CHAPTER 14 Painful Periods
The Liver, Penetrating Vessel and Directing Vessel are responsible for the physiology of menstruation. For a normal period to occur, Blood must be abundant and move adequately. Proper movement of Blood relies on the free flow of Liver-Qi and of the Qi of the Penetrating Vessel.
As we have seen in Chapter 2 on physiology, four different phases may be identified in each menstrual cycle. During the pre-menstrual phase, Yang rises and Liver-Qi moves in preparation for moving Blood during the period. Thus, a proper movement of Liver-Qi and Liver-Blood is essential for a pain-free period. If Liver-Qi stagnates, it may cause pain, especially before the period, while if Liver-Blood stagnates, it causes pain during the period. Stagnation is therefore the most important pathological condition causing painful periods: even in deficiency conditions when the pain is mild, it is some element of stagnation that causes it.
The earliest mention of Painful Periods is probably in the Synopsis of Prescriptions of the Golden Cabinet which says: “If a woman has irregular periods with abdominal pain and fullness, and the periods are irregular, use Tu Gua Gen Powder”.1
Another passage in the same book appears to describe an episode of severe dysmenorrhoea from Cold:
When Cold invades the Lower Burner the menses may become scanty and painful with a dragging pain in the vagina and a feeling of cold in the abdomen … there is an acute pain on Qichong [ST-30] … there may be sudden vertigo and the woman may pass out … this is a gynaecological problem and is not due to an attack of evil spirits …2
Aetiology
Emotional strain
Emotional strain is a very important aetiological factor in painful periods. Anger, frustration, resentment, worry and guilt all may lead to Liver-Qi stagnation. In women, Liver-Qi stagnation causes Blood to stagnate in the Uterus leading to painful periods. In some cases, stagnant Liver-Qi may turn into Liver-Fire and this, in turn, may lead to Blood-Heat. Blood-Heat often combines with Damp-Heat in the Uterus.
External Cold and Dampness
Excessive exposure to Cold and Dampness, especially during the puberty years, may cause Cold to invade the Uterus. Cold contracts and causes stasis of Blood in the Uterus and therefore painful periods. In cold and damp countries where young girls dressed in shorts play school sports and games, this is a very common cause of painful periods. During puberty, the body is in a vulnerable state because it is undergoing profound changes, and it is therefore very likely to be affected by pathogenic factors. Invasion of Cold in the Uterus is the most common cause of painful periods in adolescent girls.
Women are also prone to invasion of Cold in the Uterus during and soon after the period when the Uterus and Blood are in a relatively weakened state. At this time, therefore, they should take particular care not to be exposed to cold and dampness. Fu Qing Zhu says:
Overwork, chronic illness
Physical overwork or a chronic illness leads to deficiency of Qi and Blood, especially of Stomach and Spleen. Deficiency of Blood leads to malnourishment of the Penetrating and Directing Vessels so that the Blood has no force to move properly thus causing stagnation and pain.
Excessive sexual activity, childbirth
The Liver and Kidneys are weakened by excessive sexual activity (which affects women somewhat less than men), too many childbirths too close together, and sexual activity starting too early. A deficiency of Liver and Kidneys induces Emptiness of the Penetrating and Directing Vessels so that they cannot move Qi and Blood properly, thus causing painful periods.
Pathology
Thus, stagnation of Qi and/or Blood, which may arise by itself or be caused by Cold in the Uterus, is the most important factor in painful periods. Even deficiency types of painful periods, caused by Blood or Liver/Kidney deficiency, involve an element of stagnation as the deficient Blood fails to move properly.
The main patterns causing Painful Periods are therefore:
Stagnation of Qi and stasis of Blood are very common patterns occurring in Painful Periods. They very often accompany other patterns. For example, a deficiency of Qi and Blood may occur in combination with some stagnation of Qi and/or Blood. Similarly, Cold obstructing the Uterus obviously leads to stasis of Blood. In gynecology, stagnation of Qi and of Blood is always related to the Liver and the Penetrating Vessel.
