CHAPTER 16 No Periods
Obviously, the temporary interruption of the menses that occurs after childbirth and during breastfeeding is not considered amenorrhoea, nor, similarly, is the stopping of the menses for 1 or 2 months as a consequence of sudden environmental or living condition changes. If a woman presents with secondary amenorrhoea, it is of course very important to exclude pregnancy first of all because, were the patient treated for amenorrhoea, one might prescribe herbs which are contraindicated in pregnancy. I shall call this condition ‘No Periods’ rather than ‘amenorrhoea’.
A basic differentiation must be made between No Periods from a deficiency and No Periods from an excess. No Periods from a deficiency includes Blood deficiency, Spleen and Kidney deficiency, and Liver and Kidney deficiency. It should be further differentiated between that from a pre-natal weakness and that from a post-natal weakness. Obviously primary amenorrhoea is more likely to be due to a deficiency of the Pre-Natal Essence and secondary amenorrhoea to a deficiency of the Post-Natal Qi. No Periods from excess is usually due to stagnation of Qi and/or Blood, Phlegm or Cold.
In the Yellow Emperor’s Classic, No Periods was called “woman having no moon” (i.e. no monthly flow) or “moon affair not coming”, indicating the early connection of menstruation with the moon phases.
Aetiology
Emotional stress
Anger, intended in a broad sense to include frustration, resentment, hatred and irritation, may cause stagnation of Qi which, with time, may lead to stasis of Blood: this causes an excess type of No Periods.
Sadness and grief are very common factors in the development of amenorrhoea. They deplete Qi of the Lungs and Heart: the Lungs govern Qi, the Heart governs Blood, and when Qi cannot make or move Blood and Heart-Blood cannot descend to the Uterus, the menses stop. The Secret Prescriptions for Gynaecological Patterns and Treatment by Ye Tian Shi says:
The Heart governs Blood and the Spleen is the Root of Qi and Blood. Worry and pensiveness injure the Heart making Heart-Qi depleted; this cannot generate Blood, the Spleen is the child of the Heart and [therefore] loses its nourishment, the appetite declines which cuts off the Root of generation and transformation [i.e. the Spleen].1
Excessive physical work or exercise
This weakens the Spleen which fails to make Blood and, when occurring at puberty time, it may also cause stagnation of Qi and Blood in the Lower Burner, thus causing primary amenorrhoea. In this case, the amenorrhoea is due to a deficiency (of Blood) complicated by an excess condition (stagnation of Qi and Blood in the Lower Burner).
Hereditary weakness
A hereditary Kidney weakness can of course cause primary amenorrhoea. In this case, there is a deficiency of Kidney-Essence and usually also of Liver-Blood.
Diet
A diet poor in nourishment leads to depletion of Qi and Blood and therefore secondary amenorrhoea from Blood deficiency and Spleen deficiency. This becomes a cause of disease especially if it occurs at a young age when girls are likely to adopt a slimming diet or a vegetarian diet that fails to substitute for the meat protein a judicious combination of vegetable types of protein. Excessive consumption of dairy foods and greasy foods leads to the formation of Dampness and Phlegm: these can obstruct the Lower Burner and lead to amenorrhoea. These women are often overweight. The Chinese Medicine Gynaecology says: “Amenorrhoea in overweight women is due to Dampness and Phlegm obstructing the Membranes.”3
Overwork
Overwork in the sense of working long hours without adequate rest for many years leads to deficiency of Liver- and Kidney-Yin which, in turn, may cause secondary amenorrhoea.
Contraceptive pill
Very often, when a woman comes off the contraceptive pill after being on it a long time, the periods do not return for a long time. I have seen this happen in practice many times when a woman’s periods may not return for over a year after being on the pill for a number of years.
My experience is that the contraceptive pill causes a Blood deficiency and a Kidney deficiency and those are the reasons why the periods do not return.
Pathology
From a pathology point of view, the main distinction to be made is that between deficiency and excess types of amenorrhoea. The two main deficiency types are Qi and Blood deficiency and Liver and Kidneys deficiency. The two main excess patterns are Qi and Blood stagnation and retention of Dampness and Phlegm. The pathology of these patterns will be discussed briefly.
