Kidney deficiency

Kidney deficiency, one of the major pathologies in gynecology, is at the root of many women’s problems. It is probably more common in women because of the triple relationship of Blood–Uterus–Kidneys: a deficiency of Blood, which often occurs in women, affects the Uterus, and since this is functionally related to the Kidneys, the Kidneys also become deficient. Hence, in women, a Blood and a Kidney deficiency are often overlapping.

In women more than men, a Kidney deficiency often involves both Yin and Yang, albeit one will always be predominant. The tongue illustrates clearly which is predominant: if it is Pale, Kidney-Yang deficiency predominates; if it lacks a coating, Kidney-Yin deficiency predominates.

The reason why Kidney-Yin deficiency and Kidney-Yang deficiency often occur simultaneously in women is three-fold:

Figure 3.1 Kidney-Yin and Kidney-Yang as an oil lamp.

In women, a simultaneous deficiency of Kidney-Yin and Kidney-Yang is far more common after age 40. As Kidney-Yin and Kidney-Yang can both be deficient, in women this causes the very common situation when there are both Hot and Cold symptoms. This is because the Yin-deficient part of the Kidneys can give rise to Empty-Heat even if there is a predominance of Yang deficiency. For example, a woman may have backache, frequent, pale urination, swollen ankles, cold feet, Pale tongue (symptoms of Kidney-Yang deficiency) and hot flushes. Vice versa, a woman may suffer from backache, dizziness, night sweating, a Red-Peeled tongue, hot flushes (symptoms of Kidney-Yin deficiency), but cold feet and frequent urination. Figures 3.2 and 3.3 illustrate the above clinical situations when there is a deficiency of both Kidney-Yin and Kidney-Yang with a predominance of Kidney-Yang and Kidney-Yin respectively.

Figure 3.2 Simultaneous deficiency of Kidney-Yin and Kidney-Yang with a predominance of the latter.

Figure 3.3 Simultaneous deficiency of Kidney-Yin and Kidney-Yang with a predominance of the former.

This clinical situation is so common in women aged over 40 that I think it is the rule rather than the exception. Over the years I have made a note of all the cases presenting with contradicting Hot and Cold symptoms stemming from a simultaneous deficiency of both Kidney-Yin and Kidney-Yang (there are other causes of contradicting Hot and Cold symptoms not related to the Kidneys, which will be explained later). The following is a partial list of the most glaring examples, with the patient’s age indicated at the start of each entry.

A few interesting observations can be made analysing the above list. First, all the women listed (bar one) are over 40, and the overwhelming majority are in their 40s. This is because, before 40, as the pathology is less long-standing, there is usually a clear-cut deficiency of either Kidney-Yang or Kidney-Yin. As the energy of the Kidney starts declining after 40 and it is often intertwined with a Blood pathology, a deficiency of Yang begins to induce a deficiency of Yin or vice versa, hence the overlapping of Kidney-Yin and Kidney-Yang deficiency (Fig. 3.4). After this time, in a woman over 60, whichever deficiency is primary will start to settle in and predominate over the other. Another observation that can be made is that the overlapping symptoms of Heat and Cold usually manifest in the feet with cold feet or hot feet at night, or in the face with a feeling of heat (the face does not usually have a feeling of cold).

Figure 3.4 Symptoms of simultaneous deficiency of Kidney-Yin and Kidney-Yang.

The above are only few of the presenting symptoms to illustrate the presence of Hot and Cold symptoms from a simultaneous deficiency of Kidney-Yin and Kidney-Yang. There are other causes of the simultaneous occurrence of Hot and Cold symptoms and they are discussed below, under the ‘Qi and Blood Pathology’ heading.

As explained in the chapter on physiology (Ch. 2), the waxing and waning of Kidney-Yin and Kidney-Yang are responsible for the menstrual cycle. However, Kidney-Yin and Kidney-Yang are also interdependent and, because a deficiency of one often implies a deficiency of the other, often both are tonified, especially in the treatment of infertility. For example, Dr Lian Fang advocates adding Yin Yang Huo Herba Epimedii to Kidney-Yin tonics and Nu Zhen Zi Fructus Ligustri lucidi and Han Lian Cao Herba Ecliptae to Kidney-Yang tonics when treating infertility.¹ Indeed, the two important formulae You Gui Wan Restoring the Right [Kidney] Pill and Zuo Gui Wan Restoring the Left [Kidney] Pill, which tonify Kidney-Yang and Kidney-Yin respectively, contain herbs that tonify Kidney-Yin and Kidney-Yang respectively. In fact, You Gui Wan (which tonifies Kidney-Yang) contains Gou Qi Zi Fructus Lycii which nourishes Kidney-Yin, and Zuo Gui Wan (which nourishes Kidney-Yin) contains Tu Si Zi Semen Cuscutae and Lu Jiao Jiao Colla Cornu Cervi which tonify Kidney-Yang.

