A regular menstrual cycle is the natural prerequisite for women’s fertility and therefore lies at the center of fertility treatment in TCM. In contrast to biomedicine, TCM offers numerous treatment options in this area: by means of a sophisticated differential diagnosis, it is able to harmonize a woman’s cycle without any side-effects.

When we compare the physiology of the female organism from the biomedical perspective with the way in which TCM looks at it, we find many similarities and overlaps, but also some basic differences.

From the biomedical perspective, as a rule one egg from the pool of prenatally formed egg cells that enter a dormant stage after birth becomes fertilizable from the onset of puberty on under the cyclical influence of the hormones. In the ideal case, this hormonal cycle takes 28 days, but can deviate by 3–5 days. Around the 10th– 14th day of the cycle, ovulation takes place. In this context, it is considered normal if ovulation fails to take place once or twice a year even in healthy women. The female cycle is divided into two phases in accordance with the stages of follicle formation:

• the follicular phase and
  
• the luteal phase (phase of the corpus luteum)

The regulation of the menstrual cycle is directed by the hypothalamus, which stimulates the hypophysis by releasing GnRH (gonatotropin releasing hormone), to secrete the follicle-stimulating hormone (FSH). In this way, the monthly cycle is set in motion.

Parallel to the maturing of the ovum, estrogen is released in the uterus. This triggers the formation of a new mucous membrane, 0.8–1 cm thick and relatively poor in secretions, on top of the basal layer of the endometrium that was left over from the previous menstruation. This stage is called the proliferative phase.

After the egg has left the ovary, the remaining tissue transforms into the corpus luteum, which now begins to produce progesterone. This is responsible for converting the endometrium by means of secretions, as a result of which the endometrium swells more strongly and at the same time becomes able, as tissue rich in glycogen, lipids, and enzymes, to nurture a fertilized ovum. This is referred to as the so-called secretory phase.

The fertilization of the egg takes place in the fallopian tube. While the fertilized ovum is moving down the fallopian tube to the uterus, as a trophoblast it is already secreting human chorionic gonadotropin (hCG), which preserves the function of the corpus luteum and even causes a rise in progesterone production. Without hCG, the lifespan of the corpus luteum is only 14 days. This so-called measurable pregnancy hormone indicates the additional changes of the endometrium in the case of a pregnancy, referred to as decidualization. Essential for the further development of the endometrium is progesterone, which causes additional changes in the stroma cells, epithelial glands, leucocytes, and arteries, making implantation possible in the first place.

If no fertilization and therefore no implantation of the ovum in the endometrium takes place, the corpus luteum disintegrates and the progesterone level drops, as a result of which the microcirculation of the endometrium is impaired. This leads to the rejection of the tissue, and the menstrual period begins.

In TCM, we know of four functions in which female physiology differs from male physiology:

• menstruation
  
• vaginal discharge
  
• pregnancy
  
• birth

Modern TCM pays special attention to the uterus (bao gong ). As an extraordinary organ, the uterus combines the properties of both viscera and bowels in one. In its role as a viscus, it stores essence, blood, and the fetus; as bowel, it opens during ovulation to receive sperm, as well as during menstruation and during birth.

Because of its special position, the uterus is connected neither to the viscera and bowels nor to the regular channels, but depends for its supply on:

• the eight extraordinary vessels (qi jing ba mai )
  
• the uterine vessel (bao mai )
  
• the uterine network vessels (bao luo )

As vessels, these structures either receive or release qi as needed.

The extraordinary vessels relevant for gynecology include the thoroughfare vessel (chong mai, ), the controlling vessel (ren mai, ), and the governing vessel (du mai, ), as well as the girdling vessel (dai mai, ). The chong mai is regarded as the sea of blood and of the 12 channels, the ren mai as the sea of the yin channels, and the du mai as the sea of the yang channels. The dai mai as the girdling vessel unites all extraordinary vessels, regulates the connection between the upper and lower parts of the body as well as the connection between the fluids, and, like a belt, performs a holding function.

The ren mai, du mai, and chong mai all originate in the uterus and thereby share the same source, while the dai mai rises out of the kidneys. All extraordinary vessels are connected to the dai mai. For this reason, we can also indirectly achieve a regulation of any functions of the other three extraordinary vessels by means of the dai mai.

As we can see from most classical formulas (e. g., the formula Dang Gui Shao Yao San [Chinese Angelica and Peony Powder] from the Jin Gui Yao Lüe), treatment for regulating menstrual periods originally focused on balancing qi and blood. By contrast, the therapeutic approach today aims more commonly at affecting the viscera and bowels. Ultimately, the art of gynecology lies in the ability to bring these two—qi and blood—into harmony. Qi and blood regulate each other: thus, blood functions as the mother of qi by nourishing qi, while qi in turn forms the blood, moves and circulates it, and holds it in the channels.

If qi is exhausted, this can subsequently lead to blood vacuity as well, which affects menstruation in the form of delayed or reduced menstrual periods. If qi fails to contain the blood in the channels, the result is bleeding. If qi stops moving, the circulation of blood is impaired, which results in blood stasis.

Weakness in the blood, on the other hand, means that qi loses its foundation and consequently ascends upward and outward. Blood vacuity can lead to wind and because of reduced fluidity to blood stasis. Any form of blood stasis in turn impairs the formation of new blood. Severe blood loss is bound to also mean a loss of essence (jing) because essence and blood are closely connected in women.

The viscera (zang ) and bowels (fu ) carry out all the physiological functions in the body. Because the viscera form qi and blood, they are essential also in connection with the relationship between qi and blood and for menstruation. This is the reason for our contemporary therapeutic approach to treat menstrual disorders primarily via the viscera and bowels. The most important viscera for the formation of blood are:

• the spleen
  
• the heart
  
• the kidney

The function of controlling the blood is performed by the following viscera:

• the spleen
  
• the liver
  
• the heart

It is always the qi of the relevant viscera that is responsible for these functions.

The heart (xin ) is regarded as the ruler of the internal organs. In principle, it only plays a secondary role in gynecology, but because of the psychological strain that women with fertility problems experience and because of its role as a bloodforming organ, we should still always consider the heart as well, especially since it can affect all other organ functions. In addition, the heart is directly linked to the uterus through the bao mai. The notion that the bao mai is associated with the heart and sends the blood down to the uterus via the heart comes from the Qing period (1644–1911).

The liver (gan ) regulates the circulation of qi and stores the blood. It decides how much blood is in circulation and fills the chong mai with blood. In its important function of blood storage, some physicans of old regarded it as the source of prenatal qi (xian tian zhi qi ) in women—a role that is normally attributed to the kidney. This makes regulating the liver a key issue in all gynecological problems.

The kidney (shen ) is the carrier of prenatal qi and thereby supports growth and reproductivity. Sharing the same yin root (kidney water) with the liver, the kidney supports the functions of the liver, but at the same time stabilizes the functions of the spleen by its yang activity (kidney fire):

The heavenly water (tian gui ) is that part of kidney essence that is responsible for human growth and sexual maturity. The activity of the tian gui becomes apparent in girls when, around the age of 14, the kidney matures, the chong mai overflows, and the ren mai opens. This signifies the arrival of menarche. Menstruation is hence the result of the harmonic cooperation of the tian gui, the extraordinary vessels, and qi and blood with the uterus.

The menstrual cycle (yue jing ) is divided into four phases:

• the menstrual phase
  
• the follicular phase
  
• the ovulatory phase
  
• the luteal phase

Questioning a female patient about her menstrual cycle is an essential prerequisite for making an accurate diagnosis and corresponding therapy in fertility treatment. A healthy menstrual period recurs every 28–30 days and lasts for about 5 days. The menstrual fluids should be discharged without pain and without dribbling bleeding at the beginning or end. The discharged blood can be absorbed by four to five sanitary pads or tampons per day. The blood itself should be neither too runny nor too sticky, without accumulations of lumps or phlegm. The color of normal menses is deep red, almost as if caused by a cut.

Any deviations from the description above offer clues to a woman’s disease pattern and are discussed in detail in each of the corresponding menstrual disorders below. If delayed periods have occurred ever since the beginning of menarche, this can certainly constitute the individual cycle of a woman, which is then to be judged as normal.

According to the author’s personal experience, it is always important in the treatment of gynecological problems to record the exact date of the menstrual periods. This is the only way that we can ensure a precise assessment of the results of any treatment. Only after we have collected the gynecological facts (including the previous history of the patient, the date of her menarche, the entirety of symptoms related to menstruation, lower body disorders, births, etc.), can we then look at additional symptoms that represent the relationship between qi and blood and subsequently the functions of the viscera and bowels. For this purpose, the usual questions, for example about defecation, urination, digestion, or sweating, in combination with pulse and tongue diagnosis, offer clues to localize the disturbance more precisely. In certain cases, it can make sense to work with a basal temperature curve.

Sometimes it becomes necessary during treatment to work with the different phases of the cycle, to support the physiological processes that are natural in each specific phase instead of working against them. We point out such instances in the relevant disease patterns below.

As a rule, we can say that if you want to supplement, it is important to avoid using medicinals that are too warming or too drying. In any strategy, we have to guarantee that blood and yin are maintained and protected. When working with yang, we always have to look after yin at the same time. If it makes sense therapeutically to drain heat to reduce excessive menstrual bleeding, for example, we should use very cold medicinals only as briefly as necessary. Astringing substances to stanch bleeding are permissible, but may not be used at the very beginning of the period, to avoid impeding the natural discharge of blood or even triggering a stasis. It is also important to note that long-lasting periods tend to be at least partly related to blood stasis.

One of the difficulties in presenting treatment here lies in the differences between various therapeutic approaches. Some practitioners work in accordance with the menstrual cycle and write a number of prescriptions (formulas) during one cycle; others attach less value to the cycle and only give one prescription in a single menstrual cycle, but use it deliberately with exact timing. The author tends to follow the latter practice and give a maximum of two prescriptions, usually only one. Some practitioners view the kidney as the crucial organ in the treatment of fertility disorders, others the liver. Furthermore, practitioners today often combine biomedical knowledge with TCM, which can occasionally make a lot of sense but should not distract from the Chinese perspective and diagnostics.

For all these disease patterns, the author has selected representative formulas that are intended to increase our understanding of the treatment of menstrual disorders. In borderline cases, the author has oriented herself by the way in which these subjects are treated in China today. Most of the formulas mentioned in this chapter can be found in standard gynecology texts. This does not mean that there are not many other formulas that could be used. In clinical practice, though, we often find that the combination of patterns and symptoms, personal circumstances, and the causes of menstrual disorders differ greatly from patient to patient and therefore require a flexible approach to the selection of formulas and individual substances. Very famous formulas are hereby only mentioned by name, the author’s personal experiences have been incorporated.

This group subsumes abbreviated cycles and menstrual periods that are too heavy or last too long. The volume of blood lost in a menstrual period is determined by its duration and heaviness. This means that the periods discussed here do not necessarily involve heavier than normal bleeding. A period that has arrived too early or lasts too long can also be very weak. From the perspective of TCM, these disturbances nevertheless all require similar treatment principles and are therefore described here in the same context.

