Dysmenorrhea
Dysmenorrhea, or painfulmenstruation, refers to lowerabdominal pain or other discomfortsthat occur before and aftermenstruation or during the menstrual periods, and always occur periodicallywith the menstrual cycle. Clinically, menstrual pain that starts at menarche is primary dysmenorrhea, while secondary dysmenorrheais menstrual pain that occurs at any time after the menarche. The patientsusually are between 15 to 25 years in age, and the incidence of menstrual painis greatest in girls of puberty,unmarried women or married women who haven’t had a child.
[Etiology and Pathogenesis]
(1) Qi Stagnation and Blood Stasis: Painful menstruation can result from stagnation of qiand blood when internal injury by the seven emotions allows the six climatic evils to attack the body or frominsufficiency of qi and blood caused by deficiency ofthe liver and kidney. If the emotions are depressed, liver-qiwill become stagnated and cannot promote the flow of blood. When blood flow isobstructed, blood stagnates in the uterus. As we know, obstruction brings onpain, so the obstruction in the uterus causes dysmenorrhea.
(2) CongealedCold and Damp: If, during menstruation, the patient iscaught in the rain, contracts pathogenic cold, drinks cold beverages, or sitsor lies on the damp ground, dampness and cold will attack the lower energizerand settle in the uterus, causing cold and damp to coagulate in the menstrualblood. Obstruction of blood flow causes pain.
(3) Deficiencyof Qi and Blood: Constitutional deficiency of qiand blood or consumption of qi and blood due to asevere or prolonged illness can result in weak blood circulation. Though theblood flow is not stagnated, it is not smooth and there is pain.
(4) Deficiencyof Kidney and Liver:Insufficiency of congenital essence, multiparity, andexcessive sexual activity can all damage the liver and kidney, leading to theinsufficiency of yin blood. The seaof blood is empty and deficient and cannot nourish the uterus, causingabdominal pain due to deficiency.
(5) Down-PouringDamp Heat: Dampheat is another risk factor of menstrual pain. When the internal stagnation of dampheat flows to the thoroughfare and conception vessels, it obstructs the flow ofqi and blood, causing pain. Damp heat contractedduring menstruation or after childbirth can also be retained in thethoroughfare and conception vessels or in the uterus. It then fights and mingles with menstrual blood,causing pain.
[Key Points of Diagnosis]
(1) The mainclinical feature of dysmenorrhea is lower abdominalpain during menstruation. The pain usually begins 1-2 days before or after thebeginning of menstruation. It may also occur when the period is about to finishor 1-2 days after it finishes.
(2) The paincan either be paroxysmal spasmodic pain, distending pain or down falling painin the lower abdomen, possibly radiating to the lumbosacralregion or lower back, anus, vagina and thighs. In severe cases, it coexistswith other symptoms such as a pale complexion, cold sweat, cold limbs, nauseaand vomiting, fatigue, diarrhea, and even fainting. A few patients may havesigns of bladder irritation, such as frequent or urgent urination, etc. Theduration varies from several hours to 2 or 3 days. The pain usually is mostintense on the first day of menstruation, and then gradually subsides ordisappears. Patients withmembranous dysmenorrhea may have large flakes break off from the endometrium, and the pain is relieved when the flakes aredischarged. Functional dysmenorrhea can gradually abateas the patient ages and usually disappears after marriage or delivery.
(3) Agynecological examination can reveal any abnormities in the shape, position,size and quality of the uterus, and any presence of thickening, lumps and tenderness in the bilateral appendixes.
(4) Ultrasoundexamination, pelvic pneumography and celioscopy can be carried out to determine whether the painis caused by functional dysmenorrhea or organicdisease.&www.med126.comnbsp; Measurement of the levelof prostaglandin (PG) in the menstrual blood shows an abnormal increase.
(5) Dysmenorrhea should be distinguished from the acuteabdominal pain caused by extra-uterine pregnancy, rupture of corpus luteum or torsion of ovarian cyst etc., as well as thelower abdominal pain brought on by acute pelvic inflammation, acute cystitis,urinary lithiasis, appendicitis, colitis or acutegastroenteritis etc.
[SyndromeDifferentiation and Treatment]
The syndromedifferentiation of dysmenorrhea should first focus onidentifying the syndrome as cold or heat, deficiency or excess. This is basedon the comprehensive analysis of the time, nature, location and degree of thepain in combination with the duration, quantity, color and quality of themenstruation and secondary symptoms as well as the manifestations of the tongueand pulse. Generally speaking, pain before or accompanying menstruation mostlybelongs to excess, while pain after menstruation belongs to deficiency. Severeand incessant pain which is aggravated by pressing belongs to excess, whereasdull pain which is abated by pressing pertains to deficiency. Pain relieved byheat pertains to cold and pain aggravated by heat is related to heat. If painis more than distention and it is relieved after the discharge of blood clotsor stabbing pain mostly belongs to blood stasis, while if distention is moreprominent than pain, it mostly belongs to qistagnation. Colicky pain and crymodynia are relatedto cold and burning pain is related to heat. Pain in both sides of the lowerabdomen is mostly ascribed to disorders of the liver, whereas pain in the lowerback mostly pertains to disorders of the kidney.
