Dear all, I wonder whether anyone can offer any ideas about this new patient? The patient is a 32yo female. She has been trying to conceive for a year and a half. She has a history of amenorrhoea. She is over-producing prolactin and has been producing what she calls 'discharge' from her breasts for 1 year now. She is taking Cabergoline medication to reduce the prolactin levels. This stimulates her menstrual cycle. She came off the pill in June 07. She had her first menstrual cyle in Jan 08 (stimulated by the medication). The period was very light, 2 day flow followed by spotting, dark colour, no clots, slight abdominal pain on day1. She had 2 more periods, 34 day cycle. Then she stopped the medication which resulted in her periods stopping again. She then restarted the medication and has had 1 more period 2 weeks ago (mid September 08). MRI scan showed no abnormalities. Ultrasound scans suggest there may be mild PCOS and a thin endometrium. She experienced menarche at 12yo. Her periods at this time were very heavy and very painful and so she was put on the contraceptive pill to control this. She has been on the pill for the best part of 20 years, therefore. She did come off for 9months aged 21 and for 6months aged 29. Both times she experienced amenorrhoea. She is slim and friendly. She describes herself as quite negative, a worrier and quite anxious. She has a good appetite, regular bowels although suffers bloating with too much wheat. She sleeps very well. She rates her energy levels as 6 out of 10. She is more cold than hot. Tongue: very red tip with raised papillae. Normal colour, moist and possibly slightly swollen. slight yellow tongue coat at the back with some red spots.Pulse: steady regular beat, St/Sp slightly floating. He and Kid Yin xu and deep; LV slightly full. Any ideas about the pathology and treatment principles would be very happily received. I mainly treat with acupuncture although I am able to prescribe Giovanni's Patent remedies also. Thanks All the best Diane
Over production of prolactin, infertility and amenorrhoea
Hi Diane -
If this patient has a history of Galactorrhea and Prolactinemia with the Amenorrhea, and the Cabergoline restores her menstrual cycles, it's fairly certain that the prolactinemia is what's causing the amenorrhea. I am surprised, however, that the MRI showed no pituitary microadenoma. It is not uncommon for patients with acute, or transitory amenorrhea to have mildly elevated prolactin levels that are exacerbated by stress, i.e. the young girls who go off to college away from home and stop having periods for the first few months. However, if there is a long history of Amenorrhea and also some galactorrhea, there will usually be a benign pituitary micoradenoma as the cause of the elevated prolactin levels. Cabergoline is first-line therapy for this.
One think to have checked - if it hasn't already been checked - is her thyroid. Low thyroid function can lead to elevated prolactin levels in some patients, and this can also be associated with ovulatory dysfunction and Amenorrhea.
The TCM patterns most commonly associated with Prolactinemia are Liver Qi Stagnation and Depressive heat primarily, and a smaller subset of patients with Kidney yin xu and deficient heat. The guiding formulas are respectively Jia Wei Xiao Yao San aka Dan Zhi Xiao Yao San + Mai Ya (30-60 grams) for galactorrhea; and, Zhi Bai Di Huang Tang with additions and subtractions for the Yin-Xu heat pattern. Both of these may be safely administered in conjunction with the cabergoline.
Hope this helps,
Ray Rubio, D.A.O.M., L. Ac. FABORM
President ABORM
www.westlakecomplementarymedicine.com
From a clinical perspective, suggest she make a tea from 60 g Mai ya daily. It also does not taste bad. If you are using raw then not a big deal to add it to your formula. If you are using concentrated powders it may be easier to send her to china town to take 60g daily of dry fried Mai Ya tea.
Lorne
www.acubalance.ca
www.prodseminars.com
Hi Diane,
Because we are Chinese medicine practitioners, I would stick with your differential diagnosis and he treatment. I would not recommend thyroid testing yet.
I would work to bring all that qi in her chest and heart (red tipped tounge- heat in the heart) down to her womb.Primary dysmennorrhea indicates jing xu which helps explain why she is not bleeding regularly. It fits nicely with wanting to fall pregnant to add some (warm) jing herbs to her formula.
My teacher, Sharon, has a great formula from her teacher called 'Ji Mai San', which is for specifically this situation, infertility/amenhorrhea/prolactemia. I have the complete formula in my clinic, i will get it today. These are some herbs in it:
Mai Ya
Ju Luo
Ju He
Bai Ji Li
Because of the Jing deficiency and the want to fall pregnant, I would add Ba Ji Tian, Yin Yang Huo, Tu si zi. If she has a very cold belly and butt, you could add a bit of Jiao Ai Tang, Huang Lian and Rou Gui, which would help the heat from her heart root in her belly where it needs to be to keep her womb warm. If she isn't particularly cold below, you could just see what happens to the red tipped tounge when you encourage the movement of qi away from the chest with those qi movers and warm below with the Jing tonics. It may be less red without having to add cold herbs that drain heat from the heart.
.
Hope this helps,
Jennifer
Jennifer Tongren, MAOM, Lic.Ac
White Pine Healing Arts
86 Henry St.
Amherst, MA 01001
413-230-4400
http://www.axisacupuncture.com/
www.whitepinehealingarts.com
Diane (and Jennifer, and others) -
I'm not sure what the comment "because we are Chinese Medicine Practitioners, I would stick with your differential diagnosis and treatment" means. Having thyroid testing done to see if that is part of the picture in her Prolactinemia and Amenorrhea simply brings more light to the situation. It's no more outside of the framework of this case discussion, than stating the other pertinent western clinical information, i.e. prolactinemia, galactorrhea, negataive MRI, and so on.
Also, in my original response regarding this case, I specifically mention the TCM patterns/differential diagnoses most commonly associated with Prolactinemia and Galactorrhea, and their corresponding formulas.
I would also question the statement, "primary dysmennorrhea indicates Jing Xu". Really? In a patient whose menarche was not delayed, and started at age 12? Also, the reason she is not bleeding regularly is because she is not ovulating. This is due to either the Prolactinemia, the PCOS, or both.
