integrative woman’s health course · 2019-12-09 · t1a2: the area of cancer invasion is between...
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Clinical Case Dr Cai, Xiao Sun 蔡小蓀 28yo,single.FirstVisit5-12-2005 Intermenstrualbleedingfor5years.Menarcheage14,7/30,LMP4-21,slightfaFgue,coaFngthinyellow,Fpandsidered,pulsethin.
Diagnosedasovulatorybleeding(Intermenstrualbleeding)
Definitions Intermenstrual Bleeding (IMB) Intermenstrualbleeding(IMB)referstovaginalbleedingatanyFmeduringthemenstrualcycleotherthanduringnormalmenstruaFon.
ItcansomeFmesbedifficulttodifferenFatetrueIMBbleedingfrommetrorrhagia(irregularlyfrequentperiods).
Postcoitalbleeding(PCB)isnon-menstrualbleedingthatoccursimmediatelyaRersexualintercourse.
BreakthroughbleedingisirregularbleedingassociatedwithhormonalcontracepFon.
Midcycle Spotting or Bleeding OvulaFonbleedingormid-cyclespoVngisatermusedtodescribemildbleedingorspoVngthatoccursataroundtheFmeofovulaFon.Inmostcases,thisbleedingoccursapproximately14to16daysaRerthelastmensesinanormal28-daycycle.
AtovulaFon,estrogenlevelsdiptemporarily,whichisoRenenoughtocausesomespoVng.AnovulaFonisthemostcommoncauseofabnormalbleedinginpremenopausalwomen.
IMB and PCB IMBandPCBarebothsymptoms,ratherthandiagnoses,andwarrantfurtherassessment.
Theyoccurcommonlyandareemphasizedinreferralguidelinesforsuspectedgynecologicalcancers.
Genitaltractmalignancyisanuncommoncauseofbleedingandararecauseinyoungwomen,itmustbeconsideredinallpaFents.
Epidemiology Around14%ofpremenopausalwomenexperienceirregularorexcessivelyheavymenstrualbleeding.(UKpopulaFon)
IthasbeenesFmatedthatinthosewomenwhopresenttoprimarycarewithmenstrualproblems,aroundonethirdwillhaveIMBorPCBinaddiFontoheavymenstrualloss.
Thetwo-yearcumulaFveincidenceofIMBhasbeenshowntobe24%andthatofPCBwasaround8%inastudyofperimenopausalwomen.
UnscheduledbleedingcausesanxietyandconcernbecauseitcanbeapresenFngsymptomforgynecologicalcancer,parFcularlycervicalandendometrialcancer.
Etiology ThecausesofIntermenstrualbleedingtypicallyvarywithage
Amalignantcauseisveryuncommoninyoungerwomen.
InaddiFon,thelikelihoodofuterinepolypsandfibroidsincreaseswithage. Ifitisaregularoccurrenceduringmid-cycle,thismightbeduetoovulatorybleeding.
ManywomenwillpresentwithacombinaFonofPCBandIMB.
Causes of postcoital bleeding (PCB) InfecFon. Cervicalectropion(turnoutofcervix)-especiallyinthosewomentakingthecombinedoralcontracepFvepill(COCP).
Cervicalorendometrialpolyps.
Vaginalcancer.
Cervicalcancer-usuallyapparentonspeculumexaminaFon.
Trauma.
The Cervix ThecervixispartofthefemalereproducFvesystem.
Around2–3cenFmeters(0.8–1.2in)inlength.
Thecervixisthelowerpartoftheuterussituatedbetweentheexternalos(externalorifice)andinternalos(internalorifice).
Thecervicalcanalconnectstheinteriorofthevaginaandthecavityofthebodyofuterus.
Cervical Polyp Acommonbenignpolyportumoronthesurfaceofthecervicalcanal.
TheycancauseirregularmenstrualbleedingbutoRenshownosymptoms.
Treatmentconsistsofsimpleremovalofthepolypandprognosisisgenerallygood.
About1%ofcervicalpolypswillshowneoplasFcchangewhichmayleadtocancer.
Theyaremostcommoninpost-menarche,pre-menopausalwomenwhohavebeenpregnant.
Vaginal Cancer Vaginalcancerisadiseaseinwhichmalignant(cancer)cellsforminthevagina.
AgeandbeingexposedtothedrugDES(diethylsFlbestrol)beforebirthaffectawoman'sriskofvaginalcancer.
Signsandsymptomsofvaginalcancerincludepainorabnormalvaginalbleeding.
