GYNAECOLOGICAL DISORDERS
馬
萬
里
ENDOMETRIOSIS
POLYCYSTIC OVARY SYNDROME
MENOPAUSAL PROBLEMS
THE FOUR PHASES OF THE MENSTRUAL CYCLE
Phase 1: Period Phase 2:
Post-menstrual Phase 3: Mid-cycle Phase 4: Pre-menstrual
YANG
36.2 36.5 37.1
HYPOTHALAMUS
PITUITARY
FOLLICLE CORPUS LUTEUM
Oestrogen Progesterone
Gonadotropin releasing hormone GnRH
FSH LH DU MAI REN MAI Pituitary Hypothalamus Ovary Uterus
THE FOUR PHASES OF THE MENSTRUAL CYCLE
PHASE 1
•Maximum of Yang (at onset)
•Yang decreases rapidly
•Qi and Blood moving downwards
•Activity centred on central abdomen (Xiao Fu)
•Transformation from Yang to Yin
•Under influence of Heart for discharge of menstrual blood
•Treatment principle: invigorate Blood (stop bleeding as well if period is heavy)
PHASE 2
•Blood and Yin relatively empty •Yin beginning to grow •Crossroads of Yin and Yang •Important phase to establish good menstrual cycle •Treatment principle: nourish Blood, tonify the Kidneys
PHASE 3
•Chong, Ren and Du in full activity to promote ovulation •Yang beginning to rise
•Yin at its maximum •Transparent secretion •Beginning of upward movement of Qi and Blood •Physiological activity in lateral abdomen (Shao Fu) •Treatment principle: tonify the Kidneys, strengthen Chong and Ren, tonify the Spleen, resolve Dampness
PHASE 4
•Yang rising rapidly and approaching maximum
•Qi moves
•Yang gives warmth to Uterus to eliminate Yin pathogenic
factors (Blood stasis, Cold, Phlegm)
•Treatment principle: move Qi, warm the Uterus, invigorate Blood
The Xiao Fu (‘Small Abdomen’) and Shao Fu (‘Lesser Abdomen’) and their relationship with the four phases
In Phase 3 (mid-cycle phase) activity is centred on the “Shao Fu”
In Phase 1 (menstrual phase) activity is centred
PHASE 1 – MENSTRUATION
There is a downward movement of Qi and Blood under the influence of the descending of Heart-Qi and Heart-Blood.
Under the influence of Liver-Blood and Chong Mai (although the main
activity is in the centre of the abdomen in the Ren Mai area). So, activity of both Chong and Ren Mai.
Yang decreases rapidly. If Yang does not decrease, period may not start or start late. If Yang decreases too much (because there is pre-existing Yang Xu) then menstruation may be early and heavy.
Herbs that conduct Blood downwards during the menses are: Chuan Niu Xi – Ze Lan – Dan Shen. These herbs cannot be used if period is heavy.
PHASE 2 – POST-MENSTRUAL
Three characteristics:
1. Yin starts to grow from its minimum level. This is an increase of Kidney-Yin, corresponding to oestrogen and the follicular phase. This
phase is very important to lay the foundation for the whole menstrual cycle. During this phase, Jing matures to nourish the Uterus and the follicles;
promotes growth of endometrium.
2. Decrease of Yang in this phase ensures growth of Yin (mutual
consuming of Yin and Yang). If Yin or Yang fails to grow/decrease at the right time, it means that Yin and Yang at that time are too “equal” and the cycle cannot progress normally.
3. Growth of Yin also implies growth of fluids in the vaginal and the beginning of the formation of the vaginal secretion in mid-cycle.
PHASE 2
Very important phase to “set the foundation” of a good menstrual cycle.
Under the influence of Ren Mai, Liver-Blood and Kidney-Yin. Essential time to tonify the Kidneys (especially Yin).
Yin not growing: ovulation delayed. Yang not decreasing: ovulation may occur early.
PHASE 3 – MID-CYCLE (OVULATION)
Two characteristics.
1. The flourishing of Chong and Ren ensures ovulation. There is a lot of activity of Qi and Blood which may cause distension in the
Shao Fu abdomen, mood changes and breast distension.
2. During phase 3, Yin reaches its maximum and a transformation from Yin to Yang occurs. Oestrogen reaches its highest level. At this time, there is a physiological cervical secretion that is
PHASE 3 – MID-CYCLE (OVULATION)
Under the influence of Chong, Ren and Du. Ren and Du ensure balance of Yin and Yang (oestrogen and progesterone).
Strictly speaking, one can distinguish two sub-phases in phase 3: before/during ovulation and after ovulation. In the first phase, the influence of Ren and Du is obvious and Yang rises rapidly (hence the rise in temperature). After ovulation, is under the influence of the Chong Mai and the increase in Yang flattens out. However, for the purpose of treatment, it is not essential to distinguish these two sub-phases.
The cervical secretion occurring before ovulation occurs in phase 3: it is under the influence of the Ren Mai and is a direct expression of Kidney-Jing. If it is absent or too short, it automatically indicates a deficiency of the Kidneys.
During phase 3 Yin is decreasing and Yang increasing: if these two do not occur, Dampness and Phlegm are easily formed in the
PHASE 3
Thus, Excess of Yin in phase 3 means Dampness or Phlegm obstructing the Uterus: this may delay ovulation. The same would happen in Deficiency of Yang.
Vice versa, if there were Excess of Yang, ovulation may come early: the same in case of Deficiency of Yin.
PHASE 4: PRE-MENSTRUAL PHASE
Two characteristics.
1. During this phase, Yang grows rapidly and Yin decreases. The growth of Yang provides warmth to the Uterus which makes
endometrium receptive to implantation. The growth of Yang in this phase ensures the expulsion of Yin pathogenic factors from the Uterus such as Cold, Phlegm, Dampness and Blood stasis. For example, endometriosis and ovarian cysts represent Yin pathogenic factors: growth of Yang in phase 4 is therefore
important to prevent Blood stasis and Dampness/Phlegm/Cold.
2. The decrease of Yin in this phase ensures the growth of Yang: this is comparable to the decrease of Yang in phase 2 but it is clinically more significant.
PHASE 4
Under the influence of Liver-Blood and Liver-Qi. Also Chong Mai.
Best time to move Qi; also a good time to invigorate Liver-Blood.
Phase 4 is also a good time to eliminate Yin pathogenic factors, i.e. expel Cold and resolve Damp-Phlegm.
TREATMENT PRINCIPLES ACCORDING TO THE FOUR PHASES PHASE 1
Invigorate (move) Blood. As Blood is already moving down, it is the best time to invigorate Blood. However, we can invigorate Blood at this time only if the bleeding is normal or scanty. If bleeding is heavy, then we should invigorate Blood and stop bleeding simultaneously. There are Chinese herbs that do this: Pu Huang, Qian Cao Gen, Di Yu, San Qi.
The formula to invigorate Blood in the Lower Burner is Ge Xia Zhu Yu Tang (Stir Field of Elixir). The formula to invigorate Blood and stop bleeding is Invigorate Blood and Stem the Flow.
