Chapter 3　Characteristics of Female Reproductive Pathology

Etiology in Chinese medicine is a term that covers a wide range of causes. The causes of gynecological diseases in Chinese medicine are related to an ancient classifcation, the “theory of three types of disease causes”, viz, external causes, internal causes, and causes that are neither internal nor external.

Here we refer mainly to the causes that lead to disorders of menstruation, pregnancy and delivery, pelvic organs and other related diseases. The most common ones are the six pathogenic factors, the seven emotions, and constitutional or life style factors. These factors, under certain circumstances, cause malfunction of the viscera, the channels, qi and blood, and the uterus, leading to gynecological disorders.

The term ‘pathogenic factor’ is a collective name for the six pathogens: wind, cold, summer-heat, dampness, dryness, and fire. These are the six natural climatic factors （six qi）, but when they are excessive, inadequate, or are present at a wrong time, they are pathogenic and become the six pathogenic factors. All of these can cause gynecological diseases. However, for women, blood is the basis of life, and of the six pathogens, cold, heat and dampness tend to afect the blood more easily, leading to various gynecological diseases. Therefore, we will mainly discuss them. Meanwhile, we should remember that there are also internal cold, heat, and dampness pathogens that result from visceral disorders.

（1） Property: This is a yin pathogen that is contracting and congealing and tends to impair yang qi.

External Cold: External cold can easily invade the body during the menstrual period or the postpartum period, or with intake of excessive cold or uncooked food.

Internal Cold: Constitutional yang deficiency generates an internal cold, and this renders the patient more vulnerable to cold pathogens.

（2） Characteristics: Cold coagulates qi and blood, obstructs the fow of blood and qi in the channels causing late periods, dysmenorrhea, amenorrhea or infertility due to a cold uterus amongst other things.

（1） Property: This is the yang pathogen. Its property is to fame up consuming qi and exhausting fluid, injuring the blood and the collaterals, and forcing the blood to move frenetically.

External Heat: This refers to summer-heat or heat toxin, or excessive intake of food that is acrid, spicy, or heating.

Internal Heat: Constitutional yang excess or imbalance of the seven emotions or the fve minds can transform into internal fre. A constitutional yin defciency can also generate internal fre.

（2） Characteristics: Pathogenic heat will quicken and scorch the superficial vessels, forcing the blood to fow frenetically, impairing the chong mai and the ren mai. This causes early periods, menorrhagia, fooding and spoting （ Bēng Lòu, 崩漏）, vaginal bleeding during pregnancy, menstrual hematemesis and epistaxis （vicarious menstruation）, lochiorrhea, puerperal fever, and so on.

（1） Property: This is a yin pathogen which, being stagnant, tends to obstruct qi movement. It sinks downward and dampens the lower body.

External Dampness: Long term occupation of a damp residence, or walking in the rain or wading in water can result in the contraction of pathogenic dampness.

Internal Dampness: This results from a weakness of spleen qi failing to transform and transport such that dampness turbidity is generated, with an accumulation of water and dampness.

Noxious Dampness: This refers to long term accumulated damp-heat or that directly contracted as a sexually transmited disease.

（2） Characteristics: Pathogenic dampness enters the lower jiao, becoming leukorrhea. Dampness may also permeate the lower intestines, causing menstrual diarrhea.

Water-dampness overfows into the skin, causing menstrual edema, and edema during pregnancy. Accumulated dampness develops into phlegm and may obstruct the channels, causing amenorrhea and infertility. Pathogenic dampness always intertransforms between yin and yang as well as defciency and excess. If the body tends to have exuberant yang, for example, the dampness will be converted into a heat-dampness. If the body tends to have insufcient yang it converts to a cold-dampness.

Emotional factors refer to the seven emotions; joy, anger, worry or overthinking, anxiety, sorrow, fear, and fright. If excessive an emotion can become an endogenous pathological factor.

Women ofen encounter excessive mental stimulation and emotional challenges, which give rise first to qi disorders and then to blood disorders. Disharmony between qi and blood will cause an imbalance of yin and yang, malfunction of the viscera and consequently diseases.

Within the seven emotions, anger, worry, and fear have more infuence on gynecological disorders, so they are discussed below:

Anger: Depression and anger always lead to qi stagnation, reverse qi fow and disorders at the blood level. This may result in late menstrual periods, dysmenorrhea, amenorrhea, menstrual hematemesis and epistaxis （vicarious menstruation）, abdominal masses, breast distension or difculties in breast feeding.

