just before or after flow
	Cramping or labor-like pain
	Lower abdominal pain and can radiate to the back or thigh
	Often unremearkable pelvic examination findings.
Secondary Dysmenorrhea	Begins in 20’s or 30’s, often after relatively painles cycels
	Can cause heavy flow or irregular bleeding
	Pelvic abnormality with physical examination
	poor response to NSAIDs and OCPs
	Infertility, Dyspareunia (painful intercourse), Vaginal discharge
common causes of Secondary	Endometriosis- menorrhagia (heavy bleeding) less likely, dyspareunia common
	Adenomyosis- often misdiagnosed as fibroids
	Uterine Leiomyoma (fibroid)- commonly and menorrhagia
Qi to Blood phase of period	Before: menses in Qi phase: qi stagnation type
	During: Blood phase, Blood stasis type
	Later: menses more deficient: vacuity type.
What does pain with bleeding tell you?	Blood is not moving smoothly
	Blood stasis is a BRANCH, must find the root to stop pain.
	Excess: worse with pressusre, tender, severe
	Deficient: worse with fatifue and exertion, better with pressure and rest.
	Qi Stagnation: distention and bloating, breast tender before bleeding.
	Heat: worse with heat, feel hot, will reject heat.
	Cold: severe pain, better with heat
Dysmenorrhea: quality	Dull and vague pain is more Qi stagnation
	Sharp and fixed pain is more Blood stasis
	Prefers heat is more cold type
	Prefers pressure is more vacuity type
in 5 zhang fu	Cold – Damp obstruction causing blood stasis
	Liver qi stagnation- causing blood stasis
	Qi and blood vacuity causing blood stasis
	Liver and Kidney vacuity of Yin causing blood stasis.
Where do we see blockage causing stasis?	In Yang ming and Shao  Yang causing heat
	Da Chai Hu tang for excess in the middle and flanks
	Acu: Ren 3,4, ST25, 29, Li4, Li11, Liv 2,3,5, SP 6,8,10. Liao points Shi Qi Zhi Shui (in the sacrum)
Deficient cold causing pain (melt the ice)	Tai Yin and Jue yin
	Shao Fu Yu Tang- Warm and invigorate blood
	Acu: Ren 4,6, moxa, SP4,6,8, UB20, 23, 32 and Moxa (Moxa box is good). Liao points Shi qi zhi xue
Qi and blood vacuity	Pain at end or after menses in pale, deficient type patient with fatigue, pain better with rest
	Ba Zhen Yi Mu tang (8 treasure pill to benefit mothers)
	Tonify with moxa: ST36, Du20, lower ren.
Liv/KD yin vacuity: dry deficient types	Pain at end or after menses more, mild, chronic in dry, yin vacuity type patient, dizzy, scantier bleeding, tongue reddish
	Tiao Gan Tang: regulare liver decotion
	Acu: Ren 4,6, SP 6,8, Liv 3,8, KD 3, Shu points.
Location of Pain	Liver: lateral abdomen radiating to thighs: Bai shao, Xiang Fu, Acu: Liv6 xi-chelf, GB27, GB41/TB5
	Kidney: low back, oftern dull. Du zhong. Acu: KD5, DU/Shu points, Liv14, UB 62/SI3.
	Uterus: middle abdomen and pelvis: Xu duan, SP8, ST29, SP4/PC6, LU7/KD6.
Irregular menses: early/late, no fixed cycle	Liver qi stagnation with varying degree of SP/KD vacuity, heat/damp
	acu: Liv3, SP6, LI4, ST25, Ren 4,6. if spleen: ST36, UB17, 18, 20
	Tonify for two weeks then move for two weeks.
	Herbs: Fu Qing-Zhu: regulare bleeding and timing. Ding Jing Tang (regulare the menses decotion)
	or Tiao Jing Fang (regulate menses formula)
acupuncture	Excess patterns: focus on regularing liver qi and blood to stabalize Chong and Ren: Liv 2,3,6,8,13, GB34, SP6m ST36, Ren4
	If blood not arriving on time: SP10, ST29, 30 or Liao points
	Vacuity pattern: focus on tonfiying to stabalize Chong and Ren: Ren4,6, KD3, SP6, UB 17,18,20, 23
	If blood not arriving on time: SP4, 10,ST29.30, Laio points
Extra Channels
Ren Mai	Conception vessel, must be open and unobsructed path to Bao gong, master to uterus and embryo during gestation: Lu7/Kd6
Chong Mai	Sea of blood, must be ful of blood, arises from uterus and ren mai, acts as a bridge to balance and connect pre/post natal essences
	and store blood. SP4/PC6
Dai mai	Belt meridia, holds in place. Too loose- discharge, miscarriage, sinking, too tights: stagnation. Guides and supports the uterus
	firm dai mai needed to maintain the uterus position during pregnancy and premenstrually. GB41/TB5. GB 26,27,28
Du mai	Controls all the Yang activity of the boy. SI3.BL62 (best for more physical issues)
Case Study 1:	CC: menstrual pain and heavy bleeding
	S: discontinued OCP 1 year ago, 27-28 day cycle, abdominal cramping, PMS, moddiness, breast pain
	facial acne, constipation, insomnia, facial flushing. High pain scale 0-6 is 6. 500 mg ibuprofen. Moves around to feel better.
	pain worse firs 2 dats, 104 days heay bleeding w/o clots. 7-8 days of changing pad.
	ROS: drinks water, eats good, dreads weak prior to period,
	T: red edges, slight dry. P: wiry. A: tight
Excess | Deficient, Hot | Cold ??	Excess and Hot
assessing the bleeding and pain:	Bleeding is heavy and gusy red: Heat type
	Not clotting- not static
	Pain: precedes bleeding : Qi movement not smooth
	pain is #6- severe blood stasis
	abdomnial- yin channels
	movement helps- stasis
ROS assessment	PMS, moody, breast pain, acne, constipation, insomnia, flushing: Wood related stasis, Heat, Yang ming closed
	Face: heat in face
	Tongue: heat in liver
	Pulse: liver excess
assessment:	liver qi stagnation with heat causing reckless bleeding, lacking smooth movement
TX principle:	soothe liver by harmonzing shao yang, Clear hat, cool blood, harmonize qi and blood
	Primary dysmenorhea and menorrhagia.
tx:	blood phase: sp6, 8, 10, ST25, 29, Li4, liv3.6 (regulate movement of blood, stop pain)
	Yin phase: ren 3,4, sp4/pc6, zigong, ST36, sp6, Kd3, Liv3, li4 (nourish and regulate to ovulation)
	Yang phase: Li4, liv2,3, GB20, du20, ren17, sp6, sp5/pc6 (regulate movement of Qi and blood, control yang
	Qi phase: Li11, xi cleft points. Strong movement of Qi. Cool.
	Jia Wei xiao yao san (with Shi xiao san during period)
Case study 2: Uterine Myoma	31 yo F, G 0, P 0
induced Menorrhagia and dysmenorrhea	CC: menstrual pain and heavy bleeding. Dx: uterine myoma, wants a baby
	S: pain and bleeding increases 4 months ago. Menarche at 11 yo. Normal 28 day cycle
	day 1 light red bleeding, increasing lateral and central sharp pelvic pain to sacrum.
	by day 2 pain and bleeding most intense with large dark mushy clots. About a 3 day period.
	pain is 5 out of 6, relief with heat pad, takes advil, increase in fatigue, intolerance to cold, thirst and constipation
	P: weak and thin, empty on left cun. T: pale dry, think white fur
	Ab- soft
assessment bleeding and pain	Bleeding: stasis from vacuity, vauity bleeding, losing blood vacuity.
	pain: SP/Liv/Kid channels, sharp pain- blood stasis,
	vacutiy pulse and tongue
Final	Vacuity of yang qi SP/KD cause blood vacuity and stasis
Causes of Female Infertility
Infertily	male 30%, Female 30%, both 10%, unexpalined 25%, other 5%
Female	Ovulatory disorder, endometriosis, unexplained, Uterine/Cervical, tubal/Peritoneal
	aging, 35 and up: fewer eggs in ovaries, eggs not as healthy, health condition causing infertility, likely to have miscarriage
	other: smoking, excessive alchohol, extreme weight heavy/light, excessive physical and emotional stress
Impediments to fertility	Ova: mature enough, old, few
	Ovulation: failure due to PCOS, FHA, Hypothyroid, prolactinemia, dimished ovarian reserve, premature ovarian failure, thyroid
	Fertilization: healthy cervical mucus, tubes open
	Implantation: anatomical obstructions, myoma, septum, adhesion, polyp, tubal, endometriosis
Ovarian factor infertility: 40% of cases	anovulation, oligo ovulation, POF, PCOS
	Failure to ovulate- fail to conceive. Quality and quantity of eggs decrease with age
ovulatory cycle:	BBT sustained rise
	Luteal progestoerone >2 NG/mL
Basal Body temperatue BBT	at first waking get temperature. Typically 97 in follicular phase, 0.5 in luteal phase (increase by .5)
	oral or vaginal, progesterone will increase heat in yang phase, thermal shift for many days.
	Plot on chart- 97.8….many days ovulation (small drop) then 11 days it is usally 98.5. get the coverline.
Vaginal discharge NORMAL	1-5 mL (1 tsp is 5mL
	color- clear, colorless, white, pale yellow, red (blood)
	discharge is most copious in ovulation
	common to confuse normal vaginal discharge with vaginitis
Cervical mucus	changes throught the menstrual cycle. Early follicular- pinkish to red, brown, purple dark
	Mid- follicular- minimum
	Late follicular- yellow, whoite, cloudy, sticky
	Ovulation- clear and slippery, egg white
	Luteal- sticky, gluey, thick white
Vaginits- infectious	Candidiasis- not an STI, white cottage cheese, yesty odor
	Bacterial vaginitis- not STI, grey thin water and fishy odor
	Trichomoniasis- STI, greenish discharge
	Infectious cervicitis- gonorrhea, chlamydia, HSV-2 all STI.
	Refer patient with unusal discharge.
Anovulation	Hormonal imbalance, low GnRH, high Androgen, high prolactin
	Tyroid dysfunction
	PCOS polycystic ovarian syndrome
	functional hypothalamic amenorrhea (FHA)
	Irradiation from cancer treatment
	Premature Ovarian insufficency/failure
	Menopause
Functional hypothalamic amenorrhea (FHA)	Post OCP amenorrhea (birth control)
	Low BMI from isufficent nutriton, excessive exercise, stress
	Premature Ovarian insufficency/failure
Yin Phase and Ovulation	No growth, no moisture, no warmth, no ovulation,
	Follicles flaccid: vacuity
	Follicles frozen: cold
	Follicles gooey: damp/phlegm
	Follicles blocked:  stasis
Tai yang – moving north to south	Tai yang carries yin and yang up and out to the surface in eastern direction to become harmonzied ying and wei.
	Vacuity patterns: amenorrhea, delayed ovulation, scanty bleedning due to dry and deficient
	Excess pattern: amenorhea, blocked ovulation or delayed cycle due to frozen surface unable to absorb and transform.
	Deficiency leakage: Gui Zhi type formula
	Frozen blockage: ma huang type formula
	Deficient Tai yang, Ying and wei not harmonized yang goes up and yin goes down, not integration of yin and yang
	Classic Ying-wei is anxiety. Aversion to wind and cold is agitation and insomnia, tight muscles- flushing up, thin body- sweat,leakage
Tai yang minifests jue yin patterns	Gui Zhi tang treats middle dryness deficiency and dry blood patterns, connects uterus back to heart.
	Flaccid follicles- ming men fire is weak, middle burner not extracting good quality qi and blood. KD and SP not making growth.
	Fatigue, poor spleen transform/transport, skin saggy, edema- Bu zhong Yi qi tang for the SP/KD vacutiy
	Frozen surface of ovary- ma huang is used to unblock frozen tai yang, bring warmth to the surface and push yang qi up and out.