If we need to “break Blood” in case of abdominal masses or
endometriosis, the formula is Gui Zhi Fu Ling Wan (Harmonizing the Moon).
LIVER-3 TAICHONG 太 冲
Su Wen, chapter 1
“When a girl is 14, Tian Gui arrives, the Ren Mai is open, the Taichong Vessel is flourishing, menstruation begins and she can conceive.”
In this passage the Chong Mai is called the “Liver-3 Vessel”: this point is closely identified with the Chong Mai due to its descending branch reaching this point. Whenever we use this point, therefore, we activate the Chong Mai and invigorate Blood (although we may also subdue rebellious Qi). The gynaecological effect of this point is due to its being a Chong Mai point.
ACUPUNCTURE
The main points to move Liver-Blood and eliminate stasis of Blood are the same as those that eliminate stagnation of Liver-Qi, i.e. LIV-3 Taichong (this is the main one), G.B.-34
Yanglingquan, LIV-14 Qimen.
These points should be needled with reducing or even method. In addition, two points which specifically invigorate Blood are BL-17 Geshu (with needle, no moxa) and SP-10 Xuehai.
In gynaecology: Chong Mai (SP-4 and P-6) with KI-14, ST-29. Others: SP-6, P-6. LIV-3 GB-34 LIV-14 BL-17 SP-10 KI-14 ST-29
PHASE 2
During phase 2 it is the best time to tonify the Kidneys (Yin or Yang) and to nourish Blood. It is a very important phase to establish a regular cycle and promote the follicular phase. Important not only to promote fertility but also to regulate the period and to treat Beng Lou.
There is no single, specific formula to do this: it depends on whether there is Kidney-Yin or Kidney-Yang deficiency.
The formulae I use to tonify the Kidneys and promote fertility in phase 2 are
Unicorn Pearl for Kidney-Yang deficiency and Growing Jade for Kidney-Yin deficiency.
PHASE 2
Acupuncture
- Nourish Kidney-Yin: Ren Mai (LU-7 and KI-6), Ren-4, KI-13, KI-3, SP-6.
- Tonify Kidney-Yang: Ren Mai (LU-7 and KI-6), Ren-4, KI-13, KI-3, SP-6, BL-23. Moxa.
PHASE 3
The treatment principle in phase 3 is also to tonify the Kidneys; in addition, strengthen Ren, Chong and Du to promote ovulation. If necessary, Phase 3 is also a good time to resolve Dampness or Phlegm.
The formulae I use to tonify the Kidneys are the same as those used in Phase 2.
To resolve Phlegm, I use Qi Gong Wan (Clear the Palace).
PHASE 3
Acupuncture
- Resolve Dampness: Ren Mai (LU-7 and KI-6), Ren-3, ST-28, BL-22, Ren-5, Ren-9.
- Resolve Phlegm: Ren Mai (LU-7 and KI-6), Ren-3, ST-28, ST-40, BL-22, Ren-5, Ren-9.
PHASE 4
During phase 4 it is the best time to move Qi, invigorate Blood and eliminate Yin pathogenic factors (Cold, Phlegm).
The formula to move Qi in phase 4 is Xiao Yao San (Freeing the Moon). The formula to invigorate Blood in phase 4 is the same as the one for phase 1, i.e. Ge Xia Zhu Yu Tang (Stir Field of Elixir).
The formula to expel Cold from the Uterus is Wen Jing Tang (Warm the Menses).
The formula to resolve Phlegm from the Uterus is Qi Gong Wan (Clear the Palace).
PHASE 4
Acupuncture
- Move Qi: Ren Mai (LU-7 and KI-6), GB-34, LIV-3, Ren-6.
- Invigorate Blood: Chong Mai (4 and P-6), KI-14, LIV-3, SP-10.
- Warm the Uterus: Ren Mai (LU-7 and KI-6), Ren-4, Zigong. Moxa.
WESTERN MEDICAL PERSPECTIVE
Endometriosis is a condition resulting from the presence of actively growing and functioning endometrial tissue in locations outside the uterus.
The areas where endometriosis may occur are widespread and usually multiple. They include:
ovaries uterine wall
Fallopian tubes
umbilicus
rectum ureters
bladder
sigmoid colon
Endometriosis should be differentiated from adenomyosis
(historically thought to be similar) which describes an ingrowing of the endometrium into the myometrium.
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Women between the ages of 25-40 who have not had children
Occurrence
Teenagers (previously not thought to be commonly affected)
Familial incidence
Women who have undergone elective tubal sterilization
Correlation between endometriosis and:
tampons
AETIOLOGY
Retrograde menstruation and tubal reflux: menstrual blood forced out along the fallopian tubes into the peritoneal
cavity. Menstrual blood contains fragments of
endometrium which may implant on pelvic structures and grow.
Celomic metaplasia: all tissues in which endometriosis arises are
embryologically derived from celomic epithelium, i.e. peritoneal cells change into endometrial tissue. Chronic irritation of the peritoneum by Excessive uterine contractions characteristic of primary
dysmenorrhoea may contribute to a bidirectional menstrual flow from the uterus
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implant in the new sites. This explains why endometriosis may be found in surgical scars
Genetic and immunologic factors: there is a 5.8 percent familial incidence among immediate female siblings
Lymphatic dissemination: normal endometrium might “metastasize” via
lymphatic channels and thus spread to extrauterine sites where
implantation and growth would produce the characteristic lesions of endometriosis
Vascular theory: normal endometrium deported via the veins to remote areas of the body.
Pathology
The typical lesion will show an abundance of:
Ovarian endometriosis occurs in the form of small superficial deposits on the surface of the ovary or as larger cysts which may be up to 10cm in size (known as endometriomas or “chocolate cysts”) and which may rupture. There is usually considerable fibrosis and puckering of the ovarian surface in the region of the cyst as well as adherence to neighbouring structures.
In the other most frequently involved areas, i.e., throughout the pelvic peritoneum, the lesions are normally smaller and more numerous and are surrounded by dense, fibrous scar tissue.
Inflammatory cells
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This is a section through an enlarged 12 cm ovary showing a cystic cavity filled with old blood with formation of an endometriotic, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black colour.
Clinical manifestations
• Dysmenorrhoea (97%) • pelvic pain (62%)
• lower backache radiating to the anterior thigh • heavy periods
• irregular bleeding • infertility (47%) • dyspareunia (59%)
• pain sometimes accompanied by nausea and vomiting or diarrhoea
• pain on defecation (68%) • rectal pressure
Clinical manifestations (Endometriosis Association USA)
• dysmenorrhoea (96.2%) • dyspareunia (59.6%)
• heavy periods or irregular bleeding (65.3%) • infertility (44%)
• pain sometimes accompanied by nausea and vomiting (57.7%) • diarrhoea (79%)
• dizziness, headaches with period (59%) • fatigue (82.1%)
• low-grade fever (29.4%)
• low resistance to infection (39.1%) • no symptoms (2.6%)
AGE AT WHICH ENDOMETRIOSIS FIRST PRESENTS (Endometriosis Association, USA)
- Under 15: 14.9% - 15-19: 25.7% - 20-24: 19.6% - 25-29: 23.3% - 30-34: 12.5% - 35-39: 4%
5 million women in USA 68.6%
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Endometrial inplants may even occur in the nose, in which case, there would be nosebleed with the period.