Thetherapeutic principle of treating dysmenorrheaprimarily consists of regulating the qi and blood ofthe thoroughfare and conception vessels. Treatment varies depending on thesyndromes: they include promoting qi or bloodcirculation, clearing away heat, tonifyingdeficiency, dispelling cold or purging excess. The treatment is divided intotwo stages: first, regulating blood and relieving pain in the menstrual period forsymptomatic relief, and second, finding out the root cause of disease to giveradical treatment between the periods. At the same time, it is appropriate toregulate qi, harmonize the blood and unblock thethoroughfare and conception vessels by regulating the liver, invigorating thekidney, or nourishing the spleen according to the patient’s constitution. Thepain is cured when the smooth flow of menstrual blood is regained.
(1)Syndrome of Qi Stagnation and Blood Stasis.
Symptomsand Signs: Distending or down-falling pain in the abdomen, pain is aggravated bypressing, pain occurs during menstruation or 1-2 days before it, heavy orslight menses, inhibited dripping menses, dark purple blood containing clots,possible discharge of large decomposed pieces, pain is relieved with dischargeof clots, tender breasts, distending pain in the hypochondriac region; darkpurple tongue, petechiae on the edges, deep and wirypulse
Analysis: Emotional depression causes qi and blood stagnation in the thoroughfare and conceptionvessels, so the flow of qi and blood is unsmooth,causing distending pain in the abdomen that happens during or 1-2 days beforemenstruation. The pain is aggravated by pressing. Menstruation is scanty or itsflow is inhibited. When menstruation is obstructed, the color becomes darkerand it contains clots. If the blood clots are discharged, the obstruction islessened, leading to temporarily smooth flow of qiand blood and the relief of pain. The stagnation flows out with the menstrualblood, so the pain stops after menstruation. The obstruction of qi movement causes distending pain in the hypochondriacregions and the breasts. Both the tongue and the pulse show signs ofstagnation.
Treatment Method: Soothing the liver, regulating qi,removing blood stasis and arresting pain.
Prescription: Ge Xia Zhu Yu Tang (Under-Diaphram Blood Stasis-Dispelling Decoction) (from
Ingredients: Dang gui(Chinese angelica), chuan xiong (Szechwan lovage rhizome), chi hao(red peony root), tao ren(peach kernel), hong hua (safflower), zhiqiao (orange fruit), yuan hu (corydalistuber), wu ling zhi (trogopterusdung), mu dan pi (treepeony bark), wu yao (combined spicebush root), xiang fu (nutgrass galingale rhizome), gancao (liquorice root).
In theprescription, orange fruit, spicebushroot and nutgrass flatsedgerhizome regulate qi and soothe the liver. Chineseangelica nourishes and harmonizes blood. Szechwanlovage rhizome, red peony root, peach kernel,safflower and tree peony bark promoteblood circulation to remove stasis. Corydalis tuber and trogopterusdung remove stasis and arrest pain. Licorice root, which is harmonious incharacter, coordinates the effects of all the other ingredients in the formula.When qi and blood are regulated and become normal,the pain stops.
Modifications: If the liver-qi attacks thestomach, wu zhu yu (evodia fruit) and ban xia (pinelliatuber) are added to the formula. If there is a sensation of down-bearing and distentionin the lower abdomen, chai hu(bupleurum root) and shengma (largetrifoliolious bugbane rhizome) need to beincluded.
(1) Syndrome of Cold-Dampness Coagulation andObstruction
Symptoms and Signs: Cold pain in the lower abdomen that occurs before orduring menstruation and is aggravated by pressing and relieved by warming,scanty menses, dark purple blood that contains clots or looks like decoction ofblack soybean, aversion to cold, loose stool; light purple tongue, white moistor slimy coating, deep and wiry pulse
Analysis: Pathogenic cold-dampness is heavy and turbid innature and has a tendency to coagulate. When the two pathogenic factors invadethe thoroughfare and conception vessels and the uterus, they tangle with themenstrual blood, causing the unsmooth flow of menstrual blood, so the patientfeels cold pain in the lower abdomen before or during menstruation. Blood iscoagulated by pathogenic cold, so it is dark and contains clots. Whencoagulation and stagnation are alleviated by heat, the pain is relieved. Boththe tongue and pulse show symptoms of cold-dampness stagnation.
