Diagnosis

CHAPTER 5 Diagnosis

Diagnosis in gynecology naturally follows the same basic principles as in other diseases and is articulated in the four methods of interrogation (‘asking’), palpation (‘touching’), observation (‘looking’) and auscultation (‘hearing and smelling’).

These diagnostic methods are aimed at identifying both the Chinese disease-symptom (bian bing) and the pattern (bian zheng). Chinese disease-symptoms of course differ from the Western concept of ‘disease’ and there is no direct correspondence between the two. In a Western sense, Chinese disease-symptoms are obviously not ‘diseases’. For example, ‘Painful Periods’ (Tong Jing) is a ‘disease’ category in Chinese gynecology but in Western medicine is a symptom, not a disease. The Western diseases which might cause this symptom are, for example, endometriosis, pelvic inflammatory disease or myoma.

However, to diagnose a condition correctly and to find the appropriate strategy and method of treatment, it is essential to identify the Chinese disease-symptom first: this procedure is called bian bing, which literally means ‘differentiating the disease’. This should be done before identifying the pattern (bian zheng) because, even if this is diagnosed correctly, the treatment will not be focused if the disease is not identified too. For example, a case of abnormal uterine bleeding could fall into any of the following categories of Chinese disease-symptoms: ‘Early Periods’ (Yue Jing Xian Qi), ‘Late Periods’ (Yue Jing Hou Qi), ‘Irregular Periods’ (Yue Jing Xian Hou Wu Ding Qi), ‘Heavy Periods’ (Yue Jing Guo Duo), ‘Scanty Periods’ (Yue Jing Guo Shao), ‘Prolonged Periods’ (Jing Qi Yan Chang), ‘Bleeding between Periods’ (Jing Jian Qi Chu Xue), or ‘Menorrhagia/Metrorrhagia’ (Beng Lou).

Each of these Chinese disease categories has its own peculiar aetiology, pathogenesis and therefore treatment method, and simply to identify the pattern in order to treat them would not suffice. For example, Blood-Heat is a pattern that might cause ‘Early Periods’, ‘Heavy Periods’, ‘Prolonged Periods’, ‘Bleeding between Periods’ or ‘Menorrhagia’, but the formula used to treat Blood-Heat would be different in each disease category. Thus, if one were to ask how to treat ‘endometriosis’, the answer would be that by identifying the Chinese ‘disease’ accurately (bian bing) and diagnosing the pattern correctly (bian zheng), one arrives at the appropriate treatment method.

Thus, for each Chinese ‘disease’ there are several patterns. For example, the disease of ‘Painful Periods’ may manifest with several patterns such as Liver-Qi stagnation, Liver-Blood stasis, Cold in the Uterus, Damp-Heat in the Uterus (Fig. 5.1). On the other hand, each pattern may be found in many different diseases and the important point is that, although the pattern is the same, its treatment will differ somewhat according to the disease with which it is manifesting. For example, the pattern of Liver-Blood stasis may be found in many different gynecological diseases such as ‘Heavy Periods’, ‘Flooding and Trickling’, ‘Painful Periods’, ‘Bleeding between Periods’, ‘Abdominal Masses’, etc. and its treatment will differ in each case (Fig. 5.2).

Figure 5.1 Identification of disease and identification of pattern: one disease, many patterns.

Figure 5.2 Identification of disease and identification of pattern: one pattern, many diseases.

However, there is a very important caveat here. Although I have just said that identification of the (Chinese) disease and pattern is sufficient to treat any gynecological condition, this does not mean that we can ignore the Western diagnosis. This is extremely important for prognosis. For example, dysmenorrhoea due to endometriosis is definitely more difficult to treat than purely functional dysmenorrhoea. Another obvious example would be that of uterine bleeding after the menopause: since this may be a sign of cervical cancer it would be totally wrong simply to treat it as menorrhagia without recourse to a proper Western diagnosis. Yet another example is that of a breast lump: we would definitely need to know whether it is benign or malignant. A Western diagnosis is also extremely important to identify cases which Chinese medicine cannot cure. For example, if heavy menstrual bleeding is due to a large myoma, it is unlikely that Chinese medicine can provide a lasting cure for this condition (even though it might help to a certain extent).

