12.8 Reproductive Conditions: Menstrual Disorders, Infertility, Pregnancy, Menopause, Breast, and Prostate
Key Takeaways
PCOS is diagnosed when two of three features are present: irregular or absent ovulation, signs of high androgens, and polycystic ovaries on ultrasound.
Infertility is no pregnancy after 12 months of regular unprotected intercourse, or 6 months if the woman is 35 or older.
Preeclampsia is new blood pressure of 140/90 mm Hg or higher after 20 weeks of pregnancy with protein in the urine or signs of organ damage, and it can occur up to six weeks after delivery.
Menopause is confirmed after 12 months without a period; any bleeding after menopause needs medical evaluation.
Erectile dysfunction can be an early warning of cardiovascular disease, and PDE5 inhibitors must never be combined with nitrates.
12.8 Reproductive Conditions: Menstrual Disorders, Infertility, Pregnancy, Menopause, Breast, and Prostate
Quick Answer: Reproductive health is a major part of acupuncture practice, so the BIOM exam expects you to recognize normal and abnormal presentations and to know when to refer. Key points: primary vs. secondary dysmenorrhea, endometriosis and fibroids, PCOS (two of three Rotterdam criteria), the 12-month definition of infertility, pregnancy complications such as preeclampsia and ectopic pregnancy, postpartum warning signs, menopause and postmenopausal bleeding, breast lumps and mastitis, erectile dysfunction, and prostate conditions. Urinary conditions and pelvic floor disorders are covered in Section 12.4.
Menstrual and Uterine Disorders
| Condition | Key features |
|---|---|
| Primary dysmenorrhea | Cramping pain caused by prostaglandins, starting within a year or two of the first period, with no underlying disease |
| Secondary dysmenorrhea | Pain from an underlying condition (endometriosis, adenomyosis, fibroids, pelvic inflammatory disease); often starts later in life or changes pattern |
| Endometriosis | Endometrial-like tissue outside the uterus; painful periods, pain with intercourse, chronic pelvic pain, infertility; confirmed by laparoscopy |
| Uterine fibroids (leiomyomas) | Benign muscle tumors; heavy or prolonged periods, pelvic pressure, urinary frequency, anemia |
| Abnormal uterine bleeding | Bleeding between periods, very heavy bleeding (soaking a pad or tampon every hour for several hours), or bleeding after menopause needs evaluation |
Infertility and PCOS
Infertility is the failure to conceive after 12 months of regular unprotected intercourse, or 6 months if the woman is 35 or older. Both partners should be evaluated.
- Polycystic ovary syndrome (PCOS): diagnosed by the Rotterdam criteria when two of three are present: irregular or absent ovulation, clinical or laboratory signs of high androgens (acne, excess hair growth), and polycystic ovaries on ultrasound. It is linked to insulin resistance, obesity, type 2 diabetes, and a higher risk of endometrial hyperplasia.
- Male factor: low sperm count (below about 15-16 million per mL by WHO reference limits), poor motility, or abnormal shape. Causes include varicocele, heat exposure, smoking, alcohol, anabolic steroids and testosterone use, and obesity.
Acupuncture is often used alongside IVF. Coordinate timing with the fertility clinic and follow the clinic's protocols.
Pregnancy
Normal pregnancy lasts about 40 weeks; full term is 39 to 40 weeks plus 6 days. Common discomforts include nausea, back and pelvic pain, heartburn, and fatigue.
| Complication | Warning signs |
|---|---|
| Ectopic pregnancy | Positive pregnancy test with one-sided pelvic pain, vaginal bleeding, shoulder-tip pain, fainting: 911 |
| Miscarriage | Bleeding and cramping before 20 weeks |
| Hyperemesis gravidarum | Severe vomiting with weight loss and dehydration |
| Gestational diabetes | Usually screened at 24-28 weeks |
| Preeclampsia | New BP of 140/90 mm Hg or higher after 20 weeks with protein in the urine or organ involvement; severe headache, visual changes, upper abdominal pain, and swelling of the face and hands |
| Placental abruption or previa | Painful bleeding with a hard uterus (abruption) or painless bright red bleeding (previa) in later pregnancy: 911 |
| Preterm labor | Regular contractions, pelvic pressure, or fluid leakage before 37 weeks |
Perinatal Support and the Postpartum Period
Labor preparation acupuncture is commonly given weekly from about 36-37 weeks, with the obstetric provider's knowledge. After delivery, watch for:
- Postpartum depression: "baby blues" (mood swings and tearfulness) are common in the first two weeks and resolve. Symptoms that are more severe or last longer suggest postpartum depression and need referral. Postpartum psychosis (confusion, hallucinations, thoughts of harming the baby) is an emergency.
