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A Practical Approach to Common Women’s Health Conditions CSNNAA Webinar April 11, 2017 Dr. Sarah Oulahen Turner HBHSc, ND

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Women complain about PMS, but I think of it as the only time of the

month when I can be myself - Roseanne

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Copyright Dr. Sarah Oulahen

Do not distribute without permission

OUTLINE Introduction and differential

Diagnosis Supporting your clients with: Dysmenorrhea Uterine fibroids Endometriosis PCOS

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1. WOMEN’S HEALTH CONDITIONS – INTRO & DIFFERENTIAL DIAGNOSIS (DDX) Breaking down a “normal” menstrual cycle & thorough assessment

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The Menstrual Cycle



THE MENSTRUAL CYCLE

D1 Menses Ovulation ~D15

New Moon Full Moon

Follicular phase :: Estrogen dominates – egg ripening

Inspiration time: Energy is outgoing and upbeat: enthusiasm, new ideas, creativity

Luteal Phase :: Progesterone dominates – uterine lining develops

Intuitive, evaluative and reflective time: looking at negative or difficult aspects of our

lives that need to be changed or adjusted

Northrup C. Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing. 2010.



INVESTIGATE THE MENSTRUAL CYCLE

• Age of menarche? Regularity? • Length – how many days is your cycle? (measured

from the beginning of bleeding) • Flow – when & how long do you bleed? What is it like? • Symptoms:

• Pain or discomfort anywhere? • Emotions? • Aggravating and relieving factors? • Associated symptoms

• Family History, Personal Medical History, Labs

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TERMINOLOGY:

• Dysmenorrhea: painful menstruation. Primary: caused by menstruation. Secondary: triggered by another condition (e.g. endometriosis)

• Menorrhagia: abnormally heavy bleeding at menstruation (>80ml or >7days)

• Amenorrhea: absence of menstruation (>6 months) • Oligomenorrhea: light or infrequent menstruation (>35

days) • Polymenorrhea: frequent menstruation (<21 days)

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WHAT’S ‘NORMAL’ FLOW:

• Amount of bleeding: on average ~35ml (typically 25-50ml) >60ml reduces iron stores, >80ml considered heavy

• Days of bleeding: ideal is 3-5 days, >7 days considered heavy

Note on general amounts collected: • Fully soaked super pad: 10ml • Fully soaked super tampon: 12ml • Menstrual cup ~30ml

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MENSTRUAL FLOW DDX 10

Menorrhagia Oligomenorrhea

• Uterine Fibroids

• Endometrial polyps

• Bleeding Disorders

• Hypothyroidism

• Advanced liver disease

• Medications: IUDs

• Age: nearing menopause

Always look at iron levels!

• Pregnancy/breastfeeding

• Ovarian conditions: PCOS or

premature ovarian failure

• Low body weight/eating

disorders/stress

• Hyperthyroidism

• Elevated prolactin

• Medications: birth control

• Age: early reproductive years



DIFFERENTIAL DIAGNOSIS Common Symptoms

Endometriosis The most common symptom is pelvic pain, particularly in relation to menstruation,

sexual intercourse, and/or bowel movements

Uterine Fibroids Abnormal uterine bleeding, particularly prolonged and/or heavy menstrual flow

Pelvic pressure or fullness, which may lead to urinary frequency and nocturia, urinary

incontinence, & constipation

PCOS Gynecologic symptoms of amenorrhea or oligomenorrhea, infertility or difficulty

conceiving, and abnormal uterine bleeding. PCO on ultrasound.

Symptoms of diabetes or glucose intolerance; Increased androgens; Anxiety

Hypothyroidism Menorrhagia and amenorrhea. Other common symptoms such as: cold intolerance,

fatigue, constipation, dry skin, brittle hair and nails, edema

Perimenopause Many of the features of PMS are also found in women entering menopause, when the

cycle may be irregular with menorrhagia, breast tenderness, moodiness, and bloating

for several weeks prior to bleeding. Typically other symptoms like hot flashes or vaginal

dryness.



