Membranous Dysmenorrhea/When to use E Zhu and San Leng

As a young practitioner my formulas were simplistic.  I left school thinking that all Qi stasis could be resolved with Xiao Yao San and all blood stasis could be resolved with Tao Hong Si Wu Tang, Xue Fu Zhu Yu Tang or Shao Fu Zhu Yu Tang.  Practice dispels such naiveté quickly!  This is one reason I loved and posted Dr. Xia Gui-Sheng’s little expose on his own learning process regarding the treatment of dysmenorrhea.  It showed how he had to really think it through for himself while studying and considering the nature of various herbal formulas and their ingredients.

Little tidbits from experienced doctors can make all the difference in practice.  For example, Dr. Xia notices that many women get diarrhea when they menstruate.  Because Dang Gui moistens and loosens the stool, he will substitute Dan Shen for Dang Gui in formulas just before and during menstruation for women who suffer from this.  Each herb in his formulas is considered carefully.

In this post I want to introduce readers to another concept I have found helpful in the more refined diagnosis and treatment of dysmenorrhea.  This is the concept of “membranous dysmenorrhea”.   After translating the portion below from Dr. Xia’s work, I expanded my questioning regarding dysmenorrhea in my patients.  I began to ask not only if they had clots in the blood but also 1. Is their pain better after passing a clot? and 2. are any of the clots hard or meat like or even rotten smelling?   These questions are designed to determine, not only if there is membranous dysmenorrhea, but more, if I am going to use San Leng and E Zhu in my formula.  Dr. Xia really enlightened me as to the appropriate use of these herbs.

I had always thought of San Leng and E Zhu as very “harsh” herbs, almost like dynamite!  I thought of them as herbs to use for fibroids.  I thought of them as so harsh dispersing that I had to take a lot of care not to use them if there was deficiency or heavy bleeding.  After reading the passages I am posting below, my view of these herbs changed.  In fact, my view of “breaking blood” Po Xue 破血 changed as as well.   I now feel that I know how and when to work with these herbs.  I especially like the case study at the end in which Dr. Xia first tried his formula mentioned in the previous post Tong Jing Tang but it was not effective.  Looking more deeply he saw that she had clots like corroded meat.  He switched his formula to one that contained E Zhu and San Leng even though she had very heavy bleeding.  He successfully slowed her heavy bleeding with this formula but, when she goes home to Shandong, another doctor quickly takes her off the herbs because he was trained just like I was!  He gives her styptic herbs and what do you know – her bleeding got heavy again!

So now I think of San Leng and E Zhu as pungent deeply “conducting and penetrating” herbs that break down hard accumulations, making them disperse and flow.  Many times heavy bleeding is due to the hard accumulations and so, these herbs can be essential in cases in which there is heavy bleeding due to blood stasis.

I also really like Dr. Xia’s in depth description of what happens in a woman’s pelvis when there is stasis.  I try to encourage my students to SEE, to visualize what is actually happening in their patients.  Dr. Xia makes this effort and teaches us a bit about how to do this.  Here is his writing:

Dysmenorrhea has a relationship to pain presentations.  It is a pain presentation that appears premenstrually, during menstruation, after menstruation or in between menstruation.  This particular pain appears in the abdomen, the breasts, the head or the body.  However it is still related to the menstrual cycle and the formulas relates to this type of illness.  This is generally seen as primary dysmenorrhea, endometriosis, membranous dysmenorrhea, simple dysmenorrhea, menstrual cycle abdominal pain, menstrually related headache, menstrually related body pain or menstrually related breast distention and pain.  The most commonly seen illnesses are primary dysmenorrhea, endometriosis, membranous dysmenorrhea, menstrually related headache and menstrually related breast distention and pain.  I have fumbled about with this for many years and have developed the formulas articulated below:

Zhu Yu Tuo Mo Tang

Ingredients

Dispensing Method:

Take during menstruation, one package each day in 2 doses.

Function:

Warm the menstruation, benefit the Yang, dispel stasis and shed the endometrium.

Applications:

Membranous blood stasis and dysmenorrhea and membranous congealed blood profuse bleeding.