Liver and Kidney deficiency
Liver and Kidney deficiency involves a deficiency of Kidney-Essence and Liver-Blood, which in turn leads to emptiness of the Penetrating and Directing Vessels. It can be caused by hereditary weakness of the Kidney-Essence, too many childbirths too close together or overwork.
The Kidney-Essence is the origin of menstrual Blood and the Liver stores Blood: a deficiency of these two organs therefore leads to a malnourishment of the Uterus and of the Penetrating and Directing Vessels. The True Transmission of Medical Theory (Yi Xue Zheng Chuan, 1515) says: “The menses are a transformation of Kidney-Water, when this is deficient, menstrual Blood dries up.”4
Qi and Blood deficiency
A deficiency of Qi and Blood stems primarily from a weakness of the Spleen and Stomach which fail to make Blood. A deficiency of Heart-Blood is often also involved as Heart-Blood plays a role in the making of menstrual blood. Apart from this, of course a deficiency of Liver-Blood is a frequent cause of amenorrhoea. The Simple Questions says in Chapter 40:
Dryness of Blood may be caused by a severe loss of blood which occurred at a young age or by entering the bedroom [i.e. having sexual intercourse] in a drunken state. This will exhaust Qi and injure the Liver so that the period does not come.5
A deficiency of the Spleen and Stomach is of course primarily caused by dietary factors such as a diet lacking in nourishment and Blood-producing foods. A deficiency of Heart-Blood can result either from a failure of Spleen and Stomach in making Blood, or from emotional problems. There are, however, several other causes of Stomach and Spleen deficiency such as a long, severe disease, repeated miscarriages and breastfeeding for too long. The Secret Collection of the Orchid Room (Lan Shi Mi Cang, 1271) by Li Dong Yuan (celebrated author of the Discussion on Stomach and Spleen) says: “When in a woman Stomach and Spleen are deficient for a long time, Qi and Blood become depleted and menstruation ceases.”6
Yin deficiency, Blood dried up
A primary deficiency of Liver- and Kidney-Yin, resulting from overwork, a long, chronic disease or too many children too close together, leads to a drying up of Yin and Blood and therefore the cessation of the menses, as the Sea of Blood of the Penetrating Vessel becomes Empty. In such cases, the disease may also pertain to the Chinese category of Exhaustion (Xulao) with amenorrhoea as a secondary symptom.
The Complete Book of Jing Yue (Jing Yue Quan Shu, 1624) says: “When Yin is depleted and Blood dried up … there may be cough with a feeling of heat at night … and amenorrhoea …”.7
Qi stagnation and Blood stasis
Qi stagnation and Blood stasis result from emotional stress such as anger, irritation, frustration, resentment, worry, guilt or anxiety. Although ‘anger’ is always mentioned as the emotion that may lead to stagnation of Liver-Qi, other emotions such as worry, anxiety or even sadness may affect the Liver. Long-term stagnation of Liver-Qi in women easily leads to stasis of Blood: stagnant Blood obstructs the Uterus, the Penetrating Vessel’s Qi cannot flow to produce the menses, hence amenorrhoea results. This is an excess type of amenorrhoea as the period fails to arrive not because the Blood is deficient but because it is stagnant.
Damp-Phlegm obstructing the Uterus
Damp-Phlegm is usually associated with Spleen deficiency and it is caused by the excessive consumption of cold foods (such as iced water or ice-cream), raw foods, dairy foods or greasy foods. Dampness obstructs the Lower Burner and the Uterus so that Blood cannot flow in the Uterus vessel and amenorrhoea develops. Cold is also an important pathogenic factor in the pathogenesis of amenorrhoea: it obstructs the Uterus and this leads to stasis of Blood: obstruction of the Uterus Vessel and Uterus Channel prevents the Blood from flowing and the period from coming.
