Analysis of uterine artery and sex hormones in treating diminished ovarian reserve with tiaojing decoction

Meng-Jie Wang, Hui-Jun Xu

1.Master of Science in Integrated Traditional Chinese and Western Medicine Center, College of Basic Medical Sciences, Qingdao University, Qingdao, China

2.Women's Division, Qingdao Haici Medical Group, Qingdao, China

Abstract

Key words: Diminished Ovarian Reserve, Tiaojing decoction, Uterine artery blood flow

Background

Diminished Ovarian Reserve (DOR) mainly refers to low-response or poor fertility of ovaries in women of appropriate age [1].DOR has shown the reproductive potential of women.The number of mature eggs discharged by patients decreases, the quality decreases, and the fertility decreases.It has been reported that it can further become premature ovarian failure (POF), which is one of the main causes of infertility in women of appropriate age [2].Traditional Chinese medicine does not have the term "decreased ovarian reserve function".According to clinical symptoms, it can be classified as "irregular menstruation", "amenorrhea", "blood dryness", "infertility", and "post-menopausal symptoms".The pathogenesis is based on kidney essence deficiency, followed by liver qi stagnation, and also includes blood stasis, spleen qi deficiency, phlegm block, and imbalance of responsibility.Insufficient kidney yang, insufficient warmth function and blood stasis that caused by slow blood flow, both block cell palace impulse.That makes it difficult for the eggs to be discharged and the ovaries gradually increase.In addition to the decline in ovarian reserve function and the decline in patient's reproductive capacity, it can also cause the decline of ovarian function and estrogen levels in the patient, which can cause perimenopausal manifestations such as hot flashes, night sweats, and irritability, causing discomfort in life.Therefore, whether early detection and clear diagnosis of DOR patients can be realized is with great significance for the improvement of patients' life discomfort and the restoration of fertility [3].

Antimüllerian hormone (AMH) combined with antral follicle count (AFC) is currently the two indicators for assessing ovarian reserve sensitivity and specificity.The basal follicle stimulating hormone (bFSH) [4] also has certain reference value.The risk factors of DOR are related to poor family economic conditions [5].At present, the detection of AMH has not been popularized in China.Considering the actual conditions and the economic affordability of patients, if the diagnostic value of color doppler ultrasonography for DOR can be explored, it is important for the early detection and early intervention of DOR.

At present, the treatment of DOR is mainly focused on the protection and replacement of ovarian function, the satisfaction of fertility needs and the improvement of mental and life [6].A variety of Chinese and western medicine treatments have good efficacy in the above three aspects of the problem [7].Existing therapies mainly include Hormone Replacement Therapy (HRT), oral contraceptives, Dehydroepiandrosterone (DHEA), oral administration, ovulation induction, Assisted Reproductive Technique (ART) and traditinal Chinese medicine therapy.However, there are some defects in the existing western medical law, such as HRT, breast cancer contraindications and high risk of thrombosis [8].Some patients have resistance to hormone replacement.The traditional Chinese medicine treatment of DOR is mainly to tonify the kidney, mimic the normal changes of women's menstrual cycle, and increase or decrease the corresponding drugs according to the physiological stage, so as to adjust the balance of kidney-scorpio-Chongren-cell axis [9].In order to achieve regular menstrual cycle, improve the symptoms of estrogen deficiency and protect the ovarian function.Studies have shown that traditional Chinese medicine with the function of tonifying kidney and promoting blood circulation can significantly improve ovarian reserve, relieve symptoms of patients, restore regular menstrual cycle, and has significant curative eあect, which is one of the eあective methods for treating DOR [10].In addition, Chinese medicine treatment of DOR can improve women's fertility, but also delay the development of POF.Therefore, TCM therapy with clear curative eあect, low cost and few side effects [7], which has important potential in the treatment of DOR.

