Chapter 7　Menstrual Diseases

The term ‘early menstrual period’ refers to menstrual cycles of 3 weeks or less that occur for more than two consecutive cycles.

This condition falls under the TCM category of menstrual diseases. In Western medicine, the condition may be associated with hormonal imbalances, inadequate luteal function or pelvic inflammation and can be treated as such.

The major causes of early menstrual period are qi deficiency or blood heat. The pathology is located in the chong and ren mai and the uterus and the resulting instability of the chong and ren mai fails to control the flow of blood.

The nature of this condition can be either deficiency or excess, with deficiency being more common. Periods which occur more than seven days early often have a heavy flow and, in severe cases lead to flooding and spotting or functional uterine bleeding.

Qi deficiency leads to failure to control blood and instability of the chong and ren mai. Blood heat causes frenetic movement of blood which interferes with the chong and ren mai; both causes can result in early menstrual period.

Constitutional weakness, physical exertion or overstraining, excessive worry, or dietary irregularities that impair spleen qi and cause middle qi deficiency can contribute to imbalance of the chong and ren mai with failure to control blood.

Sexual overindulgence, multiparity, or kidney impairment due to prolonged illness or aging causes kidney qi deficiency, leading to instability of the chong and ren mai with failure to control blood.

Constitutional yang exuberance, excessive intake of warm, spicy foods, or invasion of external pathogenic heat can all impair the chong and ren mai and lead to frenetic and uncontrolled movement of blood.

Constitutional yin deficiency, yin injury from blood loss, multiparity consuming essence and blood, or excessive thinking impairing the ying and yin; any of these may give rise to yin-blood deficiency and internal deficient heat. Internal heat then causes instability of the chong and ren mai with failure to control blood.

Chronic emotional disturbance results in binding constraint of liver qi, which transforms into heat over time. The heat disturbs chong and ren mai function, causing the blood to flow frantically, which leads to early menstrual period.

The diagnosis of early menstrual period is made according to the general condition of the patient and the history of menstruation in combination with other presenting signs and symptoms, including the tongue and pulse. The primary diagnostic evidence is the regular early occurrence of short menstrual cycles.

There is a history of blood heat conditions, internal emotional injury, or pelvic inflammation, prenatal insufficiency or postnatal lack of nourishment etc.

Early menstrual period, a menstrual cycle of less than 21 days that recurs for more than two consecutive cycles, and may be accompanied by menorrhagia.

（1） Gynecological Examination: Patients with no evidence of organic pelvic lesions generally suffer from early menstrual period caused by inadequate luteal function or by early ovulation. In patients who do show signs of pelvic inflammatory disease （PID）, the early menstrual period is caused by inflammation.

（2） Auxiliary Examinations: The patients, whose early menstrual period is caused by inadequate luteal function, have a biphasic type basal body temperature （BBT）; but the luteal phase is less than 12 days. Their body temperatures may drop early and rise slowly with a range of less than one-half degree Celsius （0.3℃）, or it may fluctuate significantly during the luteal phase. An endometrial biopsy （a sampling of the lining of the uterus）that is done within 12 hours from the first day of menstruation will show an inadequate endometrial function.

Those patients who tend to ovulate early （sometimes associated with high FSH levels）, will show a short follicular phase on the BBT.

Menstruation which arrives ten or more days early should be distinguished from intermenstrual bleeding （bleeding between periods）.

Intermenstrual bleeding （ovulatory bleeding in Western medicine） usually occurs during the 12 ^th to the 16 ^th day of a menstrual cycle. The bleeding, which is a very light flow or spotting, lasts for few hours up to several days. It may also present as a sticky, transparent discharge mixed with traces of blood.

Diagnosis can be made in combination with Basal Body Temperature （BBT） charts. Early periods usually have roughly the same amount of bleeding each cycle and the duration of bleeding is like a normal period.

Pattern differentiation lays emphasis on how early the menstruation occurs and changes in the blood amount, color, and quality. This information is combined with the signs, symptoms, and tongue and pulse condition to establish a pattern of excess, deficiency, or heat.