- Postpartum hemorrhage: soaking a pad in an hour or passing large clots.
- Postpartum preeclampsia: can occur up to about six weeks after delivery.
- Deep vein thrombosis: risk is higher for several weeks after delivery.
- Mastitis: see below.
Menopause
Menopause is confirmed after 12 consecutive months without a period; the average age in the United States is about 51 to 52. Perimenopause brings irregular cycles, hot flashes, night sweats, sleep disturbance, mood changes, and vaginal dryness (genitourinary syndrome of menopause). Complications include osteoporosis and increased cardiovascular risk. Any postmenopausal bleeding needs medical evaluation to exclude endometrial cancer. Menopause before age 40 is premature ovarian insufficiency.
Breast Conditions
- Breast lumps: any new lump needs evaluation. Suspicious features include a hard, fixed, painless lump; skin dimpling or orange-peel skin (peau d'orange); nipple retraction; bloody nipple discharge; and a lump in the armpit.
- Mastitis: usually in breastfeeding women, with a red, hot, tender area of the breast, fever, and flu-like symptoms. Continued breastfeeding or pumping is encouraged. A fluctuant, persistent mass suggests an abscess, and a red, swollen breast that is not improving in a woman who is not breastfeeding may be inflammatory breast cancer; both need referral.
Male Reproductive Conditions
- Erectile dysfunction (ED): often vascular and shares risk factors with heart disease, so it can be an early warning of cardiovascular disease. Other causes include diabetes, low testosterone, medications (antidepressants, beta blockers), and psychological factors. PDE5 inhibitors such as sildenafil must not be combined with nitrates.
- Benign prostatic hyperplasia (BPH): weak stream, hesitancy, frequency, urgency, and waking at night to urinate in older men. Sudden inability to urinate is urgent.
- Prostatitis: acute bacterial prostatitis causes fever, chills, painful urination, and perineal pain and needs prompt antibiotics. Chronic prostatitis or chronic pelvic pain syndrome causes long-standing pelvic pain; a 2021 randomized trial in the Annals of Internal Medicine found acupuncture improved symptoms more than sham.
A 28-year-old patient has irregular periods, acne, and excess facial hair. Her ultrasound shows polycystic ovaries. How many of the Rotterdam criteria for PCOS does she meet?
None, because a PCOS diagnosis first requires a positive pregnancy test result
One, because only the ultrasound finding counts toward the diagnosis
All three: irregular ovulation, high-androgen signs, and polycystic ovaries
Two, because acne does not count as a sign of high androgens
A patient who is 32 weeks pregnant reports a severe headache, blurred vision, and swelling of her face and hands. Her blood pressure is 158/104 mm Hg. What is the most appropriate action?
Treat the headache with local points and recheck blood pressure next week
Refer her for emergency obstetric evaluation for possible preeclampsia
Recommend more salt and fluids
Apply moxibustion at BL 67
A 58-year-old patient whose periods stopped three years ago reports new vaginal spotting. What is the appropriate response?
Reassure her that this is a normal part of menopause
Treat with Spleen-tonifying points and observe for six months
Refer her for evaluation to exclude endometrial cancer and other causes
Advise her to start a phytoestrogen supplement such as red clover or soy
A 55-year-old man with high blood pressure and high cholesterol reports gradually worsening erectile dysfunction. Why does this matter beyond sexual health?
ED is always psychological in origin and never needs any medical evaluation
ED can be an early sign of cardiovascular disease, so heart risk should be evaluated
ED occurs only with low testosterone, so a hormone panel is the only test that is ever needed
ED is a common side effect of acupuncture
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