Worry: Worry induces qi stagnation and blood stasis, causing amenorrhea, menstrual irregularities, and abdominal masses.

Fear: Fear in excess causes a sinking disorder of the qi and a loss of control of the blood, leading to menorrhagia, fooding and spoting and actual or threatened miscarriage.

Lifestyle factors are important causes of maintaining or damaging one’s health.

（1） Excessive Sexual Activity: This term includes a constitutional deficiency, early marriage, excessive sexual activity, many pregnancies or extended lactation afer delivery. Any of these can damage the kidney qi and exhaust qi and blood. Kidney qi insufciency and an imbalance of qi and blood will cause menstrual disorders, excess vaginal discharge and threatened or actual miscarriage.

（2） Improper Diet: Overeating or drinking, excessive intake of sweet or faty foods, a partiality to a particular food or favor, or inappropriate ingestion of cold or hot foods will harm the stomach and the spleen, causing many diseases.

Eating too much food that is acrid, pungent and heating may lead to early periods, menorrhagia, menstrual hematemesis and epistaxis （vicarious menstruation）, and threatened miscarriage. Eating too much cool, cold or uncooked food may result in dysmenorrhea, amenorrhea and vaginal discharge.

（3） Overwork and Inactivity: Women must work and rest appropriately during the menstruation, pregnancy and puerperium.

Too much exertion during menstruation may cause a longer period or menorrhagia. Overwork during pregnancy can easily lead to a threatened or actual miscarriage.

Conversely, inactivity will lead to the stagnation of qi and the blood, causing menstrual disorders or prolonged labor. Carrying heavy objects or returning to work too soon afer delivery can lead to uterine prolapse.

（4） Falls and Injuries: During menstruation or pregnancy, women should not climb up to high places or risk falls, lift or carry heavy things, as this may cause flooding and spoting or threatened miscarriage and so on.

The constitution of the human body varies greatly in its ability to fght against disease. It not only determines whether pathogenic factors can or cannot injure the body, thus causing diseases, but it also decides the type, the degree, and the prognosis of the disorders.

In Spiritual Pivot—The Beginning of Various Diseases （ Líng Shū—Băi Bìng Shĭ Shēng, 灵枢·百病始生）, there is a saying “If you come across swif wind and heavy rain, but do not catch disease, this is because you are not weak, for pathogens alone cannot hurt you”. This explains that the constitution of the body is a very important factor in one’s immunity.

In A Summary of Medical Principles （ Yī Lĭ Jí Yào, 医理辑要）, Wu De-han, a physician of the Qing Dynasty, said: “People become sick from the wind due to exterior qi defciency; from cold, because of yang qi defciency; from heat, because of yin qi defciency; from diet, due to spleen and stomach defciency; and from work, due to center qi defciency. It should be noticed that the time that an illness occurs is when the healthy qi turns into a defciency.”

We can then see that even living in the same environment, people of a strong constitution will not become ill; while those of a weaker constitution are unable to protect themselves from the pathogenic factors. There are diferent types of constitutions due to diferences in prenatal makeup, postnatal nutritional status and lifestyle habits.

Some people have an excess of yang constitutionally. They tend to sufer constipation, and a feverish feeling in the palms and soles. Others have a yin excess, and they often experience loose stools, have an aversion to cold and have cold limbs.

Early marriage and excessive sexual activity leading to an impaired kidney qi affect different constitutions differently. Those with mainly kidney yang deficiency, where the true fire of mìng mén （gate of vitality, 命门） is lacking, may suffer from menstrual diarrhea, leukorrhea, edema during pregnancy and infertility of the patern of kidney yang defciency. Others with mainly a kidney yin defciency （lacking yin essence, the true fuids）, may sufer fooding and spoting, amenorrhea, perimenopausal syndrome, or threatened miscarriage of the patern of kidney yin defciency.

Similarly, invasion by pathogenic dampness will affect different constitutions differently. For some, the pathogenic dampness turns to heat from yang, manifesting in vaginal infection or pruritus vulvae of the patern of damp-heat. For others, the pathogenic dampness turns to cold from yin, manifesting in various patterns of cold-damp such as dysmenorrhea and amenorrhea due to congealing cold-damp. Strong people will encounter mild illness and recover completely in a short period of time. Weak people will sufer from a severe or prolonged illness, and will not recover so easily or in a short time.