The discussion of diagnosis in gynecology will be carried out according to the following topics:

• Interrogation.

• Observation.

• Auscultation.

Interrogation

The main areas of questioning are:

• menstruation

• vaginal discharge

• fertility, pregnancy and childbirth

• miscarriage, abortion.

Menstruation

Asking about menstruation is of course an absolutely essential part of diagnosis. One should ask a female patient about the menarche, cycle, amount, colour, consistency, pain, pre-menstrual symptoms, and other symptoms occurring at period time. When describing the areas of questioning with regard to menstruation, I am assuming the woman is not on the contraceptive pill or other forms of hormones and has not been fitted with an intra-uterine device (IUD). Obviously, the answers to questions are unreliable if the woman is on the contraceptive pill or has an IUD. The contraceptive pill changes the cycle, amount, colour, consistency and pain of the period: it usually makes the cycle regular, the period scanty, the colour lighter, the consistency usually without clots and the period painless. The IUD makes the periods heavier and more painful. In such cases, it is important to ask the patient what her menstrual cycle was like before she began using the contraceptive pill or IUD.

Menarche

The age of menarche ranges between 10 and 16 with a mean at 12.8. Menarche tends to occur at a younger age in industrialized countries compared with developing, agricultural societies. Early menarche (i.e. before about 13) may indicate Blood-Heat while late menarche (after about 16) may indicate Blood and/or Kidney deficiency.

Why do we need to ask about the menarche and how the periods were then? It might be argued that it does not matter how the periods were then because we must always treat a woman for the condition as it is at the time of treatment, not years earlier. However, it is important to ask about the menarche and how the periods were then. First of all, when forming an opinion about the menstrual history at the time of menarche, we should always ask how the periods were about 2 years after menarche. This is because it takes about that time for the periods to settle down into some kind of regular cycle (if there is one). The reason it is important to ask about the menstrual history around the time of menarche is to form an idea about the menstrual constitution of a woman. This is also important when there are deviations from this constitution. For example, if a woman’s periods always lasted 5 days, then that means that 5 days is her menstrual constitution which has not changed over the years. But say we see a 40-year-old woman coming to us for infertility and she tells us that her periods now last 5 days. Five days is not abnormal and indeed it suggests normality. However, if her periods lasted 7 days when she was young about 2 years after the menarche and continued to last 7 days until she was about 32, this suggests that her menstrual constitution is 7 days and she is now deviating from this constitution. This indicates that she suffers from a slight Blood deficiency (because the periods have gone from lasting 7 days to lasting 5 days). By contrast, if a woman’s periods had always lasted 5 days, then we could not diagnose that she suffers from Blood deficiency.

Cycle

The length of the cycle is ideally 28 days but it may vary from this norm but this should not be interpreted too rigidly. The regularity of the cycle is somewhat more important than its absolute value; thus, if the cycle is consistently of 32 days, this can be deemed normal and would not be considered as ‘late periods’. Moreover, an occasional deviation from a regular cycle should not be considered abnormal as the menstrual cycle is influenced by many factors such as travelling, emotional stress, etc. The following are the main areas of questioning with regard to the cycle:

• Always early (i.e. more than 5 days early): either Qi deficiency or Blood-Heat.

• Always late (i.e. more than 5 days late): Blood deficiency, stasis of Blood or stasis of Cold.

• Irregular (sometimes late, sometimes early): stagnation of Liver-Qi, stasis of Liver-Blood, Spleen deficiency or Kidney deficiency.

It should be borne in mind that for approximately the first 2 years from menarche, the menstrual cycle may be somewhat irregular: this is quite normal. To have an idea as to how the periods were in the beginning, I therefore always ask how they were about 2 years after menarche. The Golden Mirror of Medicine says: “When periods come early, it is due to Heat, when late, it is due to Blood stasis.”¹

Colour

The colour of the menstrual blood varies slightly during the period. In general, it is usually dark-red, being lighter at the beginning, deep-red in the middle, and pinkish at the end of the period. The following are the main areas of questioning with regard to colour:

• Dark-red or bright-red: Blood-Heat.