If there was epistaxis, what would this tell us from the Chinese point of view?
If there was epistaxis with the period in a woman with endometriosis, from the Chinese point of view this would indicate:
• Most probably the presence of Heat as a cause of bleeding (as opposed to Qi Xu)
• Often the presence of Liver-Fire. • Rebellious Qi of the Liver.
• Rebellious Qi of the Chong Mai.
• The need in treatment to subdue rebellious Qi (with Chuan Niu Xi for example).
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Danazol: affects the release of hormones by the pituitary gland and thereby inhibits ovulation and the normal
hormonal cyclical change.
Norethisterone: a progesterone compound given
continuously in an effort to suppress ovulation and prevent menstruation.
Initial treatment may also be carried out during the initial
laporoscopy when endometriotic deposits may be removed by
laser
BIOMEDICAL TREATMENTS FOR ENDOMETRIOSIS
• Combined contraceptive pill • Progestins • Mirena IUD • GnRH agonists • Danazol • Aromatase inhibitors • Painkillers
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MY VIEW OF BIOMEDICAL TREATMENTS FOR ENDOMETRIOSIS
• Combined contraceptive pill: useless. Induces Blood Xu, merely masks problem.
• Progestins: useless. Mask problem, cause Dampness and Liver-Qi stagnation.
• Mirena IUD: same as above. On top of that, obstruction of uterus causes Blood stasis (which is the cause of endometriosis in the first place).
Doubly bad.
• Danazol: useless, masks the problem. Causes Dampness and Phlegm.
• Aromatase inhibitors: useless, mask the problem by inducing menopause. Cause Kidney deficiency.
• Painkillers. Merely symptomatic.
In conclusion, I do NOT combine Chinese herbal treatment with Western hormonal treatment because Chinese herbs cannot regulate the hormones naturally when the woman’s hormonal system is being manipulated
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ENDOMETRIOSIS IN CHINESE MEDICINE-AETIOLOGY
Intercourse during menstruation
When a woman becomes sexually aroused, the Minister Fire goes upwards. If this happens when menstrual
blood is flowing downwards, the two will “meet”,
blocking each other and therefore leading to stagnation of Qi and Blood in the Uterus.
Early sexual activity
By “early” sexual activity is meant sexual activity before puberty, during puberty and within 2 years from puberty. During puberty, the Uterus is in a vulnerable condition and it is easily affected by pathogenic factors.
Early sexual activity damages the Chong and Ren Mai and causes Blood stasis.
MINISTER FIRE
STASIS
Excessive physical work or exercise
Excessive physical work or exercise can weaken the Spleen, Liver and the Kidneys and adversely affect the Chong and Ren Mai. This is especially the case during puberty when the Chong and Ren are in a state of change and not yet fully developed. Depending on the constitution of the girl, excessive physical work or exercise will either weaken these two vessels or cause stagnation.
Excessive exercise, especially at puberty, during the period or when pregnant, will weaken the Spleen and Kidneys possibly leading to a whole host of problems including a deficiency of Yin, Yang, Qi or Blood and stagnation of Qi and Blood.
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Tampons and intra-uterine devices block the normal downward flow of menstrual blood thereby leading to Blood stasis. “Retention of menses” (Dr Xia).
External Cold
Women are particularly prone to invasion of Cold just before, during and just after the period, as well as just after childbirth . When Cold invades the Uterus, it contracts causing Blood to stagnate.
Emotional strain
Emotional strain as a cause of endometriosis may derive from anger, repressed anger, resentment, worry, shame and guilt. All these
2/4/2019 copyright 2006 Free template from brainybetty.com ALL RIGHTS RESERVED. 47 BIAN ZHENG 辨 证 BIAN BING 辨 病 “PAINFUL PERIODS” “ABDOMINAL MASSES”
“Abdominal masses” could only be diagnosed by ancient Chinese doctors on palpation when masses are palpable.
“BLOOD STASIS”
A large, palpable myoma is a good example of an abdominal mass from Blood stasis.
ENDOMETRIOSIS
“PAINFUL PERIODS”
“ABDOMINAL MASSES”
症 瘕
In other words, is it legitimate to make a Chinese Bian Bing on the basis of Western diagnosis?
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PATHOLOGY
The Western disease entity of “endometriosis” broadly corresponds to the Chinese disease-symptom of “Painful
Periods”: in other words, the pathology, patterns and treatment for Painful Periods is applicable to endometriosis.
However, there is an important difference. It is generally agreed by all Chinese gynaecologists that in endometriosis there is always Blood stasis and that endometriosis should be treated as
“Abdominal Masses” (Zheng Jia) in Chinese gynaecology.
In other words, the endometrial lesions should be considered a form of abdominal masses even though they are not palpable. The important implication of this is that, in the herbal treatment, herbs that “break Blood” and dissolve masses should be chosen, for example:
In endometriosis there is always Blood stasis, but in infertility due to endometriosis there are other factors at play and especially Kidney-Yang deficiency causing a luteal insufficiency. In treatment, place the emphasis on Biao, i.e. Blood stasis especially if the period is very painful.
The temperature chart is flat in endometriosis for two reasons, one due to Biao, the other to Ben. The
temperature does not decrease enough during the period because of Blood stasis (Biao) and it does not increase enough after ovulation due to Kidney-Yang deficiency (Ben).
There is always a Kidney deficiency and disharmony of Liver and Spleen. Retention of menses is an important factor, often occurring after childbirth. “Retention of menses” refers to an insufficient discharge of blood during menstruation.
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Endometriosis: TCM Pathology
1. Blood Stasis = BIAO
• ‘Biao’ is synonymous with ‘abdominal masses’
• Prevents the temperature from going down during the period • Tongue: Degree of stasis increasing
Normal Purple sides Whole T Purple
Treatment principle: •Invigorate Blood
•“Break” Blood Herbs:
E Zhu San Leng Ze Lan Distended-dark sublingual
2. Kidney-Yang Deficiency - BEN •‘Ben’
•Prevents the temperature from rising after ovulation •For example:
Cold Uterus Fullness
injures Kidney-Yang
Yang-Deficiency invades
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ENDOMETRIOSIS – TREATMENT PRINCIPLE
Use Tong Xia 通 下 method (penetrating downwards) to stop pain
To stop pain, calming the Heart is also important
Treat Biao and Ben, i.e. invigorate Blood and tonify the Kidneys. Invigorating Blood only is not enough. It is necessary to regulate the menses according to the 4 phases.
Must warm the Uterus even if there are no specific signs of Cold in order to ensure the growth of Yang in phases 3 and 4. Obviously not if there Liver-Fire or Damp-Heat.