It is not uncommon at all for patients who have undiagnosed PCOS to have irregular and quite painful periods, and they are frequently simply put on OCP's to regulate their cycles and ameliorate their dysmenorrhea without their OBGYB ever really discovering that they have PCOS. Then, years later when they stop the OCP and are ready to conceive, the oligomenorrhea returns, and a more thorough investigation reveals the PCOS that was probably there all along. Also, Prolatinemia is typically associated with excess syndromes primarily, and PCOS can present with both excess and xu syndromes.
Another thing to mention regarding the suggestion to use Vitex. This is actually a good recommendation, because Vitex has been shown to reduce elevated prolactin levels clinically. However, the Vitex used in these situations is Vitex Agnus Castes (the english Vitex), not Man Jing Zi (Vitex Rotundifolia or Vitex Trifolia).
While we must always treat our patients from the foundation or medicine's principles and treatment strategies, to discount other pertinent clinical information is probably not wise.
Ray Rubio, D.A.O.M., L. Ac. FABORM
President ABORM
www.westlakecomplementarymedicine.com
Hello Diane and all...
I am not denying that Western clinical information is important, or that we should ignore certain signs that point to a situation where a Western diagnosis would benefit the patient. But I question the timing. Why not try to give herbs and acupuncture first? What would having her thyroid checked do for this patient, what would it bring to light for our Chinese diagnosis and treatment? It may help her regulate her menses and get pregnant, but she would end up on medication that ultimately, in my view, does not get to the root of why she is not having a period or getting pregnant and could lead to other symptoms down the road.
I think that getting acupuncture and drinking herbs will do the same thing (help her regulate her period and get pregnant and treat an imbalanced thyroid) and really heal the disharmony that is leading to the symptoms. This is my bias. Kiiko Matsumoto says that the thyroid is related to the Kidneys. Why not treat the Kidneys first and see if the whole dynamic in this woman changes?
Menarche is related to the 7 year cycles, which is a Jing function. In my view and clinical experience (and that of my teachers), when a woman begins her period late (like 15, 16, 17), or when there is irregularity/pain from the very first cycle, the Jing is involved. Obviously, one needs to weigh other signs and see the dynamic of what is happening in the body to decide whether to focus on this aspect of disharmony. But in this case, it would fit very well. There are relatively neutral Jing herbs (Tu Si Zi, Gou Qi Zi) or warm Jing herbs (Ba Ji Tian, Yin Yang Huo). Because this woman tends to be cold and her main complaint is wanting to get pregnant, it would be incredibly beneficial to treat the Jing.
So here is the formula and indications for Ji Mai San which has been handed down:
"Ji Mai San:
Bai Ji Li 9
Ba Yue Zha 9
Da Mai Ya 12
Qing Pi 3
Ju He 3
Ju Luo 3
Pu Gong Ying 9
Function: Course the liver, rectify the Qi, disperse knots
Principle Use: Liver Constraint breast lump, amenorrhea, painful menses and infertility.
Experience in Application: The liver belongs to Wood and it likes orderly reaching. The liver values happiness and ease and fears constraint and knotting. Women easily develop constraint which gives rise to Liver constraint and Qi stasis. This causes many pathologies relating to menstruation, pregnancy, birth and development. This is why the ancients said, "For Women, the Liver is the Pre-Heaven". This clearly means that there is a close relationship between the Liver and women's physiology and pathology. Ji Mai San is my experiential formula for Liver constraint leading to breast lumps, painful menstruation, amenorrhea and infertility. As long as the differentiation of patterns is precise the effect is outstanding. "
This from a doctor in China, Dr. Qiu Xiao Mei. (hopefully i spelled her name right). The way I use it in the clinic is for women who experience a lot of breast tenderness before their period, or any breast issue that has to do with a painful/blocked menses (with Liver constraint as a primary pattern).
One can use parts of this formula if it applies.
Interesting topic and I'm glad to have the discussion!
Best,
Jennifer
Diane/Jennifer and all -
Again, there seems to be some miscommunication occurring here. Having the patient's Thyroid checked to see if this is part of the problem here is actually very important at the outset, because if her Thyroid is part of her prolactinemia/oligomenorrhea issue, then it is useful to chart this information in case the herbs and acupuncture don't work. Testing her thyroid function with western labs does not ipso-facto mean treating it with western medicine if there is a problem. It simply provides added clinical information that can assist in a prognosis for this patient.
I agree with you Jennifer that it is not the best outcome for a patient to be put on Synthroid for the rest of their life, if their pattern of disharmony and constitutional weaknesses can be addressed with Chinese Medicine. But Chinese Medicine does not always work, any more than any other medicine. So, if the patient wants to conceive, and if we apply our best differential diagnosis and treatment principles utilizing Herbal Medicine and Acupuncture, and it doesn't help the patient to conceive, or maybe it doesn't help the patient to conceive in the time-frame they can afford - then we have still helped the patient on her journey to conception if we have been instrumental in deducing that the Thyroid was part of the problem.
I'll give you a different example: I had a 35 year-old nulligravida female with 1 year of primary infertility come to me for acupuncture and herbal medicine to help her get pregnant. She had a history of of scanty menses (1-2 days) since the onset of menarche, and she had failed to develop more than a 5 mm uterine lining during 4 cycles of ovulation induction with Clomiphene Citrate. She had average follicular recruitment on the Clomid (2-4 follicles per cycle), but the lining was an issue. The patient was constitutionally thin, cold, vegetarian, etc. I suspected that she was kidney yang deficient and liver blood deficient based upon her other diagnostic signs and symptoms. I was fairly certain that the clomid was part of the reason she had not conceived with the four rounds of ovulation induction/IUI because it's a SERM, and can lead to thinner linings in patients who have normal linings. As I mentioned, this patient's periods were always short (1-2 days), so I presumed that she may have had thin linings all along.
Because this patient had been working with her regular OB for the Ovulation Induction, I thought she might benefit from seeing and REI for a more thorough work-up, and perhaps using gonadatropins (instead of clomid) for any future IUI's, because they don't thin the lining like Clomid.