Tiaojing decoction is added from the "Fu Qiingzhu Nuke" Yijing decoction, which consists of Dihuang (Radix Rehmanniae) 15 g, Nuomi 12 g, Shanyao (Rhizoma Dioscoreae) 18 g, Duzhong (Cortex Eucommiae) 12 g, Danggui (Radix Angelicae Sinensis) 15 g, Baishao (Radix Paeoniae Alba) 15 g, Danshen (Radix Salviae Miltiorrhizae) 15 g, Chaihu (Radix Bupleuri) 9 g, Dangshen (Radix Codonopsis) 15 g, Baizhu (Rhizoma Atractylodis Macrocephalae) 12 g, Zaoren (Semen Ziziphi Spinosae) 9 g, Beishashen (Radix Glehniae) 9 g.A total of 12 traditional Chinese medicine composition.The key is to play the role of kidney and spleen, liver and blood circulation.The disease is caused by kidney yin and yang at the same time, so the Chinese herbal medicine is suitable for kidney yang, rehmannia glutinosa and nourishing kidney yin.Modern pharmacological studies have found that saponins such as Bajitian (Radix Morindae Oき cinalis) and Dihuang (Radix Rehmanniae) have estrogen-like effects, which can improve the secretion of estrogen caused by POF, endometrial receptivity, secretion of cervical mucus, and facilitate the passage of sperm.Traditional Chinese medicine for tonifying kidney yang can improve the function of the corpus luteum and facilitate embryo implantation.The blood-activating and stasisrelieving medicine can expand the local blood vessels, thereby improve the blood flow of the organs and the hypercoagulable state of the organs.At the same time, stabilize the internal environment of the uterus and the fallopian tubes.Therefore, the combination of kidney and spleen medicine and Shugan Huoxue Tongluo medicine is beneficial to menstruation and fertility, and it is the integration of Chinese and Western pathology, pathogenesis and pharmacology, which is the soul of the party.Clinical application has a certain effect on patients with kidney yin deficiency type ovarian reserve function decline.This article aims to verify the eきcacy of Tiaojing decoction on the treatment of DOR kidney yin deficiency by the changes of sex hormones (bFSH, bE2) and uterine artery hemodynamic parameters (PSV, EDV, RI, S/D); Try to collect data to verify the correlation between sex hormones and uterine artery blood flow parameters to explore the value of uterine artery blood flow parameters for DOR diagnosis.

Information and methods

Study object

In the outpatient case of Women's First Division of Qingdao Haici Medical Group, total 60 patients with ovarian reserve function diagnosed as kidney yin deficiency were screened.The time range of treatment was from March 2016 to September 2016, the age of 25-38 years old (mean age 34.48±4.08) was divided into experimental group and control group by 30 cases by random number method.

Diagnosis and inclusion criteria

Western diagnostic criteria:

According to "ESHRE Guideline: management of women with premature ovarian insuきcienc" (2016) [11]and clinical experience, the diagnostic criteria are:1) ages between 18-40; 2) Laboratory examination: venous blood examination on the 2-4th day of the menstrual cycle: 10mIU/ml ＜ bFSH ＜ 25mIU/ml.

Both indicators are available, combined with clinical manifestations such as changes in the patient's menstrual cycle, can be diagnosed as DOR.

TCM Syndrome Standard:

Refer to the "Guidelines for Clinical Research of New Drugs in Traditional Chinese Medicine" [12] combined with clinical practice to establish DOR syndrome differentiation criteria for kidney yin deficiency.

Main symptoms: menstrual cycle is uncertain, or late menstruation, or amenorrhea, less, color, thin, with or without lumbosacral pain, sore and weak.Tongue: The tongue is light or pale, the fur is white, and the pulse is deep or thin.Essential symptoms, more than one of the 1-5 items of secondary disease, combined with the tongue can be identified as kidney yin deficiency syndrome.

Case inclusion criteria:

1) Meets the two standards of Chinese and Western medicine; 2) No other medications have been used within 22 months; 3) Liver and kidney function, coagulation mechanism, tumor markers are normal, breast, pelvic color Doppler ultrasound is abnormal, TCT, HPV are negative, no gram-age medication contraindications; 4)Clearly diagnose the unpregnant person; 5)Patients with good compliance, voluntary and can cooperate with treatment.