• Pale: Blood deficiency.

• Blackish, very dark: stasis of Blood.

• Purplish: Full-Cold.

• Brownish like soya bean sauce and dilute: Empty-Cold.

• Scarlet-red: Empty-Heat in Blood.

The Golden Mirror of Medicine says:

When the colour [of menstrual blood] is pale and amount scanty, it is due to Deficiency, the period is not usually painful; if the colour is dark and the amount heavy and there is pain, it is due to Fullness.²

Pain

Apart from a slight discomfort, normally the period should be almost painless. The main areas of questioning with regard to menstrual pain are as follows:

• Pain before the period: stagnation of Qi or stasis of Blood (the latter is typically relieved by the onset of the period and especially by the passing of dark clots).

• Pain during the period: Blood stasis or Blood-Heat.

• Pain after the period: Blood deficiency.

• Severe, stabbing pain: stasis of Blood.

• Severe, cramping pain, eased by application of heat (such as a hot-water bottle): stasis of Cold.

• Mild pain: either Blood-Heat or deficiency of Blood.

• Dragging feeling in the lower abdomen with mild pain: sinking of Qi.

• Feeling of heaviness in the lower abdomen with pain: Dampness.

• Pain on ovulation: Dampness.

Pre-menstrual symptoms

Pre-menstrual tension with irritability, depression, tendency to crying, etc., indicates Liver-Qi stagnation, especially if accompanied by abdominal or breast distension.

Nausea or vomiting before the period denotes stagnant Liver-Qi invading the Stomach, while pre-menstrual constipation indicates stagnant Liver-Qi invading the Intestines and Spleen.

Headaches before the period indicate Liver-Qi stagnation or Liver-Yang rising. Distension of the breasts denotes Liver-Qi stagnation, but if the breasts become very swollen and painful, it may denote Phlegm (which, in pre-menstrual problems, usually combines with Qi stagnation).

Retention of water with oedema before the period indicates Spleen-Yang and/or Kidney-Yang deficiency.

Pre-menstrual irritability with insomnia and thirst may be due to Liver-Fire and/or Heart-Fire.

Please note that not all pre-menstrual symptoms are due to Liver-Qi stagnation.

Other symptoms

Headaches that occur during the period are usually due to Liver-Yang rising or Liver-Fire blazing, these occurring against a background of Blood-Heat. Headaches occurring after the period indicate Liver-Blood deficiency.

Constipation before the period is due to Liver-Qi stagnation or Cold in the Uterus; during the period, it may be due to Liver-Fire; constipation after the period is due to Blood or Kidney deficiency.

Insomnia during the period indicates Blood-Heat, often with Liver-Fire and/or Heart-Fire. Insomnia after the period denotes Blood deficiency.

Diarrhoea after the period indicates Spleen-Yang and/or Kidney-Yang deficiency.

Pain

Apart from the pain occurring during the period itself, many women suffer from lower abdominal pain in general. From a Western point of view, it is obviously all-important to distinguish whether the pain is of intestinal or gynecological origin. In Chinese medicine, this distinction is somewhat blurred and, strictly speaking, not that important from the point of view of treatment. What matters most is the correct diagnosis and identification of the pattern according to the basic principles of Heat, Cold, Full, Empty, Pathogenic Factors and internal organs. Thus, a woman who complains of painful periods may well suffer from abdominal pain at other times too, the two types of pain having a common root (e.g. Qi stagnation, Blood stasis, Dampness, etc.).

As for the significance of the area of pain, the central area of the lower abdomen below the umbilicus is called xiao fu, i.e. ‘small abdomen’, whereas the lateral sides of the abdomen are called shao fu, i.e. ‘lesser abdomen’ (Fig. 5.3). Pain in the central area of the lower abdomen (the ‘small abdomen’) is usually related to the Kidneys and the Directing Vessel. Pain in the lateral sides of the abdomen (the ‘lesser abdomen’) is usually related to the Liver channel and the Penetrating Vessel.

Figure 5.3 ‘Small abdomen’ and ‘lesser abdomen’.

The following are therefore the main areas of interrogation with regard to abdominal pain:

• Dull ache: deficiency-type pain.