	Ma huang is used with amenorrhea, cysts, anovulatory cycles, long cycles, scanty bleeding, dry blocked surface w/cold shao yin
	Ma huang Xi Xin Fu zi tang- at ovulation (EWCM) . Shao yin poor warming, Tai yin poor steaming, jue yin not juicy, cold body
pain at ovulation with blood stasis	at lu lu tong, wang bu liu xing, and wu Zhu yu
	Gui zhi fu ling wan if PCOS
	add Moxa
Uterus obstructed and clogged” Gooey	Transform phlegm and damp, awaken uterine gate: Cang fu Dao Tan Tang and Tao Hong Si Wu tang
	Unble to burst tai yin and shao yin, impaired amenorrhea, GI damp, phlegm lumbs, cysts, slippery pulse, swollen tongue
	Tian Hua Fen/Mu li- 20-30 gm
	Acu: SP9, ST40, GB26,27, Ren12
Acupuncture to induce ovulation	Ren3,4, zigong, Kd3,5,6, or 7, UB23, 52, SP4,6, PC6, ST36, Li4, Liv3. estim at EWCM
	ovulation symptoms: liido change, bloating, cervix positons, senses heightened, body temp up, spotting
	e-stm: black on ziogn, red on ren4, rend on ren3 and black on zigong
PCOS Polycystic ovarian syndrome	If not nourished, blood becomes think. Sea of blood stops, East affected, the Ren does not open through, west affected.
	Cells not absorbing nutrients so are malnourished like in insulin resistance, Excess gloucose in the blood not
	getting to cells which then crave sugar. Chronic stress also pushes sugar into blood.
	Often from chemically modified , sweets. Adipose cells created to store poisons , may be overweight.
	Affects 1 in 10 of child bearing age in USA. 2 or more: irregular/absent menses- intertility, hirustism, acne, thinning hair,
	, Insulin resistence, weight gain, ovarian cysts.
	It is a spectrum of symptoms and pathologic findings and laboratory abnormalites.
Heterogeneous	Women with PCOS may display a wide range of clinical symptoms but they usally present in three primary:
	these are menstrual irregularities, infertility, and symptoms of androgen excess.
	Not al women with ovarian cysts have PCOS, but all women with PCOS have ovarian cysts.
Western medicine Treatment of PCOS	Hormones: combo of OCP or Progestin pill or IUD if not TTC (trying to conceive)
	If TTC Clomid, letrazole or injectible gonadotropins to induce ovulation.
	Metaformn/Inositol to regulate insulin resistance. Side effects: weakness, diarrhea, gas, low blood sugar, nausea, chills, dizzy, GI isues
	Spironolactone for Acne.  (not at time of TTC)
	Inositol for PCOS: 2000mg of myo-inositol plus 200 ug of folic acid 2x a day for 3 months reduce aMH levels in polycystic ovaries.
	It increases the eqq quality and reduce risk of ovarian hyperstimulation  syndrome in woemn undergoing ovulation induction.
TCM medicine	Patterns: Amenorrhea, irregular/Delayed cycle, Abnoral uterine bleeding
	Etiologies: Kidney vacuity +/- phelgm/damp stais
	Spleen vacuity + damp/phlegm
	Liver imbalance +/- heat/Blood stasis
Opening through” to vitalize blood	Harmonize the menses, fine tune to regulate flow. When blood is thick the sea of blood stops flowing and
	ren vessles does not open through. Thick blood is like the blood of men: it does not flow down but becomes facial hair.
	When there is fullness above and lack of bleeding below, there is late, scanty or absent menstruation most often due to PCOS.
	SX: fullness, pain, up bearing symptopms, lack of smooth flow of menses.
	TX: before menstruation acupuncture ” ST29, Liv5, SP8, Ren17, 3. Herbs: Niu xi, Rao Ren, Hong hua, Yi mu Cao, Wang Bu Liu Xing.
Dr. Wu on PCOS	If constitution weakness of Kidney, PT will have HX of late menarche, delay or absent cycle.
	Weak Kd yag does not support spleen yang which then cannot properly transform causing damp/phlegm.
	Weak KD yin can cook fluids into phlegm cysts.
	Poor diet, overthining/worry, can damage spleen.
	Chronic frustration/stress can impair Liver spreading function.
PCOS pattern:	Kidney def. with damp phlegm. Sx- late menarche, delayed or absent cycle, fatigue, back pain, weight gain, hirsutism,  FSH low, LH high
	TX: Yi shen Dao Tan Tang, Tu si zi, xu duan, yin yang huo, gou qi zi, Cang zhu , fu ling, dan nan xing, Zao jiao, dang gui, Huai Niu xi, Gui Zhi
	Stagnation of Damp-phlegm: SX: anouvulatory cycle with fatigue, lethargy, nausea, chest fullness, bloating, poor appetite, loose stool
	vaginal discharge, greasy skin, cyctic ovaries
	TX: Cang Fu Dao Tan Tang: Cang zhu, xiang Fu, Ban xia, fu ling, Shi Chiang pu, Dan nan xing, Zao jiao Ci,
	Bei Mu, Zki ke, Dang Gui, Chuan Xiong
PCOS acupuncture	Kidney Def.: kd3, ren 3,4,6, UB23, Sp6
	Spleen def.: St36, Sp3, 4, Ren 12, UB20
	Yang def.: du4
	Yin Def.- Kd6, UB17,18
	Empty heat: Kd2
	Damp-phlegm: Sp6, St28, ST40, Ren9
	Blood stasis: SP8, SP10, Liv3, ST29
	Liver qi stagnaiton: Liv3, Li4, GB34, GB41, Liv14, UB18
Combing WM 60-70% respond to TCM well.	If 3 months no improvement, consider metaformin or Inositol for TTC
	If Amenorrhea- consider progesterone induction to prevent hyperplasia
	Can combine or alternate with Clomid or Letrazole to reduce E@ antagonist side effects like LPD, thin endometrium
	Dietary advice for Insulin resistant patient.
Luteal Phase Defect (LPD)	3-10% in infertile women
Short luteal phase due to:	Lutenizing hormone (LH) inadequate
	Insufficent progesterone
	Poor endometrial response to normal progesterone
	BBT: minimal rise in Luteal phase, <12 days, delayed rise, early fall, horseshoe type luteal phase.
	WM tx: progesterone supplementation +/- hCG injection.
LPD and TCM	KD vacutity +/- Liver Stagnation
	Kd yang vacuity: You gui Wan
	Kidney Yin Xu: Zuo gui Wan
	Liver Stagnation: Xiao yao San
	Treat 2-3 months without TTC to reduce miscarriage risk.
	Acupuncture: SP and KD tonic points: Du20, moxa if Yang Xu.
	Once thermal shift achieved focus on stabilize LP at ST36, Sp3, SP6, KD3, Ren4, Shu points.
	If Saw tooth BBT (uneven rise and fall of BBT) add 4 gates.
LUFS: Luteinzed unruptured follicle syndrom	Follicle does not rupture and no egg is released despite s/sx of ovulation, biphasic BBT.
	Can occur in 23% of normal menstrual cycles.
	Frequent in women with Endometriosis, PID and unexpalined infertility
	Only detectable with ultrasound.
TCM medicine patterns	Kd vacuity and blood stasis: short shift slow rise/gradual fall in luteal phase.
	Herbal: Yi Shen San yu Fang. Ovarian door opener – Ma huang.
	Acupuncture: tonify KD, move qi and blood and use moxa.
	Kd vacuity and Liver qi stgnation- slow rise with sawtooth, more PMS, irritable and stress. Dry and deficient. Takes longer to help.
	Herbal: chai Hu Shu Gan San
	Acu: 4 gates and kd points.
	Liver and Kidney vacuity: lower temps, short overal low shift, scant CM, thin and late light bleeding
	Herbal: Yang Xue Tain Jing Fang
	Acu: Tonify KD points
	Damp-heat with blood stasis: high temp, slow rise, pure excess pattern, long-term infertility, PID, Endo.
	Herbal: Qing Re Tong Luo Fang
	Acu: mid-cycle move with SP6, SP9, St25, ST28, ST29, GB26, GB34, stim: ren3, ren4, Zigong
	If poor response move blood/warm kidney at mid-cycle.
Thyroid effects on Infertility	Hypothalamus- releases TRH to pituitary gland which release TSH to Thrid which creates T4/T3 back to pituitary and hypothalamus.
	metabolism and overall function of the body.
	Thyroid can disrupt the mentrual cycle making it harder to conceive, interfere with prolactin, ovulation and cuase luteal phase defect.
	It can reduce sperm count in men. Increase risk of miscarriage in women. Premature birth risk.
	Normal range TSH is 0.5 to 4.0 mIU/L but not when TTC.
	TSH ghigher than 4.0 can impair fertility 2.- to 2.5 is preferred.
	Requirements 30% higher in conception and first trimester.
	2nd and 3rd trimester guidelines recommend between 3.0 and 3.5 mIU/L
	Higher TSH associated with higher FSH, lower AFC and aMH (antral foolicle count and anti mullerian hormone)
Hypothyroid	5% of population, 5-10x more likely in females and increases with age/genetic link
	Can result from irregular ovulation, increase rsik of miscarriage, elevated prolactin levels, luteal phase defect
	SX: weight gain, fatigue, constipation, cold, thinning hair, pale skin, menstrual and fertility disorders. Often in PCOS patient.
	Refer out if having these symptoms. Get thyroid checked.
WM tx hypothyroid	T4: Levothyroxine, synthroid, Levoxyl
	T3: Cytomel
	glandular tyroid from pigs (Armour Thyroid)
	Side effects: hyperthyroid, palpitations, sweating, tremors, irritability, insomnia, increased appetite.
	Long term can effect bone density and cardiac health.
tcm	shao yin and Tai yin- ming men not brining fire to tai yin to transform and steam up. Not absorbing and transforming- dry or fluid accum.
	Treat based on hot or cold, excess/def, often support KD yang , Kd and Ht points.
Hashimotos (autoimmune thyroidism)	chronic inflammation, hypothyroid signs, 1-2% of population
Hyperthyroid and Graves Disease	1-3% population, 4-5% older women. Graves is in younger (immune), 30% develop Graves opthalmopathy (eye disease)
	SX: anxietty, insomia, tremor, palpitations, heat sensitive, goiter, menstrual and fertility disorders.
	weight loss, sweating, agitation, fatigue, muscle weakness, thinning hair, rapid pulse.
TCM	Fatigue: qi not available either deficient or blocked
	Cold: Yang qi not warming
	Delayed menses: irregular
	hair loss, dry skin: lack moisture and nourishment
	Constipation: slow LI movment
	Irritable/depressed: emotions stagnant, blocked
	Poor libido: ming men fire weak
	Weight gain: poor transformation of pathological fluids.
	TREAT BASED ON PATTERN, SIGNS, AND SYMPTOMS!
Ovarian Cysts	Common. Fluid filled sac in or on ovary. Most are harmless and self resolve, some can torque and burst.
	Functional type 1: follicular cyst from unruptured follicle. Corpus luteum cyst after ovulation
	Type 2: Dermod cyst/teratoma (embryonic), Cystadenoma (if large can rupture), endometrioma.
	Only problematic if pain or cycle problems exist or result of IVF.
TCM	Zheng Jia= fixed or mobile abdominal masses
	Chang Tan = soft masses at the sides of the abdomen
	Type 1 funcitonal: support spleen, resolve damp, +/- blood stasis , +/- heat, very common in IVF cycles.
	Type 2 solid cysts: Move qi and blood, +/- damp and heat, must rule out tumor markers before treating.
Treating functional cysts	1. Can follow some principles as PCOS treatment
	2. Dr.. Liang;s Qi and blood stagnation treatment. Qi stag. Xiang leng Wan. Blood stasis- Gui Zhi Fu Ling Wan
	3. Dr. Wu’s spleen damp +/- heat or +/- stasis. Liu Un Zi tang and Wu Ling San if SP qi def w/damp=phlegm.
	Kai Yu Er Chen Tang: for phlegm accum. And blood stasis (pain and distention). Qing Re Li shi Tang: damp-heat with blood stasis.
	WM: OCP or surgery. Cysts 4 cm should be referred.
	Zao Jiao Ci- bursts Cysts and promotes ovulation.
Type 2 cysts TCM tx:	Gui zhi fu ling wan if qi and blood stagnation. Cyst with matter and fluid, PMS.
	Ju He Wan: damp=phlegm and blood stasis: heavy, achy, clotty, bleeding.
	Mu Jia Xiao Zheng Fang: damp-heat with blood stasis.
Acupuncture	Spleen def and damp phlegm: Sp3,4,6,9, St25,28,36,40. Pain: sp8, Kd5, Liao pts., Mid cycle- 4 gates, sp10, st29/30
	Phelgm and blood stasis: same with more moving parts during entire cycle.
	Damp heat and blood stasis- phelgm as above and Liv2,5,11. mid cycle GB34, Sp10, ST29/30
	Qi and blood stasis: 4 gates, GB34/41. Liv14, St25, Sp6,10, St28/30 or liao pts. Mid cycle same
	Lifestyle- adequate rest and diet. Eat seaweed.