The Synopsis of Prescriptions of the Golden Cabinet says:
In gynaecological diseases, deficiency, accumulation of Cold and stagnation of Qi cause the cessation of the period which may last for over one year. The Blood becomes cold, the Uterus door is knotted and Cold injures the channels … When Cold is in the Lower Burner, the period is scantier than normal.8
The General Treatise on the Aetiology and Symptomatology of Diseases (AD 610) says:
When the period does not come, it is due to injury of Qi and Blood. When the body is a weakened state, Wind-Cold invades the Uterus and injures the Directing and Penetrating vessels and the Small Intestine and Heart channels; the Uterus Channel is severed and Blood cannot get through. The Directing and Penetrating vessels originate from the Uterus and are the Sea of the Channels. The Small Intestine and Heart channels are exteriorly–interiorly related and govern the downward [infusion] of menstrual Blood. Wind-Cold injures the menstrual Blood. When Blood is warm it flows well, when it is cold it shuts down because Cold causes stagnation. When Blood is knotted inside the period does not come.9
Differentiation from pregnancy
Obviously No Periods should be differentiated from the symptoms and signs of the very early stages of pregnancy: Table 16.1 highlights the main differential points.
Table 16.1 Differential signs of amenorrhoea and early stage of pregnancy
| Amenorrhoea | Early Pregnancy | |
|---|---|---|
| Symptoms and signs | The periods stop after having been irregular for some time; they may also stop suddenly but in this case there is abdominal pain | Normally regular periods stop suddenly, there is nausea, possibly a strange attraction to or dislike of certain foods, desire to lie down |
| Pulse | Deep, Choppy or Fine | Slightly Slippery, relatively strong on the Rear position |
| Gynecological examination | No signs of pregnancy | Uterus feels soft, cystic and round (after 5–6 weeks), enlarged (only after 8 weeks), breasts enlarged with veins appearing on their surface, Montgomery’s tubercles (enlargement of sebaceous glands around the edge of the areolae) |
Identification of patterns and treatment
Empty conditions
Liver and Kidney deficiency
Clinical manifestations
Menses not started by 18, or stopped after becoming scanty, tiredness, lower backache, knee-ache, dizziness, depression, mentally tired, lack of will-power, feeling cold. Tongue: Pale. Pulse: Deep, Weak. This is essentially a deficiency of Kidney-Yang and Liver-Blood not filling the Penetrating and Directing Vessels. This pattern occurs more frequently in young women.
Acupuncture
BL-18 Ganshu, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi, KI-13 Qixue, Xuefu (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method. Moxa is applicable.
Herbal treatment
a Prescription
Explanation
b Prescription
Explanation
This prescription, simpler than the previous one, nourishes Liver-Blood and tonifies Kidney-Yang. Compared with the previous prescription, it tonifies Kidney-Yang more than Liver-Blood.
c Prescription
Explanation
This formula is composed of three separate formulae to be administered for about 1 week each, the idea being that the first is taken for a week before ovulation, the second for a week during ovulation and the third for a week after ovulation. Obviously, since in this case the woman has no periods, these three formulae are to be taken for 3 consecutive weeks followed by a break of 1 week in order to establish a menstrual cycle. The first formula nourishes Kidney-Yin, the second nourishes and invigorates Blood and the third tonifies Kidney-Yang and Blood.
d Prescription
Explanation
This formula is composed of four prescriptions: for the follicular phase, ovulation, the luteal phase and the menstrual phase. For each phase, there are two alternative formulae, one for Kidney-Yang and the other for Kidney-Yin deficiency. As explained in the chapter on Infertility (Ch. 57), the menstrual cycle is a manifestation of the waxing and waning of Kidney-Yin and Kidney-Yang and treatment of this organ is therefore essential to restore the regularity of menstruation. This formula is specific for amenorrhoea due to polycystic ovary syndrome. In the follicular phase, the treatment principle is to tonify the Kidneys; in the ovulation phase, to tonify the Kidneys, nourish and invigorate Blood; in the luteal phase, to tonify the Kidneys and nourish Blood; and during menstruation, to tonify the Kidneys and invigorate Blood. Obviously, in this case the patient has no periods and these formulae are therefore taken for 1 week each consecutively in order to establish a menstrual cycle.