Then, one last piece of information caught my eye. I am sure that you all having the standard question on your intake forms of whether or not the patient's mother had taken DES. I do, and this patient indicated no. However, she did say that her mother had suffered from multiple miscarriages before she had conceived, and that the doctors had given her mother some "medication to help her keep the baby". DES was taken off the market in 1972, but this patient was conceived and born in Australia in 1973. There have been reports that it took some time for the news about DES-related mullerian anomalies to reach other countries after 1972. So, knowing that DES-related mullerian anomalies could also possibly account for her scanty menses, and difficulty conceiving, I asked her to get a work-up from an REI that I work closely with. At this point, I still suspected that her scanty menses and difficulty conceiving were due to her Kidney yang and liver blood xu, but I thought it might be best to rule out this other issue before beginning treatment.
Fortunately, my hunch was correct. The patient's Saline Ultrasound revealed a t-shaped uterus related to in-utero exposure to DES. This is obviously beyond the scope of TCM, and this patient is now in the second trimester of pregnancy using a uterine surrogate.
Look, we are all practitioners of this amazing medicine that is so rich in history, and clinical efficacy. I too, have studied with Kiiko, and David Euler, and Dr. John Shen, and Yitian Ni, and Mazakazu Ikeda, and Randine Lewis, and Jeffrey Yuen, and so on. I love Sharon's work as well. Jennifer, you are lucky to work with her at White Pine Healing Arts.
But I also feel that we have taken an oath to help our patient's alleviate their suffering if possible. If part of their suffering comes from an inability to conceive, and our medicine -for whatever reason - doesn't help them to achieve that goal, but we point out some morsel of relevant western clinical information does - we have still fulfilled our oath. By all means, we should try the Chinese Medicine first, and resort to western medicine second, if necessary - but we owe it to our patients to present to them all options and information so that they can make an informed choice.
Thanks again for the discussion from everyone. By the way, I love the formula Jennifer. Very interesting. I also very much appreciate being able to go over cases like these with the high level of clinicians that participate here on CMT. Great community.
Ray Rubio, D.A.O.M., L. Ac.
President ABORM
www.westlakecomplementarymedicine.com
All,
I have been loving this latest thread. It's depth is so useful clinically for all of us:-)
I wanted to add to Ray's great thoughts on seeing western diagnostic tests as contributions to good medicine, not as the usual us against them mentality that so often takes place. In many ways I believe that medicine is medicine is medicine. There are many different styles of diagnosing and treating that exist in the world, it may be between western and chinese, or even within Chinese itself. The point is that some information, regardless of its source can be extremely useful to the practitioner to help influence a good therapeutic outcome.
I am presently reading the book "Currents of tradition", whereby Volker does a great job of showing how Chinese medicine itself has evolved over the centuries to become the medicine it is now. It has been a progressive growth that includes important contributions from famous docs through out history. The wen bing theory is a case in point. Doctors had noticed that the classical way they know of to treat certain disorders were not as effective so they devised a different theory to support better clinical outcomes. Some of the theories from the Wen Bing are so useful even today.
To me western medical testing is like this. It is a newer contribution to an old journey of discovery. I think in the future we will not discriminate so much between western and eastern testing, we will just call it testing!
I too love this community of learners and practitioners. I find this forum to be such a useful tool, both for practice and as well to connect.
Trevor
I am also really enjoying this thread. Clinically, b/c I have an very similar patient to the examples being discussed. 22 yo female, lactating for 10 months, no menstruation for one year, 3 years of abnormal pap smears with cryosurgery and a recent LEEP, no pituitary tumor (negative MRI). She is also a student in a very challenging field (aeronautical engineering), anxious, insomnia, sinus/asthma issues, etc... She has done very well with treatment, is sleeping and much calmer, and no more sinus issues, but is still lactating (although a bit less... starting her on Mai Ya as soon as it arrives in the mail), and no menstruation, yet.
Her diagnosis is: Counterflow of the Chong and Ren, causing Blood to move upwards (lactation), instead of downwards (amenorrhea). She also has some Heart and Spleen Blood deficiency, as well as phlegm dampness.
I'm also enjoying reading about the blending of Western and Eastern medicine. I think Chinese medicine is amazing at treating so many things (unexplained infertility, for one), but sometimes (as in the case of a T-shaped uterus, or a septum, or no fallopian tubes, for example), we just can't help them, or see inside to figure out how to help them, and that's where Western medicine is a fantastic complement.
First off, Ray I am terribly offended that you did not list my name as one of your influential teachers. I thought the 3 hours we spent at your clinic in August should warrant some honorable mention. By the way thanks for the curing pills you so generously gave me after you poisoned me with Thai food.
I have been taking Sharon Weizenbaum's courses. I agree with Ray about how fortunate you are Jennifer to have Sharon as a mentor. Sharon has translated numerous material from her "old doctors" in China plus she has studied with Dr Huang Huang. Actually, I remember the formula from one of the courses I just completed of hers. That is also where If you have a chance look into her graduate mentorship program she offers both in Chicago and Amherst. Her clarifying diagnosis course is great.
We hope to be offering three of Sharon's courses in the new year online at prod Seminars plus she is teaching a live seminar in Vancouver Feb 2008 on PCOS, weight loss and diabetes.
Lorne
www.acubalance.ca
www.prodseminars.com
Rachel and all,
This is such a big question...when to refer our patients to get western tests! I think with Chinese medicine's rising popularity, we will encounter this a lot in the future.
I don't think just simply having a western test done (like a thyroid test in this case) is so neutral as Ray is pointing out. I have seen that getting a western diagnosis sweeps patients into a route that most often leads to intervention/medication. Often this intervention leads to other interventions, like a snowball (i.e- side effects being treated). There are so many instances where getting screened and treated does not reduce the death rate (heart disease being one example), and could instead lead to a decline in quality of life and side effects.