Obstructive Infertilty Disorders Implantation	Tubal blockage, Myomas, Endometriosis.
	Tubal infertilty is 25-30% of all cases. Fallopian tube prevent sperm from reaching ovum. Infections like gonorrhea or chlamydia. PID,
	Hysterosalpingogram- if abnormal laparoscopy.
	Tx: surgical or IVF
Ectopic pregnancy	SX: positive pregnancy, vaginal spotting, one sided pelvic pain, bowel surgery, severeal abdominal or pelvic pain, bleeding, lightheaded.
uterine Factor infertility 2-5% of cases	Congenital or acquired- polyps, fibroids, PID. Embryo failure to implant, surgery can fix. TX: IVF with gestational surrogate.
Leiomyomas aka uterine Fibroids	Pelvic masses occuring in 20-50% of women >30. 4 types: intramural (within uterine wall), Subserous (outside uterus),
	Submucosal (penetrate into endometrium), Pedunculated (on a stalk).
	Myopma problems: menorrhagia, Dysmenorrhea, infertility, pegnancy complications, rectal and bladder Sx.
	Will atrophy in menopausal women. Surgery is 5cm with GnRH agonist and FSH analogs.
herbs	Hai Zao Yu Hu Tang if bleed and pain is not severe
	Avoid Tu Si Zi, seeds that tonify myomas and cysts.
acupuncture	transform phegm and regulate qi and blood, stop pain and bleeding: sp4, 6,8,9,10, ST 25,36,40, 4 gates, Ashi, if heat Liv2, Li11, GB34.
Endometriosis and Adenomyosis	inflammation of uterine lining, adhesions, cysts. Adenomyosis is endometrial tissue in the myometrium
	sx: chronic pelvic pain, dysmenorrhea (80%), Menorrhagia (40-60%), abdominal masses, dyspareunia, rectal and bladder pain.
	WM TX: OCP, surgery, diagnosed via laproscopy.
TCM and Enometriossis	Need IVF to get pregnant. Pain similar to Dysmenorrhea.
	patterns: Qi and blood stagnation, Blood stasis due to cold, Blood stasis due to heat, phlegm and blood stasis, Blod stasis qi vacuity
	Blood stasis and KD vacuity.
herbs	Gui zhi Fu Ling Wan, Dang gui Si Ni tang, Wen Jing Tang, Wu Mei Wan, Dang gui Jian Zhong Tang. Dang gui Shao yao San
	Hot compreses, herbal pastes.
Immune infertilty and miscarriage	Autoimmune disorders:
	Anti phospholipid antibodies (APA) is most common
	Anti Sperm antibodies (ASA)
	Anti Tyroid antibodies (ATA) hashimotos
	Anti ovarian antibodies (AOA)
	Anti endometrial antibodies (AEA)
Understanding Biomedical OB/GYN
terminology: Pelvic pain, Fertility, Pregnancy
Acute Pelvic pain
Non-gynocologic	Genitourinary 9infection, stome). Gastrointestinal (appenditis, gastro enteritis, IBS, Diverticulitis), Musculoskeletal
Gynecologic- Pregnant
extrauterine	Ectopic pregnancy**
Intrauterine	Placental abruption**, spontaneous abortion, labour, molar pregnancy
Gynecologic: non-pregnant
Uterus	Fibroid, enodmetriosis, adenomyosis. Pyometrium, Hematometra, Congenital Anomaly, Dysmenorrhea
Ovary	Tubo-ovarian abcess**, Tortion**, Ovarian cyst, endometriosis, ovulation pain.
Fallopian tube	Tubo-ovaria abcess**, PID, Torsion, Endometriosis, Hydrosalpinx
**obstetrical EMergency	**Gynecologic cancer- uterine cancer, cervical cancer
Chronic and Cyclic Pelvic pain
Cyclic or Recurrent pelvic pain	Primary Dysmenorrhea, Mittelschmerz, Endometriosis
Non cyclic chornic pelvic pain	Endometriosis, Pelvic adhesions, cystic ovaries.
Painful menstruation	Dysmenorrhea: primary or secondary. Primary occurs in absence of pelvic pathology. Secondary: identifiable organic disease
	Primary: after menarche, 48-72 hour before or after flow, cramping, labor like pain, low abdominal pain, to back or thigh.
	Sx: malaise, fatigue, nausea, vomiting, diarrhea, low back, headache
	Tx: NSAID, OCP, IUD, exercise, heat pad, acupuncture and herbs.
	Secondary: 20s-30s, heavy menstration, irregular bleeding, pelvic abnormality, NSAID poor response,
	infertility, dyspareunia, vaginal discharge.
	Endometriosis- menorrhagia, dyspareunia, , Adenomyosis- 40s, Uterine leiomyomas- menorrhagia.
	Mittelschmerz- mid-cycle pain, Sx: unilateral pain, can alternate sides per cycle, 20-25% women experience.
Chronic Pelvic pain unrelated to cycle	can be chronic, episodic, recurrent: endometriosis, fibroid, PID, IBS, intersitial cystitis, pelvic congestive syndrome,
	pelvic adhesions, MDA, sexual abuse, depression.
diffuse or porly localized abdominal pain	adrenal isuficency, angioedema, aortic aneurysm, appedicitis, ascites, bowel obstruciton, colitis, dehydration, diabetic ketoacidosis,
	drug side effect, enometriosis, herpes zoster, IBD, IBS, mesenteric ischemia, PID, peptic ulcer, peritonitis, sicle cell, syphilis, SLE
Infertility
Impediments to Female	Ova: not mature enough, too old, too few, Dor- diminished ovarian reserve?
	Ovulation: failure due to PCOS, FHA, hypothyroid, Prolactinemia?
	Fertilization- cervical mucus healthy, tobes open?
	Implantation: anatomical obstruction, Myoma, Septum, adhesion, Polyp?
	Defined by location: “tubal factor infertility” or “Cervical factor infertility”
	5 types: Ovarian, Tubal, Cervical, Uterine, Peritoneal
Ovarian Factor infertility	Failure to ovulate is 40% and most common of all cases. Anovulation, Oligo ovulation, POF
	Ovarian reserve testing:  blood Anti-mullerian hormone (AMH) ideally  >1. Follicular Stimulating hormone (FSH) CD 2-5 Ideally <10.
	Ultrasound: Antral Follicle Count (AFC) with FSH Ideally > 3-8 per ovary.
	Treatment: Fertility drugs, egg donation, IVF
Tubal Factore Infertility	Abnormalites/damage to fallopian tubes, prevents sperm from getting to ovum. Congenital or acquired.
	Common: infections like gonorrhea, chlamydia, w/wo PID, tuberculosis or ruptured appendix.
	Post surgical scarring, enodmetriosis.
	Detected by HSG hysterosalpingogram. Iodine and flouroscopy (x-ray)
	TX: surgery or IVF
Cervical factor Infertility	5-10% of cases. Two types:
	Abnormalites of mucus-sperm interaction: mucus needs to be thin and watery 9Spinnbarkeit) and not contain ASA anti-sperm antibodies
	Stenosis: Cervix too narrow- congenital, scarring
	TX: intrauterine insemination (IUI)
Uterine Factor Infertility	2-5% of cases. Congeintal or acquired defects. Bicornuate uterus, large polyps, large Fibroids, PID
	can cause failure of embryo to implant or grow
	some can be fixed surgically or IVF with surrogate.
Peritoneal factor infertility	Abnormalities involving the peritoneum (scar tissue or endometriosis)
	Adhesions of tubes or uterus may impact fertiliztion or implantation
	Peritoneal factors are hypothetical cause of infertility in patient with endometriosis in pelvic cavity with no other endometrial implants that
	would affect fertility.
LPD- Luteal Phase Defect	LH inadequacy, insuffiencent progesterone. 3-10% of infertile women.
	Minimal rise in BBT after ovulation. TX: Progesterone supplementation +/- hCG injection.
LUFS Lutenized unruptured Follicle syndrome	Follicle does not rupture and no egg is released despite s/sx of ovulation biphasic BBT.
	ovulation dysfunction, common in women taking Clomid.
	More frequent in women with Endo, PID and unexpalined infertility. Detectable with ultrasound.
Blighted Ovum (leading cause miscarriage)	Gestational sac develops without an embryo. Embryo never or stops developing. Usually seen in first few weeks of pregnancy.
	Sx: minor cramping, light spotting, bleeding.
	Similar to a chemical pregnancy. Eventual miscarriage may occur or may require medication or procedure to remove.
Female hormone Panel	FSH 3mUi min. 10 mUI max. cycle day 3-5
	LH 2 mUI min. 10 mUI max. cycle day 3-5
	Estradiol 25 pg min., 75 pg Max., cycle day 3-5
	Prolactin 0 ng min., 20 ng max., cycle day 3-5
	Progesterone >5 ng, cycle day 21
	AMH 0,7 ng min, 3,5 ng max.,
FSH	follicular stimulating hormone released, start new menses, not pregnant. Peak CD 2-3 values <10 ou/ml ideal, up to 20.
	Ifi elevated, indicates ovarian reserve lower. Normal to see slight elevatin with aging. High in POI/POF and perimenopause.
	Males- can indicate chomosomal or testicular abnormality.
LH	Lutening hormone relased by pituitary to stimulate/trigger egg release 2-10 iu/ml is ideal. LH suregs tested in ovulation prediction kits.
	LHL: FSH ration 1:1 normal 2:1 or 3:1 indicates PCOS. Low levels in malnutrition or anorexia
	In males LH triggers testosterone releae.
TSH	Low Thyroid Stimulating hormone can interfere with ovulation. Normal I s 0.2-4.7 iu/ml.
	for fertility, often advised <2-2.5 for duration of TTC-> pregnancy and postpartum
	Not unusual to see FSH and TSH both rise in Menopause. Both influence bone remodeling.
Estradiol	E2 Estradiol is primary circulating estrogen in reproductive age women 30-400 pg/ml NL.
	Highest at ovulation, lowest at menses. E1 Estrone in menopause. E3 Estriol in pregnant women.
	Secreted by the ovaries to encourage the growth of follicles, Uterine lining, and cervical fluid.
	Can surge IVF cycles and perimenopause. Collapses in Menopause <30 pg/ml
Progesterone	relased by corpus luteum in ovary after ovulation, creates the thermal shift on BBT. Sustains the lining until conception occurs.
	If no conception, P drops until lining releases, triggering new cycle.
	Normal range is 5/-20 ng/ml 9unless pregnant) highest CD 21 or 1 week after ovulation
	Low levels indicate less viable follicles or poor endometrial response, chronic stress-> cortisol can low progesterone.
	SX: spotting irregular cycle, increased miscarriage risk.
Prolactin	Secreted for breastmilk. Abnormal levels can induce galactorrhea in both genders and suppress ovulation in female.
	Causes: pituitary tumor, hypothyroid, medications for depression and HBP, herbs: fenugreek, fennel seeds, red clover. Stress, foods.
	No cause found in 1/3 of all cases.
	NL levels 25 in women and 80-400 in pregnancy and postpartum.
AMH and Inhibin B	Anti Mullerian hormone secreated by Follicle 1-4 NL
	<1 indicates poor ovarian reserve. Measured with CD 3 FSH and AFC (Antral follicle count) can indicate Ovarian Aging and Egg count
	An endocrine marker that reflects the transition of resting primordial follicles to growing follicles, decrease near menopuase.
	Inhibin B is low in women with diminished ovarian reserver >45 pg/ml considered WNL.
Testosterone	Moderately elevated in Adrenal hyperplasia and PCOS. Low in ED and Peri-menopause
	NL range in males is 270-1070 ng/dL
	NL range in Females is 15-70 ng/dL
Ultrasound and AFC	used to visualize the Uterus and ovaries for abnormalities in anatomy, lining, cysts, polyps.
	Oftern CD 3 with FSH to measure AFC and ongoing through ART to measure ovarian response in follicle production and ovulation.
	3-8 ovary avg. but varies, hyperstimulation in ART a concern , not unusual to see many in PCOS.
Ovarian reserve	1-2 million ovarian follicles at birth. Eggs continuouly lost so by puberty 100,000 to 400,000 eggs left.
	At the onset of menopause most only have <1000 eggs left. Loss of eggs accelerates after 35 yo.
	1 egg is ovulated but 10-20 follicles are activated each month and reabsorbed (atresia).
