CHAPTER 18 Pre-Menstrual Syndrome

The term Pre-Menstrual Syndrome (PMS) broadly describes emotional and physical symptoms occurring before a period. These may include depression, sadness, irritability, anxiety, lethargy, loss of concentration, aggressiveness, changes in libido, changes in bowel habit, skin eruptions, food cravings, crying, propensity to outbursts of anger, clumsiness, distension of abdomen and breasts, and insomnia. These symptoms can vary in intensity from very mild to extremely serious; a woman suffering severe Pre-Menstrual Syndrome may actually injure a member of her family or some other person. The symptoms vary in duration as well as in intensity, ranging from 1 day to 2 weeks before the period. Rarely, these symptoms may be experienced after the period. Pre-Menstrual Syndrome is more common in the 30–40 age group.

Aetiology

Pathology

In order to understand the pathology of Pre-Menstrual Syndrome, we must recall the physiology and pathology of phase 4 (i.e. the pre-menstrual phase). During phase 4, Liver-Qi moves in preparation for the period and Yang rises to reach a maximum just before the onset of the period. This means that excess of Yang may also give rise to pre-menstrual symptoms and so can deficiency of Yang.

As for the organs involved, the Liver is not the only organ causing pre-menstrual symptoms. Other organs may be involved and especially the Lungs, Heart, Spleen and Kidneys. For example, pre-menstrual symptoms may be due to Heat in the Heart or Lungs, or to Lung-Qi stagnation. Deficiency of Yang of the Spleen and Kidneys may also cause pre-menstrual symptoms.

In my opinion, Liver-Qi stagnation is grossly overemphasized as a cause of pre-menstrual symptoms and, as a consequence, Xiao Yao San Free and Easy Wanderer Powder is overused.

To summarize, the following are the main pathological conditions causing Pre-Menstrual Syndrome together with the clinical manifestations:

• Liver-Qi stagnation: breast and abdominal distension, irritability, depression.

• Lung-Qi stagnation: breast distension, sighing, crying.

• Liver-Heat: irritability, anxiety, depression, propensity to outbursts of anger.

• Heart-Heat: irritability, anxiety, insomnia.

• Spleen- and Kidney-Yang deficiency: depression, crying, tiredness.

• Phlegm: swelling and discomfort of the breasts.

The most important thing to establish is whether the Pre-Menstrual Syndrome derives from a Full or Empty condition. In case of Liver-Qi stagnation, if it arises independently from emotional problems it is a purely Full condition. In this case, the pulse will be Wiry, either in all positions or only on the left. If it is secondary to a deficiency of Liver-Blood, Liver-Yin or Liver- and Kidney-Yin, the condition is primarily Empty. In such a case, the pulse will be Fine and Weak, at least on one side.

In women, Liver-Qi stagnation often derives from Liver-Blood or Liver-Yin deficiency. In fact, Liver-Qi and Liver-Blood/Yin are the Yang and Yin aspects of the Liver. Liver-Blood and Liver-Yin are the root and the material basis of Liver-Qi. If Liver-Blood/Yin are deficient, Liver-Qi is deprived of its root and stagnates.

Identification of patterns and treatment

Full conditions

Liver-Qi stagnation

Clinical manifestations

Abdominal and breast distension before the period, irritability, clumsiness, moodiness, depression, hypochondrial pain and distension. Tongue: in light cases, the tongue body may be unchanged. In chronic cases, the sides may be Red. Pulse: Wiry all over or only on the left.

Treatment principle

Soothe the Liver, eliminate stagnation, calm the Mind, settle the Ethereal Soul.

Herbal treatment

c Prescription

– CHAI HU SHU GAN TANG

– Bupleurum Pacifying the Liver Decoction

Explanation

This formula, already explained, is selected if the stagnation of Liver-Qi is severe and there is breast and abdominal pain as well as distension. Table 18.1 compares and contrasts the above three formulae for Pre-Menstrual Syndrome from Qi stagnation.

