-Irregular Menstruation

By EVERWELL Chinese Medical Centre, Prof Engin CAN (Enqin Zhang)   

                      Lecture for TCM Week at Royal Society of Medicine U.K.

 (1 Wimpole Street , London , W1G 0AE, on 30/07/2008 at 2.30-3.00pm)

As you know, menstruation is the periodic shedding (usually monthly) of the lining of the womb. Generally speaking, menstruation starts during puberty around 10-16 years old and continues until the menopause about 45-55 years old. The average menstrual cycle lasts about 28 days, but women can vary between 24-35 days. According to a study most women have more than 500 periods in a lifetime. Any abnormality of the above menstrual conditions can be regarded as irregular. 

In Traditional Chinese Medicine (TCM) theory, irregular menstruation is termed ‘Yuejing Shitiao (irregular menstruation)’, referring to disorders in the menstrual cycle and abnormalities in the amount, colour and nature of the menstrual blood.                                            

Clinically, an irregular menstruation includes many different menstrual conditions in TCM, such as early menstrual cycle, delayed menstrual cycle, irregular menstrual cycle, menorrhagia, scanty menstruation, etc. It is fair to say that most, if not all, women have experienced symptoms of irregular menstruation at some point in their lives.                                     

TCM has had thousands of years of experience in the treatment of most patterns of irregular menstruation with acupuncture, herbal medicine and other therapies.

1. Aetiology and Pathology

In TCM theory, menstrual blood is discharged from the uterus, but it is related to the internal viscera, meridians, qi and blood, especially to the kidney-qi. According to the records in the [Huangdi Neijing] i.e. “The Yellow Emperor’s Canon of Internal Medicine” in English, the earliest TCM classical text in China (BC 475-221), the kidney is the key internal organ for the physiological development of women throughout their lifetime including menstruation. It states that, ‘at the age of 7, a female is increasingly rich in kidney-qi as she begins to get her adult teeth and grow long hair.  At the age of 14, ‘the Tian Gui’ (a reproductive substance like a hormone in the Western medicine) is well developed, the circulation of the Ren Meridian is smooth; and the Chong Meridian predominates. As a result, menstruation occurs regularly. However, on reaching the age of 49, the Ren Meridian becomes deficient, the Chong Meridian declines, the Tian Gui  has been exhausted and menstruation stops’.

Additionally, the liver, spleen and other organs are also connected with the formation and development of menstruation in TCM theory.

TCM believes that the irregular menstruation can be caused by many factors :

1) Emotional disorders, such as worry, stress, upset, depression and restlessness, may cause stagnation of the liver-qi and then develop into blood stasis in the Ren Meridian and the Chong Meridian;

2) Invasion of the Ren Meridian and the Chong Meridian by pathogenic cold, heat or dampness can affect the circulation of the qi and blood as well as the function of the kidney, liver and spleen;

3) Lack of proper care after prolonged illness and from excessive sexual activities can consume the kidney-qi and blood.

All the above factors can lead to some pathogenic conditions such as heat in the blood, deficiency of the qi, blood stasis, cold in the blood and stagnation of qi, etc.

Basically, heat in the blood may drive blood out of the blood vessels and cause an early menstrual cycle or profuse menstruation; and deficiency of spleen-qi can cause out of control blood circulation leading to an early menstrual cycle or profuse bleeding; and blood stasis and cold in the blood generally results in a delayed menstrual cycle or scanty menstruation; stagnation of qi is often one of the causes leading to irregular menstrual cycle.

2. Differential Diagnosis

1) Common Conditions of Irregular Menstruation:

(1) Early Menstrual Cycle: The menstruation occurs 7-10 days earlier than usual. If menstruation occurs only 3-5 days earlier than usual or just occurs occasionally, both are still regarded as normal, but the continuous occurrence of early menstruation for 3 months can be diagnosed as Early Menstrual Cycle.

(2) Delayed Menstrual Cycle: The menstruation occurs a week or more later than usual. However, an occasional delayed menstruation is still regarded as normal; if delayed menstruation occurs for consecutive 3 months, it can be diagnosed as Delayed Menstrual Cycle.

(3) Irregular Menstrual Cycle: The menstruation which occurs irregularly and alternatively over 7 days, sometimes earlier and sometimes later than usual, is termed as Irregular Menstrual Cycle.

2) Common Syndromes of Irregular Menstrual Cycles

(1) Heat in the Blood: Early menstrual cycle, or profuse menstruation, marked by bright, or dark red menstrual fluid, or fluid that is thick and sticky, accompanied by a flushed face, restlessness, a dry mouth and excessive thirst, yellow urine, constipation, a red tongue with yellow fur, and a rapid pulse.

(2) Deficiency of Qi: Early menstrual cycle, or profuse menstruation, marked by light-coloured and thin menses, poor appetite, loose stools, tiredness, pale  tongue with thin and whitish fur, and a fine and weak pulse.