Ovaria reserve Test	FSH >10 can be a sign of low eqq number and DOR (diminished ovarian reserve)
	AMH <1 indicate lower eqq number and growing follicles, too high can indicate PCOS.
	AFC: number of follicles on each ovary to estimate the number of eggs available that month. Number fluctuates each month.
Ovulation Predictor Kits (OPKS)	Urine on stick, Tests for LH, confirms ready to ovulate, ovulation up to 36 hours. Sperm live for 5 days.
Fertility Treatments
Cascade of invertentions	Hysteroscopy/HSG/Endo biopsy- Clomind/Letrozole +/-IUI -> Injectiblres +/- IUI -> IVF/ICSI/PGS -> Donor egg/sperm or embryo.
Endometrial biopsy (scratch test)	If uterine lining is responding to estrogen and progesterone, can evaluate abnormal uterine bleeding. Doens 3-7 days before period.
Fertility Drugs	Clomind- oral med to stimulate ovulation, usually taken for 5 days in follicular phase.
	Letrozole/Femara- blocks estrogen at hypothalamus increasesing FSH and LH
	Lupron
	Injectible gonadatrophin/Agonists
	Antagonists
	Synthetic LH/hCG
	Progesterone
Injections	Menotrophins, FSH, hcG, GnRH, GNRH agonists and antagonist.
other drugs in treatment-	Progesterone for luteal phase, baby aspirin for clotting disorders
	Oral contracptives- prioir to ovarian stimulation to prevent ovarian hyperstimulation, control mentral cycle,
	GnRH agonists or antagonist can be used prior to IVF to suprress ovulation.
Intracervical Insemination (ICI)	Semen is places at the opening of the cervix. Sperm is washed, woman given trigger shot to ovulate.
Intrauterine Insemination (IUI)	used in low sperm count and motility cases esp. forward progression. Unexplain infertility, timed with ovulation.
In vitro Fertilization (IVF)	sperm and egg mixed in lab dish- fresh or frozen
	consultation- then baseline blood work- then ovarian stimulation- oocyte mature- egg retrieval- fertilization- embryo transfer
	then a 2 week wait- pregnancy test.
Intracytopasmic sperm injection (ICSI)	Developed in 1991- a micropipette injects a sinple sperm into the egg.
OHSS Ovarian hyperstimulation syndrome	exaggerated response to excess hormones due to injectable hormone medications to stimulate the development of eggs in ovaries.
	SX: after a week of the injectibles, up to two weeks. Nausea, vominting, diarrhea, abdominal pain, bloating.
	Severe: rapid weight gaon, severe abdominal pain, blood clots, decreased urinaiton, shortness of breath, enlarged abdomen.
	Risk Factors: PCOS, under age 35, low body weight, 20+ follicles stimulated, high estradiol.
	Complication: fluid in chest and abdoone, , electrolyte disturbance, blood clots, ovarian torsion, lung clot, miscarriage, death.
Donor Egg, sperm and embryo	often used in LGBT community or severe cases of infertility
Surrogacy	person carries the baby for you. Tight laws around the country. Check with your state.
Cryopeservation	Freezing egg, sperm, and embryo. Can do up to 24 years.
Pre-implant Genetic screening (PGS, PGD, NGS)	Aneuploid- abnormal. PGS removes one or more cless for IVF embryo to chromosomal testing.
	PGD- tests for specific diseases.
	NGS- next generation sequencing looks for defects.
Pregnancy	Gravidy- number of times a person has been pregnant, includes miscarriages
	Parity- number of pregnancies reaching 20 weeks, includes miscarriage/still birth
	G0P0- never been pregnant
	G1P0- currently pregnant or had spontaneous abortion.
	G2P2- two pregnancy and two children
Fertilizaton	Zygote forms, it secretes hCG human chorionic gonadotropin to preserve corpum luteum and sustain progesterone
	egg- zygote- 2 cell stagge- 4 cell stage- morula- blastocyst
Implantation	3-5 days after fertization zygote enters uterus. 5-8 days implantation in uterus, 9-10 days blasstocyst embeds in endometrium
	medically successful implantation is conception,
Amniotic sac and fluid	thin but tough sac tht holds empryo/fetus 10-12 days. The fluid is protective cushion.
Fetal age and gestational age	Gestational age- calculated by last menstruation. 16 weeks pregnant. Fetal age is ago from fertiliztion.
	Embryo is up to 10 weeks. Fetus is after 10 weeks.
	almost all organs are developed by week 10. Most malformation occur during the first 10 weeks: drugs, radiatin, viruses, alcohol.
	After week 10 structures form and grow, lungs and brain will continue, placenta is 18 to 20 weeks.
	viability is after 24 eeks, preterm is before 37 weeks. Full term is 37 weeks.
Prenatal visit labs:	PAP,HPV, urinalysis, CBC including hemoglobin and hematocrit.
	Hba lc (blood sugar) Rh factor blood type, STI- HIV syphilis, hepatitis, HSV, rubella, gonorreha, chlamydia.
	Thyroid TSH, , Vitams D.
Viability Ultrasound 7-9 weeks	verigfy pregnancy, determin gestational age, single or multiple pregnancy, location in uterus.
noninvasive screening	DNA, genetic disordes like Down Syndrome, Trisomy 21, Trisomy 18 Iedwards syndrome) Trisomy 13 (patau syndrome), sex of baby.
	Nuchal translucency ultrasound- checking the head and neck, nuchal fluid
	Ultrasound week 20- major organs, heart, spine, kidney, bladder, etc. genital/sex, placenta and umblical cord.
	HDFN- hemolytic disease of fetus testing.
	Gloucose tolerance testing for gestational diabetes
	Group B strep test for streptococcus infection.
	Braxton Hicks- contractions that start in early pregnancy- go to hospital or midwife.
Assisted Reproduction Technology (ART)
% of success for average couples	15% will have difficulty conceiving or maintaining pregnancy
	50% by age of 37 and 90% by age of 42 will have difficulty.
	20-25% of all couples trying to conceive will succeed in any given cycle.
	spontaneous Abortion (Sab age 30 is 10%, late 30s 18%, early 40s 34%.
	at age 35, live-birth rateis half of those younger women.
	Worse prognosis if trying is 4 years.
Contraception
Prevent STD	external condom, internal condom, diaphragms, cerival caps
	Oral contracptives pills (OCP), Depo Provera injection, contraception implant (nexplanon).. Birth control ring (Nuvaring)
	IUD’s Copper is Paraguard, Hormonal (Mirena, Kyleena, Skyla), Withdwal method, Rhythm method/BBT, Sterilization Tubal ligatio, vasectomy
	Emergeny contraception pill, Induced Abortion.
Lubricants	Most KY are too acidic for sperm. There are also sperm friend lubes like Preseed.
Male Factore Infertility	Sperm anatomy- Acrosome at head tip, Nucleaus in head, Centriole at neck, mitchondiral, start of tail, Axial filament is the tail.
risk factors	40 yo and older, Obesity, smoking, alcoholism, marijuana, testosterone replacement therapy, Radition exposure, high temperatures
	medications, environmental toxins like pesticides, lead, cadmium, mercury.
root problem	3 locations: Pretesticular, Testicular, post-testicular
Pretsticular	Factors that affect the normal hormonal regulation of the testicle
	Congential or acquired diseases of kypothalmus-pituitary axis.
	ex. Obesity, low testosterone, medications, steroids, narcotics.
Testicular causes	Foctors that affect normal sperm production by the testicles.
	Varicocle, undescended testicles, marijuana, alcohol, trauma to teticles, chemotherapy, testicular cancer, genetic factor chromosomal disorder.
	gential infections, prescription drugs.
Post testicular cause	Congential or acquired factors that affect the ability of sperm to travel from the site of production (testicle) to leave the body in the ejaculate.
	Hernia repair, absent vas deferns, ejaculatory duct abnormality, vasectomy, genital tract infection, cystic fibrosis, retrograde ejaculation,
	erectile dysfunction.
Lifestyle factors to infertility	Low BMI- weight loss associated with stress and eating disorders.
	Obesity: decresase sperm quality
	Extreme exercise- excessive secretion of endorphins interferes with the normal production of
	FSH and LH, associated with oligospermia (low sperm count).
	Excessive radiation damages the germinal cells. Lead, heavy metals, pesticides decrease sperm qualtiy.
Treatment:	Correct lifestyle factors
	Surgical correction of varicocele, tubal conditions
	Treatment of infections
	Clomid for low testosterone. *note is testosterone is not used.
	Complete Azospermia: surgical sperm  retrieval is used via needle.
	ART: can be successful with low sperm count, intrauterine insemination, IVF, and ICSI.
Semen Studies	3 major facotrs” Number, shape and motility
	volume: normal is >1.5 mL
	pH: normal 7.1 to 8.5
	concentration: 15 million/<L
	Motility: >40
	Morphology: > 4 (normal vs large head, small head, two tails, two heads, tapered head, abnormal mid-piece)
TCM and male Infertility	Low volume/spearm count: Yin and jing nourish
	Low Motility: tonify Yang and Qi
	Poor liquification: nourish Yin and Circulate Blood
	Impotence: Tonify yang
	Premature Ejaculation: calm shen, soothe liver, clear heat
	Morpology: Nourish Yin and Jing
	Wait 3 months before re-testing, sperm regenerate about every 74 days.
Kidney Vacuity
Kindney Yang	Sx: weak leakage, weak Libido: You Gui Wan
	poor motility- ba ji tian, yin yang huo, Suo Tang, rou gui
	Impotence: Sha Yuan Ji Li, Lu rong, Ba Ji Tian, Tu si zi
	Emission: Yi Zhi ren, Jin Ying Zi, Fu Pen Zi, Shan Zhu yu.
	Acu” Ren 4, Du 4, UB23, Ub52, KD 3, Kd7, Ear testes.
Kidney Yin	Sx: dryess, high libido, agitation from deficency heat- herbal formula: Zuo gui wan
	Low volume: Nu zhen zi, Han Lian Cao, Gou Qi Zi, Huang Jing
	Poor liquification: sheng di huang, mai men dong, dan shen, xuan shen
	Acu: Rn 3, UB23, UB52, KD3, KD6, SP6, Ear testes.
Wu Zi Yan Zong Wan (5 seed ancestor pill)	Impotence, poor erection, premature ejaculation, poor libido, infertility
	Gou Qi Zi, Fu Pen zi, Che qian zi, Tu si zi, wu wei zi
	elevates semen volume and sperm density in men with low sperm count.
Liver qi and Blood Stagnation	anger causes Qi to rise and obstruct, signing, wiry pulse. Xiao yao San or Xiao chai hu thang/Da Chai hu tang
	Duct blockage, Varicocele, ED: Wang Bu Liu xing, Lu Lu tong, Xiang Fu, Yu Jin, Zhi Shi, Bai shao
	Acu: 4 gates, Du 20, yintang, Ren3, ST 27/28/29, Ju yang medial to GB30 needle towards groin.
Damp obstruction +/- Heat	Damp obstructs Qi
	sx: heavier patient, tends to edema or greasy skin, malodorous skin flolds. Greasy tongue, digestive distress- bloat, relux, BM
	sluggish with gas, urinary burning.
	Marvel powders Er Miao San or Si Miao san, or Er chen tang
	Er Miao San is Huang Bai and Cang Zhu (Si Mao San and Niu Xi , Yi Yi ren)
	Acu: Sp6, St36, St40, Ren3, St28, Liv 3,5.
6 confluents apply- sperm is Tai yang phase
Best Semen herbs	Bai Ji Tian, Tu Si Zi, Sha Yuan Ji Li, Yin Yang Huo, Rou cong rong, Dang Gui, Gou Qi zi.
Unexplained Infertility	12 months or more of natural conception attempts for under 35
	6 months or more in women over age of 35.
	“Unexplained” is that all basic fertility tests are normal. 15% of al couples TTC (Trying to conceive).
Biomedical Infertility Work Up	1 year of TTC
	woman age 35 and up.
	history of male infertility
	History of endometriosis or PCOS (Polycystic ovarian syndrome)
	history of fallopian tube obstruction
	Known diethylstilbestrol (DES) exposure
	History of PID Pelvic inflammatory disease
	History of pelvic surgery
Female endocrinologist initial evaluation	blood work: hormones
	Pelvic Ultrasound
	HSG to check tubes
	Possible genetic testing
	Possible Endo Scratch
Male endocrinologist initial evaluation	Blood work for hormone levels
	Semen analysis
	Urologist eval for Varicocele
	Possible genetic testing
Infertility History of present illness Female	Hisotry of previus pregnancies and their outcomes
	Menstrual hisotry, frequency, patterns since menarche
	History of weight changes, hirsutism (hair), frontal balding, and acne.