Table 18.1 Comparison of Xiao Yao San, Yue Ju Wan and Chai Hu Shu Gan Tang for Pre-Menstrual Syndrome

Modifications

The following are variations applying to all three previous formulae.

• If the breast distension is very pronounced, add Qing Pi Pericarpium Citri reticulatae viride and Yu Jin Radix Curcumae.

• If abdominal distension is pronounced, add (or increase) Xiang Fu Rhizoma Cyperi.

• If there is mental depression, add He Huan Pi Cortex Albiziae and Yuan Zhi Radix Polygalae.

• If there is irritability and propensity to outbursts of anger, add Suan Zao Ren Semen Ziziphi spinosae.

• If there is irritability, restlessness and insomnia, add Long Chi Fossilia Dentis mastodi and Zhen Zhu Mu Concha Margaritiferae usta.

• If there is insomnia and anxiety from Blood deficiency, add Long Yan Rou Arillus Longan and Bai Zi Ren Semen Platycladi.

• If there is a headache before each period, add Tian Ma Rhizoma Gastrodiae, Gou Teng Ramulus Uncariae cum Uncis and Fang Feng Radix Saposhnikoviae.

• If there is pronounced water retention, add Zhu Ling Polyporus, Yi Yi Ren Semen Coicis, Ze Xie Rhizoma Alismatis and Gui Zhi Ramulus Cinnamomi.

• If stagnant Liver-Qi has given rise to Heat, add Shan Zhi Zi Fructus Gardeniae and Mu Dan Pi Cortex Moutan.

• If there is stasis of Blood, add Wang Bu Liu Xing Semen Vaccariae, Yu Jin Radix Curcumae and Dan Shen Radix Salviae miltiorrhizae.

• If the breasts are swollen and hot (or if there is mastitis), add Xia Ku Cao Spica Prunellae and Pu Gong Ying Herba Taraxaci.

• If there are skin eruptions, add Bai Xian Pi Cortex Dictami.

• If the breasts are painful, add Mo Yao Myrrha.

Women’s Treasureremedies

– FREEING THE MOON

This remedy is a variation of Xiao Yao San Free and Easy Wanderer Powder: it nourishes Liver-Blood, pacifies the Liver, moves Qi, calms the Mind and settles the Ethereal Soul. The tongue presentation appropriate to this remedy is either a normal-coloured or a Pale tongue body: it may also be Pale only on the sides. The pulse corresponding to this remedy is Choppy or Fine and slightly Wiry on one side only (typically the left side).

– FREEING CONSTRAINT

This remedy is a variation of the formula Yue Ju Wan Gardenia-Chuanxiong Pill which pacifies the Liver, moves Qi and eliminates stagnation. The tongue presentation appropriate to this remedy is a body with Red sides: the whole body might be Red as well. The pulse appropriate to this remedy is Wiry on all positions. The difference in action and indications between this remedy and Freeing the Moon is the same as that between Yue Ju Wan and Xiao Yao San indicated above.

Case history

A 38-year-old woman had been suffering from pre-menstrual tension for 10 years, starting after the birth of her first child; the problem got worse after the birth of the second child. For 1 week before the periods she experienced irritability, aggressiveness, anger, and abdominal and breast distension. Her cycle was often short, the period lasted 5 days and the menstrual blood was dark red without clots. She often felt hot and frequently had lower backache. Her tongue was slightly Red and her pulse was Weak on the left Rear position and slightly Wiry in general.

Diagnosis

This is a clear case of Liver-Qi stagnation with some Heat, occurring against a background of Kidney deficiency (weak Kidney pulse and backache). The Heat is evident from the slightly Red colour of the tongue body and the feeling of heat.

Treatment principle

The treatment principle adopted was to pacify the Liver, clear Liver-Heat, move Qi, calm the Mind, settle the Ethereal Soul and tonify the Kidneys. She was treated with both acupuncture and herbs.

Explanation

The first eight herbs constitute the formula Dan Zhi Xiao Yao San which clears Liver-Heat deriving from Liver-Qi stagnation.

• Yuan Zhi, Suan Zao and He Huan Pi were added to pacify the Liver, calm the Mind and settle the Ethereal Soul.