GENERAL HORMONAL COMPLETE LAB ASSESSMENT & TIMING 12

ASSESSMENT TIMING IN CYCLE JUSTIFICATION

Follicle stimulating hormone (FSH)

Day 3 High levels can indicate menopause or declining fertility. Ovulatory factor.

Luteinizing hormone (LH) Day 3 Triggers ovulation when surges, excessive levels may indicate PCOS.

Progesterone APPROX Day 21 (7 days postovulation)

Confirms ovulation. Eliminates luteal phase defect.

Prolactin Any day Inhibits ovarian production of estrogen.

Estradiol Day 3 Stimulates egg maturation and endometrial maturation for implantation; responsible for fertile quality cervical fluid.

Testosterone, DHT, DHEA-S Any day Eliminate Polycystic Ovary Syndrome (PCOS) or testosterone dominance.



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ASSESSMENT TIMING IN CYCLE JUSTIFICATION

hCG Any day Rule in/out pregnancy!

Transvaginal ultrasound

Day 7 General assessment of pelvic organs for diagnosing abnormalities of the uterus and ovaries.

Hysterosalpingography Day 7

Assessment of pelvic organs: tubal blockage and/or uterine abnormalities

General Health Screen

CBC, urinalysis, liver function tests, iron studies, TSH and thyroid panel, Clotting factors if indicated, Fasting glucose/HbA1c, cholesterol profile

General health assessments to eliminate other abnormalities.

GENERAL HORMONAL COMPLETE LAB ASSESSMENT & TIMING

2. PRIMARY DYSMENORRHEA Is your period painful?

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PRIMARY DYSMENORRHEA - INCIDENCE

• Reported in 92% of adolescents • Estimates in the population vary but approx 30-50% of

women • As many as 15% of women will have symptoms severe

enough to prevent normal function (miss school/work) • Onset is usually shortly after menarche and before age

20. If > 2 years after menarche, consider secondary dysmenorrhea

• Tends to get better with age and after having children

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PRIMARY DYSMENORRHEA - SYMPTOMS

• Crampy pain starts around the onset of menstruation and peak at maximum blood flow (typically pain lasts 48-72 hours)

• Reproducible from one period to the other • Dull midline pain can extend to the back & thighs • Associated symptoms: diarrhea, nausea and vomiting,

light-headedness/dizziness, headache • Pelvic exam is normal

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DYSMENORRHEA DDX

• Primary dysmenorrhea = absence of pathology • Secondary dysmenorrhea = underlying pelvic pathology

E.g. Endometriosis, Adenomyosis, Uterine fibroids, Endometrial polyps, Cervical stenosis, obstructive malformations of the genital tract

• Other causes: PID, pelvic adhesions, IBS/IBD, Interstitial cysistis

• Sudden onset: PID or unrecognized ectopic pregnancy or miscarriage

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PRIMARY DYSMENORRHEA – CAUSE 18

Lefebvre, Guylaine, et al. "Primary dysmenorrhea consensus guideline." J Obstet

Gynaecol Can 27.12 (2005): 1117-1146.



PRIMARY DYSMENORRHEA – LIFESTYLE FACTORS • Good posture and spinal alignment • Stress reduction to relax pelvic and low back muscles • Exercise may improve blood flow to the uterus as well

as deep breathing • Consider “clean” menstrual products • Avoid smoking • Limit alcohol use • Coffee (!?)

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Elimination of caffeine is 25% slower during the luteal phase when progesterone and

estradiol are the highest. >2 cups of coffee daily increases estradiol levels.

Smith BD, Gupta U, Gupta BS. Caffeine and Activation Theory: Effects on health and Behavior. CRC Press. 2007.