Infertility History of present illness Male	Previous semen analysis results
	History of Impotence
	Premature ejaculation
	Change in Libido
	History of testicular trauma
	Existence of offspring from previous partners.
	History of any previous pregnancy in partners.
Assisted Reproductive Technology (ART)	CDC refers to ART as only when sperm and oocytes are handled, such as IVF but NOT sperm-only procedures like IUI.
	Some fertility clinics and websites will call fertility procedures as ART including IUI.
TCM on Fertility Drugs:	Hyperstimulation of the ovaries= pushes 3 Yin, exhausts blood, yin and Yang.
	How is an ovary able to discharge multiple eggs while using drugs and hormones?
	This is extractoin of “True fire” and it severs the root of life, and any such severing can last for generations.
	Ovaries become like a popcorn popper, but it is ovaries forced to produce eggs.
IVF stimulation	Ovaries are hyperstimulated to produce excess follicles  starting CD 3 x7-14 days.
	Folicular development closely monitores via bloods and TVUS until retrieval.
	hCG injection timed to release folicles prior to retrieval typically when follicles high teens (natural ovulation 20 mm)
	Numbers to watch: AFC, follicles mature at retrieval, how many fertilized, how many developed into Blasts, how many available to transfer,
	PGS (genetic testing) or freeze.
	Embryos transferred back to uterus after mature or tested.
IVF post-transfer	IVF egg insemination conventional or ICSI.
	Embryology culture (3-5 days)
	embryo transfer (can be fresh or frozen delayed (FET)
	Post-transfer waiting if implantation was successful
	Pregnancy test 10-14 days after embryo transfer.
Paulus study of 202 acupuncture and IVF	Significant increase inpregnancy rate using acupuncture the day of embryo transfer (ET).
	Pre ET: pc6, sp8, liv3, du20, st29
	Post ET: St36, Sp6, SP10, LI4, ear: shenmen, uterus, endocrine and brain.
Risks to Women IVF:	Ovarian hyperstimulation, multiple pregnancies, anxiety and depresssion, ovarian torsion, ectopic pregnancy, pre-eclampsia, pacenta previa
	placental separation and increased risk of cesarean section. Cancer risk is debatable.
ART stats	General IVF birthrate 25% of all ages.
	All AART: early 30’s 55% live births
	Age 43 and up: <4% birthrate
	Add TCM up to 50% chance increase.
Cost of IVF	15k to 30k
TCM and unexplaned fertility	1. Treat what you see: balance any patterns that present.
	2. Unless femal is over 40 (or known factor) advise treatment for 3 cycles.
	3. Educate how to use BBT
	4. if no success, refer to GYN or RE for initial assessment of both partners.
TCM and ART	BBT will be reflection of artifical hormones, therefore, often not used, but can still detect abnormalities.
	Do not over tonify during stimulation parts of cycle as overstimulation of ovaries high risk and can advance cycle too quickly (OHSS).
	Common to regulate phases of cycle with acupuncture alone.
How TCM helps:	Promotes the number of oocytes and sperm.
	Optimizes response to meds, but also moderate side effects.
	Resets proper function after failed ART.
	Help patients manage stress and calm mind.
	Stimulate pelvic micro circulation, improve blood flow to uterus and ovaries.
	Prevent or reduce OHSS
	Increase endometrial receptivity.
	Support older patients with poor ovarian reserve.
Studies on Acupuncture	Acupuncture on day of embryo transfer significantly improves the reproductive outcome in infertile women in randomized trial.
	Acupuncture and IVF: critique of the evidence and application to clinical practice.
	Reduces the stress of patient going through IVF, improves endometrial thickness, improves patient satisfaction,
	overall increase in pregnancy and live births. Up to 30% when acupuncture is used.
	increased implantation rate by 28%.
	increased IVF pregnancy by 33%.
	increased live births by 33%.
	decreased the risk of chemical pregnancy by 51%.
	manual acupuncture without stim increased pregnancies by 33%
	e-stim acupuncture increased IVF pregnancies by 41%.
	TEAS acupuncture (transcutaneous estim) increased preganancies by 32%.
Six stages to accompany IVF and ICSI	Prepare by regulating
	Down-regulate by nourishing
	Menstruation by purging
	Stimulation by promoting
	Egg collection- relaxing
	Embryo tranfer with consolidating.
Before Stimulation	Regulate and Nourish the cycle prior often OCP, Lupron or E2 prep
	Nourish blood and replishing jing: tu si zi, fu ling, chai hu, (KD yang def: fu pen zi, yin yang hou), er zhi wan (KD yin def)
Acupuncture before cycle	Regulate and support clearning the uterus and calming patient
	Du 20, yintang, Ear- sympathetic, uterus, Li4, Liv3, Ren 3,4,12, ST 25,28,36, SP 3,6,8,10, Li 11, Ht7, PC6, KD 3,6,7
Blood phase	Clear the Uterus, promote smooth menses to regulate bleeding/apin
	Herbal: Tao Hon si wu tang, Dr. Wu’s Taio jing Feng (dang gui, bai shao, xiang fu, yi mu cao, wu ling zhi, Pu huang, he shou wu, Zhi gan cao.)
	Acu: clear if stagnant and being to tonify blood and yin, if harmonious may possibly not treat until the end of bleed, CD5, unless treating bleeding
	Ren 3,4,6,12, ST29, pc6/sp4, SP6,8,9,10, Liv3, yintang, back shu points, ear
	Deficient patient: Ren 4,6, sp6, liv3, Pc6/sp4, St36
	Excess patient: Ren 3,4,St29, Sp6, Liv3.
	Cold patient- moxa abdomen
	Heavy blood: Liv 1,2, sp10, Liv8, Sp1
	Pain: Sp8, 4 gates, St29
	Damp: SP9, ST40, GB26, GB41 for discharge
	GI sx: Ren12, PC6.SP4
	Heart: yintang or shenmen to calm mind.
IVF starts	Number of follicles growing each side (ideal 3 to 8)
	Lining thickness (near 8m at retrieval)
	Once retrieved: how many? How many matured? How many fertilized? ICSI? How many blastocyst or frozen for PGS?
Yin Phase	Support growth of follicle and lining to prepare for ovulation
	Herbal formulas: Jane Lyttleton’s Gui Shao , Dr. Wu’s Zi Shen Tiao Chong Fang, Dr. Liang’s Ding Jing Tang
	Common herbs in all 3: Tu si Zi, Dang gui, shu di huang, Ba ji tan, Chai hu, Shan yao, Fu ling, Bai shao,
	Acupuncture: tonify and promote ovulation (estim) nearing ovulation EWCW
	Ren 3,4,6,PC5/SP4, zi gong xue, ST36, kd3,6,7,13, Ren 7, Du 20
Support ovulation	Add yang tonics and blood movers to use ovulation formula x3 days
	Cu Pai Luan Tang – dang gui, chi shao, chuan xiong, hong hua Dan shen, Ze lan,, ji xue Teng.
	Acupuncture: KD13, Ren 3,4, Zigong, GB26, PC6, HT7, Liv3, KD3, SP6,8, yintang, Du20, ear – ovary, shen men
Cautions in Yin phase	Follicles monitoring, if more than 12 risk of OHSS and could be life threatening.
	Becareful using blood movers as to not rupture follicle too soon.
Yang phase and Qi	strengthening support and SP and KD yang, keep rising, Yang under control.
	Consolidate chong and ren until pregnancy test
	Herbal formuals: Dr. Wu’s Yishen gu chong feng, Jane Lyttleton: Yougui or Zuo gui wan
Post transfer	assit blood circulation in uterus, maintain implantation, nourish embryo growth and gently relax the uterus to prevent contractions/miscarriage
	KD yang, An Tai Feng (fetus safety formula), KD Yin: Yang Tai Fang (Nourish Fetus)
	Acu: sustain yang, cool and calm if heat rising
	Du 20 to hold and calm , Si shen cong
	Ren 6, st36 boost qi, Zigong promote progesterone, DU4, BL23, KD3,7 boost kidney
	UB32 circulate blood for implantation
	KD6 if yang rising too much, Liv2/3, SP6
	LI11, SP10 for excess heat
	Ear: shenmen , kidney
Qi phase	Liv 2,3, PC6, SP4
Prevent miscarriage	tonify SP and KD, nourish blood, stop bleeding
	Herbal: Ba zhen Tang avoid fu ling and chuan xiong (draining and moving) add chen pi, sha ren, sheng jiang for digestion support
	Shou Tai wan (fetus support) with mod:
	heat- huang qin and bai shao
	Blood xu: shu di, gou qi zi, he shou wu
	SP vacuity: huang qi and Dang shen
	Damp: Bai zhu and Shan yao
	KD yin Def- shan Zhu yu, mai men dong
	Kd yang Xu- Sha yuan ji li, Bu gu Zhi
	bleeding from cold- Ai ye, Jing jie tan
	Bleed with vacuity heat- Han lian cao, sheng id huang
Early pregnancy	“the pulse of a woman is moderate, but the yin (chi) pulse is small and weak. She is thirsty and has no appetite, without cold and heat.
	this indicates a pregnancy and Gui zhi tang governs. In normal pregnancies, these signs should appear within 60 days.”

Western Biomedical OB/GYN Terminology
Obstetrical Complications	Ectopic pregnancy- implantation outside the uterus in fallopian tube. RED FLAG- send to ER if suspected
Perimenopause and menopause	seen in first 8 weeks of pregnancy with one sided pain, bleeding, pleateau to hormones.
Vaginal disorders	Hyperemesis Gravidarum- “Morning sickness”  excessive nausea and vomiting, can lead to dehydration, may require IV fluids. 1st trimester.
Reproductive cancers and Breast pathology	TX medications: diclegis and Zofran.
	Miscarriage/Sponteanous abortion. Loss of pregnancy <20 weeks. 80% of miscarriages occur in first trimester (0 to 13 weeks).
	Blighted ovum- embryo doesn’t devleop but leaves a sac on ultrasound.
	Week 6 a heartbeat can be found, “Missed miscarriage” no heartbet and embyro/fetus is not developing.
Miscarriages causes	Chromosomal abnormalites 50%
	Infections in uterus/cervix: listeria, parvo, toxoplasm, herpes, cytomegalovirus, rubella
	Uterine anatomical disorder- septum, large fibroid
	Clotting disorders- blood clot in pacenta, Lupus anticoagulation, antiphospholipid syndrome.
Still birth	Loss of pregnancy after 20 weeks. 1% of all pregnancies.
	Half of all cases have no known cause for the loss.
	Chromosomal, pacental, IUGR, infection can contribute.
High risk pregnancy 6-8%	Maternal factors (conditions prior to pregnancy).
	Pregnancy conditions: multifetal/multipregnancy, Gestational diabetes, Preeclampsia, genetic, Down syndrome,
	Neural tube defects: spina bifida, anecephaly.
PCOS	increases risk of Gestational diabetes
	hypertension and preeclapsia
	Macrosomia – high birth weight >9 lb.
	3x risk for sponataneous abortion
	premature delivery
Gestational diabetes	High blood sugar
	2-10% of pregnancy
	24th to 28th week.
	Asymptomatic – fatigue, poludipsia, polyphagia, ployurua (unusual eating, thrist, and urination)
	Cause knowns- possible hormones secreted by placenta causing insulin resistance.
	Most cases- diet, exercises, blood glucose checks.
	10-20% of gestational diabetes patients need insulin to control blood sugar.
Risk factors	over 25 age, NBP, history of family diabetes, oveweight, gain weight in pregnancy, expecting multiple babies
	PCOS, glucorticods, miscarriage or stillbirth n past, african, native american, asian hispanic.
Toxemia in Pregnancy	Hyperviscosity of blood- high rate of miscarriage, poor fetal development, neural tube defect, premature labor, pre-eclampsia
	post partum hemoohage, post partum depression, lactation issues.
Preclampsia and HELLP	Hypertension and Proteinuria- 20 wks, 140/90 BP. 3-10% pregnancies. 17 in 100,000 die.
	At Risk: previous PE, prematurity, HTN, >40 ys, IVF, multiples, Obesity, DM, Lupus.