Second, getting a western 'diagnosis' for many women can be life changing, insofar as a person's identity is strongly correlated with this new diagnosis because the Western medical culture is so persuasive. I will use myself as an example. I got a diagnosis of a bifurcated uterus while in acupuncture school. For 2 years I thought of myself as infertile. Then after 2 more ultrasounds, it was shown that I had a perfectly normal uterus. Either the first diagnosis was wrong, or something changed in those two years. Regardless, my identity was strongly affixed to this diagnosis, and still haunts me a bit to this day. Getting a western diagnosis is not neutral.
Women with T shaped uteruses do fall pregnant without Western intervention. Ray, did you try using warm Jing herbs with your patient with a T shaped uterus? You said this woman was constitutionally thin. This underdevelopment, along with her scanty menses since menarche, leads me to the use of Jing herbs. It is entirely possible that with some Jing support, this woman's uterus could develop in a fuller way and she could have had the support she needed to support a pregnancy. Right now, she has a baby, and that is wonderful. But maybe she will be a bit more prone to osteoporosis later?
Maybe we can think of those tests that would strongly help our diagnostics (like getting a salpingogram will point us to using herbs that open the fallopian tubes) and those that are immediate benefit to the patient (like in an ectopic pregnancy). We can think of those tests that if we referred to a western route too early may lead to unnecessary intervention (like a T shaped uterus), or not give us any more information for our Chinese diagnosis (like a thyroid test).
In all good medicine,
Jennifer
Jennifer Tongren, MAOM, Lic.Ac
White Pine Healing Arts
86 Henry St.
Amherst, MA 01001
413-230-4400
http://www.axisacupuncture.com/
Dear all,
My internet went down for a few days so apologies for not replying sooner.
Thanks a lot for all your thoughts. It's wonderful to have such input and very interesting to read different perspectives. Certainly much food for thought.
My treatment principles have been to rebalance Chong and Ren. To nourish the Kidneys and move the Liver.
Main points: SP4 P6 DU20 LU7 KD6 Ren6 KD14 ST29 LV3.
Any thoughts more thoughts very welcome
Thanks again
Diane
Also I have not studied herbs as yet so I'm not sure whether it would be appropriate for me to suggest teas like the Mai Ya tea that Lorne recommends.. any ideas??
Hello all,
I agree that this thread brings up so many interesting issues.
Of course we cannot make generalizations about recommending western diagnostic tests. As much as all tests are not equal, our individual patients and their doctors also vary a lot. It can be easy to think that more western information is just plain better but this ignores so many of the complicated issues around the meaning and implications of such information. Information is not neutral. Each situation (i.e. the condition of our patient, their relationship to their own body, the western medical milieu they are connected to, the test being considered) must be looked at individually. Because of this, I agree with Jennifer that I would not necessarily recommend a baseline thyroid test for all patients coming in for fertility issues even if I suspect that a thyroid test would come back as abnormal.
It takes a lot of work and careful attention to pick apart and weigh much of the information we receive about western medical tests. Though there is so much value in some of the information available from tests and the treatments they imply, we don't do our patients any favors to send them for tests without considering all the complexities, including the controversies around the accuracy of certain tests, their actual clinical meaning and the plethora of differing opinions on how to respond to the tests. Thyroid illness is a good example of an inexact science that is practiced differently by different doctors with varied results. I agree with Jennifer in that we should exercise caution when we push someone toward that modality as if going there guarantees good care if we fail.
For a very interesting discussion on the risks and benefits of cancer screening (which I know is a different issue) I point to this three part series from Radio National in Australia. It very clearly articulates some of the risks of screening, especially in this modern age in which the screening is heavily promoted by the drug companies.
http://www.abc.net.au/rn/healthreport/stories/2005/1440410.htm
As for the T shaped uterus story, yes, it is wonderful that this patient found a pathway to motherhood though I was struck, like Jennifer with the early dropping of the possibility this patient could conceive and carry a child. When I studied with Dr. Qiu in Hang Zhou, I saw her treat many cases of infertility due to "maldevelopment of the uterus". In many cases the women were underdeveloped, small with small breasts and very little pubic hair and the bimanual exam reveal small or malformed uterus. Along with differential diagnosis, this was treated with strong Jing tonics and I watched as the women and their uterus' grew. The amenorrhea or scanty menstruation as well as the BBT improved as well and fertility was achieved. Perhaps this kind of treatment for this type of illness is not well known in the west enough for it us to consider Chinese Medicine as a possible solution to such a problem. I have a few case studies I'll translate and try to post on this topic.
Thanks for all the good input everyone.
Sharon
Sharon Weizenbaum
86 Henry Street
Amherst, MA 01002
www.whitepinehealingarts.com
Wow, this thread is awesome and really suits the climate that we all work in today!
I agree with Jennifer and Sharon about being cautious around over testing, digging, and then defining someones problem from a test that may or may not be faulty. This can have a snow ball effect and lead to deep emotional wounds that will most likely affect the patient physically.
Now I want to bring up the fact that this phenomena is not just limited to Western medicine and its modern testing, it is also very common within the Chinese medicine community. Many patients that I see come in with a pattern diagnosis that they were given by a different practitioner (or Book that they read) and hold onto that information just as much as someone given a western Dx. Often times I have to question the accuracy of the chinese diagnosis they have been given.
For example, a menopausal woman sees an acupuncturist and is told she is Kidney Yin deficient, but when I meet her I notice that she is very over weight, has a very flushed face with rosacea, has a very full and wiry pulse, sweats profusely and on and on. To me this woman's problem is not so much one of deficiency, it is more to do with excess.
But with the age of easy access to info through the internet, the above mentioned woman will stick to her original Dx because she has found a way to associate herself with it through her self research and because she is stuck by what the first practitioner told her- even though she may have used Chinese herbs and/ or acupuncture for a year and DID NOT feel any different. The practitioner could have told her that this woman's problem being yin deficient is very deep and so takes a long time to change.
Now if a woman takes a treatment for over a year and does not notice much change, I would think that either the Dx or Tx needs to change. Anyways this was only an example, I have seen many different types of problems in clinic that are similar and from reading the Shang Han Lun it seems that this has been a problem since the beginning of time.