• Tu Si Zi was added to tonify the Kidneys.

This patient was treated with variations of this formula for about 5 months after which her pre-menstrual tension disappeared nearly completely.

Case history

A 19-year-old woman had been suffering from pre-menstrual tension ever since her menarche at 14. For about 1 week before the period she felt very irritable and depressed and had severe abdominal and breast distension. During this time she also experienced papular skin eruptions on her face. Her periods were regular, lasted 7 days but were not too heavy. She felt hot in general and thirsty. She also experienced headaches on the temples and her eyes were blood-shot. Her tongue was slightly Red with a redder tip and with many Red points on the sides and tip. Her pulse was very Rapid (100).

Diagnosis

This is another example of Pre-Menstrual Syndrome from stagnant Liver-Qi turning into Heat: in this case, the Heat symptoms and signs are more pronounced as the tongue shows clearly. Also, the Heat has affected the Heart as well as the Liver (the Red tip of the tongue shows this).

Treatment principle

The treatment principle adopted was to pacify the Liver, clear Liver-Heat, move Qi, clear Heart-Fire, calm the Mind and settle the Ethereal Soul. She was treated only with herbal medicine as she did not like the idea of needles.

Case history

A 27-year-old woman had been suffering from pre-menstrual tension for 13 years (more or less ever since her menarche). She had two children and the pre-menstrual tension became worse after each birth. Her main symptoms were abdominal distension, severe irritability, anger and aggressiveness. She had been given a progesterone pill but this had not helped and had only given her headaches. Her periods were regular, lasted 4 days and were heavy; the menstrual blood was bright red. She also suffered from constipation and, on interrogation, it transpired that she experienced backache and dizziness, she often felt cold, she had cold feet and her urination was frequent and pale. She did not sleep well and occasionally experienced some tingling of her limbs. Her tongue was Pale and slightly Thin with teethmarks. Her pulse was Wiry.

Diagnosis

The main pattern at the root of the pre-menstrual tension is Liver-Qi stagnation manifesting with the typical pre-menstrual symptoms and a Wiry pulse. This occurred against a background of Kidney-Yang deficiency (feeling cold, cold feet, frequent urination, backache, dizziness) and some Blood deficiency (insomnia, tingling and a Pale-Thin tongue).

Treatment principle

The main emphasis should be on pacifying the Liver, moving Qi and calming the Mind. However, one should also attend to the deficiency by tonifying Kidney-Yang and nourishing Blood. She was treated with acupuncture and herbal remedies.

Herbal treatment

I prescribed the Three Treasures remedies Strengthen the Root to tonify Kidney-Yang (to be taken for about 12 days after the period) and Freeing the Moon to pacify the Liver and move Qi (to be taken for about 12 days before the period).

After 3 months of treatment (with fortnightly acupuncture sessions), her pre-menstrual tension was very much reduced. This patient is still under treatment at the time of writing.

Liver-Heat

Clinical manifestations

Pre-menstrual tension, irritability, anxiety, agitation, depression, abdominal and breast distension, thirst, feeling of heat, red eyes, headache, dizziness. Tongue: Red sides. Pulse: Wiry-Rapid.

This is a condition of Liver-Heat deriving from longstanding Liver-Qi stagnation.

Treatment principle

Move Qi, pacify the Liver, clear Liver-Heat, calm the Mind, settle the Ethereal Soul.

Herbal treatment

Liver-Qi stagnation with Phlegm

Clinical manifestations

Premenstrual tension, irritability, depression, crying, sadness, worry, swollen, distended and painful breasts, abdominal distension, a feeling of oppression or tightness of the chest, slight breathlessness, sighing, expectoration of sputum in the mornings, possibly benign breast lumps. Tongue: Swollen, sticky coating. Pulse: Wiry-Slippery.

Treatment principle

Move Qi, pacify the Liver, resolve Phlegm, tonify the Spleen.

Herbal treatment

Tags: Obstetrics and Gynecology in Chinese Medicine

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

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Pre-Menstrual Syndrome

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