Painful Menstruation

Dysmenorrhea is a very common presentation in our clinical reality, either as a main complaint or as a symptom women have become resigned to.  Many practitioners have the experience of women telling us that there menstruation is normal.  When we question more deeply we hear that they experience significant pain, managed by medication.  Dysmenorrhea is considered to be a normal part of being a woman by many.

For some women, the pain is so extreme that they KNOW it is not normal. It is often accompanied by other symptoms such as vomiting, fainting, migraines, exhaustion, and digestive upset.  Dysmenorrhea can be very debilitating.  In addition, many of our patients who suffer from dysmenorrhea are unable to become pregnant.

As a teacher of Chinese herbal medicine, I am aware that our foundational educations often leave practitioners with very limited tools for treating this illness.  All we really learn is that dysmenorrhea is blood stasis and to treat blood stasis we give formulas like Tao Hong Si Wu Tang or Xue Fu Zhu Yu Tang.  These types of formulas will have very limited if any effectiveness.  So, I thought I would do a series of blogs posts on dysmenorrhea.

Some of this information is taken from the writings of Dr. Xia Gui-Sheng, some from one of my teachers Dr. Qui Xiao-Mei, some ideas regarding the use of classic formulas and some ideas from my own experience.  You can see other writings of the two above mentioned doctors by looking at the categories to the right.

I am starting this series with a wonderful passage from the writings of Dr. Xia Gui-Sheng from his book Gynecology Formulas and Herbs: My Clinical Experience in 15 Chapters.

The passage below is one of my favorites because it shows us that Dr. Xia had to go through his own experience of feeling limited by what he had learned.  He thought about his experience deeply and, over time, integrated what were the essential ideas.

Dr. Xia, when exploring the treatment of dysmenorrhea, realizes the importance of the following:

1. Regulating the Qi and freeing flow
2. Stopping ppain
3. Warming
4. Going to the right location – the uterine vessels
5. Suffering is related to the Heart

“When treating dysmenorrhea, pain is the principle symptom.  In the course of exploring the treatment of dysmenorrhea, I’ve looked into formulas such as Xue Fu Zhu Yu Tang, Ge Xia Zhu Yu Tang, Shao Fu Zhu Yu Tang and Hu Po San.  In the beginning, I followed the idea that “when there is free flow, there will be no pain and that pain is due to lack of free flow.  I first used Xue Fu Zhu Yu Tang, which is Tao Ren and Hong Hua with Si Wu Tang, Chai Hu, and Jie Geng to up-bear and Niu Xi and Zhi Qiao to down-bear and I observed some effect but it was far from ideal.

I continued to consider dysmenorrhea, realizing that I must stop pain.  Therefore, on a foundation of vitalizing the blood, transforming stasis, opening through the menstrual blood, I also added stop pain herbs such as Wu Ling Zhi and Yan Hu Suo.  To integrate this idea, I used Ge Xia Zhu Yu Tang.  This formula is also a commonly used gynecology formula but it still did not have an ideal effect.

I continued to consider this.   There is the principle that when the blood is warm it will move.  When there is dysmenorrhea, there is a relationship with blood stasis.  For this it is appropriate to warm the Yang and vitalize the blood and this is not really because there is cold there.  Generally blood stasis does not manifest with Heart and Liver fire flourishing.  The transformation of stasis and the opening through of the collaterals must be assisted with herbs to warm the Yang.  I add Rou Gui and Ai Ye for this.  This is integrating the ideas of Shao Fu Zhu Yu Tang.

For the Yang heat to transport the warmth to the uterine blood vessels I also add Du Zhong and Chuan Duan to supplement the Kidney and benefit the Yang.  This not only addresses the idea of warming to move the blood. It also addresses the idea of treating the root.  In practice this sure enough brings results.

However, for really stubborn serious dysmenorrhea, this is also not ideal for controlling the pain.  One must reconsider the location of the pain. In this case the pain is in the Heart and Liver.  The Heart and Liver not only control the movement in the blood vessels, they also are the seat of the experience of pain.  Because of this, one must also use the method to calm and settle the Heart and spirit while emolliating and harmonizing the Liver.  Adding Hu Po San to the formula that is vitalizing blood, opening the collaterals, stopping pain and warming the Yang completes the effect.

This becomes my experiential formula Tong Jing Tang”.

Tong Jing Tang

Application Method

During menstruation take on package each day decocted in water

Function

Vitalize blood and transform stasis, warm the menses and stop pain

Applications

This formula is principally used for primary dysmenorrhea, which is called functional dysmenorrhea.

Formula Constituents

This formula contains Gou Teng and Dan Pi which both clear the Heart and Liver, calming the Spirit and Hun.  Pain has a relationship with the Heart and Liver Spirit and Hun.  Only when the spirit is calmed and sedate can pain be controlled.  This is the premise behind stopping pain.  Based on the idea “when there is free flow there is no pain” I use Chi Shao, Wu Ling Zhi and Yi Mu Cao to vitalize blood, transform stasis, regulate menstruation and stop pain.  Rou Gui, Chuan Duan and Du Zhong supplement the Kidney, warm the uterus, warm the Yang and vitalize the blood.  These herbs not only assist in vitalizing the blood, transforming stasis, and promoting the easy flow of Qi and blood, there is a deeper layer of meaning as well.  When the Yang Qi is warm and glowing the stasis in the womb is dissolved and the congealed stasis in the womb can be dispelled.  Yan Hu Suo and Wu Ling Zhi not only transform stasis and regulate the menstruation, they are also herbs that stop pain.  Fu Ling calms the spirit and disinhibits dampness.  It assists in discharging turbidity and transforming dampness.  Altogether, these herbs are effective in treating dysmenorrhea.

Case Example

Functional dysmenorrhea is most often seen in unmarried women but can be seen in married women as well.  I treated a 30-year-old woman named Qian who suffered from dysmenorrhea for 10 years.  She had been married for 2 years without becoming pregnant.  On the first or second day of her menstruation she had extreme pain.  The amount of menstruate was average but the blood had clots in it.  Premenstrually she experienced chest oppression, agitation, breast distention, back soreness and fear of cold.  Her tongue was pale red and her pulse was wiry and thin.  Although her BBT showed that she was biphasic, the luteal phase was unstable.  There was an irregular wave and in general, the temperature was low.  This illness was not only dysmenorrhea.  It was also causing infertility.  Because of this, I needed to work in two key phases.  During menstruation I gave her Tong Jing Tang and during ovulation I gave her Bu Shen Cu Pai Luan Tang.  I treated her for 3 menstrual cycles and after this her dysmenorrhea was relieved.  I continued on for another 3 months and she became pregnant”.