Both TCM and biomedicine regard a menstrual cycle of up to 25 days as normal. If the cycle is shorter than that, though, this can have an effect on the woman’s ability to conceive.

From the biomedical perspective, the following possibilities present themselves: an abbreviation of the follicular phase or of the luteal phase. A disturbance in the follicular phase leads to insufficient maturation of the egg cell and results in problems in the luteal phase, with reduced preparedness for pregnancy and an increased rate of miscarriages. Most of the time, though, the luteal phase is too short. It should last for at least 12 days. An abbreviated luteal phase often shows a weakness of the luteinizing hormone that resulted from a disturbance in the follicular phase even if this was not abbreviated. In cases with a weakness of luteinizing hormone, the nidation of a fertilized egg cell is no longer guaranteed. If the period arrives even earlier, it is questionable whether ovulation has taken place at all.

From the TCM perspective, the cycle is often shortened due to heat or to qi vacuity, causing an inadequate build-up of yin in the postmenstrual phase. Causes for abbreviated periods are:

• blood heat
  
• insufficiency of qi
  
• blood stasis
  
• damp-heat

They are listed here in the order of their frequency. Accordingly, damp-heat is the least common cause.

Blood heat disturbs the regulation of the chong mai and ren mai. Blood heat is the most common cause for a shortened menstrual cycle, whereby we must distinguish between repletion heat (which includes stagnation heat as well) and vacuity heat. Medicinals should be ingested if possible at the beginning of the first half of the cycle so that we can influence a premature ovulation.

In repletion heat, heat penetrates into the bloodstoring chong mai and causes heavy and premature bleeding. This pattern mostly affects women with a strong yang constitution who furthermore have been consuming heating foods and alcohol and tobacco. These “power women” do not feel nearly as exhausted after heavy bleeding as, for example, women with qi vacuity.

Thick, bright red or purple blood, increased blood flow, typically also a feeling of heat in the genital area during the discharge of blood, yellow urine, constipation, thirst, and a red face. The tongue is red with a yellow fur, the pulse is rapid and stringlike or slippery.

Clear repletion heat, cool the blood, and secure the chong mai.

The following formulas all clear repletion heat with cold bitter drugs. For this reason, we must not prescribe them during menstruation because they can otherwise cause blood stasis and further complicate the situation. To push the onset of the menstrual period back in cases with premature bleeding, the best time for taking medicinals is in the first phase of the cycle—that is, directly after the end of the period. At this point of the menstrual cycle, formulas should be very balanced in their thermal nature. We therefore prescribe very cold formulas only after ovulation, and only until 3 days before the expected onset of menstruation, to reduce the amount of discharged blood at the very beginning of the period. During very heavy periods, you can also administer astringing or bloodstanching substances in addition, to better control the period and avoid excessive blood loss.

The following formula represents the classic treatment principle found in any number of gynecology texts. It gently treats repletion heat, nourishes blood, and is suitable for taking right after the menstrual period.

• LR-1, KI-2, ST-44
  
• SP-1 + CV-4 + SP-6 + SP-10

Heat that arises due to stagnation is called depressed heat (also mu yu hua huo, literally: “depressed wood transforming into fire”). The liver is especially susceptible to this pattern, in which case the liver’s storage function makes it quite likely that the heat might move into the blood. This condition is a repletion heat pattern as well.

A shortened cycle with moderate to heavy discharge of dark blood with small clots. At the same time, we may see intermittent complaints like a feeling of pressure below the ribs, dizziness, fullness in the chest, tension in the chest, and a bitter taste in the mouth. Conspicuous also are mood swings and irritability. The tongue is livid and has a thin white or yellow fur, the pulse is stringlike and possibly rapid.

Clear liver heat, regulate the qi, cool the blood, and regulate menstruation.

In cases with latent development of heat in the liver, we can prescribe standard formulas like Jia Wei Xiao Yao San (Modified Free Wanderer Powder) and Jin Ling Zi San (Toosendan Powder), in combination with Si Wu Tang. The specific cause determines the different indications of these two formulas: In cases with insufficient yang, add chai hu (Bupleuri radix); in cases with insufficient yin, increase the amount of chuan lian zi (Toosendan fructus). We can prescribe these formulas in the first half of the menstrual cycle if the patient is balanced, otherwise only in the second half.

Modifications:

• For very pronounced bleeding, remove dang gui from the formula. It is better to add huang qin and sheng di huang to the formula than to replace bai shao yao with chi shao yao (Paeoniae radix rubra), because the latter is too strongly moving.
  
• A proven combination for Xiao Yao San is dan shen (Salviae miltiorrhizae radix) to cool and move the blood, with xiang fu (Cyperi rhizoma) to move the congested qi even more strongly. Dan shen affects the chong mai as well.
  
• Very heavy periods can be cooled and stanched by adding di yu and ce bai ye (Platycladi cacumen).

• LR-2, LR-8, LR-14
  
• LR-6 + HT-4 + HT-5

In patients with vacuity heat, the menstrual periods are characterized by scanty amounts of blood, which are caused by an excess of heat (fire) and an insufficiency of yin (water). The consistency of the blood is rather thin, the color is red to dark red. Additional symptoms are: elevated temperature in the evening, hot palms and soles, disquietude, reduced thirst, a red tongue without fur, and a fine and rapid pulse.

Nourish yin and cool the blood.

The following formula supplements yin and the bodily fluids, to cool vacuity heat and thereby regulate menstruation. Zeng Ye Tang (Humor-increasing Decoction) affects the chong mai and forms the basis of this formula. This is complemented by bai shao yao (astringing and cool), e jiao (drawing the blood inward and thereby mildly blood-stanching), and di gu pi (clearing vacuity heat and affecting the blood level). The formula is outstanding for mid-cycle bleeding, which is usually caused by yin vacuity in combination with heat.

• SP-8, KI-5, KI-14, KI-2, KI-8
  
• CV-6 + LR-1 + KI-10 + LR-3

Securing and holding are functions of the spleen and kidney. When we can no longer discern these functions, this can point to an insufficiency of qi (qi vacuity). An insufficiency of qi leads to an insecurity of the chong mai and ren mai (chong ren bu gu ). We distinguish between spleen qi vacuity and kidney qi vacuity. Depending on the symptoms, we either treat the spleen, the kidney, or both organs simultaneously.

Most early menstrual periods related to qi vacuity are caused by spleen qi vacuity. The spleen is unable to seal the channels and hence cannot hold the blood in the channels because the spleen’s yang function of holding blood is weakened. As a result, we see early menstrual periods with pale red blood in copious amounts, which is, however, not sticky. The longer these periods last, the more they weaken the blood and accordingly lead to lighter and lighter periods.

Exhaustion, shortness of breath after minor straining, reduced appetite, a feeling of pressure in the abdomen, diarrhea, a pale soft tongue with a thin white fur, and a vacuous pulse.

Strengthen qi, secure the ren mai and chong mai, and stanch bleeding.

Bu Zhong Yi Qi Tang is a very popular formula for strengthening the spleen, regaining control over the blood and the chong mai, and lifting qi. It is extremely effective in the treatment of early, but also of heavy menstrual periods. The core ingredients huang qi, ren shen (Ginseng radix), and gan cao have a fortifying effect on the qi. Chai hu and sheng ma (Cimicifugae rhizoma) lift the qi and bring clear yang back to the top. In general, this formula is modified.

Modifications of Bu Zhong Yi Qi Tang (Center-supplementing Qi-boosting Decoction):

The following formula is guided by a similar attempt to lift qi. It is meant to supplement the insufficiency of qi that leads to bleeding and resulting yang vacuity, and thereby fortify the blood.

Rx. Ju Yuan Jian (Origin-lifting Brew):

• huang qi, 12 g
  
• ren shen, 9 g
  
• zhi gan cao (Glycyrrhizae radix cum liquido fricta), 9 g
  
• sheng ma, 3 g
  
• bai zhu, 9 g

Modifications:

• The formula is modified most commonly with gan jiang (Zingiberis rhizoma) or pao jiang (Zingiberis rhizoma praeparatum), ai ye (Artemisiae argyi folium), and hai piao xiao, to stanch existing bleeding more quickly and prevent premature menstrual periods. By adding e jiao, we likewise gently stanch bleeding, while at the same time supplementing the blood.
  
• For severe yang vacuity, we can also include rou gui (Cinnamomi cortex) in addition to pao jiang.

Comparison with Bu Zhong Yi Qi Tang

Compared with Bu Zhong Yi Qi Tang, Ju Juan Jian focuses more on lifting the center. Citri reticulatae pericarpium (chen pi) is removed from Bu Zhong Yi Qi Tang in order to avoid its precipitating effect. Furthermore, e jiao is a better choice for very heavy periods than the warm and slightly moving dang gui. By contrast, Bu Zhong Yi Qi Tang instead emphasizes the lifting (chai hu and sheng ma) and precipitating (chen pi) effects and thereby supports the physiological function of the center. The author herself has achieved excellent results in the treatment of premature or heavy periods with Bu Zhong Yi Qi Tang.

If the patient suffers not only from weakness of the spleen but also from blood vacuity in the heart, Gui Pi Tang is indicated. In such cases, the patient also suffers from palpitations, sleep disorders, and a tendency to brooding and anxiety.

Modifications of Gui Pi Tang (Spleen-returning Decoction):

• Chronic insufficiency of qi is bound to result in blood stasis. In this case, we can, as mentioned above, add xue yu tan and zong lu tan, which both stanch bleeding and move the blood at the same time.

• SP-6, SP-8, ST-25
  
• SP-10 + SP-1 + ST-36

Kidney qi vacuity is a common concomitant complication, even though the literature tends to discuss it as an independent cause. Women who have experienced several miscarriages or interrupted pregnancies tend towards kidney qi vacuity. Young girls also often lean towards kidney qi vacuity. According to a treatment rule in traditional Chinese gynecology, we should treat young women via the kidney, women between the ages of 21 and 42 via the liver, and older women via the spleen. As such, we should generally treat young girls with gynecological problems via the kidney anyway.

Early, very runny menstrual periods that in one cycle are too heavy (inability to contain) and in the next cycle are rather too light (not enough blood and essence). Pain in the lower back, urinating at night, and a deep and vacuous pulse are typical symptoms. The tongue is pale and shows a white fur.

Replenish kidney qi and secure the chong mai.

Rx. Gui Shen Wan (Kidney-returning Pill)²²:

• shu di huang
  
• gou qi zi (Lycii fructus)
  
• shan zhu yu (Corni fructus)
  
• shan yao
  
• tu si zi (Cuscutae semen)
  
• du zhong (Eucommiae cortex)
  
• dang gui
  
• fu ling

Modifications:

• For very strong bleeding, you can add pao jiang, ai ye tan, or hai piao xiao.
  