Exclusion criteria:

1)Those who do not meet the diagnostic criteria and inclusion criteria; 2) Combined with endometriosis, sacs and other organic lesions; 3) Combining patients with serious diseases such as heart, brain, liver and kidney, and mental illness; 4) Patients with menstrual disorders caused by hypothyroidism, PCOS and other diseases; 5) Amenorrhea patients caused by surgery, trauma; 6) People who are allergic to research drugs; 7) Poor compliance, can not strictly follow the experimental requirements; 8) HRT treatment contraindications.

有着近40年农资从业经验的谭凤明是个闲不住的人，用他自己的话说：“一辈子奔波，从采购员到总经理，都是用腿跑出来的。”记者的采访过程可谓一波三折，肥料销售旺季打电话时，他的电话一直占线；淡季打通电话，他又带着团队下乡做回访调研。直到在一次会议上偶遇，才终于有幸一闻他的故事。

Elimination criteria:

1) Withdrawal from the treatment during the observation period; 2) Patients with poor compliance, serious adverse reactions and complications, it is not appropriate to continue the experiment and exit; 3) Those who are not strictly required to perform the experiment and take other drugs during the observation period.

Research methods

Treatment plan: Control group: the use of hormone replacement therapy.Keling Meng (produced by Bayer Schering Pharmaceutical Co., Ltd., National Pharmaceutical Standard J20080037, pharmaceutical composition: 11 pieces of white sugar-coated tablets (Estradiol valerate 2mg per tablet); 10 pieces of light orange red sugar-coated tablets (Valeric acid female) 2mg of diol and 1mg of cyproterone acetate per tablet).One tablet per day, starting from the fifth day of menstruation or hormone withdrawal, and even taking 21d, waiting for menstruation.Experimental group: based on the above western medicine treatment, add Tiaojing decoction: Dihuang (Radix Rehmanniae) 15 g, Nuomi 12 g, Shanyao (Rhizoma Dioscoreae) 18 g, Duzhong (Cortex Eucommiae) 12 g, Danggui (Radix Angelicae Sinensis) 15 g, Baishao (Radix Paeoniae Alba) 15 g, Danshen (Radix Salviae Miltiorrhizae) 15 g, Chaihu (Radix Bupleuri) 9 g, Dangshen (Radix Codonopsis) 15 g, Baizhu(Rhizoma Atractylodis Macrocephalae) 12 g, Zaoren (Semen Ziziphi Spinosae) 9 g, Beishashen (Radix Glehniae) 9 g.One dose per day, half an hour after breakfast and dinner, 200 mL each time.

The efficacy evaluation was performed after three menstrual cycles.Do not eat spicy, cold products during the medication.All the traditional Chinese medicines used in this experiment were provided by the Qingdao Haici Medical Group Preparation Room (the State Administration of Traditional Chinese Medicine, the third-level laboratory of Chinese medicine).The western medicine was provided by the hospital western pharmacy.

Sex hormone examination:serum bFSH and basal estradiol (Estradiol, E2) levels were measured on the 2-4th day of the menstrual cycle before and after treatment.5 ml of fasting blood in the morning, stand at room temperature for 60 min, centrifuge at 3000 r/min for 10 min, take serum, and store at -20 °C until detection.(The bFSH and bE2 tests were carried out by the Laboratory of Qingdao Haici Medical Group.The laboratory is equipped with ABBOTT AXSYM Plus: supplied by Abbott Laboratories, USA.)

Imaging examination:B-ultrasound measurement of peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index of uterine artery blood flow on days 2-4 of the patient cycle Resistance index (RI) and peak systolic velocity/end-diastolic blood flow velocity (PSV/EDV, S/D).(B-related indicators are provided by the gynecological B-ultrasound room of Qingdao Haici Medical Group, which is equipped with Siemens Acuson x300 digital color Doppler ultrasound diagnostic instrument manufactured by Siemens AG, Germany.B ultra-colored sampling frame is placed in the cervix to monitor uterine arterial blood flow parameters.)