PRIMARY DYSMENORRHEA – DIETARY FACTORS

• **Look for any individual food sensitivities & optimize bowel function

• Avoid foods high in arachidonic acid and saturated fats (produces PgE2): red meat, egg yolks, poultry, pork, lamb, moderate coconut oil intake

• Avoid sugar • Dairy can increase discomfort • Salt can increase fluid retention (watch

processed/packaged foods)

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PRIMARY DYSMENORRHEA – DIETARY FACTORS

• Focus on: • Fish and omega 3s produce PgE3 which reduces

inflammation • Nuts, seeds, beans, vegetables, fruits all help regulate

bowel function • 2 tbsp ground flax per day

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PRIMARY DYSMENORRHEA – SUPPLEMENTS

• Fish Oils: 1080mg EPA and 720mg DHA and/or EPO 500-1000mg up to 3 times per day

• Probiotics: 10 billion CFU + • Vitamin D: optimize levels; min 2000IU/day • Magnesium: 500-800mg daily • B Complex: which includes active B6 (P5P)

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Vitamin D can independently improve pain sensitivity

Lasco A, Catalano A, Benvenga S. Improvement of primary dysmenorrhea caused by a single oral dose of

vitamin D: results of a randomized, double-blind, placebo-controlled study, Arch Intern

3. UTERINE FIBROIDS The most common benign growth in women

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UTERINE FIBROIDS – BACKGROUND INFO & INCIDENCE • Muscular growths that reside in the wall of the uterus,

stimulated by estrogen • Arise during reproductive years, grow during pregnancy

and regress postmenopausally • They are noncancerous (<1% are malignant) • They have many different names: Fibroids, Myoma,

Leiomyoma, Fibromyoma • Occur in 20-50% of reproductive age women

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African ancestry is considered a key risk factor for fibroid development. African American

women are diagnosed younger & are more likely to be symptomatic.

Eltoukhi, Heba M., et al. "The health disparities of uterine fibroid tumors for African American women: a

public health issue." American journal of obstetrics and gynecology 210.3 (2014): 194-199.



UTERINE FIBROIDS – LOCATION AND TYPES 25



UTERINE FIBROIDS – SYMPTOMS

• 50-80% of fibroids do not cause symptoms • Abnormal bleeding (menorrhagia and metrorrhagia)

occurs in 30% of women with fibroids – anemia is common

• Other symptoms: pelvic pressure, bloating, congestion, urinary frequency, backache, pain with vaginal sexual activity

• Thought to cause 2-10% of cases of infertility

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UTERINE FIBROIDS – DIAGNOSIS

• On pelvic exam: enlarged firm uterus or uterus with irregular edges on palpation

• Typically diagnosed via vaginal/transvaginal ultrasound

• Important to track hemoglobin and ferritin levels • More in depth imaging may be necessary: MRI,

Hysterosalpingiogram (HSG), laproscopy

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UTERINE FIBROIDS – LIFESTYLE FACTORS

• EXPECTATION: prevent further growth (very difficult to shrink/cure a fibroid completely)

• Important to balance the ratio of estrogen : progesterone • Decrease estrogen by: reducing environmental

xenoestrogens, supporting liver/bowel function, regulating blood sugar/insulin levels

• Increase progestrone by: decreasing stress and supporting the adrenal glands

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UTERINE FIBROIDS – DIETARY FACTORS

• Follow dietary advice discussed for dysmenorrhea

• Brassica vegetables: focus on 2 servings (minimum) per day to support liver detoxification

• Soy foods: act as selective estrogen receptor modulators and in the uterus have an antiestrogenic effect

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UTERINE FIBROIDS – SUPPLEMENTS

• Replete iron stores as necessary to decrease bleeding • Lipotropic factors: 1000mg of choline and 1000mg of

methionine and/or cysteine a day

• Indole-3-carbinol (I3C) (300-600mg) or Diindolymethane (DIM) (100-200mg)

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Iron stores affect the amount of bleeding – repleting iron stores is a key priority to

manage bleeding.

4. ENDOMETRIOSIS A common cause of infertility

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ENDOMETRIOSIS – BACKGROUND INFO AND INCIDENCE

• Occurs when endometrial tissue is found outside the uterus (on the ovaries, fallopian tubes, in the abdominal cavity or other abnormal sites)

• This tissue responds to hormones but has no place to go during menstruation.