• In patients with back ache, if du zhong is not enough to treat this symptom, we can consider xu duan and possibly also bu gu zhi (Psoraleae fructus).
  
• For abnormally frequent urination, remove fu ling and add substances like yi zhi ren (Alpiniae oxyphyllae fructus) and jin ying zi (Rosae laevigatae fructus).
  
• For manifestations of cold, lu jiao jiao (Cervi cornus gelatinum) or the considerably cheaper lu jiao shuang (Cervi cornu degelatinatum) can warm, stanch bleeding, and lengthen the menstrual cycle.

• KI-5, CV-4, CV-6, CV-7, TB-6
  
• CV-6 + KI-13 + BL-23 + SP-6

Blood stasis emerges as an accompanying pathology in patients with early menstrual periods, but can certainly also be the primary cause of early periods. Because the channels are blocked, the blood can no longer be contained, which generally leads to irregular and early periods. We often find this pathology in combination with myomas. Blood-moving medicinals should be taken shortly before the onset of menstruation, but especially during menstruation. When the blood clots have already disappeared during the period, it is important in the first half of the cycle to eliminate the accompanying residual heat that possibly caused the premature periods.

Early, heavy, sticky menstrual periods with large, dark red (to almost black) blood clots. The period is accompanied by sharp or stabbing pain that lessens after the blood clots are discharged. The tongue is dark; the pulse is rough or stringlike.

Quicken the blood and eliminate blood stasis.

Rx. Tao Hong Si Wu Tang (Peach Kernel and Carthamus Four Agents Decoction):

• sheng di huang
  
• chi shao yao
  
• dang gui
  
• chuan xiong
  
• tao ren (Persicae semen)
  
• hong hua (Carthami flos)

Modifications:

• Yi mu cao causes the uterus to contract again and can be added in combination with the cooling qian cao, which is able to move the blood and at the same time stanch bleeding and resolve blockages. San qi and pu huang are important additions for eliminating blood stasis.

• LR-2, SP-8, SP-6, PC-5
  
• KI-14 + BL-17 + BL-22 + ST-36

This pathology is the rarest cause of abbreviated menstrual cycles discussed here. In general, it tends to be a concomitant pathology, caused by impaired transformation in the center and often accompanied by heat in the blood. Sometimes, damp-heat also enters from the outside. More commonly, we find this pathology in delayed menstrual periods (see below).

Here, the same rule applies as in repletion heat: bitter, cold medicinals should not be taken during menstruation.

The menstrual period itself is too early, slimy, and has an unpleasant odor. Such women often also have vaginal discharge, which does not have to be yellow but can also be grayish, and burns and itches. We are more likely to find this pattern in very active women who have a lot of heat and therefore sweat a lot and tend towards acne or oily skin. In addition, we see dark, sticky stools and dark urine, a red tongue with a slimy yellow fur in the rear third of the tongue, and a stringlike or slippery and rapid pulse.

Clear heat and eliminate dampness.

The formula Er Miao San (Mysterious Two Powder) is the standard formula for damp-heat in the lower burner and is a good choice in this situation. Gu Jing Wan (Menses-securing Pill) is a gynecological formula thatwe can use in cases of damp-heat with yin vacuity for heavy and early menstrual periods.

The following formula treats damp-heat with concurrent heat-releated damage to the blood by means of the “three yellows”—huang qin, huang lian, and huang bai—with concurrent heat-related damage to the blood.

Rx. Dang Gui Liu Huang Tang (Chinese Angelica Six Yellows Decoction):

15 g each of:

• dang gui
  
• sheng di huang
  
• shu di huang
  
• huang qi
  
• huang qin
  
• huang lian
  
• huang bai

• LR-2, CV-2, CV-3, PC-5
  
• KI-8 + SP-9 + LR-3

Menstrual periods that are regular in terms of the cycle but last unusually long (more than 7 days) and at the same time are heavier than normal are referred to as menorrhagia. They are thus linked to a large volume of discharged blood. Menstrual periods that are characterized by a normal duration but profuse bleeding, requiring more than five sanitary pads (i. e., more than 80 mL), on the other hand, are called hypermenorrhea.

Biomedicine sees the causes of these two disorders primarily in organic changes: myomas, endometriosis, endometritis, polyps, or malignant causes. The cause can, however, also be hormonal. From the perspective of TCM, the causes of early periods and of overly profuse and long periods are identical:

• blood heat
  
• blood stasis
  
• insufficiency of qi
  
• damp-heat

As in early periods, we also distinguish here between repletion heat and vacuity heat, both of which can disturb the regulation of the ren mai and chong mai (re rao chong ren ).

When heat enters the blood level, the result is heavy, bright red, sticky menstrual periods, which may also contain small blood clots. If the heat furthermore dries out the blood, the condition is complicated by blood stasis. The formulas are prescribed before the onset of menstruation, to clear the heat before the period. As in early menstruation, the patient should stop taking medicine approximately 3 days before her period, to prevent cold from invading the chong mai.

These patients are thirsty, irritable, and disquieted, and have red lips and a red tongue with yellow fur. They frequently suffer from constipation and have only scant urine. The pulse is rapid and slippery.

Clear heat and cool the blood to regulate menstruation.

Rx. Bao Yin Jian

• SP-1, ST-25, CV-7
  
• KI-3 + SP-1 + BL-12 + GV-27

Vacuity heat can lead to prolonged periods that, as expected, are not profuse.

Dribbling red menstrual periods, a dry throat with little thirst, dry stools, a red tongue with scant fur, and a rapid and thin pulse or a superficial vacuous pulse in the chi position.

Cool heat, nourish yin, and regulate menstruation.

To treat this pattern, the formula Liang Di Tang is indicated, often in combination with Er Zhi Wan. You can prescribe this formula after the period, but beware that it should not be taken during the period. If the period does not stop in spite of treatment, stanch the bleeding from the sixth day on with astringing medicinals.

Modifications:

• To make the formula stronger, you can add huang bai.
  
• If the periods are accompanied by mild pain, move the blood until 3 days before the onset of the period with yi mu cao and pu huang.
  
• Once you have eliminated the possibility of blood stasis, you can use long gu and mu li, for example, for the purpose of containment. They have a very strong astringing effect.

• KI-5, KI-6, ST-25, CV-5, KI-7
  
• KI-1 + KI-6 + KI-10 + SP-6

In blood stasis, the blood is unable to enter the channels and therefore flows irregularly. The causes of blood stasis are manifold. A typical background in such conditions is myomas or abortions and miscarriages, in which the uterus was subsequently scraped out. Depending on the severity of the blood stasis, you can start moving blood as early as 10 days before the onset of menstruation, and only prescribe the formula until the period is finished. For milder blood stasis, support the discharge of blood only during the period itself.

Heavy periods with dark crimson blood and blood clots, and abdominal pain that is relieved upon discharge of the blood clots. The tongue is crimson with purple spots.

Quicken the blood and eliminate blood stasis to regulate the chong mai.

Rx. Shi Xiao San (Sudden Smile Powder), toasted, plus:

• yi mu cao
  
• san qi
  
• qian cao or

Rx. Tao Hong Si Wu Tang in combination with Shi Xiao San.

Modifications:

• If heat in the blood is contributing to the blood stasis, replace bai shao yao in this formula before the onset of menstruation with chi shao yao and add mu dan pi. Both of these medicinals should, however, be removed during the menstrual period to avoid an effect that is too strongly moving.
  
• If the blood stasis is pronounced, balance the formulas so that you can start moving blood right after the end of the period: blood-building medicinals like e jiao and bai shao yao are very important in this case.
  
• For heavy periods with simultaneous heat, balance with xuan shen or sha shen (Adenophorae seu glehniae radix), for yin vacuity, for example, with the formula Er Zhi Wan.

• SP-8, SP-6, CV-3
  
• KI-8 + KI-10 + LR-3 + SP-6

The loss of so much pale and runny blood manifests in symptoms like dizziness, palpitations, pronounced fatigue, shortness of breath upon exertion, and paleness; a pale and dry tongue and a vacuous pulse complete the picture.

Stimulate qi, nourish the blood, and secure the ren mai and chong mai to regulate menstruation.

All the formulas mentioned in this chapter for insufficiency of qi, such as Bu Zhong Yi Qi Tang, Ju Yuan Jian, and Gui Pi Tang are also indicated here, but we should emphasize the qi-raising function in all of them.

Modifications for Overly Heavy Periods:

• To raise qi, add or emphasize sheng ma, chai hu, and huang qi.
  
• Supplement the blood with e jiao, he shou wu (Polygoni multiflori radix) or shu di huang. For weakness of the center, you can also add sha ren (Amomi fructus), to make shu di huang easier to digest and at the same time direct it into the chong mai.
  
• To stanch very heavy bleeding, we can use ai ye, pao jiang, and hai piao xiao. Duan long gu (Mastodi ossis fossilia calcinata) and duan mu li (Ostreae concha calcinata) are indicated as well.

• KI-8, ST-30, CV-7, SP-1, HT-5
  
• CV-7 + SP-6 + BL-20 + BL-18 + SP-1

Inflammations in the lower abdomen can serve as the cause of damp-heat. In clinic, we often see this in women with IUDs. From the perspective of TCM, this pathology is understood either as damp-heat invading from the outside or in the context of weakness of the center, as a result of which the transformation of dampness is impaired. Dampheat leads to disharmony of the chong mai and ren mai (shi re chong ren bu tiao ). After sinking down, dampness quickly forms heat by means of the ming men fire in the lower burner. If dampness is more prevalent than heat, dampheat tends to manifest in prolonged periods because the dampness obstructs the normal flow of blood through the channels; if heat is more prevalent, we are more likely to see heavier bleeding.

Scant and dark menstrual periods, often malodorous, which do not stop. Before the onset of menstruation, profuse malodorous vaginal discharge and a feeling of heaviness in the body, especially in the legs. Diffuse abdominal pain also when not menstruating, a red tongue with a yellow sticky fur, and a soggy or slippery pulse, especially in the guan or chi positions.

Eliminate dampness, clear heat, and stanch bleeding.

We combine cold and warm medicinals to cool heat while at the same time supporting the center. This formula is prescribed while the patient is not menstruating.

Rx. Si Miao Wan (Mysterious Four Pill):

• huang bai
  
• yi yi ren (Coicis semen)
  
• cang zhu (Atractylodis rhizoma)
  
• huai niu xi (Achyranthis bidentatae radix)

• For inflammations in the lower abdomen, the formula is often supplemented with ren dong teng (Lonicerae caulis), a good medicinal for lower abdominal inflammations, with guan zhong (Aspidii rhizoma) to clear heat and promote uterine contractions, or with ma chi xian (Portulacae herba), a mild toxin-clearing medicinal. In these cases, bai jiang cao (Patriniae herba) is indicated as well.
  
• You can add chun gen pi (Toonae radicis cortex) when the damp-heat is almost completely cleared because of its astringent effect.
  
• To stanch bleeding, di yu, qian cao, and yi mu cao are indicated.