Focus should be laid on regulating and normalizing the menstrual cycle.

Supplementation or clearing methods are applied according to the diagnosed pattern.

If the pulse and tongue condition and the diagnosed pattern indicate an absence of heat,

treatment principles include supplementation of middle qi, consolidation of the life gate, replenishment of the heart and spleen, or dual supplementation of the spleen and kidney.

In blood heat patterns, treatment principles include heat clearing and blood cooling methods along with yin nourishing and liver soothing methods.

To avoid yin blood injury, cold- or cool-natured medicinals are prohibited to be used during the period, regardless of the presenting pattern.

[Main Manifestations]

Early menstrual period, with a heavy flow of thin light red menses.

[Other Signs and Symptoms]

Mental fatigue, tired limbs, empty bearing-down sensation in the lower abdomen, poor food intake, loose stools.

[Tongue and Pulse]

A light red tongue with a thin white tongue coating; the pulse is thready and weak.

[Pattern Differentiation]

The spleen governs middle qi and controls the blood. When spleen qi is deficient, it cannot control blood, thus leading to instability of chong and ren mai. Menstruation therefore occurs earlier, and menstrual flow is heavy. Insufficient qi fails to warm blood, so the menses are thin, clear, and light red. Deficiency of middle qi leads to mental fatigue, tired limbs, a shortness of breath and reluctance to speak, and empty bearing-down sensation in the lower abdomen. Spleen deficiency leads to failure of transportation and transformation, poor appetite and loose stools.

[Treatment Principles]

Invigorate spleen and replenish qi, control blood, regulate menstruation

[Formula]

Bŭ Zhōng Yì Qì Tāng （补中益气汤, Middle-Supplementing Qi-Boosting Decoction）

[Formula Analysis]

Huáng qí and rén shēn serve as the sovereign medicinals to replenish qi.

Gān căo and bái zhú are used as ministers to supplement the middle and invigorate the spleen.

Dāng guī supplements qi （and blood）, and chén pí regulates qi, both serving as assistants.

Shēng má and chái hú are used as guide medicinals to elevate yang.

On the whole, this formula acts to replenish qi, supplement the middle, elevate yang and help blood to return to the vessels so that the menstrual cycle will return to normal.

[Modifications]

Rén shēn can be replaced by dăng shēn （Radix Codonopsis）; larger dosages huáng qí may be used to replenish qi and control blood.

With heavy menstrual bleeding, dāng guī is removed during the menstruation; add duànlóng gŭ （calcined Os Draconis） 20 g, duàn mŭ lì （calcined Concha Ostreae） 20 g, and zōng lǚ tàn （Petiolus Trachycarpi Carbonisatus） 10 g.

With deficiency of the heart and spleen, there will be early menstrual period with palpitations, sleeplessness, profuse dreaming, a pale tongue with a white coating, and a weak and thready pulse. This pattern should be treated by supplementing the heart and spleen, strengthening chong mai, and regulating menses; select Guī Pí Tāng （Spleen-Restoring Decoction） （from Jì Shēng Fāng （ Formulas to Aid the Living, 济生方））.

[Main Manifestations]

Early menstrual period with heavy or scant flow that is darkish, thin and clear.

[Other Signs and Symptoms]

Aching lower back and knees, dizziness and tinnitus, dark complexion with dark shadows under the eyes.

[Tongue and Pulse]

A dusky pale tongue with a white moist coating; pulse is deep and thready.

[Pattern Differentiation]

The root of the chong and ren mai lies in the kidney. Insufficiency of kidney qi causes failure to store the essence, also leading to a lack of control of the chong and ren mai; menstruation thus occurs ahead of time with an increased blood flow amount. However if the kidney deficiency has lead to an insufficiency of essence and blood, the menstrual flow might be scanty. Kidney qi insufficiency gives rise to kidney yang debilitation with failure to warm the blood, so the menses are darkish, thin and clear.