Table 3.1 summarizes the Kidney patterns in gynecology.

Table 3.1 Kidney patterns in gynecology

Liver-Qi stagnation

Liver-Qi stagnation is extremely common in gynecology. Because it provides the Yang action of moving Qi and Blood in phase 4, Liver-Qi plays an important role in menstruation; it is particularly active in the pre-menstrual phase when it prepares to move Blood with the onset of the menses.

The most common cause of Liver-Qi stagnation is emotional stress related to anger, suppressed anger, resentment, worry, shame and guilt.

In pathology, if Liver-Qi stagnates, its effect is particularly noticeable in the pre-menstrual phase, causing pre-menstrual tension, distension of breasts, irritability, depression, abdominal distension, etc. However, please note that not all cases of pre-menstrual problems are due to Liver-Qi stagnation.

Liver-Qi stagnation may also cause an irregular cycle and painful periods. With Liver-Qi stagnation the tongue may not change; in severe cases, it may be slightly Red on the sides, and the pulse Wiry (which may be only on the left). The most defining symptom of Liver-Qi stagnation is a feeling of distension (zhang in Chinese). This is a bloating feeling of the lower abdomen, epigastrium or breasts.

Closely related to Liver-Qi stagnation in gynecology is Liver-Yang rising, which is often associated with it. Liver-Yang rising typically causes headaches before or during the menses. Prolonged stagnation of Liver-Qi may also give rise to Liver-Heat and this to Liver-Fire as stagnant Qi may turn into Heat after a long period of time. Liver-Heat or Liver-Fire will cause a complex pathology; on the one hand, it may heat the Blood and cause Blood-Heat; on the other, Fire may injure Yin, eventually leading to Empty-Heat. Liver-Qi stagnation may also give rise to Liver-Blood stasis manifesting with painful periods with large, dark clots and dark menstrual blood (Fig. 3.6).

Figure 3.6 Consequences of Liver-Qi stagnation.

It is important to note that Liver-Qi and Liver-Blood represent the Yang and Yin aspect of the Liver sphere: they need to be harmonized, i.e. Yin should root and ‘embrace’ Yang. Very often, if Yin is deficient (i.e. Liver-Blood deficiency), it fails to restrain and root Yang (Liver-Qi) so that Liver-Qi stagnates. I therefore distinguish two types of Liver-Qi stagnation: one I call ‘primary’ and this derives from emotional stress and manifests with a pulse that is Wiry all over; the other I call ‘secondary’ and that is Liver-Qi stagnation deriving from Liver-Blood deficiency and due to a combination of emotional stress, diet and overwork (Table 3.2).

Table 3.2 Comparison of primary and secondary Liver-Qi stagnation

That this stagnation is secondary to Liver-Blood deficiency is clear from the tongue being Pale and the pulse either not Wiry or only very slightly Wiry on the left side. In women, this situation is very common. This explains the very common clinical situation of a woman who has many typical symptoms of Liver-Qi stagnation such as pre-menstrual tension, distension of breasts and abdomen, or irritability, but whose pulse and tongue do not reflect this, i.e. the pulse is not Wiry and the tongue is not Red or Purple on the sides. If the tongue is Pale and the pulse Choppy or Fine and only slightly Wiry on the left, this clearly means that the Liver-Qi stagnation is secondary to Liver-Blood deficiency.

Please note that most modern Chinese books say that in Liver-Qi stagnation the tongue is Purple on the sides: I do not agree with this view. In my opinion, a Purple colour of the tongue body always indicates Blood stasis rather than Qi stagnation.

In my opinion, Liver-Qi stagnation is somewhat overdiagnosed both in Chinese and in Western books. Yes, Liver-Qi stagnation is very common but not as common as it is made out to be. Also, it is forgotten that Liver-Qi stagnation is often secondary to other patterns and notably a Liver-Blood deficiency or a Kidney deficiency. Moreover, it is important to note that Qi stagnation affects other organs besides the Liver, e.g. Heart, Lungs, Stomach, Intestines. In gynecology, for example, Lung-Qi stagnation affects the breasts and may cause a feeling of distension of the breasts or even breast lumps.