Therefore, constitution plays a vital role in the whole process of a disease, which includes the tendency to contract an illness and all its stages of development and its prognosis.

The mechanism of diseases in gynecology can mainly be summed up as three types: the dysfunction of zang-fu organs, disharmony between qi and blood, and direct injury to the uterus.

The mechanism of diseases in gynecology mainly refers to the damage done to chong and ren mai （also du mai and dai mai）. Physiologically, the uterus is connected with the channels through chong and ren mai. Pathologically, it is only when there is direct or indirect damage done to the chong and ren mai （also du mai and dai mai）, that disorders of menstruation, leukorrhea, pregnancy or delivery will occur.

Chong and ren mai impairment is the main characteristic of the pathogenesis of gynecological diseases. In this section, we will describe the main pathology mechanism.

The kidney stores essences and dominates reproduction. The uterine vessels also connect with the kidney. If kidney qi is defcient, it will cause instability of chong and renmai, which can give rise to many disorders. If this happens, chong and ren mai become too weak to hold the uterus, giving rise to a uterine prolapse; the fetus is not secure and there is a risk of miscarriage; the kidney’s storage function is impaired, resulting in flooding and spoting; the sea of blood is not governed, causing irregular menstrual cycles; sperm may not be able to traverse the cervix, causing infertility. If kidney yin is insufcient, the essence and the blood are deficient, leading to blood deficiency in chong and ren mai. If chong and ren mai lack blood, the sea of blood is unable to be flled in due time, causing late or scanty menstrual periods or amenorrhea. The uterine vessels lose nourishment, giving rise to perimenopausal symptoms. If kidney yin is defcient, internal heat rises and harasses chong mai. This forces the blood to move frenetically causing early periods or fooding and spoting. If kidney yang is defcient and fails to warm chong and ren mai, defciency-cold will form in the uterine vessels, causing abdominal pain during pregnancy, threatened miscarriage and infertility. During the menstrual period, blood fows downward to chong and ren mai, and the fire of mìng mén becomes weaker, resulting in menstrual diarrhea. Failure in qi transformation will occur and make dampness turbidity pour down to chong and ren mai, causing the dysfunction of dai mai and manifesting as leukorrhea. During pregnancy, chong and ren mai nourish the fetus; but the fetus obstructs qi movement, thus causing dampness turbidity to fow to the skin manifesting as edema in pregnancy, etc.

The liver stores blood, governs the free fow of qi and prefers free unfetered activity. In stressful situations, liver qi stagnates; and this will lead to the stagnation of qi in the blood, an obstruction of chong and ren mai, irregularities in the sea of blood, and consequently, menstrual disorders. If chong and ren mai are obstructed, the uterine vessels will stagnate, giving rise to dysmenorrhea, amenorrhea and the like. Heat will injure chong and ren mai if liver constraint turns into fre, forcing the blood to move rapidly and may cause leukorrhea and vulval itching. If the liver qi attacks the stomach at the same time that exuberant qi of chong mai during pregnancy flows upwards along with stomach qi, vomiting will occur. If the blood gathers in chong mai to nourish the fetus, liver blood becomes relatively more deficient and the liver yang becomes hyperactive. This may induce vertigo during pregnancy, or even an internal stirring of the liver wind, which may develop into eclampsia of pregnancy.

The spleen governs transportation and transformation and controls the center qi; and along with the stomach, it produces qi and blood. If spleen qi is defcient, an instability of chong and ren mai occurs; and the blood loses control, resulting in early menstrual periods, menorrhagia and fooding and spoting. When chong and ren mai are not secured, the fetus is not firm and it moves restlessly. There will be vaginal bleeding during pregnancy, as well as the risk of early or late miscarriage. Instability of chong and ren mai can also cause a failure to hold the uterus, and consequently lead to uterine prolapse. If spleen defciency and blood insufficiency occur and transportation and transformation are compromised, the sea of blood can’t be flled in due time and can cause late periods, dysmenorrhea, and amenorrhea. The instability of the chong and ren mai may lead to malnutrition of the fetus, fetal restlessness, and early or late miscarriage. If spleen yang fails in transportation and distribution of food essence, dampness turbidity accumulates in the body and will pour downward to chong and ren mai. This makes dai mai lose its control, and both chong and daimai function fails causing leukorrhea. Accumulation of dampness turbidity may mix with phlegm and fow adversely upward, causing vomiting.