TREATMENT STRATEGY
Treat Ben by tonifying the Kidneys (Yang or Yin). Important to tonify the Kidneys in 2nd and 3rd phases
Treat Biao by breaking Blood in phases 4 and 1
Acupuncture treatment to promote ovulation:
a)Ren-3 Zhongji, SP-6 Sanyinjiao, KI-12 Dahe.
b) Ren-3 Zhongji, SP-6 Sanyinjiao, Ren-4 Guanyuan, Zigong. Start when cervical secretion appears.
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ENDOMETRIOSIS – PATTERNS
The main patterns appearing in endometriosis and the relevant remedies are as follows:
Liver-Blood stasis (Harmonizing the Moon, Invigorate Blood and Stem the Flow)
Stagnation of Cold in the Uterus (Warm the Menses)
Damp-Phlegm in the Uterus (Clear the Palace) Damp-Heat in the Uterus (Drain Redness)
Kidney-Yang deficiency (Unicorn Pearl)
Kidney-Yin deficiency (Growing Jade)
As for the remedies to invigorate Blood listed above, the following are the guidelines for their use:
Harmonizing the Moon: this is the main remedy to treat the Biao
of endometriosis, i.e. invigorate Blood and dissolve masses. It contains herbs that “break Blood” and dissolve masses.
Generally, this remedy is used in phases 4 and 1. If the period is heavy, use Harmonizing the Moon in phase 4 and Invigorate Blood and Stem the Flow in phase 1.
Variation of Gui Zhi Fu Ling Wan
Invigorate Blood and Stem the Flow: this remedy is used in phase 1 if the period is heavy. Therefore, a common protocol to treat the
Biao of endometriosis when the period is heavy is to use
Harmonizing the Moon in phase 4 and Invigorate Blood and Stem the Flow in phase 1.
HARMONIZING THE MOON Dang Gui Radix Angelicae sinensis Chi Shao Radix Paeoniae rubra
Shu Di Huang Radix Rehmanniae preparata Chuan Xiong Radix Chuanxiong
Yan Hu Suo Rhizoma Corydalis
E Zhu Rhizoma Curcumae
San Leng Rhizoma Sparganii stoloniferi
Ze Lan Herba Lycopi
Gui Zhi Ramulus Cinnamomi cassiae Fu Ling Poria
Mu Dan Pi Cortex Moutan
Lu Lu Tong Fructus Liquidambaris Huang Bai Cortex Phellodendri Yi Yi Ren Semen Coicis
Tu Si Zi Semen Cuscutae Qian Cao Gen Radix Rubiae San Qi Radix Notoginseng
Pattern: Blood stasis in the Lower Burner, Dampness in the Lower Burner, Kidney deficiency.
Action: Invigorate Blood, dissolve masses, drain Dampness, tonify the Kidneys. Indications: Abdominal masses, endometriosis, endometrial ovarian cysts, fibroids, painful periods, heavy periods.
Tongue: Purple sides. Pulse: Wiry or choppy.
HARMONIZING THE MOON
IN A NUTSHELL: invigorate Blood, eliminate stasis and dissolve masses in gynaecological problems. Endometriosis.
CLASSICAL ANTECEDENT: Gui Zhi Fu Ling Wan.
DIFFERENCES FROM CLASSICAL ANTECEDENT: •Stronger “breaking” Blood action.
•Drain Dampness. •Tonify the Kidneys.
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BLOOD STASIS, KIDNEY-YANG DEFICIENCY AND DAMPNESS Clinical manifestations
painful periods
scanty or heavy periods
dark blood with clots
abdominal pain
mid-cycle hypogastric pain
possibly abdominal masses
lower backache vaginal discharge feeling cold
Tongue: Swollen, Pale with Purple sides, sticky coating.
Treatment Principle
Menstrual phase: invigorate Blood, eliminate stasis. Gui Zhi Fu Ling Wan (Harmonizing the Moon. If heavy: Invigorate Blood and Stem the Flow)Post-menstrual
phase (about 7
days)
: Warm and
tonify
Kidney-Yang, tonify
Spleen-Qi. You
Gui Wan
(
Unicorn
Pearl
)
Mid-cycle phase
(about 7 days)
:
Warm and tonify
Kidney-Yang,
tonify Spleen-Qi,
resolve Dampness.
You Gui Wan
(
Unicorn Pearl
)
Pre-menstrual
phase (about 7
days)
: Invigorate
Blood, eliminate
stasis, resolve
Dampness. Gui
Zhi Fu Ling Wan
(
Harmonizing the
Moon
)
COLD IN THE UTERUS LEADING TO BLOOD STASIS, KIDNEY-YANG DEFICIENCY AND DAMPNESS
Clinical manifestations
Tongue: Pale-Bluish or Bluish-Purple with sticky-white coating. severe abdominal period pain
pain central
pain relieved by the application of heat
menstrual blood scanty with small, dark clots
feeling cold
white vaginal discharge
lower backache
feeling of fullness and heaviness
Treatment principle
Menstrual phase (about 5 days): invigorate Blood, eliminate stasis, scatter Cold, warm Uterus. Gui Zhi Fu Ling Wan(Harmonizing the Moon)
Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi. You Gui Wan (Unicorn Pearl)
Mid-cycle phase
(about 7 days): tonify and warm Kidney-Yang, tonify Spleen-Qi, resolve Dampness, warm Uterus. You Gui Wan (Unicorn Pearl) Pre-menstrual phase (about 7 days): invigorate Blood, eliminate stasis, scatter Cold, resolve Dampness. Wen Jing Tang (Warm the
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DAMP-PHLEGM IN THE UTERUS
Clinical manifestations
Tongue: Swollen, Pale with Purple sides. Pulse: Deep-Weak-Slippery-Wiry.
abdominal pain that is relieved by warmth mid-cycle hypogastric pain
soft and moveable abdominal masses tingling limbs
dizziness
lower backache
painful, scanty or heavy periods dark blood with clots
excessive vaginal discharge feeling cold
Treatment principle
Menstrual phase (about 5 days): invigorate Blood, eliminate stasis, scatter Cold, warm Uterus. Gui Zhi Fu Ling Wan(Harmonizing the Moon)
Post-menstrual phase (about 7 days): tonify and warm Kidney-Yang.You Gui Wan (Unicorn Pearl)
Mid-cycle phase
(about 7 days): Warm and tonify Kidney-Yang, tonify Spleen-Qi, resolve Dampness and Phlegm. Qi Gong Wan (Clear the Palace) Pre-menstrual phase (about 7 days): Invigorate Blood, eliminate stasis, resolve Dampness and Phlegm. Gui Zhi Fu Ling Wan (Harmonizing the Moon)
LU-7 and KI-6
Ren-4: tonify Uterus, warm Uterus, tonify Kidneys, nourish Jing
Ren-6: tonify and move Qi
Ren-5: move Qi, promote fluids transformation, resolve
Dampness and Phlegm
Tonify Ren Mai in phases 2 and 3
REN MAI
.
.
.
SP-4 and P-6
KI-13 Qixue: tonify the Kidneys, strengthen the Uterus, nourish Jing
KI-14 Siman: invigorate Blood, move Qi, resolve Phlegm
KI-16 Huangshu: harmonize Heart and Kidneys, connect Heart and Kidneys, subdue rebellious Qi
KI-21 Youmen: subdue rebellious Qi
LIV-3 Taichong: invigorates Blood of Chong Mai.