I am by no means saying that my diagnostic skills are masterful or anything, all I am saying is that information is powerful and can either limit or liberate a person- depending on how it was used. This goes for Chinese medicine, Tibetan medicine, Western medicine, or what ever medicine. We as practitioners are seen as some type of superior race and so people look up to us as Gods/ Goddesses. If we present the information that we give as "this is just a possibility" or this pattern or western lab test may be having an influence. If we keep the Dx somehow open ended so that the patient understands the complexities of medicine. That medicine is an art and if one Dx or Tx doesn't work, then we can look at it from a different angle. Perhaps this will help prevent this problem of patients snow balling into self deprivation because of a faulty diagnosis.
I would say this would go for the above mentioned T-shaped uterus. the uterus is what it is, it is shaped as it is. But does this mean that someone with this condition could never change or bear children? We don't really know unless we try. We could say to the patient something like, "well based on what we know about a T-shaped uterus, it may be difficult for you to become pregnant. But I do think that it would be worth while to work with you and see if we can change your situation. I recently read some great articles (translated by the great Doctor Sharon Weizenbaum!!) which showed how some patients, with a similar situation to your own and were treated with Chinese medicine, were able to bear a child."
Oh well.... it seems that this thread has been diverging into a different realm and perhaps needs a new name?? LOL
Trevor Erikson, R. TCMP
www.skin.health-info.org
www.acubalance.ca
I would like to expand on what Trevor said about what ..... said about the danger of a diagnosis. It is my experience that most western patients do not benefit from the knowledge of an exact TCM diagnosis at all. I would say that most of the time we actually do harm. For example a patient comes in with insomnia, trouble falling asleep and she's tired with loose stools. I diagnose her with Spleen Qi and Heart Blood deficiency. If I actually tell my patient this diagnosis then I guarantee the first thing she says is "What's wrong with my Heart?" I then have to spend the rest of the appointment trying to explain that the difference between an anatomical western heart and a TCM Heart. Next time she comes in I guarantee she mentions something else about heart problems in her family etc. So instead I mention something like "Stress is affecting your ability to fall asleep, and I can help reduce the effects of this stress on your body and get you falling asleep easier" and then go into something about overthinking and stress management with her. Yes my words are not actually TCM correct. However I have explained things in a way that she can relate to, I have not added any more stress or worry to her and have given my self an in to talk about the mental/emotional aspect of her condition.
If you remember back to your own schooling it took months before you started to grasp the concepts of TCM. I see this with the 1st year TCM students that I teach. How can we expect our patients to grasp in a 10 minutes what it takes a 1st year student hundreds of hours to get?
This gets to the central aspect as our job as TCMers. Out first priority is to help the patients with their problems. The best way to do this is to get them to connect in someway with a medical system that is in a large part foreign to them. I am sure many of you get patients who come to you after see a mostly chinese speaking practitioner because they want things better explained. We do them an injustice if we try to use every TCM term word for word. Our job is to translate the medicine in a way that they can properly digest and integrate the information into their lives so they can make better decisions and improve their help. Saying that stress is affecting someones digestive system is not a bad translation of Liver overacting on Spleen and gives someone a hook into the health consequences their actions have.
Kaleb
What a great thread!
I want to offer 2 case histories as examples to illustrate some of the things I have read here so far, especially in regard to telling patients to be patient, and also in regards to referring out.
First patient: 30 yo female, very thin, night sweats, very anxious, TTC for 4 years. Blood and Yin deficient. Her OB had her take SEVEN rounds of Clomid, telling her to just keep trying, it should work eventually. The patient became more and more Yin and Blood Xu, until her periods became mostly scanty brown flow. But, accd to most OB's, this kind of flow is not a problem, right? Finally, she went to see the local RE, who did a laparoscopy and found a septum. 4 years of trying, 7 rounds of Clomid, and she would probably never have gotten pregnant, no matter how much Clomid they gave her. The RE referred her to me in conjunction with her treatments with him. SHe lasted 7 weeks/treatments with me, but she couldn't hear "wait a little longer, you will get pregnant eventually", anymore, despite positive changes in some of her symptoms, so she quit.
Patient #2 is a 30 year old female, diagnosis of PCOS, ultrasound showed very thin (5mm) uterine lining, 1-2 days of brown, mucusy menstrual flow, History of one miscarriage at 8 weeks. Every treatment, she asked what the minimum amount of treatments she can have/herbs she has to take/etc... for this to still work. Luckily, she persevered, and got pregnant after 8 weeks/treatments, and I suggested she continue with the acupuncture to help prevent miscarriage, as she has a history of it. She didn't, and miscarried at 6 weeks. She threw herself back into treatments with her RE, despite telling me how much the acu had 1. improved her lining when the meds had actually reduced it, and 2. how much cheaper the acu was than the RE, and 3. how much more relaxing the acu was than all the tests and shots and ultrasounds.
Again, from practice, I have seen that sometimes acupuncture/TCM really is the best thing for a patient (#2), and sometimes, we can't do it all, nor could the OB in example #1. It is the balance of the 2 medicines (at least for my practice) that makes our patients get pregnant. I think we can be irresponsible by not referring out, or by referring out too quickly. But who is the best person to judge that? The acupuncturist treating that patient.
Hi All,
I agree that timing in relation to fertility patients is one of the individual complexities that helps determine when to recommend a western test such as thyroid hormone levels. For me, another reason I recommend a thyroid test is when a woman shows signs of potential thyroid issues and she is not willing to wait for these signs to get better before attempting pregnancy. The reason for this is that thyroid abnormalities can cause difficulties for the baby's development and for the pregnancy. Because of the dangers of thyroid imbalance, a thyroid test may help slow the patient down and encourage her to improve her health, her BBT and her thyroid levels before attempting to get pregnant.
Sharon Weizenbaum
86 Henry Street
Amherst, MA 01002
www.whitepinehealingarts.com
Hi all!
Great discussion here!
I just want to point out the obvious that hasn't been said yet.. maybe because everyone already knows... maybe because sometimes the simple stuff is the easiest to forget. :)
Breast milk (or discharge in this case) is an extension of the blood, so if this patient has been losing "blood" for so long, it's no wonder that she is not menstruating.