A free-flowing Liver-Qi is essential to move Blood before and during the period; if Liver-Qi stagnates, Blood does not move properly and pain results. The Penetrating Vessel is also usually involved in painful periods from stagnation as it is the Sea of Blood and it flows through the Uterus: for this reason, stasis of Blood in the Uterus is often due to stagnation in this vessel. Of all the extraordinary vessels, the Penetrating Vessel is the most important one in the pathology of Painful Periods.
When the periods are painful from stagnation of Qi, the pain is accompanied by a pronounced feeling of distension of the abdomen, typically occurring especially before the periods. Other symptoms may include pre-menstrual tension, irritability, depression and a Wiry pulse. Many books list a Purple tongue as a sign of Qi stagnation: I tend to disagree as the tongue-body colour reflects more the state of Blood than Qi so that, if it is Purple, I relate that to Blood rather than Qi stagnation. In Qi stagnation, the tongue-body colour may be normal, except in severe and longstanding cases when it may be Red on the sides.
Stagnation of Liver-Qi is often secondary to or accompanied by Liver-Blood stasis (as discussed at length in Chapter 3 on pathology): when this is the case, the pulse may not be Wiry at all but Fine or Choppy (and perhaps slightly Wiry on one side) and the tongue may be Pale (from Blood deficiency).
Stagnation of Cold is a common cause of Painful Periods especially in young girls living in cold and damp countries. With stagnation of Cold, there is always stasis of Blood as Cold obstructs the Uterus and the vessels preventing a proper flow of blood. It is for this reason that with Cold, too, there are clots in the menstrual blood: however, if Cold is the cause, the menstrual blood is typically red and the clots are dark and rather small or stringy, whereas if stasis of Blood is the cause, the blood itself is dark and the clots are rather large. The pain from stagnation of Cold is very intense and cramping in character and typically alleviated by the application of heat.
Blood-Heat does not usually cause intense menstrual pain; often associated with Damp-Heat (for this reason these two pathogenic factors will be discussed together), it tends to make the periods heavy. Other symptoms include a feeling of heat, thirst, a Red tongue and a Rapid pulse. If Damp-Heat is present, there will also be a feeling of heaviness, an excessive vaginal discharge, a bearing-down sensation, a sticky-yellow coating on the tongue and a Slippery pulse.
Deficiency of Qi and Blood and Liver and Kidneys usually causes only mild menstrual pain. The latter pattern is seen more in older women. As mentioned before, even in Empty conditions there is some element of stagnation as deficient Qi and Blood fail to move Blood properly and this leads to some stagnation. In fact, Zhang Jing Yue in the Complete Works of Jing Yue (1624) says:
Diagnosis
Time of onset
Pain before and during the period is usually of the Full type, while pain after the period is of the Empty type.
Pressure
If the pain is made worse by pressure, it indicates Fullness, while if the patient gets relief from pressing the lower abdomen, it indicates Emptiness. Patients are not sure how to answer this question if it is not asked in a sensible way. Thus, instead of enquiring whether the “pain is better with pressure or not”, we should ask the patient whether she perhaps likes to hold her abdomen or whether she dislikes to be touched on the abdomen at that time. Women often find that a hot-water bottle on the abdomen relieves the pain, but sometimes they like the pressure rather than the heat of the bottle.
Heat-Cold
If the pain is relieved by the application of heat (such as a hot-water bottle), it indicates either a Cold condition or stasis of Blood from Cold. It should be kept in mind, however, that this sign is not always indicative of Cold, as other conditions, such as stagnation of Qi or Blood, may also be alleviated by the application of a hot-water bottle. Furthermore, a sensation of heat is often comforting in itself without really indicating that the pain is due to Cold. If the pain is aggravated by heat, it indicates Blood-Heat.
Cycle
If the cycle is long (i.e. the periods come consistently late) and the menstrual blood is dark and clotted, it indicates stasis of Blood. If the menstrual blood is red with small dark clots, it indicates Cold in the Uterus.
If the cycle is short, the period heavy and the blood bright red, it indicates Blood-Heat.