• Severe pain: excess-type pain.

• Pain that is relieved by the application of heat: Cold.

• Pain that is relieved by pressure or massage: deficiency-type pain.

• Pain that is aggravated by pressure or massage: excess-type pain.

• Stabbing pain: stasis of Blood.

• Cramping, spastic pain: Cold.

• Pain with feeling of heaviness: Dampness.

• Ache with a dragging-down feeling: sinking of Qi (of Spleen and/or Kidneys).

• Abdominal pain extending to the back: Kidney deficiency.

• Lower backache extending to the front: Girdle Vessel pathology (usually deficiency).

• Lower abdominal pain radiating to the back: Girdle Vessel pathology (usually excess in the form of Dampness).

• Umbilical pain along a line with backache radiating to thighs: Girdle Vessel pathology.

• Unilateral abdominal pain with distension and feeling of masses: Yin Stepping Vessel (Yin Qiao Mai) pathology, usually stagnation of Qi and/or Blood; although this type of pain is also related to the Liver channel, it will respond well to treatment of the Yin Stepping Vessel.

• Lower abdominal pain with a sense of energy rising towards the chest and a feeling of tightness there: Penetrating Vessel (Chong Mai) pathology (rebellious Qi).

Pain

• Dull ache: deficiency-type pain

• Severe pain: excess-type pain

• Pain that is relieved by the application of heat: Cold

• Pain that is relieved by pressure or massage: deficiency-type pain

• Pain that is aggravated by pressure or massage: excess-type pain

• Stabbing pain: stasis of Blood

• Cramping, spastic pain: Cold

• Pain with feeling of heaviness: Dampness

• Ache with a dragging-down feeling: sinking of Qi (of Spleen and/or Kidneys)

• Abdominal pain extending to the back: Kidney deficiency

• Lower backache extending to the front: Girdle Vessel pathology (usually deficiency)

• Lower abdominal pain radiating to the back: Girdle Vessel pathology (usually excess in the form of Dampness)

• Umbilical pain along a line with backache radiating to thighs: Girdle Vessel pathology

• Unilateral abdominal pain with distension and feeling of masses: Yin Stepping Vessel (Yin Qiao Mai) pathology, usually stagnation of Qi and/or Blood

• Lower abdominal pain with a sense of energy rising towards the chest and a feeling of tightness there: Penetrating Vessel (Chong Mai) pathology (rebellious Qi)

Fertility and pregnancy

Infertility can be due to many different deficient or excess conditions. Deficient ones are Blood deficiency or Kidney deficiency. Full ones are stasis of Blood, stasis of Cold or Damp-Phlegm.

Vomiting during pregnancy indicates rebellious Qi in the Penetrating Vessel affecting the Stomach channel. This can occur against a background of Stomach deficiency or Stomach-Heat.

Oedema during pregnancy indicates Kidney-Yang deficiency. High blood pressure denotes a Kidney deficiency with Liver-Yang rising or Liver-Wind: this may herald a pre-eclampsia state which is also characterized by headache, dizziness and blurred vision. A full eclampsia state manifests with convulsions which, from a Chinese perspective, indicate the development of Liver-Wind from Liver and Kidney deficiency.

Miscarriage and abortion

It is important to ask about miscarriages and abortion as they weaken a woman’s body. There is a saying in Chinese gynecology that states: “Miscarriage is more serious than childbirth.” It is easy to understand why this should be so: during a miscarriage there is usually a heavy loss of blood; moreover, from a mental–emotional point of view, it means a great loss to the woman with ensuing sadness and grief, which are often underestimated.

Abortion is also weakening but to a lesser degree because there is not the loss of blood that occurs during a spontaneous miscarriage. Therefore, when counting the number of children a woman has had, if she has two children and had two abortions and a miscarriage, that counts as if she had had five children.

Miscarriage before 3 months indicates a Kidney deficiency, while miscarriage after 3 months denotes sinking of Spleen-Qi, Liver-Blood stasis or Blood-Heat.

Tags: Obstetrics and Gynecology in Chinese Medicine

Jun 6, 2016 | Posted by admin in GYNECOLOGY | Comments Off

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