Formula Constituents:

Rou Gui, warms the menses and benefits the Yang.  It opens through, warms and supplements and supports the correct Qi.  It also helps in the shedding of the endometrium.  When the endometrium is congealed and knotted or when the shedding is incomplete, causing endometrial membrane to become old, this herb can help the shedding happen smoothly.  It transforms stasis and helps the membrane slough off.
Wu Ling Zhi: In addition to transforming stasis, this herb also stops pain and stops bleeding.
San Leng and E Zhu: These herbs are strong herbs for attacking, cutting and dispelling stasis.  Originally these herbs were considered the main herbs for dispersing lumps and scattering masses.  For membranous blood stasis that is relatively extreme, these herbs will conduct and penetrate.  Less drastic herbs will not be able to dispel.
Dang Gui, Chi Shao and Bai Shao all vitalize blood and synchronize the menses.
Guang Mu Xiang and Yan Hu Suo stop pain
Zhi Qiao and Yi Mu Cao cause uterine contractions and will help force out the congealed membrane.
After taking this formula, the blood clots from the membranous dysmenorrhea will become smaller and easy to force out.  The pain will lighten and the uterine contractions will become shorter.  This is a clinically effective formula.

Clinical Application

The strength of this formula lies in its ability to treat membranous blood stasis dysmenorrhea.  However, it is also effective for membranous blood stasis that is causing profuse bleeding.  In general it is good to combine this formula with Shi Xiao San.  There are other illnesses that this is appropriate for which I will list below.

Primary Dysmenorrhea:

On the first day of an unmarried girl’s menstruation, she experiences violent lower abdominal pain and an unsmooth flow.  The color of the blood is dark and contains blood clots.  These symptoms are often combined with chest oppression, vexation, and abdominal distention.  The pulse is wiry and thin and the tongue body is dark red.  If the pain is extreme add 5 grams each of Ru Xiang and Mo Yao.

Dysmenorrhea with endometriosis:

On the first day of menstruation there is extreme abdominal pain.  The amount of menstruate may be scanty or profuse with a purple red color and blood clots.  There may also be symptoms of bearing down pain in the lower abdomen or anus.  Movement makes the pain increase.  You can use this formula but you would add 3 grams each of Hu Po and Quan Xie

Retention of the placenta and fetal membrane:

After birth, there is profuse vaginal bleeding.  The color is red and there are small blood clots.  There is lower abdominal distention or pain with paroxysmal bleeding.  The pulse is thin and the tongue body pale red.  You can use this formula though you would add 15-30 grams of Ma Chi Xian and Ma Bian Cao.  If there is dizziness and body weakness with sweating, add Dang Shen 30 gm and Huang Qi 15 gm.

Incomplete miscarriage:

If during pregnancy there is bleeding that is tending to be profuse and paroxysmal with lower abdominal distention, back soreness, wiry thin pulse and pale red tongue body you can use this formula.  If the bleeding is profuse in a weak person and there is not obvious pain and distention,  this formula is not appropriate or should be used with caution.  In the past I treated a married woman and used this formula with Huang Qi, Dang Shen and Chuan Niu Xi.  This was a case of a miscarriage that was not occurring.  The fetus had dies and did not descend.  I gave her 5 packages of this formula and the effect was good.

Modifications

Modification relates to adding and subtracting herbs as well as increasing or decreasing the dosages of herbs.  If there is back soreness that is clear, you should add 10 gm. of Du Zhong, Sang Ji Sheng  and Zhi Gou Ji.  If the back pain is severe you can add 6-10 gm. of Gu Sui Bu and Bu Gu Zhi.  If the lower abdominal pain has a clear cold feeling, you can add 10 gm of Zi Shi Ying (pre-cooked) 6-9 gm of Fu Zi Pian and Ai Ye and 9 gm of Zhi Rou Gui.  These will warm the Yang, dispel cold, promote the movement of blood, and cause the endometrium to break down and shed.  If there is obvious weariness of the spirit, with a bearing down feeling in the lower abdomen and pasty stool you can add Chao Bai Zhu 10 gm, Huang Qi 12 gm, Dang Shen 15 gm and burnt Mu Xiang 9 gm.  This will fortify the Spleen and boost the Qi, warm and transport the central Yang.  This will also increase the strength of the contractions, especially the strength of the contractions.  They will increase in strength and last longer.  If there is Spleen deficiency that goes so far as to cause damp turbidity, you will need to add 10 grams of Cang and Bai Zhu, Guang Huo Xiang 6-9 gm, Pei Lan 9 gm.  If the lower abdominal pain is violent and leads to fainting and cold in the four limbs, you can add Hu Po 3-5 gm, Zhi Mo Yao and Zhi Ru Xiang 5 gm and Jing Tian San Qi 10 gm to control the pain.  The Jing Tian San Qi, Mo Yao and Ru Xiang also have the function of stopping bleeding.  If the menstruation is profuse, you can add Chao Pu Huang (wrapped)6-9 gm, Xue Jie Fen and San Qi Fen 3-6 gm.  If there is vexation, dry mouth, dry stool and constipation, you can add Zhi Qiao 10 gm, Da Huang (added after) 6 gm.  This will clear and discharge and will generally increase the effect of dispelling stasis and shedding the uterine lining.  In terms of altering the dosage of the herbs in this formula; if the stasis and knotting is milder you can decrease the San Leng and E Zhu to 6 gm.. If there is obvious back pain Chuan Duan and Du Zhong can be increased to 12-15 gm.. If there is more pain you can increase the Yan Hu Suo and Wu Ling Zhi to 12-15 gm.