Treatment principles
From the point of view of Manifestation (Biao) the central pathology of Painful Periods is a disharmony of the Penetrating Vessel and Sea of Blood. Hence the main principle of treatment for the Manifestation is to regulate the Qi and Blood of the Penetrating Vessel. As discussed in Chapter 3 on pathology, the Penetrating Vessel is the Sea of Blood. It arises from the Uterus and is therefore always involved in Painful Periods. This vessel is particularly prone to stagnation of Qi and Blood in the abdomen and many of its points (especially KI-14 Siman) eliminate stagnation. The Qi of the Penetrating Vessel is prone to rebel upwards from the abdomen towards the chest giving rise to a feeling of oppression of the chest.
Other points related to the Penetrating Vessel in treating painful periods are LIV-3 Taichong, ST-42 Chongyang and ST-30 Qichong. LIV-3 Taichong is the most important one to affect the Penetrating Vessel: by moving Liver-Qi, it regulates the Penetrating Vessel, subdues its rebellious Qi and invigorates Blood. The association between this point and the Penetrating Vessel is so close that sometimes the old classics call this vessel Taichong. In fact, the very first chapter of the Simple Questions, in describing the 7-year cycles of women, says: “At 14, the Heavenly Gui arrives [i.e. the menses], the Directing Vessel is open and the Taichong vessel is flourishing.”5 The ‘Taichong vessel’ is the Penetrating Vessel. ST-42 Chongyang also regulates Blood within the Penetrating Vessel and eliminates stasis due to the relationship between this vessel and the Bright Yang. ST-30 Qichong is one of the most important points on the Penetrating Vessel and strongly moves Qi and Blood in the abdomen. Its other name, Qijie, means ‘avenues of Qi’, referring to the channels and vessels of the abdomen which the Penetrating Vessel influences.
The most important differentiation is that between Full and Empty types of painful periods. Full types are much more common than Empty, and clinically are more important as they are characterized by more intense pain. Moreover, even in Empty types of painful periods there is an element of stasis of Blood as deficient Blood fails to move properly. For this reason, even for Empty types of painful periods, some Blood-moving herbs are added to the prescription used.
The treatment principle is often changed according to the time of the menstrual cycle. During the period one concentrates on treating the Manifestation, i.e. invigorate Blood and stop pain. At other points in the cycle one treats the Root, i.e. according to the main pattern. A deficiency, in particular, is best treated during the 2 weeks, or thereabouts, that follow the period.
Identification of patterns and treatment
Full conditions
Stagnation of Qi
Clinical manifestations
Lower abdominal pain during the period, or 1 to 2 days before the period, a pronounced feeling of distension of the abdomen and breasts, hesitant start to the period, menstrual blood dark without clots, pre-menstrual tension and irritability. Tongue: Normal coloured or slightly Red on the sides. If there is deficiency of Blood, the tongue may be Pale. Pulse: Wiry. The pulse may be Choppy if Liver-Blood deficiency predominates.
Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, SP-14 Fujie. Reducing or even method.
Herbal treatment
Women’s Treasure remedy
This remedy is a variation of the formula Xiao Yao San Free and Easy Wanderer Powder which pacifies the Liver, moves Qi, eliminates stagnation, nourishes Liver-Blood and tonifies Spleen-Qi. The formula has been adapted with the addition of herbs that move Qi and stop pain. The tongue presentation appropriate to this remedy is a normal-coloured body or slightly Pale on the sides; if the stagnation of Qi is severe, it could be slightly Red on the sides.
Stagnation of Qi
Lower abdominal pain during the period, or 1 to 2 days before the period, a pronounced feeling of distension of the abdomen and breasts, hesitant start to the period, menstrual blood dark without clots, pre-menstrual tension and irritability. Tongue: Normal coloured or slightly Red on the sides. If there is deficiency of Blood, the tongue may be Pale. Pulse: Wiry. The pulse may be Choppy if Liver-Blood deficiency predominates.
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, SP-14 Fujie. Reducing or even method.