• SP-8, SP-9, CV-3
  
• ST-28 + CV-6 + SP-10 + KI-20

This section includes the following three topics:

• acyclic bleeding
  
• intermenstrual bleeding
  
• spotting

TCM sees all these forms of vaginal bleeding as dysfunctional bleeding, even though they might fall into different categories from the biomedical perspective.

Bleeding that occurs outside of the menstrual period in roughly 2-day intervals, that is, intermittently, before or after the menstrual period and lasts for more than 7 days is referred to in biomedicine as metrorrhagia. Nevertheless, there are also combinations, in which, for example, a regular menstrual period might be connected to a new period by spotting, which is called menometrorrhagia. Hence, we often see both—menorrhagia and metrorrhagia—together and in combination, in which case metrorrhagia is characterized specifically by the fact that it is impossible to discern any rhythmic progression.

The cause of such irregular bleeding can be found either in hormonal imbalance or in endometritis, myomas, polyps, malignancies, or other diseases.

In Chinese, such bleeding is called beng lou. Beng means “flooding,” that is, sudden severe bleeding. Lou means “leaking,” which points to persistent leaking of blood. Even though beng refers to an acute condition and lou to a chronic one, the cause is the same. Both conditions can, furthermore, merge into each other. As such, a beng condition can transform into a lou state after a serious loss of qi and blood; conversely, an untreated lou condition can become a beng state after qi is exhausted or blood stasis has formed.

As a rule, the appearance of beng lou is ascribed to blood heat due to repletion or vacuity heat, spleen vacuity, kidney vacuity, and blood stasis. The presence of heat and a pronounced weakness of center qi are seen as the most important disease triggers.

Disorders of metrorrhagia are complex and their treatment is accordingly difficult. Ye Tianshi and many other physicians of old developed suitable strategies for the successful treatment of beng lou.

In general, such treatments pursue three goals:

• sai liu: to dam the flood; in other words, to stanch the bleeding
  
• cheng yuan: to seek the source of the flooding, that is, to treat the root of the disorder
  
• fu jiu: to restore the old state, or to strengthen the root and consolidate the body

These three stages ultimately merge into each other and cannot be clearly distinguished. A correct diagnosis results in the application of the right treatment principle. In clinic, we tend to find that several consecutive strategies are relevant, often even at the same time. Representative medicinals are listed as examples:

In particularly critical situations, we employ emergency treatment as an additional treatment strategy, carried out independently from the basic strategies discussed above. For this purpose, after severe bleeding we first consolidate qi, as the first step to enable us to stanch bleeding. The reason for this is that a critical loss of blood can lead to collapse, which primarily affects the qi of the center. Emergency treatments therefore call for large amounts of Korean ginseng (ren shen), to affect the original qi and to gain control over the blood:

• Rx. Du Shen Tang (Pure Ginseng Decoction) consists of nothing but hong shen (Gingseng radix rubra [red ginseng]), 15–30 g. Alternatively, you can prescribe:
  
• Rx. Sheng Mai San (Pulse-engendering Powder).

The following treatment patterns and associated symptoms have already been described above and are therefore not repeated here. It is important, however, to remember that beng lou generally involves a number of overlapping patterns. Because of the critical nature of the situation, though, other formulas are also indicated at times. The following disease patterns can be the cause of beng lou:

• blood heat
  
• spleen qi vacuity
  
• kidney vacuity
  
• blood stasis

Heat is one of the key causes in the formation of beng lou. A constitutional tendency towards yang in combination with too much spicy food or emotional strain is usually the cause of this type of uterine bleeding. We distinguish between repletion heat and vacuity heat.

This kind of beng lou is characterized by a sudden onset, most commonly before the onset of the regular menstrual period.

The blood is thick, bright red, and profuse. This is often accompanied by rising heat sensations, thirst, constipation, nervousness, and insomnia. The tongue is red with a yellow fur; the pulse is rapid and stringlike or slippery.

Clear heat, cool and nourish the blood, and stanch bleeding.

Rx. Qing Re Gu Jing Tang (Heat-clearing Mensessecuring Decoction):

• duan long gu
  
• sheng di huang
  
• chao bai shao
  
• gui ban
  
• duan mu li
  
• zhi zi
  
• huang qin
  
• e jiao
  
• zong lu tan
  
• di yu
  
• xue yu tan
  
• xi yang shen (Panacis quinquefolii radix)

This formula works on different levels at the same time: it cools the blood, eliminates heat and dampness, stanches bleeding, supplements blood and yin, and stabilizes the qi. Note also that most of the ingredients are prepared in such a way as to increase their blood-stanching effect.

Modifications:

• Di gu pi could be a good substitution here. Be careful with mu dan pi in this case because it has a moving effect!
  
• Some authors simply use gan cao to supplement qi instead of xi yang shen.
  
• To stanch bleeding, we can, of course, consider additional medicinals like: ce bai ye, for very profuse bleeding ou jie, and xian he cao, which seals incessant bleeding and can stanch bleeding anywhere, regardless of heat or cold, vacuity or repletion.

• SP-10, KI-2, TB-1, LR-14
  
• SP-10 + SP-1 + ST-36

This type of bleeding is more likely to occur after the end of the menstrual period and to continue dribbling for a long time.

Dizziness, disquietude, heat sensations toward the evening, hot palms and soles, a red dry furless tongue, and a fine and rapid pulse.

Nourish yin and cool the blood.

Under these circumstances, we recommend the above-mentioned Bao Yin Jian for vacuity heat, in place of Liang Di Tang—which is here often modified with Er Zhi Wan plus gui ban.

Modifications:

• Gui ban is an important medicinal in this pattern because it strongly nourishes yin, cools and stanches the blood, and at the same time affects the ren mai and chong mai.
  
• For heavy bleeding, appropriate blood-stanching medicinals are, for example: xian he cao, ou jie, or hai piao xiao.
  
• Dribbling bleeding can be influenced with san qi and roasted pu huang.

• KI-6, CV-4, CV-5
  
• KI-10 + LR-3 + SP-6

Spleen qi vacuity can lead to very heavy bleeding. The spleen is no longer able to seal the channels; the chong mai loses its hold and must be secured again.

The blood is runny and bright red. In addition, we see unformed loose stools, fatigue, paleness, and a tendency to bruising.

Supplement spleen qi, secure the ren mai and chong mai, and stanch bleeding.

The formula Ju Yuan Jian has an uplifting function, but must be further modified for beng lou conditions of bleeding with blood-stanching medicinals (see modifications). The following formula strengthens the blood and stanches bleeding.

Rx. Gu Ben Zhi Beng Tang (Root-securing Floodstanching Decoction):

• huang qi
  
• shu di huang
  
• bai zhu
  
• pao jiang
  
• dang shen
  
• dang gui

Modifications:

• Important! Remove dang gui from the formula for beng lou disorders because it is too strongly moving. In its place, use e jiao or he shou wu.
  
• To stanch bleeding in heavy periods, add xian he cao and hai piao xiao; ai ye tan is also appropriate— it has a warming effect while at the same time stanching bleeding.
  
• For dribbling bleeding, you can add jing jie tan (Schizonepetae herba et flos carbonisatae) and yi mu cao.
  
• For uplifting, you can add sheng ma and chai hu and also increase the dosage of huang qi.

• CV-6, CV-7, SP-6, TB-6
  
• LU-7 + SI-1 + PC-7 + CV-17

The following formula, which is related to Zuo Gui Wan (Left [Kidney]-restoring Pill), supplements the kidney, replenishes the qi, secures the chong mai, and regulates menstruation.

Rx. Gu Yin Jian (Yin-securing Brew):

This formula addresses the ren mai, chong mai, du mai, and dai mai with specific medicinals. Fu pen zi supplements the ren mai, shan yao secures the chong mai, lu jiao jiao strengthens the du mai, and wu wei zi secures the dai mai.

Modifications:

• If you want to emphasize yang more strongly, you can add xu duan and du zhong.
  
• You can replace lu jiao jiao with lu jiao shuang.

• KI-6, CV-3, CV-5, KI-27
  
• KI-15 + CV-4 + BL-32 + SP-6

In addition to the already mentioned blood clots and pain, another typical sign of blood stasis is interrupted menstruation. The period stops for 1 or 2 days and then resumes. The tongue is dark; the pulse is rough or stringlike.

Nourish the blood and eliminate blood stasis.

The formula Shi Xiao San, already recommended above for the category of early or profuse menstruation, is indicated in combination with Si Wu Tang.

Modifications:

• Yi mu cao, san qi, and qian cao are proven medicinals that support the blood-stanching effect of the above-mentioned formulas in addition to their cooling and moving influence.
  
• In cases of blood stasis due to cold, ai ye tan is the ingredient of choice. For heat, you can consider di yu. For very strong periods, we can always consider xian he cao.
  
• You can also give your patients Yun Nan Bai Yao (Stop Bleeding Powder) to take at home, thereby conveying the impression that they can take something else on their own to control their periods. This is particularly effective if they are indeed suffering from blood stasis.

• SP-8, LU-7, LR-14
  
• KI-14 + BL-17 + BL-22 + ST-36

Intermenstrual bleeding refers to regularly occurring bleeding at the time of ovulation. Traditionally, this symptom is also called mid-cycle bleeding. It is characterized by an extremely scanty amount and only lasts for 1 or 2 days at the most. It arises from a temporary decline in estrogen during the rupture of the follicle.

From the perspective of TCM, bleeding during ovulation suggests the presence of heat. Experience shows that this heat in intermenstrual bleeding is most often rooted in an existing yin or blood vacuity. The literature often mentions liver heat, dampness with heat, and blood stasis as well, in addition to vacuity heat. When yin transforms into yang during ovulation, the hyperactivity of yang in women with yin vacuity can cause the channels to break, resulting in bleeding. In general, we speak of an insecurity of the chong mai.

In treatment, we give any indicated formulas from the ninth day of the cycle for 1 week, to prevent the bleeding.

The following disease patterns can be involved:

• vacuity heat
  
• liver heat due to qi stagnation
  
• damp-heat
  
• blood stasis

Experience shows that Liang Di Tang is an extremely effective base formula when we add other medicinals in accordance with presenting symptoms.

The light bleeding is intensely red and without clots. Disquietude, lower back pain, and a dry mouth complete the picture.

Supplement yin, strengthen the kidney, clear vacuity heat, and regulate menstruation.

Rx. Liang Di Tang plus:

• Er Zhi Wan
  
• gui ban
  
• e jiao

Modifications:

• To give additional support to kidney yin while at the same time securing the chong mai, you can also add shan yao.
  
• Dark roasted jing jie tan is an excellent substance for stanching the bleeding.

Some practitioners also give the formula Wu Ji Bai Feng Wan (literally “white phoenix, black chicken pills”), a patent remedy for building blood and yin, which is, however, not able to stanch bleeding. The formula Liu Wei Di Huang Wan (Six-ingredient Rehmannia Pill) is commonly used as well, to strengthen yin and thereby treat the root.