(1) Blood Stasis: Delayed menstrual cycle, scanty menstruation, marked by dark-coloured menses with clots, pain in the lower abdomen which is alleviated after the blood clots have been discharged, a dark-coloured tongue and a taut or rough pulse.

(2) Cold in the Blood: Delayed menstrual cycle, or scanty menses with blood clots, marked by abdominal pain that can be alleviated with warmth, cold limbs, an aversion to cold, a blackish tongue with white fur, and a deep and taut pulse.

(3) Stagnation of Qi: Irregular menstrual cycle, or scanty or profuse menstruation, marked by purplish and rough menses, dysphoria, a susceptibility to rage, a preference for sighing, hypochondriac distension or pain, breast distension, a thin and white fur on the tongue, and a taut pulse.

3. Diagnosis in Western Medicine

1) A history of personal menstruation and details of menstrual cycle as well as any abnormal condition in the amount, colour and nature of menses with other accompanying symptoms are all required for the diagnosis.

2) Gynecological examinations and other necessary check-ups are needed to confirm that there is no organic change in the pelvis.

3) Some tests such as Type B ultrasonic wave examination, colposcopy, and pelvic scans, may be needed for confirming that there is no other serious organic disease.

4. TCM Treatments

1) Body acupuncture

     Basic acupoints:

     Guanyuan (Ren 4)

      Zhongji (Ren 3)

Sanyinjiao (Sp 6)

Supplementary acupoints:

For heat in the blood, add Quchi (LI 11), Hegu (LI 4) and Xuehai (Sp 10).

For deficiency of qi, add Qihai (Ren 6), Zusanli (St 36) and Pishu (B 20).

For blood stasis, add Xuehai (Sp 10), Waiguan (SJ 5) and Ganshu (B18).

For cold in the blood, add Baihui (Du 20), Mingmen (Du 4) and Dazhui (Du 14).

For stagnation of qi, add Qimen (Liv 14), Taichong (Liv 3) and Waiguan (Sj 5).

Method: Use filiform needles to puncture the acupoints selected. For the syndromes of heat in the blood, blood stasis and stagnation of qi, use the reducing method; For the syndromes of deficiency of qi, and cold in the blood, use the reinforcing method and also apply moxibustion to Guanyuan (Ren 4), Zusanli(St 36) and Sanyinjiao(Sp 6) or other acupoints selected.

Method: 3-6 points are selected for each treatment. The auricular-seed-pressing therapy can be used. The seeds should be re-placed every 3-5 days.

 3) Herbal Therapy

 (1)  Heat in the blood

Therapeutic principle: Clearing away heat, cooling blood and regulating menstruation.

Formula: Modified Qingjing San/Powder or Decoction for Clearing Menstruation-heat).

Ingredients:

Mudanpi / Moutan  bark (Cortex Moutan Radicis) 9g

Digupi /Wolfberry bark (Cortex Lycii Radicis) 9g

Baishaoyao/White peony root (Radix Paeoniae Alba) 9

Shengdihuang /Dried rehmannia root (Radix Rehmanniae) 9g

Huangbai /Phellodendron bark (Cortex Phellodendri) 9g

Qinghao/Sweet wormwood (Herba Artemisiae ) 6g

Yimucao / Motherwort (Herba Leonuri) 15g

Shengdiyu /Raw sanguisorba root (Radix Sanguisorbae) 15g

(2)Deficiency of Qi

Therapeutic principle: To strengthen the spleen to maintain the blood flow in the vessels and regulate menstruation.

Formula: Gui Pi Tang/Decoction for Strengthening the Spleen with additional ingredients.

Ingredients:

Baizhu/Bighead atractylodes rhizome (Rhizoma Atractylodis Macrocephalae) 9g

Fushen /Poria with hostwood (Poria cum   Ligno Hospite ) 9g

Huangqi /Astragalus root (Radix Astragali seu Hedysari) 12g

Longyanrou /Longan aril (Arillus Longan) 12g

Suanzaoren /Wild jujube seed (Semen Ziziphi Spinosae) 12g

Renshen /Ginseng (Radix Ginseng) 6g

Muxiang /Aucklandia root (Radix Aucklandiae) 6g

Zhigancao /Prepared licorice root (Radix Glycyrrhizae Praeparatae) 3g

Danggui /Chinese angelica root (Radix Angelicae Sinensis) 9

Yuanzhi /Polygala root (Radix Polygalae) 6g

Aiyetan /Carbonized Argyi leaf (Folium Artemisiae Argyi) 9g

Paojiang /Baked ginger (Rhizoma Zingiberis Praeparatae) 9g

Administration: All the above herbs should be soaked in a saucepan of water for 2 hours or more, then brought to the boil and simmered for 25 -30 minutes.  After this time the remaining liquid can be drained away from the herbs to make a tea or decoction, for the patient to drink.  Half the liquid should be taken in the morning, the other half in the evening.