Cervical Cancer Incident Rate TheAmericanCancerSociety'sesFmatesforcervicalcancerintheUnitedStatesfor2016are:
About12,990newcasesofinvasivecervicalcancerwillbediagnosed.
About4,120womenwilldiefromcervicalcancer.
Cervicalpre-cancersarediagnosedfarmoreoRenthaninvasivecervicalcancer.
Cervical Cancer Incident Rate CervicalcancerwasonceoneofthemostcommoncausesofcancerdeathforAmericanwomen.
Butoverthelast40years,thecervicalcancerdeathratehasgonedownbymorethan50%.
ThemainreasonforthischangewastheincreaseduseofthePaptest.
Thisscreeningprocedurecanfindchangesinthecervixbeforecancerdevelops.Itcanalsofindcervicalcancerearly−initsmostcurablestage.
Cervical Cancer Screening Cervicalcancertendstooccurinmidlife.
Mostcasesarefoundinwomenyoungerthan50.
Itrarelydevelopsinwomenyoungerthan20.
ManyolderwomendonotrealizethattheriskofdevelopingcervicalcancerissFllpresentastheyage.
Morethan15%ofcasesofcervicalcancerarefoundinwomenover65.HoweverthesecancersrarelyoccurinwomenwhohavebeengeVngregularteststoscreenforcervicalcancerbeforetheywere65.
Cervical Cancer Staging Stage0(Tis,N0,M0):Thecancercellsareonlyinthecellsonthesurfaceofthecervix(thelayerofcellsliningthecervix),withoutgrowinginto(invading)deeperFssuesofthecervix.Thisstageisalsocalledcarcinomainsitu(CIS)whichispartofcervicalintraepithelialneoplasiagrade3(CIN3).Stage0isnotincludedintheFIGOsystem.
StageI(T1,N0,M0):Inthisstagethecancerhasgrowninto(invaded)thecervix,butitisnotgrowingoutsidetheuterus.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
Stage I - The cancer has not spread to nearby lymph nodes (N0) or distant sites (M0). StageIA1(T1a1,N0,M0):Thecancerislessthan3mm(about1/8-inch)deepandlessthan7mm(about1/4-inch)wide.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
StageIA2(T1a2,N0,M0):Thecancerisbetween3mmand5mm(about1/5-inch)deepandlessthan7mm(about1/4-inch)wide.Thecancerhasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IB(T1b,N0,M0):ThisincludesstageIcancersthatcanbeseenwithoutamicroscopeaswellascancersthatcanonlybeseenwithamicroscopeiftheyhavespreaddeeperthan5mm(about1/5inch)intoconnecFveFssueofthecervixorarewiderthan7mm.Thesecancershavenotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IB1(T1b1,N0,M0):Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IB2(T1b2,N0,M0):Thecancercanbeseenandislargerthan4cm.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
Stage II StageII(T2,N0,M0):Inthisstage,thecancerhasgrownbeyondthecervixanduterus,buthasn'tspreadtothewallsofthepelvisorthelowerpartofthevagina.
StageIIA(T2a,N0,M0):ThecancerhasnotspreadintotheFssuesnexttothecervix(calledtheparametria).Thecancermayhavegrownintotheupperpartofthevagina.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IIA1(T2a1,N0,M0):Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IIA2(T2a2,N0,M0):Thecancercanbeseenandislargerthan4cm.
IIB(T2b,N0,M0):ThecancerhasspreadintotheFssuesnexttothecervix(theparametria).
Stage III StageIII(T3,N0,M0):Thecancerhasspreadtothelowerpartofthevaginaorthewallsofthepelvis.Thecancermaybeblockingtheureters(tubesthatcarryurinefromthekidneystothebladder).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IIIA(T3a,N0,M0):Thecancerhasspreadtothelowerthirdofthevaginabutnottothewallsofthepelvis.Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IIIB(T3b,N0,M0;ORT1-T3,N1,M0):either:
cancerhasgrownintothewallsofthepelvisand/orhasblockedoneorbothureters(acondiFoncalledhydronephrosis),
OR
cancerhasspreadtolymphnodesinthepelvis(N1)butnottodistantsites(M0).Thetumorcanbeanysizeandmayhavespreadtothelowerpartofthevaginaorwallsofthepelvis(T1toT3).
Stage IV StageIV:Thisisthemostadvancedstageofcervicalcancer.Thecancerhasspreadtonearbyorgansorotherpartsofthebody.