	May cause placental abruption, Lu/Liv, KD failure
	Can advance Hemolysis, Elevated Liver Enzymes, Low Platelets (HELLP)
	Sx: severe headaches, changes in vision/blurred/light sensitive, upper rt. Quadrant abdominal pain, nausea, vomiting
	decreases urine output, thromboyctomenia(low platelets in blood), impaired liver function, shortness of breath, edema, weight gain.
	Complications: fetal growth restriction, preterm birth, placentral abruption, eclampsia, HELLP syndrome, organ damage
Eclampsia	pre-eclapsia and seizure can cause death or stroke
	1 in every 2000-3000 pregnancies a year.
	70,000 maternal deaths/500,000 fetal deaths worldwide per year. Maternal mortality 0-20% (lower mortality used, magneisum sulfate,
	beta blocker, immediate delivery.
Chorionic Villus Sampling (CVS)	Prenatal test to get sample of chorionic villi for chromosomal conditions like down Syndrome.risk of miscarriage, uterine infection
Aminocentesis	risks: leaking aminotic fluid, miscarriage, needle injury Rh sensitization, uterine infection Hep C, HIV,
Spina Bifida	Preventable with prenatal Folate.
Intrahepatic Cholestasis of Pregnancy (ICP)	Normal flow of bile is affected by increase in prenancy hormones and bile builds acids in blood. Last trimester, 1 in 1000 pregnancies.
	sx: itching palms and soles, nausea, RUQ paing, jaundice, white stool. Can cause still birth and resporatory distress.
PUPPPs rash (Pruritic Urtcarial Papules and
Plaques of pregnancy	itchy rash at stretch marks of stomach. 1/150 pregnancies.
	Risks: caucasian, first pregnancy, boy, PIH, rapid weight gain
Pre-term labor sx: 20-37 weeks.	backache that wont go away, adbomnal cramping, fluid/blood leaking vagina (Red flag), uterine contractions, call OB or midwife ASAP.
	Increased pressure on pelvis or vagina.
Premature baby risks (1/3 24-26 week will have)	Immature lungs, Jaundice, immature GI system, Anemia, Retinopathy, entercolitis, Sepsis, death.
Post term pregnancy >42 weeks	abnormal fetal growth, low amniotic fluid, NICU care, c-section, perineal lacerations, postpartum hemorrhage.
Breech Treatment	Normally cephalic by 28 weeks, majority by 32.
	Acupuncture weeks 33-35 most effective.
	Do not treat if tiwns, previous C-section, PROM, bleeding , Placenta previa, abnormal uterus, Oligo, Rh antiboes, Hydrocephalic fetus.
	Western: ECV (External Cephalic version, after week 38, 30-50% successful.
Placental abruption-	Premature separation of normally implanted placenta from uterus. 20 weeks
	Sx: vaginal bleeding, uterine pain, tenderness, hemoohagic shock.
	Tx: prompt c-section if maternal and fetal stability is threatened.
Placenta Previa	Placenta partially or completely covers the cervix, vaginal delivery not possible.
Perimenopause and Menopause	Clinical diagnosis- absence of period for 12 consecutive months, average age 51 (rage 40-58)
	POF/POI (early menopause less than 40 yo.
	SX: irregular periods to amenorrhea, hot flashes, night sweats, vaginal dryness, atrophic vaginitis/vaginal atrophy, insomnia, mood changes, anxiety
	Pre-menopause- no clear definition
	Perimenopause- 3 to 10 years before menopause, reduced production of estrogen and progesterone from ovaries.
	Red flag: bleeding after menopause. Polyp, cancer sign.
	other sx: forgetful, dry skin and eyes, body odor changes, gastric-like gas, constipation, acne, hairloss, incontines, UTI, painful intercourse
	poor libido,osteoporosis, thyroid and immune changes, skin sensitivity.
	Age 45 hormones drop, 51 hormones much lower.
STRAW stages of reproductive aging workshop
Menopause increase risk	Osteroporosis, Cardiovascular disease- hypertension, stroke, myocarditis, diabetes, Gingiitis, Periodontal disease, urinary incontinence, GSM
Estrogen	Hundred of estrogen receptoiprs around the body, decline affects cardiovascular, bone, cognition, behavior.
	Low- anovulation, irregular menstruation, aging, low weight, low cholestrol, excess exercise, breastfeeding, hypothyroid, medications.
Hormone replacement-	Premarin, or bio-identicla estrdiol lab synthesized from yam and soy.
Progesterone	normal menstrual cycle, breast development, maintain pregnancy, relax blood vessels, neurotransmitters in the brain.
	low sx: mood swings, irritable, anxiety, water retention, fibrocystic breasts
	Low- anovulation, irregular menstruation, aging, low weight, low cholestrol, excess exercise, breastfeeding, hypothyroid, medications.
	Progestins mimic some of the effects of progesterone, but have different actions on progesterone receptors.
Pregnenolone	precursor steroid hormone synthesized from cholestrol for all hormones
DHEA	made in adrenal glands, converted from prenenolne, a precursor to testosterone, estradiol, progesterone, considered an androgen.
Testosterone	low: one and muscle mass, thinning skin, vaginal dryness, low libido, incontinence, fatigue, aches, depression, memory lapse.
	high: PCOS, increases body hair, acne, weight gain, oily skin, irregular menstruation
Estrogen Post menopause	Choestrol, blood pressure, risk cardiac attack, 50% chance of a fracture of hip or wrsit, mental and emotional health, weight and metabolism
Hot flashes	Vasomotor- suden heat, 75% experience, 15% severe, highest is first 2 years of menopause, can last 5-10 years.
	Triggers- stress, spicy foods, hot drinks, warm environment, alchohol, caffeine.
	Tx: hormone replacement therapy, SSRI fluoxetine 20mg, SSNRI Venlafaxine 37-150 mg, Clonidine 0.1 mg, gabapentin 600-2400mg.
Hormone Replacement therapy (HRT)	People with an intact uterus need progesterone/progestin to protect the endometrium from hyperplaisa and endometrial cancer
	caused by unopped estrogen. A person with hysterectomy with menopause symptoms may be candidate for oral E2.
	Bio-identical hormone replacement therapy (BHRT) usues plant derived estrogens and/or progesterone.
	Risks: endometrial cancer. HT is effective for hot flashes reduce heart disease, osteoporisis, vagnal dryness and alzheimers.
	There is evidence that risk of stroke, hert disease, and breast cancer in HT by NIH and WHI (Womens health Inititive).
	Breast Cancer Risk: by up to 75%. Without HT 12% or 1 in 8 have a lifetime risk.
Contraindications of (HRT)	history of breast cancer, history of endometrial or uterine cancer, porphyria, liver disease, hypertriglyceremia, DVT, endometriosis, fibroid.
	Progesterone HRT side effects: dizziness, may help with sleep, water retention, migraines, acne, menstrual delay,.
Vulvovaginal disorders	Dyspareunia– painful sex
	Vaginisumus– involuntary conctractions of vaginal muscles
	Vulvodynia- chronic pain of the vulva without known cause.
	Vestibulodynia- pain in vaginal orifice, cutting or burning pain.
	tx: pelvic floor specialist can help with many of these.
	Vaginitos- inflammation of vagina, can have discharge, itching or pain
	Vulvitis– irritation felt externally in the vulva, may/may not have vaginal discharge
	Vulvovaginitis- irritation in both vulva and vagina
	Cervictitis: inflammatin, irritation, infection of cervix with vaginal discharge.
	Vaginal discharge- vaginal fluid composed of cervical mucus, exfoliated epithelial cells, bacteria and secretions. Appreance vary
	with hormones, irritation and infection.
	Candidiasis “yeast infection” candida yeast, not a STD, thick white vaginal discharge, dysuria, luteal phase. TX: Monistat, oral fluconazole
	Bacterial Vaginosis– Gardenerella vaginalis, related to sex but not STD, vaginal odor fishy, gray discharge, vulvar irritation. During or after period.
	tx: oral or topical antibiotic.
	Atrophic or Vaginal Atrophy: thinning of vaginal wall, 50% postmenopausal, itiching, burnging, irritation, UTI, Tx: lubricants, topical estrogen cream.
	Uterine Cancer: endometrial cancers, 6th most common, 5 year survival >80%. ,
	Average age is 60. Risk is estrogen therapy, PCOS, obesity, late menopause, early menses.
	Cervical dysplasia/Cancer: endocervix with glandular cells. Exocervix with squamous cells.
	Endo and ecto meet at squamocolumnar junction (SCJ). Most cervical cancers begin in the cells around the SCJ. Normal cells change.
	HPV- Huamn papollomavirus. 200 related visrus, 90% in sexually active men, 80% in sexually active weomen will be infected with at loeast one
	type of HPV. 50% are high risk strains. 10+ high risk HPV strains, 16 and 18 cause 70% of all cases of cervical cancer and other: anal, oral, penile.
	Low-risk HPV strains 6 and 11 cause 90% of all cases of genital warts. Verruca vulgaris and anogenital warts.
	Infection with HPV is comon and most people the body can clear the infection itself. Chronic infections however risk is cancer.
	Abnormal PAP: atypical squamous cell of undetermined significance, Squamous intraepithelial lesion, atypical glandual cells, Adenocarcinoma cells
	May restest in 6 or 12 months, may have coposcopy w/wo biospy, may have LEEP Loop electosurgical excision) for cervical dysplasia or
	referred to gynecological oncologist if cervical cancer.
	Cervical Intraepithelial neoplasia (CIN) are precancerous changes in a biopsy. Squamous cells pre-cancer (90% are squamous cell cervical cancer)
	CIN1- mild dysplasia, lest serious
	CIN2- moderate dysplasia with more abnormal tissue.
	CIN3- severe dysplasia, carcinoma in situ, most serious.
	ages 35-55, early cervical cancers , pre-cancers have no symptoms, might be abnormal belleding usual discharge, pain during sex.
	Ovarian Cancer- common in 55-64, no current screening. 85 to 90% are epithelial ovarian carcinomas.
	risks: Nulliparity, IVF, hereditary breast and ovrian cancer syndromes, BRCA! And BRCA2 inherited mutated genes. OCP can reduce risk.
	sx: bloating, pelvic or abdominal pain, troubling eating/feeling full, urinary symptoms.
Breast pathology	Breast mass- bret cancer or fibroadenoma
	Skin Ulceration: thickening, inflammatory breast abscess, infection or dermatologic.
	Axillary Mass- breast cancer with lymph node involvement, could be benign lymphadenopathy.
	Blood nipple discharge0 breast cancer, could be intraductal papilloma.
	Strong family history of breast cancer, SX: cough, bone pain, headache,
Presentations	Breast Cancer- lump is hard, immobile, fixed, irregular border
	Fibroadenoma- lump is well-defined, mobile, squishy, painless
	Fibrocystic change/diseas- chronic diffuse limpiness, worse with caffein, during luteal phase, cyclic with menstrual cycle.
	Duct ectasia- signs can inclue nipple retractin, inversion, pain, greenish discharge, perimenopausal.
	Intraductal Papillomoa- bloody nipple discharge.
Key stats:	1 in 8 or 12% of femal population. Most common type of cancer in women, second leading cause of death from cancer (lung is first)
	Most common symptom is a new lump or mass, most common type is ductal carcinoma of mammary duct, it can spread in blood or lymph.
Types	In Situ (Stage 0)- ductal carcinoma, Lobular Carcinoma
	Invasive breast cancer- Invasive ductal carcinoma, Invasive lobular carcinoma,
diagnosis	Mammogram, biopsy, ultrasound, Breast MRI,
	Stage I: <20mm
	Stage II: < 20mm to 50 mm, 1 node
	Stage III: >50mm, 2 nodes
	Stage IV: any size with metastases
TX:	Surgery, Radiation, hormonal, Chemotherapy, Targeted.
	Hormonal- SERM and Aromatase inhibitors.
	Tamoxifen (TMX) selective estrogen receptoor modularor,acts like anti-estrogren in breast cells. Can slow or stop growth of the cancer.
	side effects: hot flashes, vaginal dryness, modd swings. Blood clots, stroke, risk of endometrial cancer.
	Aromatase inhibitors- Letrozole, Anastrozole, Exemestane- block aromatase from making estrogen. Post menopausal women
	take the drug for 5 years and tamoxifen for 3 years. Reproduction age may just take the Tamoxifen first.
	Another option is doing ovarian suppression with a LHGH agaonist like goserelin (Zoladex) and leuprolide (Lupron) with chemo or oophorectomy.
	side effect: fewer side effects than tamoxifen, don’t cause uterine cancers or blood clots, just muscle pain and stiff joints, bone thinning, fracture.