The heart stores the spirit and dominates the blood and the vessels. If there is an excess of sorrow or yin blood exhaustion, heart qi can’t fow downward, causing blood defciency in chong and ren mai and a shortage of blood of the blood sea. This condition will cause scanty periods or amenorrhea. A defciency of heart blood will lead to malnutrition of the spirit, visceral agitation （hysteria）, or perimenopausal syndrome.

The lung governs qi, dominates purifcation and descent, connects with all vessels, and regulates water passage. Yin defciency and dryness in the lung are exacerbated when yin blood fows downward to chong mai during menstruation. This will result in a defciency fre faring upward, impairing the lung collaterals and causing menstrual hematemesis and epistaxis （vicarious menstruation）. If the lung fails in purifcation and descent, coughing during pregnancy occurs. If the lung qi can’t regulate the water passage, it will lead to swelling, edema and retention of urine during pregnancy or during the period shortly afer childbirth.

Disharmony of qi and blood is a common pathogenesis in obstetric and gynecological diseases. This is because pregnancy, maternity and lactation are based on the blood and the blood is easily exhausted. Thus, the body is always in the state of a blood defciency and qi excess. Since qi and the blood are related to and nourish each other, damage to the blood definitely impairs qi; and damage to qi affects the blood. It is always necessary to make clear whether the disease begins with qi or blood.

（1） Qi Excess: Liver qi obstruction gives rise to mental depression, easy irritability, and breast distension before menstruation. Qi stagnation causes an obstructed blood flow, disorder of chong and ren mai, and consequently, an irregular menstrual cycle, dysmenorrhea and amenorrhea. Qi counterflow harasses the lung and the stomach, leading to menstrual hematemesis and epistaxis （vicarious menstruation）, vomiting during pregnancy, and chest distention before menstruation or during pregnancy.

（2） Qi Deficiency: Center qi deficiency leads to instability of chong and ren mai, and thus, early periods, fooding and spoting and spontaneous sweating on the chest or breasts occur. More severe qi deficiency will result in the qi sinking. Kidney deficiency makes the kidney unable to retain the uterus, causing vaginal bleeding during pregnancy, a restlessness of the fetus, an early or a late miscarriage and uterine prolapse.

Lung qi defciency leads to a lack of defense qi so that cold is contracted easily during menstruation or postpartum spontaneous sweating or fever develop.

（1） Blood Cold: Yang defciency incurs internal coldness, and it becomes powerless to circulate the blood. At the same time, blood coagulates with cold. The result is obstruction of the chong and ren mai, and dysmenorrhea, late periods, and infertility occur.

（2） Blood Heat: Heat in the blood damages chong and ren mai and forces the blood to move frenetically, leading to early or heavy periods, fooding and spoting, postmenopausal hemorrhage, postpartum fever, and excess lochia.

（3） Blood Defciency: When blood is insufcient, the blood sea can not completely fll, leading to late or scanty periods, amenorrhea, infertility, and inadequate breast milk supply.

（4） Blood Stasis: The factors leading to blood stasis include cold, heat, deficiency, stagnation, and contraction of pathogenic damp-heat afer labor. However, the mechanism in gynecology mainly refers to an obstruction of the uterus, the uterine vessels, the chongmai and ren mai. Blood flow is obstructed and is unable to return to the channels. This causes dysmenorrhea, amenorrhea, fooding and spoting, ectopic pregnancy, postpartum abdominal pain, leucorrhea, infertility, and abdominal masses, etc.

During menstruation, delivery and the postpartum period, lifestyle irregularities, direct exposure to water or rain or catching an infection can all bring about invasion of cold-damp which lodges in the uterus, chong mai, and ren mai.

Excessive sexual activities and a number of pregnancies （including miscarriages, abortions, and insertion of IUDs） can directly impair chong and ren mai and the uterus. Chong mai, ren mai and dai mai are important channels in female physiology, and once injured, these may lead to various gynecology disorders. In Complete Collection ofPrescriptions for Women （ Fù Rén Dà Quán Liáng Fāng, 妇人大全良方）, the author states that “There are 36 gynecological diseases, all of which are due to the impairment of chong and ren mai.” Therefore, chong and ren mai are essential in curing gynecological diseases.

To summarize this section, gynecological diseases, no matter if they are caused by visceral dysfunction, disharmony of qi and blood, or an impairment to the uterus by pathogens, are all due to the disorder of the female reproductive system, that is, dysfunction of the kidney, the reproduction-stimulating essence, chong and ren mai, and the uterus.