Also, the Bai Lao points are a great way to stimulate the lining of the endometrium, but you've got to be supporting the blood from another angle. If herbs aren't your thing, maybe some basic dietary advice would help your patient.
Hope this helps even just a bit and look forward to reading more!
Hi Everyone (and of course my Sensei Lorne Brown) -
Although the mention of blood being an extension of breast milk is an accurate one from a TCM point of view, this relates more to breast milk production in pregnancy, not in this situation.
In this situation, there are no menses because this patient is not ovulating on a regular basis. No follicular recruitment by the ovary, means no thickening of the uterine lining, and no ovulation, leading to no corpus luteum, means no vascularization of the lining, and hence no period. As noted in the initial post on this thread - this patient has been diagnosed with Prolactinemia (excessive production of Prolactin) and this fools the body into thinking it's pregnant, hence the galactorrhea (breast milk production).
As I mentioned earlier, because the patient's MRI was negative for a prolactin-secreting adenoma, thyroid screening is the standard of care for Prolactinemia. Because Thyroid Releasing Hormone shares the same pituitary portal system as Prolactin, hypothyroidism can result in Prolactinemia. I am sure that this was already done by the patient's RE or OBGYN, but if not, it should be done.
So - figuring out the cause of the prolactinemia - from both a western and TCM point of view is the key to treating this patient's oligomenorrhea/annovulation and galactorrhea. This assumes of course that the patient does not also have PCOS - which was mentioned as a possibility in the first post. Obviously PCOS can also lead to annovulation and oligomenorrhea.
One other little aside for Jennifer and Sharon regarding my patient with the DES T-Shaped Uterus: I did offer this patient the option of trying Chinese Medicine to strengthen her uterus, kidney jing, chong/ren/du mai. I knew - and she knew from her own research - that a small percentage of women do conceive with a T-Shaped Uterus, and an even smaller percentage (less than 5%) are able to carry the baby long enough to survive without miscarrying first. I told her that I would be more than willing to try naturally first if she preferred - but because she had already been trying for a year or more, and because of the risks of complications and miscarriage - she and her husband chose the route of Uterine Surrogacy.
Finally, I just wanted to mention that I was out in Chicago this last weekend for the AAAOM Conference and had the good fortune to catch Sharon Weizenbaum's workshop. Really inspiring material, coming from a very experienced practitioner. If any of you haven't had the opportunity to hear or see Sharon lecture, make sure to catch her upcoming lecture at in Vancouver in 2009 (check out www.prodseminars.com), or go to www.whitepinehealingarts.com.
Ray Rubio, D.A.O.M., L. Ac. (FABORM)
President ABORM
www.westlakecomplementarymedicine.com
Thanks Ray. Great seeing you in Chicago. Further to your mention of Sharon's courses, Pro D Seminars will be offering the course she did on line in an online version by the end of November. We also three distance learning courses (DVD and Notes). I am personally excited to be offering her classes as she has been very inspirational to my practice. She truly is a gem. As you mentioned we have her teaching a class in Vancouver in February 2008 plus she also teaches her graduate mentorship program. If you have a chance to read her articles in the Lantern journal, or learn from one her classes I think you will find it valuable and practical.
Lorne
www.acubalance.ca
www.prodseminars.com
Hi All,
I have been following this thread, and think that it is best so far I've seen. I hope it is one of many to come. Thank everyone who participated in this discussion, and I would like to add my two cents to this discussion though.
Ray has been very helpful in explaining Prolactinemia (excessive production of prolactin (PRL), as well as many other topics on this subject. I can see that he has an in depth understanding, and willingness to share. I wanted to get something corrected though, before we go on. Hypothyroidism and Prolactinemia. I don't see a connection.
PRL is produced in throughout the anterior portion of a gland, but more postero-laterally (of anterior pituitary), in the area called pars distalis, TSH is in medial-anterior. Other 4 major hormones are produced there: LH, FSH, ACTH and GH. By far the most common reason for Prolactinemia is some sort of pituitary adenoma or microadenoma, second being hypothalamic issues, and not hypothyroid.
I understand that MRI was negative, so CT scan may be more appropriate, and should be considered. MRI and can be a false negative.
TRH (thyroid releasing hormone) does share the portal system with PRL, as it does with the entire anterior pituitary since there is no direct neurologic connection between the pituitary and hypothalamus, and portal system serves as intermediary. CRH and other hormones from hypothalamus do that as well without cousing abnormalities. If TRH was to affect prolactin secretion via portal system, then it should also elevate TSH, because it is a TSH-releasing hormone. Here is where I think the confusion took place. In normal conditions, TSH is elevated signals a hypothyroid condition, but if TSH is elevated due to non-thyroid related causes, like pituitary or hypothalamus, both are extremely rare, would be considered a hyperthyroidism due to pituitary hyperfunction (secondary hyperthyroidism) and not hypo. sorry about technical mambo-jumbo, but I think it was necessary to point out.
All that being said, thyroid function should be evaluated, and I do that with every patient.
I think more important to also do CT scan. Oh, I forgot to mention, depending on how high the levels of PRL are, can give us some clues. High levels can be adenoma (tumor), slightly elevated likely are functional problems, i.e. ACTH over activity like in Cushing's. yet another one is dopamine deficiency, hence dopamineagonist are used for treatment of Prolactinemia. Estrogen can induce prolactinomas. Therefore, PCOS cannot be ruled out completely.
I would look for symptoms like disturbance in visual field, headache that is piercing or stabbing, GH elevation signs like acromegaly. Also see the amount of discharge, little may not even be a problem.
Symptoms of dopamine deficiency are feelings of hopelessness, self-destructive thoughts, inability to handle stress, finish tasks, aggression while under stress, isolation, lack of concern, worthlessness.
Hope the keeps the discussion going!
Thank you all!
Arthur Gazaryants, L.Ac., M.S.O.M., B.S.
20315 Ventura Blvd, Suite A
Woodland Hills, CA 91364
Tel.818.999.0300
www.Artupuncture.com
Arthur -
As usual, your posts are very informative and medically precise. You should consider teaching a workshop on Functional Medicine as it relates to reproductive disorders. Maybe for Pro D!