IVA(T4,N0,M0):Thecancerhasspreadtothebladderorrectum,whichareorgansclosetothecervix(T4).Ithasnotspreadtonearbylymphnodes(N0)ordistantsites(M0).
IVB(anyT,anyN,M1):Thecancerhasspreadtodistantorgansbeyondthepelvicarea,suchasthelungsorliver.
Tumor Extent (T) Tis:Thecancercellsareonlyfoundonthesurfaceofthecervix(inthelayerofcellsliningthecervix),withoutgrowingintodeeperFssues.(TisisnotincludedintheFIGOsystem)
T1:ThecancercellshavegrownfromthesurfacelayerofthecervixintodeeperFssuesofthecervix.Thecancermayalsobegrowingintothebodyoftheuterus,butithasnotgrownoutsidetheuterus.
T1a:Thereisaverysmallamountofcancer,anditcanbeseenonlyunderamicroscope.
T1a1:Theareaofcancerislessthan3mm(about1/8-inch)deepandlessthan7mm(about1/4-inch)wide.
T1a2:Theareaofcancerinvasionisbetween3mmand5mm(about1/5-inch)deepandlessthan7mm(about1/4-inch)wide.
Tumor Extent (T) T1b:ThisstageincludesstageIcancersthatcanbeseenwithoutamicroscope.Thisstagealsoincludescancersthatcanonlybeseenwithamicroscopeiftheyhavespreaddeeperthan5mm(about1/5inch)intoconnecFveFssueofthecervixorarewiderthan7mm.
T1b1:Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).
T1b2:Thecancercanbeseenandislargerthan4cm.
Tumor Extent (T) T2 T2:Inthisstage,thecancerhasgrownbeyondthecervixanduterus,buthasn'tspreadtothewallsofthepelvisorthelowerpartofthevagina.Thecancermayhavegrownintotheupperpartofthevagina.
T2a:ThecancerhasnotspreadintotheFssuesnexttothecervix(calledtheparametria).
T2a1:Thecancercanbeseenbutitisnotlargerthan4cm(about13/5inches).
T2a2:Thecancercanbeseenandislargerthan4cm.
T2b:ThecancerhasspreadintotheFssuesnexttothecervix(theparametria)
Tumor Extent (T) T3 and T4 T3:Thecancerhasspreadtothelowerpartofthevaginaorthewallsofthepelvis.Thecancermaybeblockingtheureters(tubesthatcarryurinefromthekidneystothebladder).
T3a:Thecancerhasspreadtothelowerthirdofthevaginabutnottothewallsofthepelvis. T3b:Thecancerhasgrownintothewallsofthepelvisand/orisblockingoneorbothureters(thisiscalledhydronephrosis).
T4:Thecancerhasspreadtothebladderorrectumoritisgrowingoutofthepelvis
Lymph Node Spread and Metastasis Lymphnodespread(N)
NX:Thenearbylymphnodescannotbeassessed
N0:Nospreadtonearbylymphnodes
N1:Thecancerhasspreadtonearbylymphnodes
Distantspread(M)
M0:Thecancerhasnotspreadtodistantlymphnodes,organs,orFssues
M1:Thecancerhasspreadtodistantorgans(suchasthelungsorliver),tolymphnodesinthechestorneck,and/ortotheperitoneum(theFssuecoaFngtheinsideoftheabdomen).
Causes of inter-menstrual bleeding (IMB) - 1 Pregnancy-related,includingectopicpregnancyandgestaFonaltrophoblasFcdisease. Physiological:◦ 1-2%spotaroundovulaFon.◦ HormonalfluctuaFonduringtheperimenopause(thisshouldbeadiagnosisofexclusion).
Vaginalcauses:◦ Adenosis.◦ VaginiFs(bleedinguncommonbeforethemenopause).◦ Tumors.
Causes of inter-menstrual bleeding (IMB) - 2 Cervicalcauses:◦ InfecFon-chlamydia,gonorrhea.
◦ Cancer(butbleedingismostoRenpostcoital).◦ Cervicalpolyps.◦ Cervicalectropion.◦ Condylomataacuminataofthecervix.
Causes of inter-menstrual bleeding (IMB) - 3 Uterinecauses:◦ Fibroids(occurinover25%ofwomenofreproducFveage).
◦ Endometrialpolyps.◦ Cancer(endometrialadenocarcinoma,adenosarcomaandleiomyosarcoma).◦ Adenomyosis(usuallyonlysymptomaFcinlaterreproducFveyears).
◦ EndometriFs.◦ Estrogen-secreFngovariancancers.