Perimenopause and Menopause	Clinical diagnosis- absence of period for 12 consecutive months, average age 51 (rage 40-58)
	POF/POI (early menopause less than 40 yo.
	SX: irregular periods to amenorrhea, hot flashes, night sweats, vaginal dryness, atrophic vaginitis/vaginal atrophy, insomnia, mood changes, anxiety
	Pre-menopause- no clear definition
	Perimenopause- 3 to 10 years before menopause, reduced production of estrogen and progesterone from ovaries.
	Red flag: bleeding after menopause. Polyp, cancer sign.
	other sx: forgetful, dry skin and eyes, body odor changes, gastric-like gas, constipation, acne, hairloss, incontines, UTI, painful intercourse
	poor libido,osteoporosis, thyroid and immune changes, skin sensitivity.
	Age 45 hormones drop, 51 hormones much lower.
	Vasomotor (79%), Vaginal dryness (25-80%), Mood issues (26%), Sleep disruptions (25%)
	34% use hormone therapy, 12% use alternative medicine, 16% used both western and eastern, 38% go untreated.
Cognitive Dysfunction	Brain fog, poor concentration, feeling confused, thining slow, fuzzy thoughts, forgetful, lost words, mental fatigue, memory issues.
Mood changes:	PMS related, ongoing, irritability, quick temper, anxiety, depression, panic attacks.
Vasomotor (75% experience)	hot flashes, heat intollerance, night sweat. First 2 years of menopause, triggers: stress, anxiety, spicy foods, hot drinks, alcohol, caffeine.
pain syndromes	headaches, migraines, joint pain, frozen shoulder, muscle aches and atrophy, tingling limbs, shock like sensations.
sensory deregulation	itcy or sensitive skin, itchy ears, tinnitus, burning tongue or mouth, changes in taste, changes in body odor.
Dryness	vaginal, dry eyes, skin, mouth, brittle nails. Drying and thinning or vagina tissue can lead to vaginal atrophy, painful sex GSM.
	Thinning of vaginal tissue is due to a decrease in estrogen
Functional issues:	Fatigue, sleep issues, palpitations, poor libido, bloating/GI issues, dizziness/vertigo, urinary incontinence.
Menopause increase risk	Osteroporosis, Cardiovascular disease- hypertension, stroke, myocarditis, diabetes, Gingiitis, Periodontal disease, urinary incontinence, GSM
Estrogen	Hundred of estrogen receptoiprs around the body, decline affects cardiovascular, bone, cognition, behavior.
	Low- anovulation, irregular menstruation, aging, low weight, low cholestrol, excess exercise, breastfeeding, hypothyroid, medications.
Hormone replacement-	Premarin, or bio-identicla estrdiol lab synthesized from yam and soy.
	contra: breast cancer history, endometical cancer history, porphyria, liver disease, hypertriglyceridemia, DVT, Endometriosis, fibroids,
	side effects: nausea, bloating, weight gain, fluid retention, mood swings, breakthrough bleeding, breast tenderness.
	OTC: Estrovera, Remifemin, Femmtrinol, Bonafided (Relizen) Amberen, Embr Wave, Funcho Chocolate bars.
Progesterone	normal menstrual cycle, breast development, maintain pregnancy, relax blood vessels, neurotransmitters in the brain.
	low sx: mood swings, irritable, anxiety, water retention, fibrocystic breasts
	Low- anovulation, irregular menstruation, aging, low weight, low cholestrol, excess exercise, breastfeeding, hypothyroid, medications.
	Progestins mimic some of the effects of progesterone, but have different actions on progesterone receptors.
Pregnenolone	precursor steroid hormone synthesized from cholestrol for all hormones
DHEA	made in adrenal glands, converted from prenenolne, a precursor to testosterone, estradiol, progesterone, considered an androgen.
Testosterone	low: one and muscle mass, thinning skin, vaginal dryness, low libido, incontinence, fatigue, aches, depression, memory lapse.
	high: PCOS, increases body hair, acne, weight gain, oily skin, irregular menstruation
Estrogen Post menopause	Choestrol, blood pressure, risk cardiac attack, 50% chance of a fracture of hip or wrsit, mental and emotional health, weight and metabolism
Hot flashes	Vasomotor- suden heat, 75% experience, 15% severe, highest is first 2 years of menopause, can last 5-10 years.
	Triggers- stress, spicy foods, hot drinks, warm environment, alchohol, caffeine.
	Tx: hormone replacement therapy, SSRI fluoxetine 20mg, SSNRI Venlafaxine 37-150 mg, Clonidine 0.1 mg, gabapentin 600-2400mg.
Hormone Replacement therapy (HRT)	People with an intact uterus need progesterone/progestin to protect the endometrium from hyperplaisa and endometrial cancer
	caused by unopped estrogen. A person with hysterectomy with menopause symptoms may be candidate for oral E2.
	Bio-identical hormone replacement therapy (BHRT) usues plant derived estrogens and/or progesterone.
	Risks: endometrial cancer. HT is effective for hot flashes reduce heart disease, osteoporisis, vagnal dryness and alzheimers.
	There is evidence that risk of stroke, hert disease, and breast cancer in HT by NIH and WHI (Womens health Inititive).
	Breast Cancer Risk: by up to 75%. Without HT 12% or 1 in 8 have a lifetime risk.
Contraindications of (HRT)	history of breast cancer, history of endometrial or uterine cancer, porphyria, liver disease, hypertriglyceremia, DVT, endometriosis, fibroid.
	Progesterone HRT side effects: dizziness, may help with sleep, water retention, migraines, acne, menstrual delay,.
Medical menopause	Chemotherapy, Hormaonal therapy, PID, GnRH agonists used in Endometriosis and ART, Tamoxifen. Trauma to ovaries, radiation, POI.
	surgical like Bilateral oophrectomy, ovarian cancer, tumors, Hysterectomy (with ovaries removal).
Premature menopause (POI/POF)	Osteroprosis, heart disease, earlier death, Parkinson-like symptoms, Anxiety/depression.
osteoporosis	tx: weight bearing exercises, calcium, vit D, biphosphonates, fosamax, Boniva, SERM and HT.
Vulvovaginal disorders	Dyspareunia– painful sex
	Vaginisumus– involuntary conctractions of vaginal muscles
	Vulvodynia- chronic pain of the vulva without known cause.
	Vestibulodynia- pain in vaginal orifice, cutting or burning pain.
	tx: pelvic floor specialist can help with many of these.
	Vaginitos- inflammation of vagina, can have discharge, itching or pain
	Vulvitis– irritation felt externally in the vulva, may/may not have vaginal discharge
	Vulvovaginitis- irritation in both vulva and vagina
	Cervictitis: inflammatin, irritation, infection of cervix with vaginal discharge.
	Vaginal discharge- vaginal fluid composed of cervical mucus, exfoliated epithelial cells, bacteria and secretions. Appreance vary
	with hormones, irritation and infection.
	Candidiasis “yeast infection” candida yeast, not a STD, thick white vaginal discharge, dysuria, luteal phase. TX: Monistat, oral fluconazole
	Bacterial Vaginosis– Gardenerella vaginalis, related to sex but not STD, vaginal odor fishy, gray discharge, vulvar irritation. During or after period.
	tx: oral or topical antibiotic.
	Atrophic or Vaginal Atrophy: thinning of vaginal wall, 50% postmenopausal, itiching, burnging, irritation, UTI, Tx: lubricants, topical estrogen cream.
	Uterine Cancer: endometrial cancers, 6th most common, 5 year survival >80%. ,
	Average age is 60. Risk is estrogen therapy, PCOS, obesity, late menopause, early menses.
	Cervical dysplasia/Cancer: endocervix with glandular cells. Exocervix with squamous cells.
	Endo and ecto meet at squamocolumnar junction (SCJ). Most cervical cancers begin in the cells around the SCJ. Normal cells change.
	HPV- Huamn papollomavirus. 200 related visrus, 90% in sexually active men, 80% in sexually active weomen will be infected with at loeast one
	type of HPV. 50% are high risk strains. 10+ high risk HPV strains, 16 and 18 cause 70% of all cases of cervical cancer and other: anal, oral, penile.
	Low-risk HPV strains 6 and 11 cause 90% of all cases of genital warts. Verruca vulgaris and anogenital warts.
	Infection with HPV is comon and most people the body can clear the infection itself. Chronic infections however risk is cancer.
	Abnormal PAP: atypical squamous cell of undetermined significance, Squamous intraepithelial lesion, atypical glandual cells, Adenocarcinoma cells
	May restest in 6 or 12 months, may have coposcopy w/wo biospy, may have LEEP Loop electosurgical excision) for cervical dysplasia or
	referred to gynecological oncologist if cervical cancer.
	Cervical Intraepithelial neoplasia (CIN) are precancerous changes in a biopsy. Squamous cells pre-cancer (90% are squamous cell cervical cancer)
	CIN1- mild dysplasia, lest serious
	CIN2- moderate dysplasia with more abnormal tissue.
	CIN3- severe dysplasia, carcinoma in situ, most serious.
	ages 35-55, early cervical cancers , pre-cancers have no symptoms, might be abnormal belleding usual discharge, pain during sex.
	Ovarian Cancer- common in 55-64, no current screening. 85 to 90% are epithelial ovarian carcinomas.
	risks: Nulliparity, IVF, hereditary breast and ovrian cancer syndromes, BRCA! And BRCA2 inherited mutated genes. OCP can reduce risk.
	sx: bloating, pelvic or abdominal pain, troubling eating/feeling full, urinary symptoms.
Breast pathology	Breast mass- bret cancer or fibroadenoma
	Skin Ulceration: thickening, inflammatory breast abscess, infection or dermatologic.
	Axillary Mass- breast cancer with lymph node involvement, could be benign lymphadenopathy.
	Blood nipple discharge0 breast cancer, could be intraductal papilloma.
	Strong family history of breast cancer, SX: cough, bone pain, headache,
Presentations	Breast Cancer- lump is hard, immobile, fixed, irregular border
	Fibroadenoma- lump is well-defined, mobile, squishy, painless
	Fibrocystic change/diseas- chronic diffuse limpiness, worse with caffein, during luteal phase, cyclic with menstrual cycle.
	Duct ectasia- signs can inclue nipple retractin, inversion, pain, greenish discharge, perimenopausal.
	Intraductal Papillomoa- bloody nipple discharge.
Key stats:	1 in 8 or 12% of femal population. Most common type of cancer in women, second leading cause of death from cancer (lung is first)
	Most common symptom is a new lump or mass, most common type is ductal carcinoma of mammary duct, it can spread in blood or lymph.
Types	In Situ (Stage 0)- ductal carcinoma, Lobular Carcinoma
	Invasive breast cancer- Invasive ductal carcinoma, Invasive lobular carcinoma,
diagnosis	Mammogram, biopsy, ultrasound, Breast MRI,
	Stage I: <20mm
	Stage II: < 20mm to 50 mm, 1 node
	Stage III: >50mm, 2 nodes
	Stage IV: any size with metastases
TX:	Surgery, Radiation, hormonal, Chemotherapy, Targeted.
	Hormonal- SERM and Aromatase inhibitors.
	Tamoxifen (TMX) selective estrogen receptoor modularor,acts like anti-estrogren in breast cells. Can slow or stop growth of the cancer.
	side effects: hot flashes, vaginal dryness, modd swings. Blood clots, stroke, risk of endometrial cancer.
	Aromatase inhibitors- Letrozole, Anastrozole, Exemestane- block aromatase from making estrogen. Post menopausal women
	take the drug for 5 years and tamoxifen for 3 years. Reproduction age may just take the Tamoxifen first.
	Another option is doing ovarian suppression with a LHGH agaonist like goserelin (Zoladex) and leuprolide (Lupron) with chemo or oophorectomy.
	side effect: fewer side effects than tamoxifen, don’t cuase uterine cancers or blood clots, just muslce painand stiff joints, bone thinning, fracture.
Pregnant patient Care:	Co-manage high risk patients
Recognzie and prevent adverse events	Threatened Miscarriage
	Premature labor
	Ectopic pregnancy
	Pre-eclapsia/HELLP
	Cholestasis
	Gestational diabetes
	GI Distress
	Musculoskeletal
	Emotional support
Western Terminology	Gravida- pregnant
	Para- delivered fetus, living childeren , children who died after birth (20 weeks or more inclues stillbirth)
	Nulligravida- never pregnant
	Primigravida- first pregnancy
	Multigravida= second or more.