The lower back is the external house of the kidney; when deprived of nourishment, the sinews and bones become flaccid, causing aching of the area and of the knees.

Dizziness, tinnitus, dull complexion, dusky pale tongue, and a deep and thready pulse are also signs of kidney deficiency.

[Treatment Principles]

Replenish and supplement kidney qi, secure the chong mai, regulate menstruation.

[Formula]

Gù Yīn Jiān （Yin-Securing Brew, 固阴煎）

[Formula Analysis]

Tù sī zĭ supplements the kidney and replenishes essence-qi.

Shú dì huáng and shān zhū yú nourish the kidney and replenish essence.

Rén shēn, shān yào, and zhì gān căo invigorate the spleen and replenish acquired qi to nourish the foundation and consolidate the life gate.

Wŭ wèi zĭ and yuăn zhì restore coordination between the heart and kidney so that heart qi can fow downward and the kidney qi is strengthened.

The entire formula has the effect of supplementing the kidney and replenishing qi, consolidating the chong mai, and regulating menstruation.

[Modifications]

Rén shēn can be replaced by dăng shēn （Radix Codonopsis） in this formula.

With thin scanty dark red menses, lumbosacral soreness and pain, excessive urine and loose stools, and a pale soft tongue, which indicate spleen and kidney qi deficiency, it is recommended to supplement the spleen and kidney with shēng má （Rhizoma Cimicifugae） ,chái hú （Radix Bupleuri）, and chén pí （Pericarpium Citri Reticulatae） removed and adding lù jiăo jiāo （Colla Cornus Cervi） 10 g, tù sī zĭ （Semen Cuscutae） 10 g, dù zhòng （Cortex Eucommiae） 10 g, and zhì fù zĭ （Radix Aconiti Lateralis Praeparata） 10 g （decocted first）.

With excessive urine and loose stools, add yì zhì rén （Fructus Alpiniae Oxyphyllae） 10 g and bŭ gŭ zhī （Fructus Psoraleae） 10 g.

[Main Manifestations]

Early menstrual period with profuse thick sticky dark red or purplish red menses.

[Other Signs and Symptoms]

Emotional vexation, a red complexion, dry mouth, small amounts of yellow urine, dry stools.

[Tongue and Pulse]

A red tongue with a yellow coating; a rapid or rapid and slippery pulse.

[Pattern Differentiation]

Yang exuberance manifests as heat which causes frenetic movement of the blood and causes instability of the chong and ren mai and the uterus. Menstruation arrives early, and the flow is profuse. As the blood is scorched by heat, the menses may become thick and sticky with a dark or purplish red color.

As internal heat harasses the heart, there is emotional vexation. Exuberant heat also consumes fluids causing thirst, yellow urine, and dry stools.

A red complexion, red tongue with a yellow coating, and rapid pulse are also signs of exuberant internal heat.

[Treatment Principles]

Clear heat, cool blood, and regulate menstruation.

[Formula]

Qīng Jīng Săn （Menstruation-Clearing Powder, 清经散）

[Formula Analysis]

Huáng băi, qīng hāo and mŭ dān pí clear heat, purge fire, and cool blood.

Shú dì huáng and dì gŭ pí clear blood heat to generate fluids.

Bái sháo nourishes blood and astringes yin.

Fú líng promotes urination and purges heat.

The entire formula has the effect of clearing heat and purging fire while nourishing yin and cooling blood. When heat is eliminated and yin is well-nourished, blood movement is calmed and menstruation becomes normal.

[Modifications]

With excessive bleeding or bleeding of prolonged duration, add xiān hè căo （Herba Agrimoniae） 15 g, dì yú （Radix Sanguisorbae） 10 g, and huái huā （Flos Sophorae） 10 g.

With vexation and thirst due to a severe heat pathogen, add shí gāo （Gypsum Fibrosum）30 g （decocted first）.

With lower abdominal pain due to blood stasis caused by heat, add yì mŭ căo （Herba Leonuri） 10 g and pú huáng （Pollen Typhae） 10 g （wrapped）.