A 32-year-old woman had been suffering from painful periods for 2 years. The pain occurred during the period in the hypogastrium, lateral abdomen and sacrum. It was dull in character and associated with a bearing-down sensation. Her periods were regular and the menstrual blood was slightly dark with a few clots. She also suffered from pre-menstrual tension with a pronounced distension of breast and abdomen and irritability. She had been on the contraceptive pill for 10 years and the periods became painful when she stopped taking it. She had been given a progesterone pill but this had not helped the dysmenorrhoea at all. Apart from the menstrual problems, she also suffered from the so-called irritable bowel syndrome causing her a spastic pain in the abdomen and alternation of constipation and diarrhoea: she had had this problem for 10 years. On interrogation, it transpired that her vision was sometimes blurred, she was occasionally dizzy and experienced tingling of the limbs. Her tongue was slightly orangey on the sides, and her pulse was Fine on the right side and Fine but also slightly Wiry on the left.
Diagnosis
This is a very clear example of stagnation of Liver-Qi associated with (or caused by) Liver-Blood deficiency. The symptoms of Liver-Qi stagnation are very obvious: pre-menstrual tension with distension and irritability, painful periods, Wiry pulse on the left, abdominal pain with constipation and diarrhoea. The symptoms of Liver-Blood deficiency are also equally clear: the dull character of the menstrual pain, the blurred vision, the tingling and dizziness, the orangey colour of the sides of the tongue and the Fine pulse. I am inclined to think that, in this case, stagnation of Liver-Qi derived from Liver-Blood deficiency and this was, in turn, probably caused by the contraceptive pill.
Treatment principle
This patient was treated with acupuncture and herbal remedies. The acupuncture points used were selected from the following:
An example of a point combination in one treatment would be: LU-7 (on the right) and KI-6 (on the left), L.I.-4 on the left, LIV-3 on the right, Ren-4, ST-36 and SP-6 bilaterally; the last three points with reinforcing method, the others with even method.
The herbal remedies used were the Three Treasures’s Brighten the Eyes to nourish Liver-Blood and Freeing the Moon to pacify the Liver and eliminate stagnation. The latter remedy (a variation of Xiao Yao San Free and Easy Wanderer Powder) also nourishes Liver-Blood, and, in addition, pacifies Liver-Qi and tonifies Spleen-Qi. The patient took Brighten the Eyes for 2 weeks after the period and Freeing the Moon from then until the beginning of the next period.
This patient reacted exceedingly well to the treatment, improving even after the first session. After only three acupuncture sessions (over a period of 1 month) and use of the remedies, she reported experiencing no menstrual pain with her last period and no abdominal bowel pain, and feeling very much better in herself. Such a quick reaction is rather unusual as it normally takes at least 3 monthly cycles to affect a menstrual irregularity.
Stasis of Blood
Clinical manifestations
Intense, stabbing pain before or during the period, dark menstrual blood with large clots, mental restlessness, pain relieved after passing clots. Tongue: Purple. Pulse: Wiry.
Acupuncture
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, BL-17 Geshu, KI-14 Siman, ST-25 Tianshu. All with reducing or even method.
Explanation
Herbal treatment
c Prescription
d Prescription
e Prescription
Explanation
Women’s Treasure remedy
This remedy is a variation of Ge Xia Zhu Yu Tang and it invigorates Blood in the Uterus and Lower Burner. The tongue presentation appropriate to this remedy is a Purple body.
Stasis of Blood
Intense, stabbing pain before or during the period, dark menstrual blood with large clots, mental restlessness, pain relieved after passing clots. Tongue: Purple. Pulse: Wiry.
LIV-3 Taichong, Ren-6 Qihai, G.B.-34 Yanglingquan, SP-8 Diji, ST-29 Guilai, SP-10 Xuehai, SP-6 Sanyinjiao, SP-4 Gongsun and P-6 Neiguan, BL-17 Geshu, KI-14 Siman, ST-25 Tianshu. All with reducing or even method.
A 29-year-old woman had been suffering from painful periods ever since the menarche. The pain occurred during the period and the menstrual blood was dark with some clots. The period started hesitantly and there was not much distension. The pain was alleviated by the application of a hot-water bottle.
She also suffered from thrush with itching of the vagina and a white, sticky discharge. She felt generally tired and her stools were loose. She had a lower backache, her memory was poor and she felt always cold. Her tongue was Pale and her pulse was Weak on the Liver and right Kidney positions and slightly Slow (68).