Clinical Experience

My clinical experience with Zhu Yu Tuo Mo Tang can be divided into three parts: 1. Dispelling stasis and shedding the lining: 2. Warming the Yang and transforming the lining: 3. Clinical practice. Clinical practice confirms theory, corrects errors and provides rich understanding.

Dispelling Stasis, Shedding the Lining and Controlling Pain:

This formula has been constructed especially for membranous dysmenorrhea.  However, it not only reduces or controls pain, it can also decrease the amount of bleeding and shorten the time of bleeding.  The basis of this formula is Tuo Mo San.  Tuo Mu San is my own experiential formula from my early days.  This formula was developed as a modification of the formula Hu Po San from the Yi Zong Quan Jian: Fu Ke Xin Fa Yao Jue.  I originally used Hu Po San for serious congealed blood pain.  This type of pain is often seen with endometriosis or membranous dysmenorrhea.  It is especially seen with membranous dysmenorrhea.  This is also associated with insufficient function of the corpus luteum.  Due to the low functioning of the corpus luteum, the secretions of the endometrium are also poor and the endometrium cannot break down and dissolve.  The lack of breakdown makes it difficult for the endometrium to peel off of the uterine wall.  This inevitably will cause and increase in the strength of contractions of the uterine muscles.  Violent contractions lead to spasming.  This is what causes the severe pain and increase in bleeding as well as the increased pain and length of time it takes to slough off the endometrium.  Therefore, dissolving the endometrium and accelerating the shedding of it will alleviate the spasming of the uterus.  The endometrium will be smoothly discharged through the vagina.  This is the principle demand this illness makes and this formula represents the principle treatment method during the menstruation.  It is only this way that the spasming pain and bleeding time will decrease.  Below I will explore the train of thought of this treatment method, formulas and herbs. In the past I went in the wrong direction.  Because there is the saying “When all is open through there is no pain, when all is not open through there is pain” I went with the idea of opening through to relieve pain.  I used Wang Qing Ren’s famous formula San Zhang Zhu Yu Tang to carry out the treatment plan.  This formula includes Tao Ren, Hong Hua, Niu Xi, Chuan Xiong and Chi Shao, which are all important herbs.  After using this formula there was an effect but it was far from ideal. In addition, the amount of the bleeding increased.  I thought of using bug ingredients but I didn’t dare.  These herbs attack and scurry to disperse lumps so I was afraid they would further increase the bleeding.  By chance, I discovered a case of membranous dysmenorrhea in which San Leng, E Zhu and Rou Gui were used.  Not only did the pain decrease but the clots became smaller and the amount of bleeding decreased.  The length of time of bleeding clearly decreased as well.  I studied books that have bearing on these herbs and they all consider them to be fierce dispelling stasis herb that function to disperse lumps, scatter knotting, attack the hard and dispel stasis.  Membranous blood stasis is very deep and far because a sticky membrane, phlegm damp and static congealed blood are formed.  Herbs that are not fierce would be insufficient to drive their way into and burrow in the mortar so as to attack, discharge and dispel.  Wu Ling Zhi is able to transform stasis and stop bleeding and is a principle herb in Shi Xiao San.  It also has a definite function of stopping pain and so it helps the San Leng and E Zhu to dispel stasis.  In addition it is able to protect from excessive bleeding.  Yi Mu Cao and Zhi Qiao both have the function of contracting the uterus and inducing the discharge of the blood.

