A hard case of dysmenorrhea
A 36 year old female patient has complaints including Dysmenorrhea with heavy bleeding and thyroid nodules. She had been suffering from dysmenorrhea since teenage years and had history of ovarian cysts and fibroid in her teens and twenties. Her period has 20 to 35 day cycle and lasts 5 to 9 days. Spotting happens often before period. Bleeding is extremely heavy with blood clots and severe cramps at scale of 6 to 8 out of 10 for 2 days at day 2 and 3. The pain is burning in nature with strong contractions, which is not relieved by heat but managed by better sleep, exercise and relaxation. She has no pain with urination, bowel movement or sexual activity. She has neither fever or nor foul smelling discharge. In 2019 she was diagnosed with thyroid nodules due to high thyroglobulin level. The nodules were measured by MRI at R 6.3cm/2.0cm/2.0cm and L 4.4cm/1.1cm/1.6cm.
She also had high blood pressure and high cholesterol. She is overweight. She has family history of hypothyroidism, diabetes, stroke, high blood pressure and fatty liver. Her job is very stressful. She often works overnight or works till midnight and is lack of exercise due to deadlines. She drinks coffee every day. Diet is not healthy including refined sugar, oil and flour. She often takes ibuprofen and prescribed NSAID for pain relief during period. She also takes fish oil and multivitamin daily.
She often feels fatigued. Her feet are very cold to touch. She likes to sleep at 65 degree , which indicates that she tends to feel hot at night. She has lower back pain , knee pain, upper back and shoulder pain. Her tongue is dusky red with thin body, scanty coating and red dots on the tip. Her Pulse is deep and thin in general and especially on both chi region. Emotionally she is easily worried and anxious. According to above signs and symptoms her TCM differentiation would be essence (both kidney yin and yang) deficiency with liver Qi, blood and phlegm stagnation. Kidney essence deficiency would manifest as cold lower extremities, lower back and knee pain, and feeling hot and sweaty at night. Liver qi and blood stagnation would manifest as pain aggravated by stress. The deep weak rapid pulses at both Chi region also indicate kidney essence deficiency.
Her blood work in 2019 showed high thyroglobulin, ALT, CRP, CALC LDL, Ferritin, and iron serum. Her insulin level was 12 with glucose level of 97 in 2019. With acupuncture treatments her nodules didn’t grow much bigger. The lab result in March 2021 showed normal ALT, Ferritin level, and Iron serum level, but her insulin level increased from 12 to 13. Her menstruation is regulated to 5 days instead of 9 days with no spotting, but her menstrual pain would improve one cycle and get worse another cycle with stress.
It is suspected that the pain is associated with thyroid dysfunction and thyroid nodules. A cross sectional study in India concluded that thyroid dysfunction is closely related to menstrual disorders, therefore thyroid function should be checked for all the patients with menstrual issues (Ajmani, Sarbhai, Yadav, Paul, Ahmad &Ajmani,2014, P.115). Her blood work in March 2021 showed normal TSH, T3, T4, and antibodies but did not test thyroglobulin level. Her thyroglobulin level should be checked again. According to a systematic review by Panth, Guerin & DiMarco Iodine deficiency is re-emerging in vulnerable group such as women of reproductive age(2019, P208). Her iodine level should be checked to rule out iodine deficiency related to her thyroid nodules. Urine iodine concentration is a excellent marker for recent iodine intake.
Pelvic ultrasound should be done to rule out ovarian cyst ,fibroid, and PCOS if the pain does not improve with managing the thyroid issues. There is possibility of PCOS according to her irregularity of menstruation, obesity, increased insulin level, high LDL, and blood pressure. Ovulation status, androgen level should be checked according to Rotterdam Criteria in order to rule out PCOS. There is also a high chance of endometriosis due to high CRP but at the same time she does not have enough symptoms like sexual intercourse pain, bowel movement pain and urination pain to confirm that. CA125 and laparoscopic procedure should be the last resort to rule out endometriosis.
Besides finding the underlying reasons for the pain, it is very important to manage the pain through exercise, diet, acupressure and acupuncture with heat. According to a 2000 study by Barnard, Scialli, Hurlock & Bertron there is significant reduction of dysmenorrhea and premenstrual symptoms related to higher level sex hormone binding globulin by following a low fat vegetarian diet. Exercise, heat and acupressure showed high to moderate effect in reducing menstrual pain. They can be potentially used as alternative to pain killers(Armour, Smith, Steel&Macmillan, 2019). According to Woo, Ji, Pak, Lee, Heo, Lee &Park Acupuncture might be more effective for reducing menstrual pain than NSAIDS(2018). Ear acupuncture is 91.9% effective compared to 60% with Chinese medicine treating dysmenorrhea related to endometriosis(Xiang, Situ, Liang, Cheng & Zhang, 2