DU MAI
SI-3 and BL-62
Ren-4 Guanyuan with direct moxa cones to tonify and warm Kidney-Yang and strengthen the Uterus.
Du-4 Mingmen with direct moxa cones to tonify and warm Kidney-Yang.
Tonify the Du Mai in phases 2 and 3. Used instead of Ren Mai if there is a pronounced deficiency of Kidney-Yang
POINTS ACCORDING TO PATTERN
- BLOOD STASIS: KI-14, LIV-3, SP-10, BL-17, SP-6.
- DAMP-PHLEGM: SP-9, SP-6, Ren-9, ST-28, BL-22, ST- 40, Ren-5.
- KIDNEY DEFICIENCY: Ren-4, KI-3, BL-23, KI-13.
ST-28 on the left was called Baomen (Door of Uterus) and on the right Zihu (Window of Baby)
. .
.
4
13
14
28
.
29
.
3
.
ENDOMETRIOSIS – EXTRA POINTS
Extra points
Jingzhong: irregular periods Qimen: infertility,
menorrhagia
Zigong: infertility
Jueyun (3 fen below Ren-5): makes woman infertile
.
.
.
.
.
.
.
.
5
.
7
3
4
6
Jingzhong
Qimen
Zigong
3 cun from midline.
Jueyun
POLYCYSTIC OVARY SYNDROME
• Amenorrhoea, hirsutism, obesity, bilateral polycystic ovaries.
• Presence of an excessive number of small follicles placed
peripherically in the ovaries
• A continuous background of
oestrogen production by the small follicles
• Ovarian stromal hyperplasia associated with excessive androgen production.
WESTERN PERSPECTIVE DESCRIPTION
Originally described by Stein and Leventhal, Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of
reproductive age. According to the initial description by Stein and Leventhal in 1935, the diagnosis of PCOS was based on the clinical symptoms
(oligo/amenorrhoea, infertility, hirsutism, and obesity) in the presence of histologically verified polycystic ovaries.
Presently, ovarian morphology can easily be identified by ultrasound, which has revealed that PCOS is not only linked to the "classic Stein-Leventhal syndrome", but women with polycystic ovaries exhibit a wide spectrum of clinical presentations.
WESTERN PERSPECTIVE
PCOS account for
75% of women with anovulatory infertility 30% to 49% of secondary amenorrhea
85% to 90% of women with oligomenorrhea.
1) The majority of patients with PCOS are hirsute.
2) Obesity is also a frequent finding among women with PCOS.
PCOS often comes to light during puberty due to period problems, which affect around 75% of those with the disease. Infrequent, irregular or absent periods are all common variations, many
finding their periods particularly heavy when they do arrive. The period disturbance is a sign that there is a problem with regular monthly ovulation.
Many teenagers use the contraceptive pill to control their periods as irregularity or heaviness is a common complaint at this time. This often leads to a delay in the diagnosis of PCOS, many not presenting until the pill is stopped and finding periods cease or become irregular.
ENDOCRINOLOGY
Endocrinologically PCOS is also heterogenous; it is characterized by
1) hyperandrogenism
2) inappropriate pituitary gonadotropin secretion 3) elevated LH to FSH ratio
Diagnostic features of PCOS are hirsutism, anovulation, and polycystic ovaries, which show arrested follicular maturation; obesity and insulin resistance are frequently associated conditions.
The major biochemical feature of PCOS is androgen excess, which
causes hirsutism. Androgens also appear to inhibit the negative-feedback effects of estrogens and progesterone on pulsatile LH release.
Women with PCOS have increased pulsatile GnRH release, which results in higher levels of LH and lower levels of FSH in most
individuals. Higher LH (and insulin) levels seem to cause increased androgen production by follicular theca cells whereas lower FSH levels lead to anovulation.
Obesity and insulin resistance decrease levels of sex-hormone-binding globulin and thereby increase testosterone bioactivity.
+
DIAGNOSIS Ultrasound scan
This is usually done as an internal scan, meaning a small ultrasound probe is placed just inside the vagina, giving the best views of the ovaries and pelvic organs.
In PCOS, the ovaries are found to have multiple, small cysts around the edge of the ovary. These cysts are only a few millimetres in size, do not in themselves cause problems and are partially developed eggs that were not released.
DIAGNOSIS
Blood tests
Two blood tests will assist in making the diagnosis - one to check the level of androgens, such as testosterone.
Another test to measure LH and FSH - in PCOS there is a characteristic rise in lutenising hormone (LH). A progesterone blood test 7 days before the expected menstrual period can check if the woman is ovulating.
Raised oestrogen Raised testosterone Raised ratio LH:FSH
Endometriosis ovarian cysts
Polycystic ovary syndrome
Poll: looking at the endometriomas and PCOS cysts from the Chinese medicine perspective, what do you think each of them is due to?
Rotterdam Consensus on Diagnostic Criteria for PCOS Two out of three of the following:
1. Oligo- or anovulation
2. Clinical and/or biochemical signs of hyperandrogenism*
3. Polycystic ovaries**and exclusion of other etiologies (congenital adrenal hyperplasia, androgen-secreting tumours, Cushing’s
syndrome)
* Hirsutism, acne, male pattern baldness, elevated total or free testosterone
** On ultrasound, ≥12 follicles of 2-9mm diameter and/or increased ovarian volume (>10mL)
CLINICAL MANIFESTATIONS • Obesity
• Amenorrhoea or oligomenorrhoea
• Infertility. Given that the period disruption with PCOS is due to irregular or absent ovulation it is a common cause of infertility. It is not usually 100% absolute, and some women with PCOS will ovulate normally, some will ovulate less frequently (leading to a delay to pregnancy) and some will not ovulate at all.
• Hirsutism
• Ovaries are enlarged and smooth. The tunica albuginea is thickened and beneath it are numerous small cystic follicles, varying in size but seldom exceeding .5 cm in diameter.
• Raised oestrogen • Raised testosterone • Raised ratio LH:FSH
• On ultrasound the classic picture is a string of small follicles, 2-8 mm in
diameter, arranged like a necklace in the periphery of the ovary with a minimum of 10 follicles in each ovary.
• The tunica albuginea is thickened and beneath it are numerous small cystic follicles.
Hyperandrogenism is the second defining characteristic of PCOS. Clinically, the most common sign of hyperandrogenism in PCOS women is hirsutism. The range of the prevalence of hirsutism in PCOS women varies between 17 and 83% (Goldzieher & Green 1963, Guzick 1998).
Hirsutism may develop peripubertally or during adolescence (Yen 1980) or it may be absent until the third decade of life (McKenna
et al. 1983). The Ferriman and Gallwey scale is most commonly used for the assessment of hirsutism (Ferriman & Gallwey 1961).
Another common sign of hyperandrogenism is acne. Overt signs of virilization, i.e. male pattern balding, alopecia, increased muscle mass, a deepening voice or clitoromegaly usually reflect the presence of an androgen-producing tumor or ovarian hyperthecosis.