As for the emotional origin of Qi stagnation, this may derive from emotions other than anger, e.g. resentment, frustration, worry, sadness, grief, guilt, etc. In my opinion, anger tends to be overemphasized in China due to the Confucian influence (which sees anger as the most dangerous and disruptive of the emotions because it induces people to ‘rebel’). I also find that Qi stagnation is automatically considered to be the consequence of ‘stress’, i.e. a person is under stress, therefore we can assume that he or she suffers from Liver-Qi stagnation.

As a consequence of the above, in my opinion the formula Xiao Yao San Free and Easy Wanderer Powder is somewhat overused.

Liver-Blood deficiency

Liver-Blood deficiency is fundamental in gynecology. The Liver stores Blood and provides Blood to the Uterus in close co-ordination with the Penetrating Vessel. Women are very prone to Blood deficiency, partly from the monthly loss of blood occurring with the periods themselves, and partly from diet, overwork and emotional stress.

Liver-Blood deficiency can cause infertility, scanty periods, delayed cycle or amenorrhoea. Please note that ‘scanty period’ is not a symptom that would be reported by most women as they would be more alarmed by heavy rather than scanty periods. It is therefore important to ask about the duration of the period in days. This is discussed more at length in Chapter 5 on Diagnosis.

As explained in Chapter 2, although menstrual blood is Tian Gui and therefore not ‘Blood’ but ‘Water’, there is an overlap between Tian Gui and ‘normal Blood’ (see Fig. 2.29 in Ch. 2). This overlap takes place thanks to the Liver which partakes both of Tian Gui and of ‘ordinary Blood’. For this reason, when there are gynecological symptoms of Blood deficiency such as scanty periods or amenorrhoea, there often are also symptoms of deficiency of ‘ordinary Blood’, i.e. the Liver-Blood that nourishes the hair, eyes, skin, nails and sinews: these would be dry hair, blurred vision, dry skin, brittle nails and cramps.

In Liver-Blood deficiency, the pulse would be Choppy or Fine and the tongue Pale and possibly Thin (although the tongue is seldom Thin, due to the common presence of Dampness or Phlegm which make it Swollen).

One important characteristic of Liver-Blood deficiency is that it is often the origin of many other pathologies as evidenced by Figure 3.7. The following is a brief explanation of these pathologies with one or more representative prescriptions for each.

Figure 3.7 Pathologies deriving from Liver-Blood deficiency.

Liver-Blood stasis

Liver-Blood stasis develops from Liver-Qi stagnation and causes painful periods with dark blood and dark clots. Liver-Blood stasis may also cause pain in the pre-menstrual phase and this may be relieved by the onset of the menses. It may also cause abdominal masses such as cysts, endometriosis or myomas.

Liver-Blood stasis is extremely common in women: this was explained in Chapter 2 on physiology. As their Lower Burner houses the Uterus which stores Blood, Blood easily stagnates in the lower abdomen. Indeed, I would go so far as saying that in chronic and complicated gynecological conditions, one should always suspect Blood stasis.

Although Liver-Qi stagnation plays a prominent role in modern Chinese books and also many Western ones, Liver-Blood stasis is far more important because it potentially gives rise to serious diseases such as endometriosis, cervical cancer, uterine cancer, polycystic ovary syndrome and myomas. Liver-Qi stagnation by itself cannot cause any of the above diseases. Moreover, although it may seem paradoxical, Liver-Blood stasis may even cause heavy menstrual bleeding. This happens because, when Liver-Blood stagnates, the blood vessels in the Uterus are obstructed by stagnant Blood. On the other hand, new Blood is being made all the time; this cannot take its place in the Uterus because it is obstructed by stagnant Blood, and it therefore spills out of the Uterus causing heavy menstrual bleeding (with dark blood and dark clots; see Fig. 3.8).

Figure 3.8 Liver-Blood stasis causing heavy menstrual bleeding.

Like Liver-Qi stagnation, Liver-Blood stasis also affects the Mind; it causes the Mind to be Unsettled leading to insomnia, excessive dreaming, mental restlessness and agitation. In severe cases, Blood stasis may also lead to Mind Obstructed with more serious symptoms and a certain loss of insight such as, for example, in post-natal psychosis.

The pulse in Liver-Blood stasis is Wiry, Firm or Choppy (the last if it is associated with a deficiency of Blood), and the tongue is Purple, sometimes only on the sides.