• KI-6, KI-27, LR-8
  
• LR-9 + CV-4 + BL-67 + SP-6

If the flow of qi in the liver is blocked, heat can develop quite easily. In particular, yin or blood vacuity often facilitate the development of stasis heat. Yang is no longer balanced by yin and blood and hence harms the channels. The most popular formula for this pattern is Jia Wei Xiao Yao San, often modified with huang qin and Prunellae spica (xia ku cao).

• LR-2, LR-3, LR-8, GV-2
  
• LR-14 + LR-2 + SP-10

During menstruation or while lying in, damp-heat can penetrate into the extraordinary vessels (especially the chong mai) because they are vacuous and vulnerable during this time. Alternatively, dampheat can arise from a weakness of the spleen, as a result of which the transformation of dampness is impaired. Absorbed by the dai mai, this dampness flows downward, stagnates in the lower burner, and easily transforms, also often due to the activity of the ming men fire, into damp-heat. At the time of ovulation, which is characterized by intense yang activity, the presence of damp-heat reinforces yang qi, further injuring the channels.

Regularly occurring intermenstrual bleeding with a slow onset and dark slimy blood; dark urine, vaginal discharge, fatigue and heavy extremities, a red tongue with a slimy yellow fur, and a slippery pulse.

Eliminate dampness, clear heat, and regulate menstruation.

Rx. Si Miao San (Mysterious Four Powder) plus:

• zhi zi
  
• ma chi xian
  
• guan zhong
  
• chun gen pi

Here, zhi zi is supposed to clear heat above the triple burner, guan zhong clears heat in the lower abdomen, and ma chi xian addresses toxic heat. Chun gen pi consolidates the dai mai and should therefore not be added to the very first prescription but only after the damp-heat is mostly cleared.

• LR-5, KI-13, SP-8, SP-9, CV-3
  
• ST-40 + CV-5

Blood stasis impairs the function of the chong mai and leads to bleeding. Experience shows that this is more likely to be an accompanying pathology.

Mild bleeding with very dark blood and blood clots. The pulse is wiry and the tongue is crimson.

Move the blood, disperse the stasis, and regulate menstruation.

• LR-2, LR-5, CV-5
  
• CV-7 + SP-6 + CV-3 + SP-10

Premenstrual spotting suggests a progesterone deficiency, while spotting after the period points more towards an estrogen deficiency.

An incomplete breakdown of the corpus luteum before the menstrual period can lead to spotting that occurs before the onset of menstruation. Occasionally, the basal temperature even fails to drop in spite of the beginning of menstruation. This would then suggest that we are dealing with a luteal deficiency whose cause in turn is found in the first phase of the cycle.

Spotting after the period indicates that the endometrium is detaching only reluctantly during menstruation. For this reason, the period continues dribbling. Sometimes new spotting recurs already after the end of the period. From the biomedical perspective, this suggests that the formation of the endometrium was not promoted sufficiently as a result of estrogen deficiency. We therefore see secondary hemorrhaging. Myomas or polyps can lead to spotting as well.

To carry out the differential diagnosis described above, a basal temperature curve is necessary. Experience shows that spotting is most often caused by blood stasis, but can also be related to yin vacuity.

Premenstrual spotting with dark red blood frequently indicates blood stasis. Nevertheless, you should not move qi and blood before the basal temperature has dropped, after you have eliminated the possibility of a pregnancy. Any blood-moving formula that corresponds to the energetic situation of a woman, such as Tao Hong Si Wu Tang will then solve this problem. To promote the normal breakdown of the corpus luteum, begin the formula 3 to 4 days before the expected onset of menstruation. To support the breakdown of the endometrium, continue the formula into the first few days of the menstrual period.

• LR-2, LR-3, ST-25, SP-10
  
• SP-10 + SP-1 + ST-36

After menstruation is over, that is, on the fourth day of the cycle, we can begin to strengthen yin.

Bright red spotting indicates a yin vacuity. Additional symptoms like heat in the palms and soles, a red tongue with no fur, and a thin and rapid pulse should support this diagnosis.

Nourish yin and the blood, stanch the bleeding.

_________

Rx. Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill)

Modifications:

• It is important to add gui ban to this base formula, as well as other supplementing medicinals like tu si zi, bai shao yao, and the formula Er Zhi Wan.
  
• Important: if the woman could possibly be pregnant (high basal temperature), you must not prescribe medicinals that stanch bleeding, like dan shen, to cool and move the blood!

• KI-6, CV-3, CV-4, CV-5
  
• CV-5 + CV-7 + LR-3

Subsumed under this heading are menstrual cycles that are too long and menstrual periods that are either too short or characterized by a scant amount of blood. Here as well, the principle that we mentioned above applies: this categorization is based on treatment strategy, even if a long cycle does not necessarily always mean a reduced loss of blood.

A period that begins only after 32–35 days or even later is clinically referred to as oligomenorrhea. The delay is most commonly caused by a prolonged first phase of the cycle. The endometrium requires more time to form than the usual 14 days. One of the most common causes from the biomedical view is an ovarian disturbance, which points to hormonal problems and can be recognized, in addition to the basal temperature curve, by an incomplete formation of cervical mucus (disturbed follicular maturation, prolactinemia, polycystic ovary syndrome, reduced response of the ovaries to FSH, or other hormonal malfunctions). Nevertheless, eating disorders and hyperthyroidism can also result in a prolonged menstrual cycle.

From the perspective of TCM, either vacuity or stagnation, both of which prevent the regular onset of menstruation, is responsible for oligomenorrhea. Delayed menstrual cycles are caused by:

• blood vacuity
  
• kidney vacuity
  
• cold
  
• stagnation

They can, however, sometimes also be the result of phlegm stagnation.

Blood vacuity is the most common cause of delayed menstrual cycles. As a rule, we say in TCM that women are more prone to suffer from blood vacuity than men. In women with blood vacuity, the body is unable to form sufficient blood within the regular 28 days to fill the sea of blood (chong mai) and the uterus for menstruation. Previous disorders, severe blood loss, long breastfeeding, or insufficient generation of blood due to spleen qi vacuity, often caused by excessive worrying or a long-term vegetarian diet, can lead to blood vacuity and thereby affect the sea of blood. In cases of spleen qi vacuity, it is important to pay attention to a good digestion and a healthy appetite. The reason for this is that the prescribed medicinals must be absorbed and transformed by the center. For this reason, we must sometimes stabilize digestion first.

The menstrual period, which starts only after 32 days or even later, is thin and pale pink or watery and brownish. The patient is pale, suffers from stupor or dizziness, dry skin or dry eyes, and physical weakness, is thin, and fails to gain weight. Sleeping disturbances may be present as well. Dull pain in the lower abdomen that is relieved by pressure is always mentioned in the literature but has rarely been observed in clinic so far. The tongue is pale red, without any fur, and dry; the pulse is floating and vacuous or fine. Loose stools and a reduced appetite indicate that the center is not functioning properly.

Nourish the blood (and supplement qi), to fill the chong mai and regulate menstruation.

Rx. Xiao Ying Jian (Minor Construction Decoction):

• dang gui
  
• shu di huang
  
• bai shao yao
  
• shan yao
  
• gou qi zi
  
• gan cao

In patients with delayed menstrual periods, you can prescribe this formula as the basis for supplementing blood immediately after menstruation from the fifth day on, to strengthen the reconstruction of the endometrium. It directs its focus clearly to the extraordinary vessels. Dang gui, the best medicinal for filling the extraordinary vessels, fills the chong mai, while gou qi zi directs the supplementing formula additionally to the ren mai and du mai. Shan yao secures the chong mai. In cases with qi vacuity, however, add qi-supplementing substances to the formula.

It is also obvious that the formula addresses the blood as the yin aspect. As in the following formulas, the most important blood-building formula Si Wu Tang is here represented as the base formula.

Modifications:

• LR-9, LR-11, CV-6, ST-36
  
• KI-8 + KI-10 + LR-3 + SP-6

If the body’s ability to supply substances from the kidney for the blood is impaired, this affects liver blood as well as the chong mai and thereby also the menstrual period.

Delayed periods with scanty amounts of blood. Depending on the condition of the kidney, the blood is either bright red (yin vacuity) or pale (yang vacuity). Pain in the lower back or knees, tinnitus, a pale (or red) tongue, and a thin and deep pulse are additional signs of a weakness in the kidneys.

Supplement the kidney and liver, nourish essence and blood, and regulate menstruation.

• CV-3, KI-13, GV-3
  
• CV-6 + CV-3 + SP-10 + SP-8
  
  
  
  • LU-7 + KI-6
    
  • KI-3, CV-4 moxa
    
  • BL-23, GV-4

Cold in the chong mai and ren mai leads to qi stagnation and blood stasis. As a result, we see delayed menstruation with rather scanty amounts of dark thick blood, possibly containing clots. If the blood is pale, this indicates vacuity cold; bright dark or even black blood indicates repletion cold.

The pain that occurs during menstruation is relieved by pressure and warmth; the patient additionally suffers from aversion to cold, cold extremities, cold buttocks and back, pain and tension in the abdomen, and weakness. The menstrual period is runny and dark without clots. The tongue is pale with a thin white fur; the pulse is deep and vacuous, but also fine and slow.

Strengthen yang to regulate menstruation.

Rx. Ai Fu Nuan Gong Wan (Mugwort and Cyperus Palace-warming Pill):

• ai ye, 9 g
  
• wu zhu yu (Evodiae fructus), 4.5 g
  
• rou gui, 6 g
  
• xiang fu, 9 g
  
• dang gui, 9 g
  
• chuan xiong, 6 g
  
• bai shao yao, 6 g
  
• huang qi, 6 g
  
• sheng di huang, 6 g
  
• xu duan, 6 g

In vacuity cold, the stomach and spleen produce less qi and blood. For this reason, vacuity cold occurs together with qi and blood vacuity. This formula promotes the generation of qi and blood by means of ren shen, dang gui, bai shao yao, and chuan xiong. Huang qi supports blood formation. Ai ye, wu zhu yu, and rou gui warm the uterus and support yang. Xu duan supplements yang and moves the blood.

• KI-13, CV-3, CV-4—moxa with cigar or box!
  
• KI-6 + CV-3 + SP-6 + zi gong (3 cun lateral to CV-3)—moxa with cigar or box!

Like a river slowed down by ice, repletion cold in the blood causes delayed, scanty menstrual periods that are dark in color. Cold tends to invade women during the menstrual period when the chong mai is emptied and blood vacuity exists there. We find cold more often than we would expect. The following formula is one of the most commonly used formulas in gynecology. As the result of blood stasis, we find heat in the upper body at the same time. Wen Jing Tang is a pronounced chong mai formula.

The period is delayed, dark, and clotty, accompanied by cold and pain in the lower abdomen, which are relieved by the local application of warmth but sensitive to pressure. This pathology presents with a pale blue tongue and a sunken, slow, and tight pulse.