For excess heat patterns with dampness manifesting with a yellow greasy tongue coating, lassitude, heaviness of the head and a poor appetite, select Lóng Dăn Xiè Gān Tāng （Gentian Liver-Draining Decoction）.

[Main Manifestations]

Early menstrual period with thick red menses which may be profuse or scanty.

[Other Signs and Symptoms]

Malar flush, a hot sensation in the palms and soles, dry throat and mouth.

[Tongue and Pulse]

Red tongue with a little tongue coating, and a rapid and thready pulse.

[Analysis]

Internal heat from yin deficiency destabilizes the chong and ren mai function and leads to frenetic movement of blood and early menstrual period.

Blood insufficiency due to yin deficiency can also affect the chong and ren mai and reduce blood volume.

Deficiency heat may damage the blood vessels; when the blood is driven by heat, menstrual flow can be heavy and thick.

Malar flush results from deficiency heat floating upward.

A feverish sensation in the palms and soles, dry throat and mouth, a red tongue with a scanty coating, and a rapid and thready pulse are all further manifestations of blood heat due to yin deficiency.

[Formula]

Liăng Dì Tāng （Rehmannia and Lycium Root-Bark Decoction, 两地汤） adds bái wēi and guī jiă.

[Formula Analysis]

Dì gŭ pí, xuán shēn and mài dōng nourish yin and clear heat.

Shēng dì huáng nourishes yin, clears heat and cools blood.

Bái sháo harmonizes blood and astringes yin, and ē jiāo nourishes yin and checks bleeding.

Bái wēi clears heat and cools blood.

Guī jiă enriches yin, nourishes blood, and subdues yang.

The entire formula has the effect of nourishing yin, clearing heat, cooling blood and regulating menstruation.

[Modifications]

With ascendant hyperactivity of yang accompanied by dizziness or surging heat and tinnitus, add mŭ lì （Concha Ostreae） 30 g, lóng gŭ （Os Draconis） 30 g, and jí lí （Fructus Tribuli） 10 g.

With insomnia due to deficiency heat, add zhī zĭ （Fructus Gardeniae） 10 g and suān zăorén （Semen Ziziphi Spinosae） 10 g.

With heavy menstrual bleeding, add xiān hè căo （Herba Agrimoniae） 15 g and qiàn căo （Radix et Rhizoma Rubiae） 10 g.

With pain caused by blood stasis, add yán hú suŏ （Rhizoma Corydalis） 10 g and chuānliàn zĭ （Fructus Toosendan） 10 g.

[Main Manifestations]

Early menstrual period with profuse or scanty thick dark red or purplish red menses, or slow （or stop start） flow of menses mixed with clots.

[Other Signs and Symptoms]

Lower abdominal distending pain, chest tightness and rib-side distention, distending breast pain, vexation and irritation, a bitter taste in the mouth and dry throat.

[Tongue and Pulse]

Red tongue with thin yellow coating; a rapid and wiry pulse.

[Analysis]

Liver depression transforms into heat that harasses the chong and ren mai leading to frenetic movement of blood and early menstrual period.

When the free-flow of qi is impaired and the sea of blood is not secured, either heavy or scanty menses can result.

Heat scorching the blood creates thick dark or purplish red menses.

Qi stagnation and blood stasis give rise to inhibited blood flow or the presence of clots; qi stagnation in the liver channel manifests with distention in the breasts, chest, rib-sides, and lower abdomen.

Vexation and irritation with a bitter taste in the mouth and dry throat, a red tongue with a thin yellowish coating, and a rapid and wiry pulse are all features of liver depression transforming into heat.

[Treatment Principles]

Soothe the liver, clear heat, cool blood, and regulate menstruation.

[Formula]

Dān Zhī Xiāo Yáo Săn （Moutan and Gardenia Free Wanderer Powder, 丹栀逍遥散）

[Formula Analysis]

Chái hú, zhī zĭ and mŭ dān pí soothe the liver, relieve depression, clear heat, and cool blood.