Supplementing the Kidneys and Warming the Yang has a deep meaning:

Membranous congealed blood  involves a phlegm damp sticky membrane.  Phlegm and damp congeal and knot and do not transform.  This has a relationship with the Yang.  There is a detailed account of this in the book I edited called Yue Jing Bing Zhong Yi Lun chapter on membranous dysmenorrhea.  The root cause of this illness is Kidney deficiency and Yang weakness.  It is also related to the Tian Gui and central Yang water insufficiency.  When there is Yang deficiency, this is also called source Qi weakness.  When there is Yang deficiency and Qi weakness, the Qi transformation is blocked.  This blockage causes a cascade of difficulties: a lack of transformation and movement of the water dampness, an inability to dissolve the turbid phlegm sticky membrane, assist the Chong and Ren vessels, synchronize the Liver Qi, warm the uterus and illuminate the sea of blood.  This is very much as it is written in Zhang Jingyue Quan Shu: Ming Men Yu Wen:  “The Yang Qi of the 5 Zang (referring to the Kidney Ming Men) should not be unable to flow out”   When the Kidney Yang is insufficient, the Qi of the Liver and Heart are also not able to express themselves.  This causes the Qi mechanism to become constrained.  Liver constraint easily causes congealed phlegm.  In addition, When the Qi of the Spleen and Stomach is unable to ascend and spread, this also causes the fluids and liquids to congeal and condense, forming phlegm damp.  The uterus and the Chong and Ren cannot obtain the warming transformation of the Kidney Yang.  Naturally, this causes a contained blockage of phlegm damp and sticky turbidity.  The Yang is deficient and the Qi is weak, the blood movement is unsmooth and this can also cause stasis.  The phlegm damp sticky membrane and the blood stasis conform to each other and this forms membranous dysmenorrhea.  Therefore, when treating during menstruation, treat according to the principles of dispelling stasis and shedding the endometrium.  When the pathology is acute, treat the branch.  You must handle this according to the illness itself, really understanding the contributing factors.  This means taking into consideration the aspect of supplementing the Kidney and benefiting the Yang.  It is because of this idea that the formula contains Rou Gui and Xu Duan.  Rou Gui is pungent, sweet and very warm.  Not only does it warm the Yang, it also helps with the function of dispelling stasis and shedding the membrane.  Furthermore, it also has the function of supplementing the Kidney and assisting the Yang.  Our predecessor, Wang Haogu considered this herb to supplement Ming Men insufficiency, boosts the fire and disperses Yin.  It is a strong herb within the herbs for assisting the Yang.  It has a two-way regulating function in that it both dispels evils and restores the correct.  It warms the Yang and transforms stasis, disinhibits water and dissolves that which is sticky. While treating the branch, it also looks after the root.  It assists the San Leng and E Zhu in their function of dispelling stasis and shedding the membrane.  Chuan Duan is also an herb for supplementing the Kidney and assisting the Yang yet is also has a clear function of vitalizing blood and transforming stasis.  It also has a dual function in that it helps the San Leng and E Zhu to dispel stasis and it helps the Rou Gui to supplement the Kidneys and assist the Yang.  Consequently, it also treats the branch while looking after the root.  It really has a deep relevance.  Rou Gui and Chuan Duan not only have the functions of supplementing the Kidneys and assisting the Yang.  They also work with Yi Mu Cao, Zhi Qiao, Dang Gui and Chi Shao to regulate the contractions of the uterus.  Strengthening the uterine contractions will achieve the function of dispelling stasis and shedding the endometrium.  However, you must alleviate degree of uterine contraction that causes the spasming.  If there is Yang deficiency with flourishing Yang then the Yang is not available to warm the earth.  This is why you will often see diarrhea during menstruation.  Zhi Qiao is rather cold and it opens and discharges Yang Ming.  It can increase and cause diarrhea.  Because of this, you must be careful during menstruation.  During menstruation, you can add Mu Xiang.  This herb also has a good effect for stopping pain.  It regulates Qi, dispels stasis, sloughs off the membrane and controls pain, deserving to be considered an herb that helps regulate Qi.