Anyway: Below is the Patient Fact Sheet on Prolactinemia published by the American Society for Reproductive Medicine. You will note that it lists Hypothryoidism - not hyperthyroidism - as one of the causes of Prolactinemia. You will also note in the paragraph below the list of what causes Hyperprolactinemia, it lists testing done for Prolactin. In order of clinical hierarchy: 1. Check for Prolactin levels. 2. Repeat test when fasting and not stressed if first level is elevated. 3. If levels are still high after second test, rule out thyroid and kidney problems. 4. If Thyroid and Kidney function are normal, then run MRI or CT to rule out adenoma.
Ray Rubio, D.A.O.M., L. Ac. (FABORM)
President ABORM
www.westlakecomplementarymedicine.com
Here it is for everyone's edification:
AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE
1209 Montgomery Highway • Birmingham, Alabama 35216-2809 • TEL (205) 978-5000 • FAX (205) 978-5005 • E-MAIL • URL www.asrm.org
PATIENT FACT SHEET
Hyperprolactinemia (Prolactin Excess)
What is Prolactin?
Prolactin is a hormone produced by your pituitary gland, the gland that sits
at the bottom of the brain. Though prolactin plays a role in the growth and
development of your breasts, its primary function is in milk production
after a child is born. Normally, it is present in small amounts throughout
your bloodstream (and in men's), kept under control by another hormone
called a prolactin inhibiting factor (dopamine). When you get pregnant,
however, prolactin levels increase significantly. Then, after the baby is
born, the combination of high prolactin levels and the abrupt drop in estrogen
and progesterone occurring after birth enable your body to produce
milk for breastfeeding.
What is Hyperprolactinemia?
Hyperprolactinemia is a condition in which too much prolactin is present
in the blood of women who are not pregnant and in men. In women, this
results in a decline in the body's production of progesterone after ovulation
which, in turn, can lead to irregular ovulation and infrequent menstruation,
cause you to stop menstruating altogether, or cause your
breasts to start producing milk, a condition called galactorrhea.
Men also can experience galactorrhea. High prolactin levels in men
can also lead to impotence, reduced libido, and infertility.
Hyperprolactinemia is relatively common. In women of reproductive
age who stop menstruating and have low FSH levels, up to a third of
women have hyperprolactinemia. Up to 90% of women who have galactorrhea
have hyperprolactinemia.
What causes Hyperprolactinemia?
Prolactin levels increase as a result of:
• Certain medications, including commonly prescribed antidepressants,
anti-psychotics, and blood pressure medications
• Herbs, including fenugreek, fennel seeds and red clover
• Chest wall irritation (from surgical scars, shingles, or even a too-tight bra)
• Stress
• Certain foods
• Exercise
• Sleep (prolactin levels are highest at night)
• Nipple stimulation
• Hypothyroidism, or underactive thyroid
• Pituitary tumors. These are usually very tiny, but account for about
30% of all cases of hyperprolactinemia.
In about a third of all cases of hyperprolactinemia, no cause is found.
How is Hyperprolactinemia Tested?
If you have absent or irregular periods, produce milk from the breasts, or
experience problems getting pregnant, especially if you or your partner
have any symptoms of high prolactin production, your doctor may order
a blood test to measure blood levels of prolactin. If those levels are high,
your doctor generally will conduct a second test while you're fasting and
when you aren't stressed.
If levels are still high, your doctor will obtain tests to rule out thyroid
and kidney problems. If the thyroid and kidneys are functioning
normally, magnetic resonance imaging (MRI) or computed axial tomography
(CT scan) can identify any tumor of the pituitary gland that could
cause this condition. If the MRI or CT scan reveals a growth, it will be
classified depending on its size. If the growth is small, it is called a
microadenoma. If the growth is larger (>1 cm in diameter), then it is
called a macroadenoma.
How is Hyperprolactinemia Treated?
The treatment depends on the cause. If your doctor cannot identify a
cause or you have a microadenoma or a macroadenoma in the pituitary
gland, the primary treatment is with medication. The most commonly
used medications are Parlodel® (bromocriptine) and Dostinex® (cabergoline).
Your doctor will start you on a low dose and gradually increase
the dose until your prolactin levels return to normal. The treatment continues
until you get pregnant. Discontinuing the medication once
pregnant should be discussed with your physician.
The most common side effects from Parlodel® include lightheadedness,
nausea and headache. Other side effects include nasal congestion,
dizziness, constipation, abdominal cramps, fatigue, vomiting, and, rarely,
neurologic symptoms such as hallucinations. Slowly increasing the dose
helps reduce side effects. You can also take Parlodel® as a vaginal suppository
or tablet at bedtime (although this is not approved by the FDA),
which also helps reduce side effects.
While Dostinex® can be taken twice a week and has significantly
fewer side effects, it is much more expensive than Parlodel®. In addition,
questions have been raised about heart valve problems being
caused by higher doses of Dostinex®. One drug, pergolide, has been
voluntarily withdrawn from the U.S. market because of this problem.
It is acceptable to choose not to treat women who have hyperprolactinemia
and no identifiable causes or a small pituitary tumor.
Similarly, there does not appear to be any risk to using oral contraceptive
pills if irregular periods are present or to prevent pregnancy.
Surgery is rarely required, only for large pituitary tumors that don't
improve with medical treatment. With larger pituitary tumors, occasional
monitoring with an MRI or CT scan should be performed.
If you have hypothyroidism, your doctor will treat it with thyroid
replacement medication, which should bring prolactin levels back to
normal. If the medication(s) you're taking (is) are responsible for your
high prolactin, your doctor will work with you to find other options. In
some cases, you may require hormone therapy to bring your estrogen
levels back to normal.