Diagnosis
My diagnosis was painful periods from mild stasis of Blood occurring against a background of Liver and Kidney deficiency (the tiredness, cold feeling, backache, poor memory and tongue and pulse all pointed to the latter). Besides this, she also suffered from Spleen deficiency (loose stools) and Dampness in the Lower Burner (vaginal itching and discharge).
Treatment principle
This case is given here as an example of adopting the wrong principle of treatment. As I came to the conclusion that the main aspect of the condition was a deficiency (of Liver, Kidneys and Spleen) with only a mild and secondary excess (stasis of Blood and Dampness in the Lower Burner), I adopted the principle of tonifying and warming the Kidneys and nourishing the Liver.
Explanation
The first eight herbs constitute a variation of You Gui Wan to tonify and warm the Kidneys and nourish the Liver.
After 10 packets of this decoction, she was no better at all. I therefore reassessed the diagnosis and principle of treatment and came to the conclusion that, although there was a pronounced deficiency, it would be better to eliminate pathogenic factors first. I did this by giving her first 10 packets of a decoction to resolve Dampness, and then 10 packets of a further decoction to invigorate Blood and eliminate stasis. The first decoction was a variation of Si Miao San Four Wonderful Powder:
Explanation
The first four herbs represent the Si Miao San.
She improved considerably after this decoction which was then followed by a variation of Ge Xia Zhu Yu Tang Eliminating Stasis below the Diaphragm Decoction to invigorate Blood and eliminate stasis:
This is a variation of Ge Xia Zhu Yu Tang with the addition of Bai Zhu to tonify the Spleen and Tu Si Zi to tonify the Kidneys and the removal of Mu Dan Pi Cortex Moutan, too cooling for her condition.
After 20 packets of this decoction, she was much better and her periods were painless. Even though neither of the above two formulae is tonifying, she had more energy. After 20 packets of this last decoction, the treatment principle reverted to the original one of tonifying Kidneys and Liver with You Gui Wan. This time, she felt well on it.
This case history is given to illustrate the importance of adopting a correct principle of treatment: even if the diagnosis is correct, adoption of the wrong principle of treatment will not yield results. This case also shows the importance, in mixed excess and deficiency conditions, of eliminating pathogenic factors before tonifying: this approach is particularly important when herbs are used, less so if only acupuncture is used.
Stagnation of Cold
Clinical manifestations
Lower abdominal pain before or after the period, pain central, pain relieved by the application of heat, menstrual blood rather scanty and bright red with small, dark clots, feeling cold, sore back. Tongue: Pale-Bluish or Bluish-Purple. Pulse: Deep and Choppy or Deep and Wiry.
Acupuncture
LU-7 Lieque (on the right) and KI-6 Zhaohai (on the left), Ren-4 Guanyuan, Ren-6 Qihai, ST-29 Guilai, KI-14 Siman, SP-8 Diji, SP-6 Sanyinjiao, ST-36 Zusanli, ST-28 Shuidao. Reducing method except on ST-36 which should be reinforced. Moxa must be used.
Herbal treatment
Empty-Cold
a Prescription
This is a famous formula from the Synopsis of Prescriptions from the Golden Cabinet by Zhang Zhong Jing (AD 220), which is primarily for Cold obstructing the Uterus. The rationale behind it is as follows. When Cold obstructs the Uterus, it makes Blood stagnate. When Blood stagnates, new Blood has nowhere to go and it cannot be contained in the Uterus: this induces a deficiency of Blood. A longstanding Blood deficiency may give rise to some Empty-Heat signs, which may mistakenly be interpreted as Heat signs; but the Pale-Purple colour of the tongue clearly indicates that this is not so. In fact, the original text refers to a parched mouth and lips as the symptoms of Empty-Heat from Blood deficiency.10 When used for its proper pattern of longstanding internal Cold occurring against a background of deficiency and leading to stasis of Blood, this formula is very effective. An essential sign for its use is that the tongue-body colour be Pale or Bluish-Purple.
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