Treatment Methods: Warmingthe channels to dispel cold, eliminating dampness to remove stasis
Prescription: Shao Fu Zhu Yu Tang (Lower Abdomen BloodStasis-Dispelling Decoction)(from Yi Lin Gai Cuo
Ingredients: Xiao huixiang (fennel fruit), gan jiang (driedginger zingiber), yuan hu (corydalia tuber), mo yao(myrrh), dang gui (Chinese angelica), chuan xiong (szechwan lovage rhizome), rou gui (cassia bark), chi shao (redpeony root), pu huang(cat-tail pollen), wu ling zhi(trogopterus dung).
In theformula, cassia tree, fennel fruit and dried ginger dispel cold and eliminatedampness. Chinese angelica, szechwan lovagerhizome and red peony rootnourish blood, promote the flow of blood and remove stasis. Corydalis tuber, trogopterus dung, cat-tail pollen and myrrh remove stasisand stop pain. Atractylodes rhizome is added to drydampness and purge turbidity, while Indian bread is included to nourish the spleen and removedampness. The whole recipe warms the channels, dispelling cold, and promotesblood flow to remove stasis and relieve pain.
Modifications: If there is a severe cold pain, dang gui jianzhong tang (Decoction of Angelica for WarmingMiddle-Energizer) can be used together with ai ye (argy wormwood leaf) and wu zhu yu (medicinal evodia fruit). If cold and dampness are severe, cang zhu (atractylodesrhizome) and fu ling (Indian bread) are added.
(3) Syndromeof Qi and Blood Deficiency
Symptoms and Signs: persistent dull pain during or after menstruationthat is relieved by pressing, possible sensation of bearing down, heavy orscanty menstrual flow, pale and thin blood without clots, pale complexion,dizziness and palpitation, fatigue; pale tongue, teeth-marked edge, thincoating, fine pulse
Analysis: Insufficiency of qi andblood causes deficiency of the thoroughfare and conception vessels, and the seaof blood becomes even more deficient after menstruation. When blood is deficient it is unable tonourish, and deficient qi is unable to promote thecirculation of blood, causing slow blood flow and stagnation. That is why dullpain that is relieved by rubbing and pressing occurs in the lower abdomen oneor two days after menstruation finishes. When the thoroughfare and conception vessels regain their normal qi and blood several days after menstruation, the paindisappears. In the case of a physically weak patient who is injured by the lossof blood and qi during the menstrual period, theabdominal pain may return after the period. Qideficiency leads to insufficiency of yangqi and blood deficiency leads to the decline ofessence and blood, therefore, the menstruation is scanty, pale, and thin, andthe patient’s complexion is sallow. Qi and blooddeficiency brings on weakness of spleen-yang,so listlessness, poor appetite and loose stool occur. Both the tongue and pulseshow signs of qi and blood deficiency.
Treatment Method: Nourishing the spleen, qi,and blood to relieve pain.
Prescription: Sheng Yu Tang (MiraculousDecoction for Restoration) (from
Ingredients: Ren sheng(ginseng), huang qi (milkvetch root), dang gui(Chinese angelica), chuan xiong (szechwanlovage rhizome), shu di huang (prepared rehmannia root), sheng di huang (rehmanniaroot).
In theprescription, ginseng and milkvetch root replenish qi.The “Four substances” ("si wu":szechwan lovagerhizome, Chinese angelica, white peony root and rehmannia root) nourish and regulate blood. Nutgrass galingale rhizome and corydalis tuber regulate qi and eliminate pain. When there is sufficient qi and blood, the blood circulates smoothly and the paindisappears.
Modifications: If a patient also suffers from aching in the lumbus, tu sizi (dodder seed) and du zhong (encommia bark) can beadded.
(4) Syndromeof Consumption of Liver and Kidney
Symptoms and Signs: scanty menstruation, dark blood without clots, dullpain in the lower abdomen after menstruation, soreness in the lumbus and knees, dizziness and tinnitus; red tongue, thincoating, deep and fine pulse
Analysis: Because of insufficiency or consumption of thekidney and the liver, the thoroughfare and conception vessels are impaired. Theessence and blood are already insufficient, and after menstruation the sea ofblood is emptied and is even less able to nourish the uterine vessels, causingdull pain in the lower abdomen and scanty, dark and thin menstruation. Kidneydeficiency results in soreness in the lumbus andtinnitus, and yin deficiency createsinternal heat, causing the appearance of tidal fever. Both the tongue and thepulse show signs of consumption of essence and blood.
Treatment Method: Nourishing blood to regulate the liver and tonifying the kidney to supplement essence.
Prescription: Tiao GanTang (Liver-Regulating Decoction) (fromFu Qing Zhu Nv Ke, or Fu Qingzhu’s Gynecology onPrescriptions)
Ingredients: Dang gui(Chinese angelica), bai shao(white peony root), shan zhuyu (Asiatic cornelian cherry fruit), ba ji tian(morinda root), e jiao(ass-hide gelatin), shan yao (common yamrhizome), gan cao (liquorice root).