Early development:	conception to implantation 7 days
	10-14 days- post-conception, blood test then urine detection for beta-hCG, check progesterone, ideal >10.
	Fetal heart beat beating by 4 weeks, 8 weeks all organs developed in rudimentary form.
Trimester 1	pulse is quick and slippery, confirm pregnancy before treatment.
	ASAP treatment for patients with infertility and habitual miscarriage, or over 35.
	treat the anxiety, nausea, insomnia, aches as well.
SX	12 weeks: breast tenderness, increase size, constipation, fatigue, morning sickness
	weight gain, mood swings, 25% may experience some bleeding, thin milky discharge.
	UTI, heartburn, sinus, skin irritations, yeast infection.
	KD9 point: harmonize maternal-fetal Qi. Calm fetus, mother and child relationship.
2nd Trimester:	Week 13 to 28 (month 4 to6). May feel better.
	Baby kicks and moves around 16-25 weeks. Preterm labor can occur.
	Baby bump appears around 12-16 weeks,
	SX: congestion, edema in legs, sensitive gums, leg cramps, varicose veins, dizziness, low back pain.
3rd Trimester	Frequent urination, edema, BP changes, dizziness, back and hip pain, sciatica, Braxton-hicks, Insomnia
	Preterm labor. Confirm baby is vertex by week 32.
	Weel 37- prep for birth.
	Estimated due date.
	Sx: fatigue, achiness, abdominal or back pain, stretch marks, dreams, contractions, forgetful, breast leakage.
TCM and precautions during pregnancy:	Referral to OB or midwife if:
	Bleeding (threat of miscarriage)
	Elevated BP (threat of Pre-eclampsia)
	Edema  (threat of Pre-eclampsia)
	Leakage of fluid from vagina (threat of miscarriage)
	Fever, infection (UTI) or itching
	Excessive pain anywhere
	Hyperemesis (acute dehydration)
	Extreme fatigue
	Decreased Fetal movements
Acupuncture Avoid points and areas	GB21, LI4, Liv14, SP6, UB60, UB67, Bai lao.
	1st trimester- below ren 1 to 8
	2nd trimester- Avoid below Xyphoid process.
Herbal cautions:	Herbs that are too invigorating or movedownward, break up stasis, or create heat, use with caution.
	Incorrect diagnosis is primary contraindication.
Other formulats:	Wen jing Tang- help to get pregnant
	Dang gui Shao yao san and Dang Gui San for during pregnancy
	Gui zhi fu ling wan for birthing
	Dang gui Yang Rou tang for post partum. Mutton stew.
Problems of pregnancy in TCM	Miscarriage “Leaky Fetus”
High risk pregnancies	Maternal factors prior to pregnancy
	Pregnancy conditions like: multifetal pregnancy
	Gestational diabetes
	Pre-eclampsia
	Chromosomal issues or neural tube defects.
TCM “Leaky fetus”	6 evils- infection diseases, febrile
	7 emotions, heart- kidney not communication
	Trauma (physical, emotional)
	disharmony of Qi and Blood in Chong and Ren
	Def. SP and Kd
	Excess heat- restless fetus
Kidney vacuity leaky fetus	SX: light bleeding, LBP, crampy, weak, dizzy, pulse weak, soft, floating
	KD yang maintains progesterone
	Kd Yin: red spotting with vacuity heat
	TX: Kd 3, ST36, Du20, Lu7, Sp1, Sp4.
	formula: Shou Ti wan (Fetus longevity pill)
Blood heat:	sx: profuse , bright red blood, red face/tongue, strong rapid pulse
	acu. Liv2, sp10, Li11, KD2, 6, PC3, 6, Ht7, Du20
	Herbs: Bao yin Jian – protect the yin decoction
Small birth- miscarriage, fetal death	Kd13/14/18. ST 28/29, SP6/4, Liv4, UB32, Ren 2/3/4
	Herbs: Sheng hua Tang   then Tao Hong si Wi Tang, to recover: Ba Zheng Tang.
	3 months of building qi and Blood after miscarriage. More than 3 miscarriages- habuitual miscarriage. Must be corrected.
Ectopic pregnancy	Huo Luo Xiao Ling Dan and 3 months recovery
Nausea and Vomiting (Morning sickness)	Fetus blocks Uterine gate, which normally receives blood for menses release. The chong overfills with Qi and blood which rise up
	when the uterus is closed and spills out into the stomach channel via ST 30.
	The spleen may be constitutionally weak, subject to liver excesss already borrowing from the kidneys,
	or may simply be overtaxed in the blood production by the pregnancy and thus disrupts the middle jiao Qi dynamic.
	As the pregnancy progresses, the excess Qi and Blood are required by the growing fetus and are used more
	easily and thus no longer counterflow upward in rebelliion.
	Usually begins week six to 12, and rearely persists whole pregnancy. Can rarely develop into hyperemesis gravidarum and TX: IV fluids.
	70-90% of women experience nausea in pregnancy. TX: 2 to 3 times a week.
	PC6, Ren 12,13, ST36/37/39, liv3, sp4, st40, kd6, 21, 27, gb34
	OTC: ginger, B6, ginger tea, crackers, walk, grapefruit.
	Middle jiao dry and cold: Xiao Jian Zhong Tang
	Spleen Wet and cold: Ling gui Zhu Gan Tang or Xiang Shu Liu Jun zi tang
	Liver and spleen not harmonized: Shu Gan yi Qi tang
	Liver invades Stomach: Jian pi He Wei Yin
	Shao yang or Yang Ming Damp heat: Huang Lian Zi su ye Tang, or Ban Xia Xie xin Tang
Other Nausea remedies	Moxa PC6, St26, Ren 12, Ren22, Ren14, Cup Ren 12.
	Guasha Du 16 (brain center for vomiting)
	Western: antihistamines, Anti nausea chemo meds (zofran), Diclegis (antihistamine and B6), Ginger-B6
GI issues: Constipation	Commonly blood and yin deficiency, loss of fluids, poor diet. Progesterone when active is very drying.
	TX; pears, pear juice, water, grens, prunes.
	UB17, 20, ST36, 37, 39, Liv8, SJ6.
TCM: Thick blood (Toxcemia/pre-eclampsia)	Blood should absord and store Qi and fluid, poor blood will not absorb fluid _> edema. .
	Qi has no home -> headache, hyper reflexes, even convulsions
	Blood becomes thick by malnutrition, long tern illness, 6 evils.
Blood vacuity stasis	T: pale and thin, dusky, sallow complexion. Sx: thirst, dry skin hair and lips, vagina, spider veins.
	tx: Dang Gui Shao yao san
Yin deficency	Yin is the root of blood so systematic Yin xu is a condtion of blood Xu/dryness. Can be SP/ST yin w/KD yin as root.
	can include HT and LU yin.
	t: small, thin, red reeled, crack, Sx: thirst, dry skin, hair, lips, vagina.
	tx: Bao Yin Jian (preserve the yin decoction)
Cold Dry blood	blood becomes cold, dry and thick.
	T: pale, purplish. Dark sallow complexion, dysmenorrhea that prefers warm tends to feel cold, thirst, dry skin, hair, lips, vagina.
	Tx: Dang gui shao yao san
Gestational Diabetes TX:	ST36, LI11, Liv3, Pc6
	water retention in pre=eclampsia- SP9, Liv2, li8/9/10, PC7, Ren9, cheng ming 1 cun behind sp6 on Kd channel.
	blood vacuity: UB17,18,20
	Yin vacuity: KD 3,6
	Yang rising: GB20
	Cold: Moxa
	Varicos veins: Lung 9 and ST32 (low vessel influ. Pt)
Early signs of labor	Baby drops into lower pelvis
	Increases braxton hicks contractions
	Cervix starts to change, dilation.
	Blood shows, discharge, brown, pink, red.
Breech presentation	Cephalic- normal head down
	types: shoulder breech, frank breech, complete breech, footling breech
	Commonly blood and qi stasis.
	Moxa BL67 10 minutes each foot, for 10 days
Birth Prep acupuncture	Du 20, ear: shenmen and point zero, LI4, Ren 4, 6, UB 31,32, GB21, 34, SP6, UB 60, 67.
4th trimester- post partum	Lochia will slough off uterus 2-6 weeks red-brown to white. Uterus contracts back to pear size, hormones change, oxytocin and prolactin surge.
	ovulation may be delayed for 6 weeks, depends on nursing.
	Baby blues can occur for days or weeks. Usually a few days after the birth. Crying can occur.
PPMD- post partum mood disorder	Anxiety, OCD, PTSD, Psychosis.
	Need to take Edinburgh post natal depressin test to scale.
	tx: yintang, du20, 24, ear shen men
	SP Qi heart blood def: depression, palpitations, poor appetite, pallor, fatigue: HT7, Ren 6, SP6, UB15,20, moxa
	Liv/Kd vacuity: insomnia, anxiety, vertigo, dry and def. signs: HT7, PC6, UB18, 23, KD3, SP6
	Liv stagnation and heat: agitated, angry, impatient, headache, nausea, wiry pulse, Ht7, Pc6, GB20,liv3, St36.
	Psychosis features: confusion, obsessive over baby, delusions, sleep distress, agitation, parania, harm self or baby attempts.
	it requires immediate treatment.
Lactation challenges	difficult latching, lip/tongue tied, low milk, engorgement, mastitis, blocked milk duct, maintaining supply.
	after birth, first 3 days breast are full of milk. Nursing is supply demand
	Qi and Blood def tx: UB17, 20, ST36, sp6, du20, ST18, ren 17, PC1, SI1, GB21
	Qi stagnation: UB18, Liv14, 3, SI1, GB21
	All disorders of breast: Ren3, GB41.
	Inflammation of breeat duct: sx; red swollen breasts, red face, tongue. : LI11, ST34.Liv3, SI1, GB21
Menopause and TCM	Kidney deficiency
Yang ming	aversion to heat, heat effusion, spontaneus sweating, dry mouth/thirst
	abdominal fullness, constipation, urinary burning, vexation, pulse large/surging
	tx: LI11, Du14, ST44
	Herbs: Bai hu jia ren shen tang
Shao Yang	cyclic symptoms (sometimes yes, sometimes no) hot flashes, insomnia, moodiness, dryness anywhere
	lack of clarity of thoughts emotions, more common than Yang ming.
	tx: Li4, Liv 2/3, GB41/SJ5
	Herbs: Chai Hu Long gu Mu Li Tang, Si Ni San
Tai Yin	tai yin absorbs nourishement and fluids through the action of minister fire which must be in position and strong enough.
	Tai yin rains fluids down to shao yin to be kidney yin. Shao yin pulls in and stores fluid and yang so that they can interact
	and become warm and nourished and create liver blood. All yin conformations absorb, hold, and move.
SP wet and dry	if SP is not absorbing there will be dryness and leakage.
	SP yang def- cold limbs, diarrhea, lack of ascending, vacuity bleeding.
	SP dry- yin def, failure to absorb with epigastric hardness and emaciation with digestive difficulties.
	Wet spleen- wet swollen tongue, fluid retention, leaky fluid.
	Tx: St36,Sp3,4,6, Ren 12, wet: SP9, ST40.
	Herbs- ling Gui zao gan. If dry: Xiao Jian Zhong Tang.
Shao yin	Contains true life aka true yang. Draws down imperial fire and receives and stores as minister fire. Weak is cold.
	Storage is weak then lower leakage- stool, urine, blood, miscarriage.
	Leakage up and out: seating, flashes.
	Tx: KD 2,3,6,7, Lu7, UB23, Du4, moxa.
	Herbs: Jin gui shen qi wan, Si ni tang.
Jue Yin	Fire in water is blood, makes it go up, turn red, harmonized as Ying-Wei. Jue yin is a union.
	Treat by supporting tai yin and shao yin, steaming to make juicy, warm blood, move blood smoothly upward.
	sx: inappropriate upsurge and blood stasis, vacuity.
	Tx: Liv3, 8, PC6, SP4, 6,10
	Herbs: Wen jing tang, Dang gui Si Ni tang, Gui zhi Fu ling wan.
Ying and Wei out of balance (Tai Yang)	Hot flashes, night sweat, anxiety, palpitations, insomnia.
Tai Yang	Tx HT7, PC6, SP4/Lu7. Magic night sweat combo: HT6, SI3, KD7.
	Herbs: Gui Zhi Jia long Gu Mu Li tang, Suan Zao Ren Tang. Crying: Gan Mai Da Zao Tang.