• Estimated 5-15% of women have endometriosis (25-50% of infertile women)

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DDX Adenomyosis: endometrial tissue grows into the muscular wall of the uterus

(myometrium)



ENDOMETRIOSIS – PATHOGENESIS THEORIES

• Sampson Hypothesis: Retrograde Menstrual Flow – suggests menstrual blood is flowing in the wrong direction, out of the fallopian tubes and into the abdomen

• Metaplasia: cells lining the pelvic cavity transform into endometrial tissue in the pelvis

• Genetics: women with first-degree relatives with endometriosis are predisposed to the disease and also have earlier, more severe symptoms

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ENDOMETRIOSIS – PATHOGENESIS THEORIES

• Altered Immunity: women with endometriosis seem to have increased inflammatory cytokines as well as increased IgM and IgG

• Autoimmunity(?): recent studies show that women with endometriosis have higher rates of autoimmune disease

• Others: iatrogenic, diet (estrogen dominance), environmental exposures

• Likely a combination of all these factors!

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ENDOMETRIOSIS – SYMPTOMS

• Get progressively worse over time • Triad: dysmenorrhea, dyspareunia (pain with vaginal

intercourse), and infertility • Pain begins before the onset of menses and can last a day

or two during menses or throughout the month • Vomiting, diarrhea, fainting can occur with intense

pelvic/abdominal cramping. Pain can radiate to legs. • Other symptoms: pain with urination or bowel

movements, bleeding (nose, bladder, bowels), fatigue

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ENDOMETRIOSIS – DIAGNOSIS

• Physical Exam: can be normal or can show a fixed, retroverted uterus; adenexal and uterine tenderness

• Ultrasound can be useful but not a definitive tool • Definitive diagnosis can only be accomplished with a

biopsy via either laparoscopy or laparotomy • Stages I – IV based on the location, depth, size, and

amount of endometrial growth found on laparoscopy

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ENDOMETRIOSIS – DIET AND LIFESTYLE

• Follow dietary guidelines for dysmenorrhea/uterine fibroids: focus on anti-inflammatory foods rich in phytonutrients, fiber, and essential fatty acids. Ground flax and cruciferous vegetables are especially important.

• Environmental exposure history: consider testing for toxins and educate on avoiding hormone disrupting chemicals in food/water and personal care products

• Castor Oil Packs • Sauna therapy

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ENDOMETRIOSIS – SUPPLEMENTS

• Basics: Fish Oils , Probiotics, B complex, Magnesium, Vitamin D

• Immune support: Curcumin; Pycnogenol; NAC; Resveratrol

• Hormone balance and liver support: I3C/DIM; Calcium-D-glucarate; Choline/methionine/cysteine

• Support progesterone: Vitex agnus-castus; Progesterone

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5. POLYCYSTIC OVARIAN SYNDROME Important due to lifelong risk factors

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POLYCYSTIC OVARIAN SYNDROME (PCOS)

• PCOS is a syndrome, not a disease. No two women have exactly the same symptoms or needs.

• Presence of at least 2 of: 1. Ovulatory dysfunction 2. Hyperandrogenism 3. Polycystic ovaries on ultrasound

• Thought to affect approximately 15-20% of reproductive-age women worldwide. Also found in: 30-40% of women with secondary amenorrhea and 75% of anovulatory intertility patients

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PCOS – SYMPTOMS

• Irregular menstrual periods: typically absent, infrequent or unpredictable (oligo- or anovulation)

• Signs of hirsutism, acne, and/or androgenic alopecia • Obesity • Infertility – PCOS is one of the most common causes of

female infertility • Oily skin

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Insulin resistance is the causative factor in PCOS (8/10 women with PCOS have some

degree of insulin resistance even though 50% of women with PCOS are “lean”)