Causes of inter-menstrual bleeding (IMB) - 4 Iatrogeniccauses:◦ Tamoxifenuse.
◦ Followingsmearortreatmenttothecervix.◦ MissedoralcontracepFvepills.◦ DrugsalteringcloVngparameters-eg,anFcoagulants,selecFveserotoninreuptakeinhibitors(SSRIs),corFcosteroids.◦ AlternaFveremedieswhentakenwithhormonalcontracepFves-eg,ginseng,ginkgo,soysupplements,andStJohn'swort.
Causes of breakthrough bleeding - 1 UnscheduledvaginalbleedingiscommonwhenanewcontracepFvemethodisstartedandoRenselleswithoutintervenFon.ItisimportanttoexcludepregnancyandalsoanyunderlyinginfecFon.
Bleedingproblemsaremorecommonwithprogestogen-onlymethods.Smokersactuallyhaveagreaterriskofbreakthroughbleeding.
COCP:◦ PreparaFonscontaining20microgramsethinylestradiolaremorelikelytobeassociatedwithbreakthroughbleedingthanthosecontaining30-35micrograms.◦ IncombinaFonwithanenzyme-inducingdrug-eg,rifampicin.
Causes of breakthrough bleeding - 2 Progestogen-onlycontracepFvepill(POCP). ContracepFvedepotinjecFons.
Intrauterinesystem(IUS)orimplant.
EmergencyhormonalcontracepFon.
TCM Etiology Kidney Yin Deficiency
ConsFtuFonalWeakness
ExcessiveLaborandSex
ExcessiveWorrying
AbundanceofStagnantFire
KidneyYinbecomingdeficient
DeficientFirestruggleswith
YangQi
DamagingYinLuo,ChongRenDysfuncFon
DeficientFireconsumesEssence
TCM Etiology Damp Heat
LiverQiStasisAlackingSP/ST
YangQiInternalMovement
iniFaFngDampHeat
WaterDampnessformed
internally.Accumulatedtotransformedto
Heat
HeatDisturbingUterus
TCM Etiology Blood Stagnation
ConsFtuFonalWeakness
EmoFonalInjury
QiStasisatChongRen
StagnantBloodAccumulaFon
InternalMovementof
YangQiStrugglingwith
BloodStagnaFon
MenstrualandGestaFonal
AccumulaFons
TCM Pathology DisorderLocaFon:ChongRenChannels Pathology:dysfuncFoninYin-YangtransiFonduringovulaFonperiod,damagingChongRen,CausingdysfuncFonofSeaofBloodinstoringandcontrolling
TCM Pathology EFology• KidneyYinDeficiency• DampHeatRetenFon• StagnancyBlockingBaoLuo
DuringOvulaFon,YangQiInternalMovement,DysfuncFonofYin-YangTransiFon
DamageofYinLuo,ChongRen
DysfuncFonofStoringfuncFonofSeaof
BloodExtravasaFonofBloodIntermenstrual
Bleeding
Diagnosis MainSymptoms:IntermenstrualBleedingoccurringaroundCD12-16for2-3dayswithspoVngorlightflowfortwoormoreconsecuFvecycles.
SecondarySymptoms:Itcancombinewithlumbago,pelvictendernessunilaterallyorbilaterally,breasttenderness,leukorrheaeitherclearorwhite
Differential diagnosis IntermenstrualBleeding
EarlyMenstruaLon
ScantyMenstrualFlow
RedVaginalDischarge(ChiDai)
Similarity VaginalBleeding
Difference MostlyaroundovulaFonFme,lastsaround2-3days,mostlylightorspoVng
MostlyearlierthanregularcycleFme,lastslikearegularmenstrualflowandcorrespondtoBBT
CycleisnormalbuttheflowquanFtyisreducedorjustspoVng
TendstobespoVngwithmucus,canoccuranyFmebetweenperiodsandhaveahistoryofcervicaldisease
Kidney Yin Deficiency Intermenstrualbrightredflow,slightlysFcky,canbelessormoreflow
Dizziness,lumbago,insomnia,fivesolerestlessheat,consFpaFon,yellowurinaFon.
TongueRed,slendertongue,pulsethinrapid NourishKidneyYin,StrengthenChongandStopBleeding
LianDiTang+ErZhiWan兩地湯 + 二至丸
Liang Di Tang + Er Zhi Wan 兩地湯 + 二至丸 LiangDiTang:ShengDi,DiGuPi,XuanShen,MaiDong,AJiao,BaiShao.生地,地骨皮,麥冬,玄參, 阿膠,白芍。
ErZhiWan:NvZhenZi,HanLianCao.女貞子,旱蓮草。
Ifprofuseflowwithpaleflow,noclots,faFgue,useDaBuYuanJian大補元煎.