Most investigators have found that 30-50% of PCOS
women are obese. PCOS women tend to have an increased waist-hip ratio, (WHR) i.e. abdominal (visceral) obesity.
HOW PCOS COMPARES TO ENDOMETRIOSIS IN TERMS OF SEVERITY FROM THE CHINESE VIEWPOINT
PCOS is a deeper, more difficult condition than endometriosis from the Chinese point of view. This is for various reasons:
1. In PCOS there is a deep hormonal imbalance that is not found in endometriosis. The hyperandrogenism, the change in pulsatility of the GnRH, the elevated LH to FSH, all point to a deep dysfunction of the Kidneys, the Jing and of the Chong, Ren and Du.
2. The peripubertal and even genetic aetiology of the disease points to a dysfunction of Kidney-Jing.
3. The disruption of the insulin metabolism points to a general disharmony involving Kidneys, Liver and Spleen.
4. The release of free fatty acids by the liver and the decreased sex hormones binding, all point to a deep Liver disharmony.
TREATMENT
Periods may be controlled by the use of the contraceptive pill, which is most suitable for women under the age of 35 who also require a good form of contraception. The other type of drug used is a progesterone-like hormone.
Progesterone is the main hormone of the second half of the menstrual cycle, maintaining its length and helping reduce the heaviness.
Progestagens are taken as tablets in a cyclical way, for example between days 12-26, the exact type and timing depending upon the woman's
individual cycle problem.
Some women have no periods at all, and either the contraceptive pill or cyclical progestagens are advisable to avoid the risk of endometrial cancer. Around 6 periods per year is adequate to protect against this.
POLYCYSTIC OVARY SYNDROME IN CHINESE MEDICINE
Hirsutism: dysfunction of the Chong Mai with imbalance between Qi and Blood. A deficiency of Blood in the Uterus leads to amenorrhoea, but this would mean that there is more Blood available at the skin level to promote the growth of hair.
Amenorrhoea or scanty periods: deficiency of Blood of the Chong Mai; also Blood stasis within the Chong Mai. Menstrual blood is a manifestation of Tian Gui and therefore there is always a Kidney deficiency which may be Yin or Yang. Also KI-Jing Xu.
According to chapter 65 of the “Ling Shu”, the Chong Mai Vessel brings Qi and Blood to the chin area and, in women, losing some Blood with
menstruation, the Chong Mai has relatively less Blood than Qi in this area compared to men. The lack of Blood in this area is the reason why women do not have a beard; as men have relatively more Blood in the head branch of the Chong Mai, this Blood promotes the growth of hair on the face.
UTERUS
PERIODS
Chong Mai hasless Blood in face
Chong Mai has more Blood in face
Obesity: Damp-Phlegm affecting both the Chong Mai and the Ren Mai.
Hormonal imbalance, raised LH: an increase in Yang (but only
relative to Yin, oestrogen) and therefore a condition of Heat in the Liver and Chong Mai.
Hormonal imbalance, raised testosterone: dysfunction of the Du Mai, the Yang aspect of the menstrual cycle.
HYPOTHALAMUS
PITUITARY
FOLLICLE CORPUS LUTEUM
UTERUS
Oestrogen Progesterone
Gonadotropin releasing hormone GnRH
FSH LH DU MAI REN MAI Pituitary Hypothalamus Ovary REN Uterus
Damp-Phlegm: there is nearly always Damp-Phlegm. The ovarian cysts are due to Damp-Phlegm.
Liver-Fire or Damp-Heat: there may be Liver-Fire or Damp-Heat in the Liver channel.
Blood stasis: there may be Blood stasis especially if the ovarian cysts are palpable and the periods painful
Kidney deficiency: there is always a Kidney deficiency causing the hormonal imbalance. Can be Yin or Yang, more often Yang. Also SP Xu.
DAMP-PHLEGM IN THE UTERUS
Leucorrhoea
Tongue swollen with sticky coating at the root Tendency to obesity
Fullness and heaviness of the abdomen Pulse is slippery
Mid-cycle problems (slight pain, heaviness, bleeding)
Treatment:
• During phase 3-4
CLEAR THE PALACE Ban Xia Rhizoma Pinelliae preparata
Cang Zhu Rhizoma Atractylodis
Chen Pi Pericarpium Citri reticulatae
Fu Ling Poria
Xiang Fu Rhizoma Cyperi
Shen Qu Massa Medicata fermentata
Chuan Xiong Rhizoma Chuanxiong
Tu Si Zi Semen Cuscutae
Bai Zhu Rhizoma Atractylodis macrocephalae
Gan Cao Radix Glycyrrhizae uralensis
Ze Lan Herba Lycopi
Lu Lu Tong Fructus Liquidambaris
Huang Bai Cortex Phellodendri
Chuan Niu Xi Radix Cyathulae
Yi Yi Ren Semen Coicis
Shi Chang Pu Rhizoma Acori tatarinowii
Pattern: Phlegm and Dampness obstructing the Uterus.
Action: Resolve Phlegm, drain Dampness, invigorate Blood.
Indications: Infertility, excessive vaginal discharge, ovarian cysts, midcycle pain, obesity, polycystic ovary syndrome, a history of tubal inflammation, irregular periods, tiredness, a
CLEAR THE PALACE
IN A NUTSHELL: drain Damp-Phlegm from the Uterus.
CLASSICAL ANTECEDENT: Qi Gong Wan.
DIFFERENCES FROM CLASSICAL ANTECEDENT: •Stronger action in resolving Dampness from the Uterus •Invigorate Blood.
Pale, Swollen, sticky coating on root Bluish-Purple, Swollen, sticky coating on root
COMBINED PATTERNS
DAMP-PHLEGM, KIDNEY-YANG XU Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, low spirits, Pale and Swollen tongue with sticky coating, Weak and
slightly Slippery pulse.
Treatment principle and prescriptions
• Phase 2: tonify Kidney-Yang. You Gui Wan. (Unicorn Pearl). • Phases 3 and 4: resolve Damp-Phlegm. Qi Gong Wan (Clear the
DAMP-PHLEGM, KIDNEY-YANG XU, BLOOD STASIS
Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark-clotted blood, abdominal pain, backache, dizziness, tinnitus, feeling cold, cold knees and back, tiredness, low spirits, Pale, Bluish-Purple and Swollen tongue with sticky coating, Weak and slightly Slippery or Firm pulse.
Treatment principle and prescriptions
Phase 1: invigorate Blood. Ge Xia Zhu Yu Tang. Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy)
Phase 2: tonify Kidney-Yang. You Gui Wan. Unicorn Pearl.
DAMP-PHLEGM, KIDNEY-YIN XU, BLOOD STASIS Clinical manifestations
Obesity, hirsutism, excessive vaginal discharge, feeling of fullness and heaviness of the abdomen, irregular periods, scanty periods, amenorrhoea, painful periods with dark-clotted blood, abdominal pain, backache, dizziness, tinnitus, night-sweating, feeling of heat in the evening, tiredness, low spirits, Swollen tongue with sticky-rootless coating or without coating, slightly Purple on the sides, Weak and slightly Slippery or Firm pulse.