Eliminate cold, warm the ren mai and chong mai, and regulate the blood.

Rx. Wen Jing Tang (Menses-warming Decoction):

• wu zhu yu, 9 g
  
• gui zhi (Cinnamomi ramulus), 6 g
  
• dang gui, 9 g
  
• chuan xiong, 6 g
  
• bai shao yao, 6 g
  
• e jiao, 6 g
  
• mai men dong, 9 g
  
• mu dan pi, 9 g
  
• ren shen, 6 g
  
• gan cao, 6 g
  
• sheng jiang (Zingiberis rhizoma recens), 6 g
  
• ban xia (Pinelliae rhizoma), 6 g

Modifications:

• If cold has caused a more serious blood stasis with severe pain and large clots, you can add e zhu (Curcumae rhizoma) to break the blood.

• KI-13, CV-3, CV-4—warm needle!
  
• KI-6 + CV-3 + SP-6 + zi gong (3 cun lateral to CV-3)—warm needle!

Stagnation by necessity always leads to blood stasis. The blood becomes thicker (a sign of excess) and blood clots form. Small clots in the menstrual blood point more towards qi stagnation, while large dark clots suggest blood stasis.

Blood vacuity is an ideal breeding ground for the development of qi stagnation. The liver, which regulates the qi, requires a lot of blood for this function. Alternately, though, emotions can also constrain the qi. If qi stagnation results, this in turn affects the blood-forming function of the spleen.

Symptoms associated with a delayed menstrual period due to qi stagnation manifest most clearly shortly before the onset of menstruation. Pulling pain in the rib-sides, mood swings, and tension in the breasts are usually important signs that qi stagnation is involved. The tongue color is inconspicuous or slightly livid, the fur is thin, and the pulse is stringlike, or also very thin when blood vacuity is present.

Regulate qi, strengthen the spleen, nourish the blood, and regulate menstruation.

Depending on the pathology, we can employ different formulas to harmonize the flow of qi. As a rule, you can prescribe these formulas throughout the entire cycle up to the onset of menstruation, whenever the volume of blood is sufficient. Otherwise you have to supplement yin and blood, when you begin taking the formula directly after the period.

Xiao Yao San (Free Wanderer Powder) is the formula indicated for liver qi stagnation with spleen qi vacuity and liver blood vacuity. It treats the liver and regulates the connection to the spleen, which is important for gynecology. This is certainly one of the reasons why Xiao Yao San is one of the most popular formulas in gynecology.

Modifications:

For patients with chronic qi stagnation without blood vacuity, Chai Hu Shu Gan San (Bupleurum Liver-coursing Powder) is an important formula that can also deliver good results in the treatment of premenstrual symptoms.

• LR-3, LR-8, CV-3
  
• LU-7 + BL-18 + BL-23 + BL-17 + SP-6

The mechanisms that lead to blood stasis vary. In all cases of blood stasis, it is important to find the cause. Blood stasis that occurs in the context of delayed menstruation tends to be rooted either in blood vacuity or in cold. The body is not strong enough to eliminate the stasis via the blood, as a result of which menstruation is delayed.

When the menstrual period finally arrives, the patient discharges large dark clots in dark menstrual blood, accompanied by stabbing pain that is relieved upon discharge of the clots. The pain is often worse at night. The tongue is purple, the pulse is typically rough.

Move the blood, resolve the stasis, and regulate menstruation.

Prescribe any formulas up to 7 days before the onset of menstruation as well as during the period, so that the uterus is emptied completely and blood formation is no longer impaired by blood stasis.

The most important formula for blood stasis in patients with blood vacuity is Tao Hong Si Wu Tang (Peach Kernel and Carthamus Four Agents Decoction). The formula Wen Jing Tang is indicated for blood stasis due to cold in patients with existing blood vacuity. It is indicative of Wen Jing Tang that we see signs of cold in the lower body and signs of heat in the upper body. Alternatively, you can also prescribe the formula Sheng Hua Tang (Engendering Transformation Decoction).

For very severe blood stasis due to cold without blood vacuity, the following formula is indicated:

Rx. Jiang Huang San (Turmeric Powder):

• jiang huang (Curcumae longae rhizoma)
  
• e zhu
  
• gui zhi
  
• dang gui
  
• chuan xiong
  
• yan hu suo (Corydalis rhizoma)
  
• mu dan pi
  
• hong hua
  
• bai shao yao

• PC-5, LR-2, LR-14, KI-2
  
• KI-14 + BL-17 + BL-22 + ST-36 + SP-6

Sometimes women mention that they discharge phlegm during the menstrual period. Occasionally, this discharge of phlegm occurs only after menstruation. This is a key sign that we must also treat phlegm in such cases. If the period is delayed because of polycystic ovaries, we should always consider the involvement of phlegm stagnation. Phlegm can be treated at any time other than during the menstrual period.

Fatigue and unwillingness to move, heavy extremities, and overweight (beware: slender women can also suffer from phlegm!), can arise. In spite of sufficient sleep, such women feel quite exhausted and dazed when they get up in the morning, a condition that often only improves 1–2 hours after getting up. Key signs for diagnostic purposes are thick and scanty menses and a sticky white tongue fur, but especially a slippery pulse in the guan position.

Transform phlegm, eliminate dampness, move qi and blood.

The two formulas below are the standard formulas found in the literature for the treatment of phlegm stagnation in connection with the blood. In clinical practice, we often incorporate this strategy into other formulas, or at least it is rare to give one of these formulas alone in this form.

Rx. Dan Xi Shi Tan Tang (Danxi’s Damp-phlegm Decoction:

• cang zhu
  
• bai zhu
  
• ban xia
  
• fu ling
  
• dang gui
  
• chuan xiong
  
• hua shi (Talcum)
  
• xiang fu

This formula treats phlegm stagnation with an aspect of qi stagnation. Dang gui and chuan xiong are supposed to gently move the blood. Hua shi opens the lower body through the urine and is commonly used in cases with blood stasis as a phlegm-eliminating medicinal (Zhang Jiebin’s strategy).

Rx. Xiong Gui Er Chen Tang (Chuanxiong and Chinese Angelica Two Matured Ingredients Decoction):

• chuan xiong
  
• dang gui
  
• chen pi
  
• fu ling
  
• zhi gan cao

• LR-2, LR-5, SP-8, KI-13
  
• ST-40 + CV-5
  
• ST-40 + LU-7
  
• SP-9, CV-12, ST-29

Menstrual periods that occur regularly in terms of the cycle but are scant in volume or last for less than 3 days are referred to as hypomenorrhea. Even though affected women often experience these as normal, they can be one of the causes of infertility. As a result of low estrogen production, the endometrium is too thin and therefore insufficient for the successful implantation of a fertilized ovum.

The endometrium develops after the menstrual period and should be approximately 8 mm thick, according to biomedicine. If the endometrium is too thin, the period will be correspondingly scant or short. If the body is unable to build up enough yin and blood, it cannot transform into yang. An abundance of yin energy is the prerequisite for the birth of yang. From the biomedical perspective, this situation can lead to insufficiently developed egg cells or even a lack of ovulation. Insufficient secretion in the middle of the cycle would also point in this direction.

From the TCM point of view, the same factors that cause delayed menstruation also lead to scant, short, or light menstrual periods. They are here again listed in the order of frequency:

• blood vacuity
  
• kidney vacuity
  
• cold
  
• blood stasis
  
• phlegm-damp obstruction

Blood vacuity is the most common pattern in short or scant menstruation. The causes of blood vacuity are found primarily in the center or the kidney, which has consumed too much essence. In the treatment of vacuity conditions, we therefore always look at the function of the blood-forming organs. Under certain circumstances, you may have to remove sticky medicinals like shu di huang from a formula to avoid straining the function of the center unnecessarily. It would be overburdened in its function of separating the turbid and the clear. Blood-moving medicinals should not be too aggressive in their effect, so as not to do additional harm to the already weakened blood.

In addition to the sign of weak menstrual periods with pale and rather thin blood, affected women present with paleness in the face, a tendency to stupor and dizziness, dry skin, and possibly also dry eyes. The tongue is pale with a thin white fur; the pulse is thin and vacuous.

Nourish the blood, supplement qi, and regulate menstruation.

Si Wu Tang is probably the most important and well-known formula for building blood. As already discussed in the section on delayed menstruation, Xiao Ying Jian is also a good formula, supplementing the blood via the liver and entering the extraordinary vessels. Both of these can easily be modified, depending on the cause of blood vacuity.

Ba Zhen Tang (Eight Gem Decoction) is a standard formula that supplements blood and qi on a general level. If the blood vacuity is rooted in a weak digestive system, Liu Jun Zi Tang (Six Gentlemen Decoction) is indicated. This is a particularly effective combination of Si Jun Zi Tang with dang gui and bai shao yao for the purpose of supplementing the blood. With the addition of chen pi, mu xiang, and sha ren, this formula becomes Xiang Sha Liu Jun Zi Tang (Costusroot and Amomum Six Gentlemen Decoction), which brings blood and qi into the ren mai and chong mai, and has proven extremely effective. The formula Ren Shen Yang Rong Tang incorporates the heart as the ruler of blood into its strategy.

Modifications:

• Blood vacuity always carries with it the danger of blood stasis; for this reason, dan shen is particularly appropriate because it enters the chong mai and easily supplements the blood.
  
• ze lan (Lycopi herba) or yue ji hua (Rosae chinensis flos) are particularly well-suited for gently circulating the blood without injuring it. Both work more by moving qi within the blood and can thereby move stasis. Yue ji hua additionally has a positive effect on the emotions as well.

• ST-30, CV-3, SP-6, ST-25, GV-7
  
• LR-11 + CV-4 + ST-29 + SP-6

Scant, pale, and watery menstrual periods and other kidney signs like pain in the lower back, tinnitus, frequent urination, a pale swollen tongue, and a sunken, vacuous, or fine pulse.

Nourish the kidney and liver, supplement essence and blood, and regulate menstruation.

• KI-13, KI-5, CV-4
  
• KI-8 + KI-10 + LR-3 + SP-6

Dark blood that is discharged only hesitatingly and in small amounts, as well as a feeling of cold in the lower abdomen, desire for warmth, which clearly eases the bleeding, cold extremities, a pale face with a pale or sometimes (in concurrent blood stasis) even dark tongue, and a sunken and tight pulse.

Warm the menses and the channels, dissipate cold, nourish the blood, and eliminate blood stasis.

Rx. Variation of Wen Jing Tang (Menses-warming Decoction):

• dang gui
  
• chuan xiong
  
• rou gui
  
• e zhu
  
• ren shen
  
• mu dan pi
  
• bai shao yao
  
• chuan niu xi

• To bring the warming ingredients of this formula into the smaller channels as well, we can further supplement the formula with hong hua and ji xue teng.

• KI-13, KI-14, CV-3, CV-4—moxa with cigar or box!
  
• KI-6 + CV-3 + SP-6 + zi gong (3 cun lateral to CV-3)—moxa with cigar.