DaBuYuanJian:RenShen,ShanYao,ShuDi,DuZhong,DangGui,ShanZhuYu,GouQiZi,ZhiGanCao
Damp Heat Intermenstrualdeepredflow,sFcky,tendstobeheavierflow
Leukorrhea,coloryellow,faFgue,bodyache,bilermouth,drythroat,chestdistenFon,restlessness,poorappeFte,abdominaldistenFon,urineshortandred.
TongueRed,coaFnggreasyyellow,pulsethreadywiryorwiryslippery
ClearDampHeat,StrengthenChongStopBleeding
QingGanZhiLinTangridofAJiao,HongZao,AddXiaoJiandFuLing.清肝止淋湯去阿膠,紅棗加小薊茯苓。
Qi Gan Zhi Lin Tang rid of A Jiao, Hong Zao, Add Xiao Ji and Fu Ling 清肝止淋湯去阿膠,紅棗加小薊茯苓 <FuQingZhuNvKe>(DrFu,QingZhu’sGynecology)傅青主女科
BaiShao,DangGui,ShengDi,AJiao,DanPi,HuangBo,NiuXi,XiangFu,HongZao,smallblackbeans
NourishBloodClearLiver
Womanblooddeficiencywithfirecausingincessantredleukorrhea.
Stagnant Blood Intermenstrualpurpleblackflow,cloly,tendstohavefluctuaFngflowamount
Pelvictendernessorpain,aversiontopressure,chestdistenFon,restlessness
Tonguepurpleorwithstagnantspots,pulsethreadywiry DissolveStagnaFon,StopBleeding
ZhuYuZhiXueTang逐瘀止血湯
Zhu Yu Zhi Xue Tang 逐瘀止血湯 <FuQingZhuNvKe>(DrFu,QingZhu’sGynecology),傅青主女科
ShengDi,DaHuang,ChiShao,DanPi,GuiWei,ZhiKe,GuiBan,TaoRen.生地,大黃,赤芍,丹皮,歸尾,枳殼,龜板,桃仁。
Ifbleedexcessively,ridofChiShaoandGuiWei,addShiXiaoSan失笑散(PuHuang+WuLingZhi)
Clinical Case Dr Cai, Xiao Sun 蔡小蓀 28yo,single.FirstVisit5-12-2005 Intermenstrualbleedingfor5years.Menarcheage14,7/30,LMP4-21,slightfaFgue,coaFngthinyellow,Fpandsidered,pulsethin.
Diagnosedasovulatorybleeding(Intermenstrualbleeding)
Clinical Case Dr Cai, Xiao Sun 蔡小蓀 YingYindeficiency NourishKidneyYin,RegulateChongRen
FuLing12,ShengDi10,ShiHu10,LuLuTong10,JiangXiang3,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ChiBaiShao10each.TobedrunkaRerperiodhasstopped.7bags
Clinical Case Dr Cai, Xiao Sun 蔡小蓀 SecondVisit LMP5-21,PMP4-21
Currentlyapproachmidcyle
FuLing12,ShengDi10,ShuDi10,ShiHu10,XiangFu10,LuJiaoShuang10,LuLuTong10,JiangXiang3,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ChiBaiShao10each,ZeXie10.12bags
Clinical Case Dr Cai, Xiao Sun 蔡小蓀 ThirdVisit ARerdrinking12bagsofherbs,nointermenstrualbleeding.CurrentlymenstruaFngwithscantyflow,slightlumbago,faFgue,pulseslightlythin,coaFngthinyellow,tonguesideFpred.
DangShen10,HuangJin12,DangGui10,FuLing12,ShengDi10,ShuDi10,HuaNiuXi10,ChuanXiong10,BaiShao10,DuZhong10,ChuanDuan10,XiangFu10,LuJiaoShuang10,,ZhiGuiBan10,MaiDong12,NvZhenZi12,XianLingPi12,HanLianCao12,RouCongRong10,ZeXie10.7bags
Cycle Analysis TheEnFreCyclewehavefocusedonNourishingtheYin,buttherearesomesubtlenuancesduringthe
enFrecycle
DuringOvulaFon,NourishYinheavilyandremoveallmovingherbs
Menstrually,addspleentonificaFonherbsto
strengthenQiandBloodtostrengthenChong
Ren
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