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DDX OF CHRONIC ANOVULATION

• PCOS is a diagnosis of exclusion Rule out: • Thyroid disease • Hyperprolactinemia • Late onset Congenital Adrenal Hyperplasia • Androgen secreting neoplasm • Cushing’s Syndrome

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PCOS – EVALUATION • Keep in mind: There is no single test for diagnosing

polycystic ovary syndrome (PCOS). Consider:

• Elevated LH : FSH Ratio • Androgens: Total testosterone, DHEA-S, Bioavailable

testosterone • AMH • Day 21 estrogen and progesterone • SHBG • HbA1c, fasting glucose, fasting insulin • Pelvic ultrasound

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PCOS – EVALUATION

• Also test: • Day 3 17-OH progesterone (congenital adrenal

hyperplasia) • Full thyroid panel with antibodies • Prolactin • Cholesterol panel and liver enzymes • 24 hour urinary cortisol (if signs of Cushing’s)

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PCOS – HEALTH CONSEQUENCES

Women with PCOS are at greater risk of developing: • Gestational diabetes and/or diabetes before age 40 • High cholesterol, hypertension and increased risk of

cardiovascular disease • Anxiety and depression • Endometrial cancer

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PCOS – DIET AND LIFESTYLE

First line of treatment should be lifestyle, weight & stress management.

• Low GI/GL/Paleo • Exercise • Meditation, breathing, yoga • Spearmint tea (2 cups per day)

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PCOS – SUPPLEMENTS

Myo-Inositol • May help induce ovulation by improving insulin sensitivity • Has been shown to: decrease serum androgens, decrease

TG, increase HDL, lower blood pressure

• The typical treatment dose is 2 grams with folic acid 400 mcg twice daily.

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Emerging evidence is promising regarding myo-inositol in the reduction/prevention of

gestational diabetes in patients with PCOS or those at risk due to a family history. Myo-

inostiol can also improve egg quality in IVF cycles.



PCOS - SUPPLEMENTS 49

NAC (N-Acetyl Cysteine) • N-acetyl cysteine (NAC) is derived from the sulfur-

containing amino acid cysteine and the precursor to glutathione (your body’s most potent antioxidant)

• NAC may reduce insulin resistance and improve fertility • NAC significantly improved rates of live births and

spontaneous ovulation compared to placebo in women with PCOS

• Typical dosage: 600mg tid

Thakker, Divyesh, et al. "N-acetylcysteine for polycystic ovary syndrome: a systematic review and meta-

analysis of randomized controlled clinical trials." Obstetrics and gynecology international 2015 (2015).



Other supplements to consider: • Vitamin D, Fish oil, B vitamins • Berberine, Chromium • Anti-androgenic herbs: licorice, reishi, white peony,

EGCG, saw palmetto, urtica dioica • Progesterogenic herbs: vitex

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6. SUMMARY Critically assess and know what hormonal condition you are treating!

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SUMMARY

Each menstrual cycle is unique – listen and assess each person in front of you

Make sure to assess and diagnose menstrual conditions effectively (think about dysmenorrhea, endometriosis, fibroids & PCOS symptoms)

Review each condition & recommended treatment to achieve optimal results with your clients

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THANKS! Any questions?

Medical Advisor Support Available at Seroyal

1-800-263-5861



REFERNCES

1. Pizzorno, Joseph E., and Michael T. Murray. Textbook of natural medicine. Elsevier Health Sciences, 2013.

2. Hudson, Tori. Women's Encyclopedia of Natural Medicine: Alternative Therapies and Integrative Medicine for Total Health and Wellness. MACMILLAN HEINEMANN, 2007.

3. Kaur, Sat Dharam, Mary Danylak-Arhanic, and Carolyn Dean. The Complete Natural Medicine Guide to Women's Health. Robert Rose, 2005.

4. Lefebvre, Guylaine, et al. "Primary dysmenorrhea consensus guideline." J Obstet Gynaecol Can 27.12 (2005): 1117-1146.

5. Segars, James H., et al. "Proceedings from the Third National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations." Human reproduction update 20.3 (2014): 309-333.

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