Three Treasures remedy
This remedy tonifies Kidney-Yang and Liver-Blood and is particularly indicated for women.
Liver and Kidney deficiency
Clinical manifestations
Menses not started by 18, or stopped after becoming scanty, tiredness, lower backache, kneeache, dizziness, depression, mentally tired, lack of will-power, feeling cold. Tongue: Pale. Pulse: Deep, Weak.
Acupuncture
BL-18 Ganshu, BL-23 Shenshu, BL-52 Zhishi, Ren-4 Guanyuan, LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), LIV-8 Ququan, SP-6 Sanyinjiao, ST-36 Zusanli, KI-3 Taixi, KI-13 Qixue, Xuefu (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All with reinforcing method. Moxa is applicable.
Blood deficiency
Clinical manifestations
Menstruation stops after several months of decreasing periods, dizziness, blurred vision, numbness and tingling, poor memory, insomnia, palpitations, slight anxiety, depression, dull, pale complexion, dry skin, dry hair, falling hair, dry eyes, tiredness. Tongue: Pale-Thin (unless there is also Spleen-Qi deficiency and Dampness in which case it would be Swollen). Pulse: Choppy or Fine.
Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu, Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All points with reinforcing method; direct moxa on BL-17 and BL-18. Moxa can be used on other points too unless there are symptoms of Empty-Heat from Blood deficiency.
Herbal treatment
a Prescription
b Prescription
Explanation
This formula is indicated if Blood deficiency occurs against a background of Yang deficiency and the tongue is Pale and Swollen.
Modifications
These modifications apply to both the above prescriptions.
c Prescription
Women’s Treasure remedy
This remedy is a variation of the formula Ba Zhen Tang Eight Precious Decoction which nourishes Blood and tonifies Qi. The tongue presentation appropriate to this remedy is a Pale and Thin body.
Blood deficiency
Clinical manifestations
Menstruation stops after several months of decreasing periods, dizziness, blurred vision, numbness and tingling, poor memory, insomnia, palpitations, slight anxiety, depression, dull, pale complexion, dry skin, dry hair, falling hair, dry eyes, tiredness. Tongue: Pale-Thin (unless there is also Spleen-Qi deficiency and Dampness in which case it would be Swollen). Pulse: Choppy or Fine.
Acupuncture
LIV-8 Ququan, ST-36 Zusanli, SP-6 Sanyinjiao, KI-3 Taixi, Ren-4 Guanyuan, BL-17 Geshu, BL-18 Ganshu, Zigong (extra point), Ren-17 Shanzhong, Ren-6 Qihai. All points with reinforcing method; direct moxa on BL-17 and BL-18. Moxa can be used on other points too unless there are symptoms of Empty-Heat from Blood Xu.
An 18-year-old girl had been on the contraceptive pill for 18 months starting when she was 16. She took this not for contraceptive reasons but as a cure for painful periods. She sought treatment when she had had no period for about a year. She had also contracted glandular fever (mononucleosis) when she was 13 and never completely recovered from it, suffering from chronic post-viral fatigue syndrome. When I saw her she complained of exhaustion, poor memory, mental confusion, depression, muscle-ache, headaches on the vertex, a feeling of oppression of the chest, insomnia and poor appetite. She spoke in a very soft, weak voice and her complexion was pale. Her tongue was Pale, without coating and cracked. Her pulse was Choppy.
Diagnosis
Her main condition was Blood deficiency as evidenced by the pale complexion, exhaustion, poor memory, mental confusion, depression, headaches on the vertex, insomnia, Pale tongue and Choppy pulse. As often happens, this condition was triggered off after stopping the contraceptive pill. Her tongue showed that the Blood deficiency was beginning to turn into Yin deficiency, for it was without coating and cracked. Apart from this, there was also some Dampness, a residual pathogenic factor from the attack of glandular fever when she was 13. The symptoms of this are muscle-ache and a feeling of oppression of the chest.
Explanation
The first six herbs are a variation of Ba Zhen Tang to tonify Qi and Blood.
After 6 months of treatment along these lines, her periods started to come every 7–8 weeks, and after a further 6 months, they were coming every 5 weeks.
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