Treatment principle and prescriptions
• Phase 1: invigorate Blood. Ge Xia Zhu Tang. Stir Field of Elixir (Invigorate Blood and Stem the Flow if the period is heavy)
• Phase 2: nourish Kidney-Yin. Zuo Gui Wan. Growing Jade.
P.C.O.S. - POINTS
• Ren Mai: LU-7 and KI-6, Ren-4, ST-28, Zigong. • Chong Mai: SP-4 and P-6, KI-14, KI-13, LIV-3. • Du Mai: SI-3 and BL-62, Ren-4.
• Points according to pattern:
-Damp-Phlegm: SP-9, SP-6, Ren-9, ST-28, KI-14, BL-22, ST-40, Ren-5.
-Kidney deficiency: KI-3, KI-13, ST-36, BL-23, BL-20, Ren-4. -Blood stasis: SP-10, P-6, BL-17, SP-6, LIV-3, KI-14.
What to do when the period is irregular
1. Wait for period : that is phase 1 and after the bleeding, phase 2
2. Check for cervical secretion: when that appears, the woman is in beginning of phase 3
3. Check BBT : when it rises, the woman is at the beginning of phase 3 and, after that, phase 4
STATISTIC
-Damp-Phlegm: 83% - Blood stasis: 25% - KI-Yang Xu: 50% - KI Xu: 25%
MENOPAUSAL PROBLEMS
“Menopause” indicates the complete or permanent cessation of
menstruation: an interval of 6-12 months is usually necessary to establish the diagnosis.
“Climacteric” indicates the phase in a woman’s life during which she makes the transition from a reproductive to a non-reproductive stage: this transition is a period of declining ovarian function which usually spans 2-5 years
around the menopause.
Thus, when we refer to the discomfort and symptoms appearing during these years, it would be more appropriate to call them climacteric
Menopause usually occurs between the ages of 48 and 55 and the median age in industrialized countries is about 51. It will be remembered that the very first chapter of the “Simple Questions” describes the 7-year cycles of women, according to which menopause occurs at 49 (7x7): this is not far from the above-mentioned median age of 51.
Furthermore, data analyses indicate that the menopausal age has remained unchanged for centuries. Indeed, the mean age at menopause is just over 50 and this is remarkably constant not only throughout the Western world but also other countries.
A survey of Malaysian women showed a mean age at menopause of 50.7 years, and another of seven Asian countries found that most women reached menopause at around 50.
The primary basis for the progressive decline of reproductive power in women is in the ovary itself, as ovarian follicles are greatly depleted by the time of the menopause.
It is interesting to note that there is a progressive decline of follicles even from the time before birth. In fact, at the time the ovaries are formed in the foetus, there are approximately 6,000,000 primordial follicles, which
decrease to about 600,000 at birth, to 300,000 at menarche and to about
This would seem to confirm that the menopause is not an event that takes place suddenly in a woman’s life but one that reflects a gradual physiological
process throughout her lifetime, starting even before her birth.
This confirms that the biological basis of the
menopause is determined during a woman’s lifetime and that, therefore, her lifestyle and dietary habits from childhood onwards determine what kind of menopause she is going to have.
If a woman has a poor diet and if she overworks for several years prior to the onset of the menopause, she will be more likely to develop problems during the climacteric years.
The severity of the problems a woman experiences during the
menopause depends, as we have mentioned above, on the lifestyle and dietary habits throughout her life.
The main problems she is likely to experience with varying degrees of severity are:
Headaches, tiredness, lethargy, irritability, anxiety, nervousness, depression, insomnia, inability to concentrate, hot flushes, vaginal dryness and sweating. By far the commonest symptom is hot flushes (flashes), from which 85 per cent of menopausal women suffer; 45 per cent may experience them for 5-10 years after the menopause.
From a Chinese perspective, menopausal symptoms are due to a decline of Kidney-Jing in its Yin or Yang aspect; however, within this basic pathology there can be many variations of pattern.
Moreover, the deficiency of the Kidneys may often be combined with Excess patterns, especially:
In a few cases premature menopause may be caused by stagnation and Phlegm rather than by a Kidney deficiency.
Dampness
Stagnation of Qi Stasis of Blood
Empty Heat
AETIOLOGY
1) EMOTIONAL STRESS
Emotional stress is an extremely important cause of menopausal problems, building up for year after year before the onset of the menopause.
Worry, anger, anxiety, fear weaken the Kidneys and lead to Yin deficiency, especially when these emotions occur against a
background of overwork as is usually the case. In the long run, as Kidney-Yin fails to nourish Heart-Yin, they also lead to Heart-Yin deficiency and Heart Empty Heat.
2) OVERWORK
Overwork, in the sense of working long hours without adequate rest usually combined with
irregular diet and worry, is the most important and frequent cause of Kidney-Yin deficiency.
3) SMOKING
Tobacco smoking injures not only the Lungs but also the Kidneys. It dries up Jing and Blood and it therefore leads to Kidney-Yin deficiency which would aggravate menopausal symptoms.
TOBACCO IN CHINESE MEDICINE
Tobacco was introduced in China in 1575. The Zhen Nan Ben Cao (Ming) concludes that tobacco is pungent in taste, hot and toxic without any
medicinal effect. The Ben Cao Cong Xin says “People nowadays inhale smoke down to the throat: this damages Blood and the voice”
TOBACCO IN CHINESE MEDICINE
Emperor Chong Zhen (Ming) enacts laws against smoking
Qu Ci Shan (Qing) says: “Tobacco is pungent and drying, it burns Jing (Kidneys) and the Fluids, damages the throat, the Stomach and the Lungs…it enters the Heart orifice causing mental confusion as if one were drunk.
It makes the tongue coating dark-yellow or black, food and drink have no taste, the medical texts have no treatment for this.”
4) IRREGULAR DIET
Eating irregularly and eating excessive amounts of dairy foods and greasy-fried foods leads to the formation of Phlegm. This often aggravates menopausal symptoms.
5) TEA/COFFEE AND ALCOHOL
Tea, coffee and alcohol are Yang in nature and would aggravate menopausal symptoms and hot flashes.
ADVICE TO YOUNG WOMEN • Do not overwork • Exercise (in moderation) • Do not smoke • Drink alcohol
in moderation • Avoid emotional
stress (easy to say!)
• Do not drink too much
coffee and tea • Do not eat too
much dairy foods • Eat foods rich in
Menopausal problems are due to a decline of Kidney-Jing which can take the form of Kidney-Yin, Kidney-Yang or a combined Kidney-Yin and Kidney-Yang deficiency.
For this reason, when using patent remedies, one can often use two remedies simultaneously (each with a reduced dosage): the Yin-nourishing remedy can be given in the evening and the Yang-tonifying one in the morning.
A combined deficiency of both Kidney-Yin and Kidney-Yang in women over 40 is very common: indeed, it is probably more the rule than the exception.