Statistical processing

Statistical analysis was performed using SPSS19.0.The data were expressed as mean ± standard deviation (x¯±s).If the measurement data satisfies the normal distribution and the homogeneity of the variance, the t test is used.Otherwise, the rank sum test is used; χ2test; rank data using rank sum test.Linear regression analysis was compared using covariance analysis, test level α = 0.05.

Results

Comparison of sex hormones and uterine artery blood flow

Before and after treatment, the levels of bFSH, bE2, and uterine arterial blood flow parameters were compared between the experimental group and the control group (Tab.1).

Table 1 Comparison of sex hormones and blood flow levels between the two groups before and after treatment (x¯±s)

Correlation between sex hormones and uterine artery blood flow parameters

Linear regression analysis and covariance analysis were performed on the sex hormone and uterine artery blood flow parameters before and after treatment in both groups.The results are shown in Tab.2.

Table 2 Comparison of sex hormones and blood flow levels between the two groups before and after treatment

As can be seen from Table 2, FSH was negatively correlated with E2 before and after treatment, PSV was positively correlated with E2, PSV was negatively correlated with FSH, and linear regression equation was statistically significant.The results of covariance analysis were better than those before treatment, and the eあect of the experimental group was better than that of the control group.The difference was statistically significant (P ＜ 0.05), indicating that the effect of Tiaojing decoction combined with Kelingeng was higher than that of single use Mongolian group.The variance analysis and regression coefficient t test of the above 12 groups of regression equations were all P ＜ 0.05.After covariance analysis, the comparison between groups was P ＞ 0.05; compared with before treatment P ＜ 0.05, P ＜ 0.05 between groups, the eあect of the experimental group was better than the control group.

Discussion

Ovarian reserve function refers to the ability of primordial follicles to develop into fertilized oocytes in the ovarian cortex, mainly in the number of follicles and the quality of the follicles [13].The decrease of ovarian reserve function (DOR) refers to the decrease of the number of follicles with growth, development and fertilization potential.This is the early stage of development of premature ovarian failure.It can be measured by FSH and other hormones and transvaginal color Doppler ultrasound to observe AFC.Due to DOR, the number of follicles in patients is lower than that in women with normal ovarian reserve function, and the level of estrogen secretion in the ovaries is correspondingly reduced.The inhibition of FSH secretion in the pituitary is correspondingly weakened, resulting in an increase in FSH levels.It has been reported [14] that changes in serum FSH levels are significantly earlier than changes in estradiol, so FSH is more sensitive to DOR.

The regulation of uterine arterial blood flow velocity is accomplished by nerve and body fluid regulation, and the process is complicated.Estrogen and progesterone play an important role in the regulation of uterine arterial blood flow velocity.Studies have shown that both estrogen and progesterone can dilate the uterine artery and reduce vascular resistance, thereby increasing the flow velocity of the uterine artery [15].It has also been reported that [16-17] a decrease in RI was found in postmenopausal patients receiving HRT, and the longer the HRT application time, the more the PI and RI decreased.Studies have shown that [15] patients with premature ovarian failure have decreased PSV, EDV, and elevated RI.This may be due to the low estrogen status of patients with POF, which reduces blood flow to the uterus and surrounding tissues.Thereby reduce the flow rate and increase the RI.Therefore, with the increase of age and the decline of ovarian function, the parameters of uterine arterial blood flow will change accordingly, which is manifested by the increase of RI and the decrease of PSV and EDV.

From this study, PSV and E2 were positively correlated between the two groups, and the PSV and E2 after treatment were higher than those before treatment.It can be assumed that high estrogen causes uterine artery vasodilation, tube wall compliance increases, and thus accelerates blood.Later, the uterine artery blood flow parameters can reflect the patient's estrogen status and may have a certain diagnostic value of DOR.