Just as blood stasis can lead to profuse menstrual periods, it can also lead to scant menstruation when the qi is not strong enough to eliminate the stasis via the blood. Under these circumstances, the blood stasis inhibits the blood flow, as a result of which we see only scant menstrual periods. Blood stasis that persists for a longer period of time furthermore prevents the generation of new blood, a problem that resolves itself when the blood stasis is eliminated. In this picture, blood stasis is often caused by qi stagnation, heat, or cold.

Menstrual periods with scant amounts of tar-like blood, containing clots. The blood is discharged only hesitatingly and the period is accompanied by pain in spite of its lightness. The tongue is dark and the typical pulse is rough and often also stringlike.

Nourish the blood and eliminate blood stasis.

Unlike in the other patterns, we give the blood-moving formulas also after the menstrual period in this pattern. Tao Hong Si Wu Tang is the allpurpose formula for moving blood. It is especially suitable in this context. It nourishes and moves the blood while at the same time protecting it from the acrid moving medicinals.

Modifications:

• In cases with more severe blood stasis, you can replace bai shao yao with chi shao yao. For additional stagnation heat that has damaged the blood fluids, replace shu di huang with sheng di huang.
  
• Chuan niu xi is added to direct the medicinals downward.
  
• To regulate the qi in concurrent qi stagnation, we can add zhi ke, xiang fu, and Linderae radix (wu yao).

• LR-2, LR-8, GB-26, KI-15, CV-7
  
• CV-7 + SP-6 + CV-3 + SP-10

Phlegm-damp leads to obstruction in the uterus (bao gong tan shi zu zheng ). Phlegm that causes scant menstruation, on the other hand, is rarer.

The menstrual period is scant, the patient has profuse vaginal discharge, a physical feeling of heaviness, and in the mornings phlegm in the throat. The tongue is swollen and has a thick fur; the pulse can be sunken and fine if the pathology has already entered deeply into the network vessels, or otherwise slippery and stringlike.

Disperse phlegm, transform dampness, strengthen the center, and regulate menstruation.

You can prescribe the formulas any time other than during menstruation. The treatment principle of nourishing and moving blood during menstruation runs counter to the treatment of phlegm—namely, to dry.

Rx. Xiong Gui Er Chen Tang (Chuanxiong and Chinese Angelica Two Matured Ingredients Decoction):

• Rx. Er Chen Tang plus:
  
• dang gui
  
• chuan xiong

Modifications:

We can modify this formula in numerous ways. Instead of or in addition to the blood-building ingredients, we can:

• LR-5, PC-5, CV-3
  
• SP-6 + SP-10 + CV-4 + TB-6

A menstrual period that occurs in longer intervals than normal (i. e., more than 28 days) is called oligomenorrhea. If the menstrual period is completely absent for more than 3 months, we speak of amenorrhea. Primary amenorrhea refers to cases where a woman has never had a menstrual period, that is, menarche never arrived in the first place. Secondary amenorrhea means that menstruation has stopped for at least 3 months, after initially beginning at the appropriate age.

Keeping track of the basal temperature curve during treatment can be very useful for matching treatment to a gradually forming cycle, if you are unsure of your pulse diagnosis. At the beginning of any treatment, focus the formula on the existing pathology and try to lay the foundations for a cycle: this means sufficient yin and blood. The next step can then be to promote ovulation. When the desired ovulation finally takes place, it is important to change the treatment principles to strengthening yang and subsequently to moving blood, to promote the elimination of blood.

In the prehistory of a patient with amenorrhea based on blood vacuity, we often find only scant, pale red menstrual periods that were initially delayed and gradually stopped altogether. The chong mai and ren mai are no longer filled sufficiently, and menstruation stops. Sometimes, menstruation fails to reappear after childbirth, miscarriage, or lactation, because the woman has lost too much blood. If breastfeeding did not last for more than 6 months, this suggests a weak constitution. In this context, it is especially important to regulate the center because it is the main source of blood formation and over time in vacuity conditions also exhausts the kidneys.

Paleness in the face, stupor, dizziness, a pale tongue, and a fine and vacuous pulse.

Nourish the blood, supplement qi, and regulate menstruation.

• LR-1, SP-4, ST-30, GV-7
  
• CV-6 + CV-3 + SP-10 + SP-8

Kidney vacuity always means a relative weakness of yin or yang.

Late menarche, always rather scant menstrual periods until menstruation finally stops completely, dizziness, tinnitus, soreness or pain in the lower back, or other signs of kidney yin vacuity, with a red or pale tongue and a sunken and fine or vacuous pulse. If you see constipation and thirst, this indicates heat, which exhausts the blood and fluids and often announces itself by overly frequent menstrual periods that turn into absent ones.

Strengthen yin and essence, reduce the heat, connect the heart to the uterus, and regulate menstruation.

• KI-5, KI-13, CV-4, GV-3
  
• KI-8 + BL-23 + CV-6 + CV-4 + SP-6

Kidney yang vacuity often occurs in combination with spleen vacuity.

Absent menstruation, sensitivity to cold, cold feet, frequent urination, diarrhea, and fatigue. The tongue is pale and moist, the pulse sunken and vacuous.

Replenish yang and regulate menstruation.

• CV-4, BL-23, KI-27
  
• KI-11 + BL-23 + CV-4 + SP-6

__________

Mood swings, pronounced frustration, tension in the breasts, pulling pain in the lower abdomen. Normal or reddish or livid tongue color with normal tongue fur. The pulse is stringlike or fine.

Regulate qi, nourish the blood, and regulate menstruation; if necessary, also clear heat.

The famous formulas like Si Wu Tang in combination with Xiao Yao San, Chai Hu Shu Gan San, and Jia Wei Xiao Yao Tang (Supplemented Free Wanderer Decoction) are very effective.

Modifications:

• To place more emphasis on treating the emotions, you can add medicinals such as Albizziae cortex (he huan pi) to gently move qi, harmonize the liver and spleen, and quiet the spirit; this is also good in combination with yu jin, which moves qi, also in the blood.
  
• In cases with developing heat, use chi shao yao instead of bai shao yao, to cool and to move, often in combination with mu dan pi to cool the liver.
  
• We can lower prolactin levels with high doses (20–30 g) of mai ya.

• LR-8, GB-26, CV-24, ST-30, LR-1
  
• LR-11 + CV-4 + ST-29 + SP-6

Insomnia, palpitations, profuse dreaming, disquietude, great sadness because of existing childlessness, and fear that this will remain so.

Stabilize the shen, regulate heart qi, and regulate menstruation.

A few of the important heart-regulating medicinals follow:

• he huan pi—moves qi and quiets the spirit
  
• gou teng—relaxes, loosens, and quiets the spirit
  
• suan zao ren—nourishes the blood of the heart and liver and leads the blood into the bao mai
  
• dan shen—moves the blood and cools the heart
  
• yuan zhi—opens the heart, in anxiety and when heart and kidney fail to communicate with each other
  
• long gu—for very strong heat and resulting disquietude

When prescribed together, suan zao ren and yuan zhi are very important medicinals in the treatment of infertility, used with the intention of bringing heart qi down into the uterus.

• KI-27, HT-5, LU-7, CV-24
  
• KI-5 + HT-5 + LR-1

It is not uncommon for blood stasis to develop after surgical interventions, but other unknown inflammations can also lead to adhesions that obstruct the blood flow. As a cause of amenorrhea, however, blood stasis is rarer. The following formula can also be modified for qi stagnation that leads to blood stasis.

Rx. Xue Fu Zhu Yu Tang (House of Blood Stasisexpelling Decoction)

Modifications:

• Xiang fu and yi mu cao are proven medicinals for focusing the formula more strongly on the lower abdomen when you remove jie geng (Platycodonis radix).

• LR-1, LR-14, LR-2, PC-5
  
• CV-7 + SP-6 + CV-3 + SP-10

When cold penetrates into the uterus, blood stasis results. The female organism is particularly sensitive to cold influences right before and during menstruation. Cold foods like ice-cream or raw foods, going outside with wet hair, or swimming during the menstrual period are common causes that can lead to amenorrhea due to cold.

Complaints that can be relieved completely by warmth. The tongue is pale and the pulse is slow.

Warm the menses, eliminate cold, nourish the blood, and eliminate blood stasis.

Rx. Wen Jing Tang (Menses-warming Decoction):

• ST-28, CV-4, CV-3, KI-5
  
• KI-8 + BL-23 + CV-6 + CV-4 + SP-6

• LR-2, LR-5, SP-8, CV-5, PC-5
  
• ST-40 + CV-5

Irregular menstrual periods are periods that fail to occur at regular intervals. They can arrive earlier or later than expected. This condition results from a disharmony between qi and blood, or in gynecological terms, a disharmony between ren mai and chong mai. In most cases, we find the cause in liver qi stagnation or less frequently in a disharmony that is the result of kidney or spleen vacuity.

In most cases, it is younger women who suffer from menstruation at irregular intervals. Experience shows that they commonly suffer from chronic tension that eventually manifests also in the menstrual periods. Liver qi stagnation on the one hand causes delayed menstruation because the stagnation obstructs the free flow of qi and blood. With the onset of the menstrual period, the body can eliminate the stagnation, but then tends to develop heat in the next cycle, which leads to the next period arriving too early. In this way, the cycle swings back and forth.

Irregular menstruation with dark blood containing small clots, pulling pain during menstruation, premenstrual complaints with persistent mood swings, very depressed, then in turn very irritated, an inconspicuous tongue, and a stringlike pulse.

Harmonize the liver and regulate the blood.

The formulas are taken after the end of the menstrual period during the entire cycle. Experience has shown that we do not have to treat cycles of different lengths differently.

Rx. Xiao Yao San (Free Wanderer Powder)

Modifications:

• To regulate liver qi and the blood even more strongly while at the same time cooling the heat, add xiang fu, chuan xiong, chuan lian zi, and yu jin.
  
• Fo shou moves qi, but at the same time also harmonizes the center, which is suffering from excessive tension in the liver.

The following formula focuses on replenishing the kidney and liver and treats the stagnation only secondarily.

Rx. Ding Jing Tang (Menses-stabilizing Decoction):

• tu si zi
  
• bai shao yao
  
• dang gui
  
• shu di huang
  
• shan yao
  
• fu ling
  
• chao jing jie (Schizonepetae flos frictus)
  
• chai hu

• LR-2, LR-5, ST-30, SP-6
  
• LR-9 + CV-4 + BL-67 + SP-6

In kidney vacuity, we are always dealing with the relative balance of yin and yang. These two aspects can swing back and forth. If the balance swings towards kidney yin vacuity, we see early menstrual periods, in which the heat is discharged. The periods are characterized by bright shiny blood. The resulting relative kidney yang vacuity leads to delayed menstruation.

Scant but runny periods without clots, fatigue and pain in the back, dizziness, and tinnitus. The tongue is pale with little fur; the pulse is vacuous, especially in the chi position.