Dāng guī and bái sháo nourish blood and soothe the liver.

Bái zhú, fú líng, and zhì gān căo invigorate the spleen and harmonize the middle.

The formula has the effect of coursing the liver, relieving depression of qi, cooling blood, and regulating menstruation.

[Modifications]

Dāng guī is acrid and warm; in cases with excessive menses, dāng guī may be temporarily removed from the formula during the menstruation.

With heavy menstrual bleeding, add xiān hè căo （Herba Agrimoniae） 15 g and dì yú （Radix Sanguisorbae） 10 g.

With excessive bleeding and blood stasis, add yì mŭ căo （Herba Leonuri） 10 g.

If there is distending pain, add chuān liàn zĭ （Fructus Toosendan） 10 g and yán hú suŏ （Rhizoma Corydalis） 10 g.

With constipation, add xuán shēn （Radix Scrophulariae） 10 g and huŏ má rén （Fructus Cannabis） 12 g.

With severe heat pathogen, add xià kū căo （Spica Prunellae） 20 g.

With liver disease transmitting to the spleen manifesting with epigastric fullness and poor appetite, add shān yào （Rhizoma Dioscoreae） 15 g, biăn dòu （Semen Lablab Album） 10 g, and hòu pò （Cortex Magnoliae Officinalis） 10 g.

With a greasy tongue coating, add cāng zhú （Rhizoma Atractylodis） 10 g, bái dòu kòu （Fructus Amomi Kravanh） 6 g （decocted later）, or huò xiāng （Herba Agastachis） 10 g.

[Treatment Principles]

Clear heat, regulate menstruation.

[Main Points]

RN 4 （ guān yuán）, SP 6 （ sān yīn jiāo）, SP 10 （ xuè hăi）

[Modifications]

For excess heat, add LV 3 （ tài chōng） or LV 2 （ xíng jiān） and LV 14 （ qī mén）.

For deficiency heat, add KI 3 （ tài xī）.

For qi deficiency, add ST 36 （ zú sān lĭ）, BL 20 （ pí shù） and BL 23 （ shèn shù）.

With profuse menses, add SP 1 （ yĭn bái）. （moxa）

With vexation, add HT 7 （ shén mén）.

[Manipulations]

Needle following the principles of treating deficiency with supplementation and treating excess with drainage. Needle with even method on RN 4 （ guān yuán） and SP 6 （ sān yīn jiāo）, and needle with reducing method on SP 10 （ xuè hăi）. For qi deficiency, apply moxibustion after acupuncture treatment, or apply warming-needle moxibustion.

[Analysis]

RN 4 （ guān yuán）, located in the ren mai, is the intersecting point of the three yin channels of the foot and serves as a key point to regulate the chong and ren mai.

SP 10 （ xuè hăi） regulates and clears heat from the blood.

SP 6 （ sān yīn jiāo） acts to regulate the liver, spleen and kidney, and is a key point to regulate menstruation.

[Ingredients]

Function: Nourishes yin and clears heat, consolidates menses and stops discharge. Indicated for blood heat due to yin deficiency, or early menstrual period with heavy dark purple menses and vaginal discharge mixed with blood.

Administration: 6 g, twice daily.

[Ingredients]

Function: Nourishes yin and clears heat, invigorates the spleen and nourishes blood. Indicated for early menstrual period with profuse menses, aching lower back and knees, bearing-down pain of the lower abdomen, vexation and irritability, and a feverish sensation in the palms and soles.

Administration: 10 g dissolved, twice daily.

Early menstrual period can resolve in most cases with proper treatment. If accompanied by very heavy or prolonged bleeding, the condition may develop into uncontrolled functional uterine bleeding, which is more difficult to treat. Active treatment for this condition is highly recommended.