Regular menstruation is a sign of female reproductive health and normal operation of female reproductive endocrine function.Once menstrual disorders occur, it is a signal of reproductive endocrine disorders.From the perspective of traditional Chinese medicine, the generation of menstruation is dominated by the kidney.The kidney is the innate foundation and hides essence.The main reproduction is the foundation of human growth, development and reproduction.Kidney possession of essence, essence can produce blood, blood can transform essence.It is the material basis of menstruation and necessary condition for pregnancy and fertility.Kidney essence is the material basis for follicle growth and development.Kidney essence and kidney qi deficiency, menstruation lack of material basis and gradually exhausted, which can result in decreased ovarian function reserve.In TCM, there is no disease name corresponding to DOR, but the records of similar symptoms are scattered in amenorrhea.For example blood dryness, late menstruation, infertility and other diseases, and you can refer to each other.The etiology of DOR is complex.The main pathogenesis is kidney deficiency, with kidney essence deficiency and blood stasis as the standard.It is an important pathogenesis of the disease.Qi deficiency, blood deficiency and liver qi stagnation also account for a large proportion in the pathogenesis of this disease.At the same time, the disharmony or too little sex life, lack of sleep, etc.are also important incentives worth further research.Existing research shows that the syndrome diあerentiation of DOR is complicated, but the main reason is kidney yin deficiency, which is accompanied by blood stasis and liver stagnation.And the treatment is to nourish the kidney and promote blood circulation and nourish the liver, kidney and spleen, etc [18].The menstruation soup used in this research is derived from "Fu Qiingzhu Nuke".In which change Danpi (Cortex Moutan) to Danshen (Radix Salviae Miltiorrhizae), add Bajitian (Radix Morindae Officinalis).Duzhong (Cortex Eucommiae) can nourish liver and kidney, condition the body, consolidate essence and stabilize fetus.Danpi (Cortex Moutan) nourished and regulated menstruation.Dihuang (Radix Rehmanniae) can nourish blood and yin, essence and fill the marrow.Shanyao (Rhizoma Dioscoreae) is good for the kidneys and strengthens the spleen and stomach.Danggui (Radix Angelicae Sinensis) nourished blood and activating blood and regulated menstruation and analgesia.Dangshen (Radix Codonopsis) can replenish the spleen and lungs, as well as blood and fluid.Chaihu (Radix Bupleuri)has the effects of evacuation and antipyretics, dredging liver and stagnation, and lifting yang.Cangzhu (Rhizoma Atractylodis) can improve qi and spleen, solidify antiperspirant and improve immunity.Beishashen (Radix Glehniae) has the effects of nourishing yin and clearing the lungs, benefiting the stomach.The main eあects of fried Zaoren (Semen Ziziphi Spinosae) are nourishing the liver, clearing the heart, soothe the nerves, and gather sweat.Previous studies [19] pointed out that emotion is closely related to the occurrence of premature ovarian failure (P ＜ 0.05), and the emotion is damaged.Danshen (Radix Salviae Miltiorrhizae) enters the heart and spleen.Bajitian (Radix Morindae Oき cinalis)replenishes the kidney and yang.The use of a pill alone can better replenish the seeds.Adding or subtracting two drugs can enhance the eきcacy of the original prescription and improve the eきcacy.

After 3 months of Tiaojing decoction and hormone replacement therapy, the E2 level of the experimental group increased, the FSH level decreased, the uterine artery blood flow velocity increased, and the RI and S/D levels decreased.The result was significantly better than the Western medicine group alone (P ＜ 0.05).The results show that Tiaojing decoction combined with western medicine can improve the sex hormone and uterine artery blood flow indicators.At the same time, the results showed that FSH was negatively correlated with E2 before and after treatment, PSV was positively correlated with E2, PSV was negatively correlated with FSH, and linear regression equation was statistically significant (P ＜ 0.05), indicating uterine artery blood flow parameters.It can reflect the levels of FSH and E2 in DOR patients, which may have certain value in the diagnosis of DOR.