Replenish the kidney and liver, regulate menstruation.

The following formula focuses on replenishing the kidney and liver and treats the stagnation only secondarily.

Rx. Gu Yin Jian (Yin-securing Brew):

• ren shen
  
• shu di huang
  
• shan yao
  
• shan zhu yu
  
• yuan zhi
  
• zhi gan cao
  
• tu si zi
  
• wu wei zi

• KI-2, KI-5, KI-8, KI-14
  
• KI-13 + BL-23 + CV-6 + SP-6

Stagnation, blood stasis, and cold, as well as vacuity of qi, blood, and of fluids can disrupt the normal flow of energy and lead to blockage, which manifests in pain before, during, or after the menstrual period.

In conjunction with menstrual pain, numerous symptoms can manifest such as diarrhea, nausea, vomiting, headache, pulling pain in the thighs, or pronounced shivering. These symptoms can often give us an indication of the overall energetic state of the patient, which we then need to incorporate into the therapy.

In qi stagnation, we can differentiate between conditions caused by vacuity and conditions caused by repletion, even though they ultimately always constitute a repletion state. On the basis of this distinction, we must treat them differently. For this purpose, we can subdivide all cases roughly into:

• qi stagnation with vacuity
  
• qi stagnation with heat

In general, we can say that menstrual pain due to qi stagnation has a tendency to arise before menstruation and to disappear with the onset on the 1st or 2nd day. Menstruation is often associated with premenstrual complaints like tension in the breasts, increased sensitivity, or the desire for physical activity before the beginning of the period. Most of the time, qi stagnation is treated in the second half of the cycle.

The period is either scant or normal in volume, starts only slowly, and tends to be dark in color. There may be small clots. Patients are sensitive to pressure, which indicates repletion. The pain comes and goes. The pulse is stringlike, in existing blood vacuity also fine.

Dysmenorrhea due to qi stagnation responds well to treatment with formulas like Xiao Yao San, especially when the cause of the pain is related more to psychological factors and the stagnation has developed as a result of internal tension against the background of qi and blood vacuity. The relationship of blood and qi in the liver is the key to a harmonious qi flow. To a certain extent, the blood controls qi to make it soft and even.

Nourish the blood and regulate liver qi to regulate menstruation.

There are many formulas that can regulate liver qi. If the stagnation enters more deeply into the blood but has not yet developed into blood stasis, Chai Hu Shu Gan San is an excellent formula.

Modifications:

• To relax the patient emotionally as well, we can add other medicinals like he huan pi and yu jin.
  
• If heat develops as the result of the stagnation, mu dan pi and zhi zi are the most important medicinals; we refer to this modification as Jia Wei Xiao Yao San. Xia ku cao and huang qin are important medicinals for liver heat as well.
  
• Painful diarrhea during menstruation is treated with additions like Saposhnikoviae radix (fang feng) and chen pi, according to the formula Tong Xie Yao Fang (Pain and Diarrhea Formula). Mild diarrhea without pain can often be regulated with bai zhu alone.
  
• If the liver invades the stomach, we can consider wu zhu yu, ban xia, and chen pi. These medicinals bring down stomach qi and thereby restore the normal flow of energy.

• LR-8, SP-8, LU-7, KI-4
  
• CV-6 + CV-7 + LR-1

If stagnation leads to heat, we often see symptoms like headache, insomnia, disquietude, or acne in conjunction with the well-known signs of qi stagnation. These appear before the period and recede with the onset of menstruation.

Nourish the blood, cool the liver, and regulate qi to regulate menstruation.

Rx. Xuan Yu Tong Jing Tang (Stagnation-diffusing Menstruation-promoting Decoction)

• dang gui
  
• bai shao yao
  
• mu dan pi
  
• zhi zi
  
• bai jie zi (Sinapsis albae semen)
  
• chai hu
  
• xiang fu
  
• chuan yu jin (Curcumae radix sichuanensis)
  
• huang qin
  
• gan cao

• LR-8, SP-8, LU-7, KI-4
  
• CV-6 + CV-7 + LR-1

Blood stasis is, like phlegm, always a secondary pathology. This means that we must consider different formulas, depending on the cause of the blood stasis. Because the uterus is located in the lower burner, cold is the most common trigger of blood stasis. We generally treat blood stasis from about 1 week before menstruation on and during menstruation itself, to free the uterus from the stasis. In cases of severe blood stasis, you can also treat throughout the entire cycle, as long as you nourish the blood itself sufficiently and protect it from the acrid medicinals. Otherwise you could easily set off premature menstrual periods.

The causes of blood stasis can be manifold. The condition develops from:

• qi stagnation
  
• vacuity cold
  
• cold-damp
  
• damp-heat
  
• qi and blood vacuity

The key symptom of menstrual pain due to blood stasis is large blood clots. After their discharge, the pain disappears. While the pain can also arise before the period, it primarily occurs during the 2nd and 3rd day, worsens at night, and has a lancing characteristic. The tongue is purple with stasis macules; the pulse is rough, stringlike, and in severe pain tight.

The nature of the pain often offers important clues to the therapeutic approach: pain that is felt only in the center of the abdomen suggests that the stagnation is located in the uterus, while pain on the sides points to an involvement of the liver channel. Pain in the back indicates an involvement of the kidney, and downward-pulling pain suggest qi vacuity, which we must treat with uplifting medicinals like sheng ma, huang qi, or chai hu, in spite of the blood stasis. Sudden knife-like pain indicates blood stasis.

• SP-8, SP-10, SP-6
  
• KI-14 + BL-17 + BL-22 + ST-36 + SP-6

In addition to the symptoms mentioned above, pain and premenstrual complaints arise already in the run-up to the menstrual period.

Regulate the qi, move the blood, and eliminate the blood stasis to regulate menstruation.

Modifications:

• It is important to remove jie geng from the formula and add medicinals such as xiang fu, which bring the formula into the lower burner.
  
• For pain that occurs primarily in the lumbus, we can add ingredients like xiao hui xiang (Foeniculi Fructus) and ju he (citri reticulatae semen).
  
• Pain in the thighs can be treated with qin jiao (Gentianae macrophyllae radix).
  
• Besides tao ren and hong hua, other important medicinals for moving blood with great clinical relevance are: yi mu cao, yan hu suo, ze lan, e zhu, and san leng (Sparganii rhizoma).

• LR-3, SP-6, SP-10, TB-6
  
• CV-7 + SP-6 + CV-3 + SP-10

Severe pain during the menstrual period, which is rather scanty. Even though the blood clots are quite small, we find typical signs of blood stasis. The tongue is pale and livid, the pulse stringlike and fine or rough.

Nourish the blood and eliminate the blood stasis to regulate menstruation.

Rx. Tao Hong Si Wu Tang

Modifications:

• If qi stagnation exists as well, we can supplement this formula effectively for corresponding symptoms with the addition of xiang fu, yi mu cao, and mu xiang.

• LR-8, LR-2, SP-8, BL-17
  
• LU-7 + BL-18 + BL-23 + BL-17 + SP-6

It is a mistake to believe that cold is practically non-existent in our latitudes and in our lifestyle with central heating. A large number of our female patients who seek treatment for dysmenorrhea do in fact get treated with a warming formula like Wen Jing Tang.

Pain that occurs already before or only during menstruation, dark blood with clots, scant amounts of blood with a tendency to delayed onset, pain that is relieved by warmth. The pulse is sunken, rough, and fine.

Eliminate the cold and the blood stasis and nourish the blood to regulate menstruation.

Rx. Wen Jing Tang (Menses-warming Decoction)

Modifications:

• For concomitant headaches, chong wei zi (Leonuri fructus) is an important medicinal.
  
• We can treat a feeling of tension in the lower abdomen with wu yao and xiao hui xiang.
  
• For very severe pain, we can add the formula Shi Xiao San.

• SP-4, SP-8, ST-30, ST-28
  
• SP-4 + SP-30 + CV-4

Pain before or during menstruation, scant sticky blood with clots, pain that is sensitive to pressure but relieved by warmth, cold and heavy extremities, and other signs of excessive dampness, a pale tongue with a white sticky fur, and a sunken and slippery pulse.

To regulate menstruation, warm the channels to dispel cold, eliminate dampness, and expel the blood stasis.

Rx. Gui Zhi Fu Ling Wan (Cinnamon Twig and Poria Pill) or

Rx. Shao Fu Zhu Yu Tang (Lesser Abdomen Stasisexpelling Decoction) plus:

• cang zhu
  
• fu ling

Shao Fu Zhu Yu Tang is warming; we must add medicinals for treating the dampness.

Modifications:

• Yi yi ren, che qian zi (Plantaginis semen), and gan jiang can be added as well to complement the treatment of dampness.

• CV-2, CV-3, KI-14, KI-2
  
• ST-25 + CV-9 + SP-6

If the patient has a pre-existing damp-heat constitution or if cold-damp transforms into damp-heat, we will see prolonged and malodorous menstrual periods and yellow vaginal discharge. In more chronic conditions, we find symptoms that affect the whole body like dry stool due to the development of heat in the blood, vaginal eczema, or dark urine. The tongue is red with a yellow fur, and the pulse is slippery and rapid.

Clear the heat, expel the dampness, and eliminate the blood stasis to regulate menstruation.

Rx. Qing Re Tiao Xue Tang (Heat-clearing Bloodregulating Decoction):

• mu dan pi
  
• sheng di huang
  
• huang lian
  
• dang gui
  
• bai shao yao
  
• chuan xiong
  
• hong hua
  
• tao ren
  
• e zhu
  
• xiang fu
  
• yan hu suo

Modifications:

• To emphasis the heat-clearing action of this formula even more, we can add hong ten (Sargentodoxae caulis) and bai jiang cao, and for the dampness, yi yi ren and che qian zi.

• LR-8, CV-2, PC-5
  
• KI-5 + SP-6 + CV-3

After the end of the menstrual period, the chong mai is empty. If the patient is weak, we will now see dull pain and exhaustion. Simple formulas like Ba Zhen Tang or Shi Quan Da Bu Tang (Perfect Major Supplementation Decoction) are indicated here as well.

The pain appears either after menstruation or during the last days of the period, when the ren mai and chong mai are already empty. The patient has a desire for physical touch, the menstrual period is weak, pale, and runny. The tongue is pale with a thin white fur; the pulse is vacuous or fine.

Supplement qi and nourish blood.

Rx. Sheng Yu Tang (Sagacious Cure Decoction):

• Rx. Si Wu Tang plus:
  
• huang qi
  
• dang shen

Here, huang qi is the main ingredient to promote the movement of blood.

Depending on the symptoms, we can add many medicinals:

• For pain in the back, du zhong, sang ji sheng, xu duan, and tu si zi are suitable.
  
• For dizziness and palpitations, consider gou qi zi and ye jiao teng (Polygoni multiflori caulis).

• LU-7, TB-6, CV-6
  
• LU-7 + BL-18 + BL-23 + BL-17 + SP-6