1. To avoid damage to middle qi, a regular diet and balanced periods of work and rest are recommended.

2. To avoid excessive mental irritation, a good mood and pleasant spirits should be actively cultivated.

3. Take adequate rest during menstruation; avoid overexertion and dry spicy foods.

Ms. Wei, age 31. Married

Initial Visit: January 30 ^th, 1977

Chief Complaint: Early menstrual period for over one year.

History of Present Illness: The patient had been married for three years without becoming pregnant; her menstrual cycle had also become irregular over the previous year. The menses were moderate, purplish red and mixed with clots, arriving two or three times each month. She also had profuse vaginal discharge, sometimes yellow in color. During the visit, the patient was menstruating and also complained of lumbar and back pain, bearingdown pain in the lower abdomen, dizziness, vexation, and dry mouth with no desire to drink. Her tongue was red and dry; the pulse was rapid, wiry and thready.

TCM Diagnosis: Early menstrual period caused by blood heat due to liver constraint.

Pattern Differentiation: Early menstrual period with purplish menses and clots, bearing-down lower abdominal sensation, dizziness, vexation, and dry mouth are signs and symptoms of liver constraint transforming into heat with frenetic movement of blood. The lumbar and back pain suggests kidney insufficiency with failure to store essence. As the daimai fails to ensure retention, profuse vaginal discharge results. Manifestations of blood heat include a red dry tongue and a rapid, wiry, and thready pulse.

Treatment Principles: Clear heat, cool blood, replenish the liver and kidney

Formula:

Administration: Three packs, taken as a decoction.

Jiā Wèi Xiāo Yáo Wán （Supplemented Free Wanderer Pill） and Liù Wèi Dì HuángWán （Six-Ingredient Rehmannia Pill） were also prescribed to be taken soon after the menstruation, in the morning and afternoon respectively.

For profuse vaginal discharge, shé chuáng zĭ （Fructus Cnidii） 9 g, wú zhū yú （Fructus Evodiae） 3 g and huáng băi （Cortex Phellodendri Chinensis） 6 g were wrapped in a cloth and brewed in water for a twice-daily hip bath.

Second Visit: February 20 ^th

Her major symptoms were alleviated with menstruation occurring the previous day, 20 days from the last menstruation. The number and amount of clots were reduced, and the lower abdominal discomfort, profuse vaginal discharge, vexation, and dizziness were all improved. However, menses were still heavy; and she complained of aching knees and legs. Her tongue was still red and dry, and the pulse was wiry and thready. Treatment was continued with the previous method, but with increased liver and kidney supplementation.

Formula:

Four packs were prescribed.

The medicinal pills and external therapy were also continued.

Third Visit: March 21 ^st

Menstruation arrived 28 days from the last menstruation. The menstrual cycle had almost returned to normal, so the decoction was deemed unnecessary. GYN examination showed unremarkable results. The patient was instructed to continue taking the medicinal pills for another month.

[Analysis]

To address the root cause, dān pí, shēng dì huáng, huáng qín tàn, bái wēi, and líng xiāo huā were first prescribed to clear heat and cool blood. Xiāng fù, chén pí, qiàn căo and liú jì nú were used to regulate qi and resolve stasis to regulate the menses.

Because there was deficiency, dāng guī and dù zhòng were used to nourish blood and supplement the kidney, and hăi piāo xiāo to stop vaginal discharge and arrest bleeding.

This formula acts to cool without congealing and arrest without astringing; this is the best method for both regulating menstruation and nourishing blood. Medicinal pills were also prescribed to support the therapeutic effect.

The second consultation focused on liver and kidney supplementation. Wū méi tàn was applied to restrain the liver, while jiāng cán was used to disperse the liver.

During the entire treatment, the treatment principles of soothing, regulating, clearing and supplementation were employed according to the disease mechanism, thus achieving an optimum result.

[Follow-up]

One year later, when the patient’s mother came to the clinic, she reported happily that her daughter’s menstruation had remained normal since treatment, and also that she had been pregnant for six months.

Source: Gynecological Case Records of Ha Li-tian （哈荔田妇科医案医话选）

How to distinguish early menstrual period from intermenstrual bleeding during the clinical practice?