Although a deficiency of the Kidney-Jing (in its Yin or Yang aspect) is always at the root of menopausal problems (with the exception of
premature menopausal problems from Phlegm), other Full patterns often accompany it, notably:
Phlegm
Thus, if a decoction is used, this should be modified to treat the above patterns too. If the above Full patterns are pronounced, then it might be advisable to deal with these first by using a decoction that resolves Phlegm, moves Qi or invigorates Blood.
Stagnation of Qi Blood Stasis
For example, were the deficiency of the Kidneys accompanied by a pronounced stasis of Blood, one might invigorate Blood and eliminate stasis first by using for a few months a formula such as Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction.
Similarly, were Phlegm pronounced, one might start with a decoction to resolve Phlegm such as Er Chen Tang.
YIN
YANG
YANG
KIDNEY-YIN DEFICIENCY (PRIMARY)
KIDNEY-YANG DEFICIENCY (PRIMARY)
Night-sweating, feeling of heat, hot flushes, tongue without coating (Red in severe cases), cold feet, frequent urination
Backache, feeling cold, cold feet, frequent urination, hot flushes, Pale tongue
Empty Heat
Empty Heat
Rootless coating, normal colour
THE TONGUE IN MENOPAUSAL PROBLEMS TONGUES INDICATING YIN XU:
Coating partially missing, normal colour
Coating missing
TONGUE INDICATING YANG XU: Pale body
In other words:
In menopausal problems, tonify Kidney-Yang if the tongue is definitely Pale; in any other case (even if it is of a normal colour) nourish Kidney-Yin.
CHONG MAI REBELLIOUS QI HOT Qi Rebellious Qi Deficient in leg branch Kidney channel REN-1 FACE UTERUS BLOOD YIN
Rebellious Qi of the Chong Mai
causes various symptoms at different levels of the abdomen and chest. It causes primarily fullness, distension or pain in these areas.
By plotting the pathway of the Chong Mai, we can list the possible
symptoms of rebellious Qi of the Chong Mai starting from the bottom:
Fullness/distension/pain of the epigastrium Feeling of tightness below the xyphoid process Hypogastric fullness/distension/pain
Fullness/distension/pain of the umbilical area Fullness/distension/pain of the lower abdomen Painful periods, irregular periods
Slight breathlessness Sighing
Palpitations
Feeling of tightness of the chest
Feeling of distension of the breasts in women Headache
Feeling of heat of the face Feeling of lump in the throat
REBELLIOUS QI OF CHONG MAI TREATMENT
SP-4
P-6
Ren-15
Ren-4
KI-13
KI-21
KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY - PREDOMINANCE OF KIDNEY-YIN DEFICIENCY
Clinical manifestations
Dizziness, tinnitus, vertigo, poor memory, hardness of hearing, night-sweating, dry mouth and throat at night, lower backache, ache in bones, tiredness, lassitude, depression, slight anxiety, cold feet, abundant-pale urine.
Tongue: normal-coloured without coating or with rootless coating.
Acupuncture
Ren-4 Guanyuan, KI-3 Taixi, KI-6 Zhaohai, KI-10 Yingu, KI-9 Zhubin, SP-6 Sanyinjiao, Ren-7 Yinjiao, LU-7 Lieque and KI-6 Zhaohai in combination (opening points of the Ren Mai).
Prescription
Zuo Gui Wan Restoring the Left [Kidney] Pill plus Ba Ji Tian Radix Morindae officinalis.
KIDNEY-YIN AND KIDNEY-YANG DEFICIENCY - PREDOMINANCE OF KIDNEY-YANG DEFICIENCY
Clinical manifestations
Lower backache, cold knees, sensation of cold in the back, feeling cold in general but also occasionally hot in the face, menopausal hot flushes, night-sweating, weak legs, bright-white complexion, weak knees,
decreased libido, tiredness, lassitude, abundant-clear urination or scanty-clear urination, urination at night, apathy, oedema of the legs, loose
Tongue: Pale.
Pulse: Deep-Weak. Acupuncture
BL-23 Shenshu, LU-7 Lieque and KI-6 Zhaohai, Ren-4 Guanyuan, Ren-6 Qihai, KI-3 Taixi, KI-7 Fuliu, BL-52 Zhishi, Jinggong extra point (0.5 cun lateral to BL-52 Zhishi). Moxa is applicable, but less than in Kidney-Yang deficiency.
Prescription
You Gui Wan Restoring the Right [Kidney] Pill plus Sheng Di Huang Radix Rehmanniae glutinosae and Tian Men Dong Tuber Asparagi
cochinchinensis.
KIDNEY- AND LIVER-YIN DEFICIENCY WITH LIVER-YANG RISING
Treatment principle
Tongue: Red without coating.
Pulse: Floating-Empty, Wiry on the left-Middle position. Clinical manifestations
Irritability, headaches, dizziness, tinnitus, blurred vision, dry eyes, dry skin, hot flushes, ache in joints, night-sweating, sore back.
Acupuncture
KI-3 Taixi, LIV-8 Ququan, Ren-4 Guanyuan, LU-7 Lieque and KI-6 Zhaohai, LIV-3 Taichong, Du-24 Shenting, G.B.-13 Benshen, G.B.-20 Fengchi, P-7 Daling. KI-3, LIV-8 and Ren-4 with reinforcing method, the others with reducing method.
KUN BAO TANG
KIDNEYS AND HEART NOT HARMONIZED
Tongue: Red body without coating with a redder tip.
Pulse: Rapid-Fine, or Floating-Empty, or Weak-Deep on both Rear positions and Overflowing on both Front positions. Clinical manifestations
Hot flushes, palpitations, insomnia, night-sweating, blurred vision,
dizziness, tinnitus, anxiety, mental restlessness, backache, a malar flush, feeling of heat in the evening, dry mouth and throat, poor memory, dry stools.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), KI-3 Taixi, Ren-4 Guanyuan, SP-6 Sanyinjiao, KI-13 Qixue, HE-6 Yinxi, KI-7
Fuliu, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, Du-24 Shenting. HE-6, HE-8 and P-7 with reducing or even method; all the others with
reinforcing method. Treatment principle
Nourish Kidney-Yin, calm the Mind, clear Empty Heat.
TIAN WANG BU XIN DAN
COMBINATION OF EASE THE JOURNEY – YIN WITH EASE THE JOURNEY – YANG
In complicated situations of deficiency of Kidney-Yin and Kidney-Yang with confusing Hot and Cold symptoms, a combination of Ease the
Journey – Yin and Ease the Journey –Yang works well.
I generally combine these two only in deficiency of Kidney-Yang, i.e. when the deficiency of Kidney-Yang is primary but the symptoms of Empty Heat are very pronounced. In such a case, I follow this protocol:
EASE THE JOURNEY – YANG: 3-4 tablets in the morning
MENOPAUSAL REMEDIES
• EASE THE JOURNEY – YANG
(Tonify Kidney-Yang, nourish Kidney-Yin, clear Empty Heat)
• EASE THE JOURNEY – YIN
(Nourish Kidney-Yin, tonify Kidney-Yang, clear Empty Heat)
• FEMALE TREASURE
(Nourish Liver- and Kidney-Yin, subdue Liver-Yang)
• HEAVENLY EMPRESS
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