Clinical Practice, Deepening our Knowledge

When there is opening through there is no pain.  This is the train of thought from many years of treating dysmenorrhea and is beyond criticism.  Yet, I tried out Dr. Wang’s San Zhang Zhu Yu Tang for this type of illness and the effect was not ideal.  In addition, after using Xue Fu Zhu Yu Tang the amount of bleeding increased.  We can see from this experience that the saying “when there is opening through there is no pain, when there is no opening through there is pain” albeit has a certain rationality, yet, when it comes to actual clinical practice, there is more complexity.  There are a variety of types of opening through that can be distinguished such as warming opening through, clearing opening through, general opening through and attacking dispelling opening through.  The herbs for vitalizing blood and transforming stasis also have a great many distinguishing characteristics and a great deal of variety in their inner content.  As I fumbled about I discovered that the effect of San Leng and E Zhu in vitalizing and dispelling blood stasis is as good as Tao Ren and Hong Hua.  However, Tao Ren and Hong Hua tend to cause excessive bleeding.    This is the first thing.
The root of this illness is deficiency while the branch is excess.  The acute issue during the menstruation is the branch for which attacking and opening through is the main principle.  But, within the branch one can care for the root so we must combine this with supplementing the Kidney and assisting the Yang.  In order to do this we should select herbs to warm and open.  For this I use Chuan Duan, Rou Gui and Zi Shi Ying.  The treatment effect is really good.
In clinical practice, when one sees serious pain one must also consider the relationship of this to the Heart and Liver.  When the patient is very anxious, this can make the pain worse.  For this I add Gou Teng and Hu Po to calm the patient down.  Simultaneously there may be violent paroxysmal pain with spastic uterine contractions.  This formula uses Dang Gui, Yi Mu Cao and Chi Shao but you can also add Quan Xie to stop the spasming.  This will control the violent contractions and pain of the uterus.
This foundational formula can function is several ways.  It can warm the Yang, attack and open, calm the heart and sedate spasms.  It is from the abundance of the clinic that I have explored these ideas.

Case Examples

I saw a 26-year-old woman who was from Jinan of Shandong province.  Recently she lived in Nan Jing and was a worker.  She had suffered from membranous dysmenorrhea for 10 years already.  It had gotten more intense in the last year.  Her menstruation began when she was 14, coming every 25-35 days and lasting 5-7 days.  The amount was relatively profuse, the color was purple red and there were relatively big clots.  She had a history of dysmenorrhea.  She got married at age 24 but had not become pregnant.  She had a lot of yellow and white vaginal discharge.  The gynecological exam showed that her uterus was slightly small and the cervix had a slight degree of inflammation.  The ultrasound exam showed no abnormality.  The BBT was biphasic but the temperature in the luteal phase was slow to rise and the luteal phase was short or it lacked stability.  The blood test revealed low estrogen.  Her pulse was wiry and thin and the tongue body was pale red.  The tongue moss was thick.  My initial conclusions were Kidney deficiency and blood stasis.  Her first visit was just when menstruation was starting.  How could I but use Tong Jing Tang.  This is my experiential formula.  After taking the herbs, her menstrual pain decreased but the effect was not ideal.  This required a deeper analysis.  I realized that this patient had violent pain on day two of her cycle and she also had heavy bleeding.  She discharged clots that were like corroded meat.  This was membranous dysmenorrhea, which is also called shedding the endometrium type dysmenorrhea.  During the next menstruation I gave her Zhu Yu Tuo Mo Tang. The pain then greatly decreased and the membranous blood clots became smaller.  The length of time she bled went form 7-8 days down to 5 days.  She used this for 2 cycles before she returned to Shandong for the holidays.  She went to the hospital there and asked for this prescription to be filled.  The doctor at the hospital looked at the formula and was concerned about her using San Leng and E Zhu when she had a history of heavy bleeding.  He took these out and instead added Zong Lu Tan and Xue Yu Tan to stop bleeding.  After taking the herbs, the pain did not become worse but the bleeding lasted for 9 days before stopping.  When she returned to Nanjing, I gave her the original formula and her menstruation went to 5 days.  I advised her to continue the process of treatment.  I used the method of supplementing the Kidneys and synchronizing the menstruation and the next year she was pregnant.  She gave birth to a daughter and after that had no painful menstruation.