Words to Know
Galactorrhea: A condition in which the breasts secrete milk in men or
non-pregnant women
Hyperprolactinemia: A condition in which blood levels of prolactin are
too high
Hypothyroidism: Underactive thyroid
Macroadenoma: Larger pituitary tumor (measuring >1 cm) that causes
release of prolactin
Microadenoma: Smaller pituitary tumor
Pituitary: A walnut-sized gland that sits at the bottom of the brain and
releases various hormones related to reproduction and growth
Prolactin: A hormone produced by the pituitary gland that controls milk
production and breast growth
Prolactin inhibiting factor (PIF): A hormone that inhibits the release of
prolactin; dopamine is believed to be PIF
Revised 2007
The American Society for Reproductive Medicine grants permission to photocopy this fact sheet and distribute it to patients.
Ray, thank you for that comment. I do love neuroendocrinology and functional medicine. To me it really compliments oriental medicine.
I think that we as healthcare professionals, should have the skills to identify basic physiologic problems. If we are entrusted the health of our patients, then that becomes our responsibility. As acupuncturist that read blood tests as standard in our practice, we need to be able to see patterns and correlations and even predict the course of problem progression. Way too often, in almost every single patient previous docs miss early even intermediate signs of disease. the follow up testing is way under par, insurance and the standardized medical protocols dictated by, won't mention names, prohibit thorough and deep investigation. unless patient raises hell or someone like us talks to the doctor and/or patient, choices for that patient are very limited. even in the best scenario, a problem is diagnosed correctly, the treatment may be contributing to overall health decline.
I am pro-western medicine, pro-testing, and pro-integration of east and west, it just everything has its place and Western Medicine has monopolized the health (disease) industry, squeezing alternatives into tiny periphery. We should be out-spoken, independent, and confident in our and even their own game!
I am not angry...
Arthur Gazaryants, L.Ac., M.S.O.M., B.S.
20315 Ventura Blvd, Suite A
Woodland Hills, CA 91364
Tel.818.999.0300
www.Artupuncture.com
Dianne - I had a similar woman - whose story is here http://sharpen-up-your-results.com/articles/lookingattheobvious/fertility-markers.html
The practitioner site - www.sharpen-up-your-results.com has a lot on Stuck Liver Qi, and on being too 'nice' - we sometimes need to scroll back and look at the person, rather than the nifty labels they have accumulated . . . .
Julianne's story being a case in point.
This was a good PCOS to baby outcome - and whilst pregnant her squirting breasts were saturating the bed - I treated her blood deficiency and stuck qi by directing energy to unleashing the inner furious little girl who (felt no one loved her) was reacting to all around her - through the lenses of her early life.
Does acup not still teach that emotions are the primary causes of disease? The disruption of heat accumulate din all forms due to modern consumption of alcohol/caffeine/sugar/drugs - of all kinds esp antidepressants and then the impotent rage over the state of the world/our own lives all builds up.
PCOS is a great example of heat accumulated in the liver meridians - and the nipples also can be seen as having the heat there due to rage - so clearing this is a great start. Hence also a great place to start with mastitis . . ..
In her case, the sedating of Liver 2 and the continual reference by me of the rage she must have to have the symptoms she did (look also to my work on fertility markers on the sharpen up site and the DVD seminars available thru Pro D). I regularly insert six 3 inch needles in GB 30 – in both bum cheeks – as wherever it is sore when pressed it is blocked - great way to undo all that female angst . . . . . along with Liver 2 which few escape from when seeing me - we are all irked by being here.
The pelvic massage esp GB 30 area after moxa on sacrum - also found on the "Birthing what Dads Can Do” - DVD’s and the kit "What Dads Can Do'” meant that when she was less reactive, and 10 kg lighter and when she had consumed all the supplements and herbs and had many many very painful massage sessions with her husband, she was pregnant the first month we trialled her on my fertility herbs and this was also the first time she had ever in her life seen ovulation mucous!!!!
She probably still had high prolactin levels.
We should always remember that women these days are tandem feeding and thus milk supply/leakage for whatever reason is not the only stoppage to fertility.
In Julianne‘s case, I very much doubt she would be a mother yet without all the heavy work she did herself. It sometimes comes down to clearing what is blocking normal – and we do not as therapists own the healing. She is a very happy mother because she undid some of the early life trauma that was holding her back.
Further to your comments Ray -
The various medical diagnoses were just readouts of the warning lights up there on the dashboard.
We don't know what to do when we see these numbers - we need to overlay them on the person who is breathing and feeling in front of us.
We have different ways of interpreting things, and using the western biomedical ones MAY be helpful.
I get most of my infertile men and women doing BBT charts –and it is alarming that almost NONE of the men have a normal temp (36.8C) - and neither do they (co incidentally) make good sperm - so what is left over (Jing from three heater production) is not useful for baby making when their engine is cooler than it should be/gut distressed - another subject to explore . . . . so their sperm results are majorly affected by bringing up BBT - so is a strong Ki Yang issue - marrying West and East . . .
What we did with the info next is the point.
In relation to THYROID – from my considerable infertility experience I would say the testing for DHEA (source of the thyroid and all the reproductive hormones – knocked out by stress – the old naturopathic concepts of adrenal stress/fatigue/exhaustion hold weight) and TSH/T4/T3/reverse T3 and thyroid antibodies give you a head start and sometimes, is the only way (with natural hormone supplementation) to get what everyone is wanting – health. Looking at the environmental and nutritional aspects that leave us with ‘our stolen future’ and hormonal disruption is every bit as important is biomedicine as their gross disease testing.
I have no idea how treating nebulous ‘Kidney’ will sort out some of the very high mercury/other metal contamination – that on a very deep level is wrecking the balance – looking to some of the effects of amalgam in our mouths, thiomersal in vaccines we have been exposed to and the fire retardants found in sperm and breast milk these days – we may need to move into the C21st with a few more tools than needles and herbs . . . . .
Restoring the blueprint is a great idea - undo all that is blocking the body healing itself can be quite a revelation.
Dear all,
Thanks a lot for all your imput on this case.
I'm very happy to say that this patient is now pregnant and extremely happy about it! She puts it down to the 3 acupuncture treatments!
Fingers crossed for a happy and healthy pregnancy.
All the best
Diane
(ps she had had the thyroid test before she came for treatment which was normal)
Joined: 2007-11-26