(3)Blood stasis

Therapeutic principle: Promoting blood circulation and removing blood stasis to regulate menstruation.

Formula: Tao Hong Siwu Tang/ Four-ingredient Decoction plus Peach Kernel and Safflower.

Ingredients:

Shudihuang /Prepared rehmannia root (Radix Rehmanniae Praeparatae) 9g

Danggui /Chinese angelica root (Radix Angelicae Sinensis) 9g

Chishaoyao /Red peony root (Radix Paeoniae Rubra) 9g

Chuanxiong /Chuanxiong  rhizome (Rhizoma Ligustici Chuanxiong) 6g

Honghua / Safflower (Flos Carthami) 9g

Administration: All the above herbs should be soaked in a saucepan of water for 2 hours or more, then brought to the boil and simmered for 25 - 30 minutes.  After this time the remaining liquid can be drained away from the herbs to make a tea, or decoction, for the patient to drink.  Half the liquid should be taken in the morning, the other half in the evening.

(4)Cold in the blood

Therapeutic principle: Warming meridians and dispelling cold to regulate menstruation.

Formula: Modified Wen Jing Tang/Decoction for Warming Meridians.

Ingredients:

Wuzhuyu /Evodia fruit (Fructus Evodiae) 9g

Danggui / Chinese angelica root (Radix Angelicae Sinensis) 6g

Baishaoyao /White peony root (Radix Paeoniae Alba) 6g

Chuanxiong /Chuanxiong rhizome (Rhizoma Ligustici Chuanxiong) 6g

Renshen /Ginseng (Radix Ginseng) 6g

Guizhi /Cinnamon twig (Ramulus Cinnamomi) 6g

Mudanpi /Moutan bark (Cortex Moutan Radicis) 6g

Shengjiang / Fresh ginger (Rhizoma Zingiberis Recens) 6g

Gancao /Licorice root (Radix Glycyrrhizae) 6g

Administration: All the above herbs should be soaked in a saucepan of water for 2 hours or more, then brought to the boil and simmered for 25 -30 minutes.  After this time the remaining liquid can be drained away from the herbs to make a tea or decoction, for the patient to drink. Half the liquid should be taken in the morning, the other half in the evening.

(5)Stagnation of qi

Therapeutic principle: Smoothing the liver-qi and nourishing blood to regulating menstruation.

Formula: Xiaoyao San /Ease Powder or Decoction.

Ingredients:

Zhigancao /Prepared licorice root (Radix Glycyrrhizae Praeparatae) 9g

Danggui /Chinese angelica root (Radix Angelicae Sinensis) 10g

Fuling /Tuckahoe (Poria) 9g

Baishaoyao /White peony root (Radix Paeoniae Alba) 9g

Baizhu/Bighead atractylodes rhizome (Rhizoma Atractylodis Macrocephalae) 9g

Chaihu /Bupleurum root (Radix Bupleuri) 9g

Bohe /Peppermint (Herba Menthae) 6g

Administration: All the above herbs except Bohe should be soaked in a saucepan of water for 2 hours or more, and then brought to the boil.  The Bohe can be added at this point and simmered with the other herbs for the required 5-10minutes.  After this time the remaining liquid can be drained away from the herbs to make a tea or decoction, for the patient to drink.  Half the liquid should be taken in the morning, the other half in the evening.

3. Lifestyle and Dietary Advic

1) During menstruation, the pudenda should be kept clean and hygienic; tension, fatigue, and heavy physical labour or working with scorching sun directly overhead should be avoided; women should strictly abstain from swimming and vaginal examinations.

2) The abdomen should be kept warm during menstruation. Cold bathing, wading across a river, being drenched with rain, sitting or lying on the wet ground or working in damp fields are not recommended.

3) Diet is very important in order to keep the body healthy and this also applies to health during menstruation. Light and nutritious foods are advised. Too much sour, pungent, aromatic foods as well as uncooked and cold foods are not good during menstruation; it is also inadvisable to drink too many caffeinated drinks such as coffee, tea, cola, etc.

4) Weight can influence the hormonal balance and menstruation. If a patient is underweight, their hormones might not be functioning properly and their periods may stop. Recent research has also shown that obesity can also throw the hormones out of balance, which may cause irregular menstruation. Therefore being underweight or overweight is not recommended.

Ladies, gentlemen and dear colleagues, it has been a pleasure to be in your company.  I hope to build on this meeting today and would welcome further academic exchanges on this subject in the future. If you need any more information, please do not hesitate to contact me .

E-mail:  prof.engincan@hotmail.co.uk

Telephone:  07846193488.