In theformula, angelica and white peony root nourish blood and soothe the liver.Asiatic cornelian cherry fruit replenishes essence and qiand nourishes the liver and kidney. Morinda rootwarms the kidney and tonifies the thoroughfare andconception vessels. Ass-hide gelatin nourishes yin and supplements blood and common yam rhizome reinforces theSpleen and tonifies the middle energizer.
Modifications: In the case of scanty menstruation, add lu jiao jiao (deer-horn gelatin) and shanyu rou (cornus).
(5) Syndrome of Down-Pouring Damp-Heat
Symptoms and Signs: Pain or burning sensation in the lower abdomenduring menstruation which increases when pressed, possible distending pain inthe lumbus, possible frequent pain in the lesserabdomen which increases upon the arrival of menstruation, frequent low fever,thick darkish red menstrual blood containing clots, thick yellowish vaginaldischarge, scant yellowish urine; red tongue, yellow slimy coating, wiry andfast or soggy and fast pulse
Analysis: Damp-heat that is contracted externally oraccumulated internally attacks the lower energizer and occupies thethoroughfare and conception vessels and the uterus. Before menstruation, whenthe sea of blood is filled, damp-heat coagulates in the blood, causing pain inthe lower abdomen which increases when pressed. The pain may extend to thelower back or there might be a burning sensation in the lower abdomen.Damp-heat tends to linger, so the patient has a low fever which rises and fallsor often suffers from abdominal pain. Stagnated heat harasses the blood and sothe menstrual blood is darkish and contains clots. Both the tongue and thepulse show signs of damp-heat.
Treatment Method: Clearing heat, removing dampness, dispersing stasisand relieving pain
Prescription: Qing ReiTiao Xue Tang(Heat-Clearing and Blood-Regulating Decoction) (from
Ingredients: Mu danpi (tree peony bark), huang lian(golden thread), sheng di huang (rehmannia root),dang gui (Chinese augelica), bai shao (white peony root),chuan xiong (Szechwan lovagerhizome), hong hua(safflower), tao ren (peachkernel),yuan hu (corydalistuber), e zhu (zedoary rhizome ) , xiang fu（nutgrass galingale rhizome)
In thisformula, tree peony bark clears away heat, cools blood and disperses stasis; rehmannia root clears heat and cools blood; golden threadclears heat and dispels evils; Chinese augelica andwhite peony root nourish and harmonize blood; Szechwan lovagerhizome, peach kernel, safflower and zedoary rhizome promote blood flow andremove stasis; nutgrass galingale rhizome and corydalis tuber regulate qi and relieving pain. The entire composition has theeffect of clearing away heat, dispersing stasis, and regulating qi and blood. Sargentgloryvinestem, patrinia and coixseed are added to reinforce the action of clearing heat, dispelling evils,removing dampness and dispersing stasis.
[AlternativeTreatments]
(1) Chinese Patent Medicine
Yue Yue Shu ChongJi (Granule for Monthly Dysmenorrhea):1 pack each time, three times a day. Indicated for deficiency syndrome.
Ai Fu Nuan Gong Wan (Argyi-CyperusUterus-Warming Pills): 10 grams each time, three times a day. Indicated for deficiency-cold syndrome.
Yuan Hu Zhi Tong Pian(Tablet of Corydalis Tuber for Alleviating pain): 4 tablets each time, threetimes a day. Indicated for syndrome of qistagnation and blood stasis.
(2) Acupuncture and Moxibustion
Body Acupuncture: Points are Zhongji (CV 3),Guanyuan (CV 4), Diji (SP8), Zusanli (ST 36), Sanyinjiao (SP 6). Use strong needling stimulation.In the case of syndrome of excess use the draining needling method.Alternatively, use moxibustion on the followingpoints: Qihai (CV 6), Zhiyin(BL 67), Zusanli (ST 36) etc. Begin the treatment oneweek before menstruation. One treatment per day, applying moxabustion for 15 to 30 minutes for each point.
⑶Auricular Acupuncture: Points are Zi Gong (Uterus), Ovary AH5Endocrine CO18, Sympathetic Nerve AH6a, Subcortex AT4.Select 2 to 4 points each treatment. Alternatively, use auricular acupressure,sticking one Wang Bu Liu Zi (Cowwww.med126.com/wszg/-herb seed) on thefollowing points: ZiGong (Uterus), Ovary AH5, Xia Jiao Duan(the end of the inferior crus of antihelix).Alternate between the left and right ears.
[Questions]
● What is the meaning of dysmenorrhea?
● What is the etiology and pathogenesis of dysmenorrhea?
● What are the key points for the syndrome differentiation andtreatment of dysmenorrhea? ● Howcan the most opportune time for treating dysmenorrheabe found?
● What are the most common syndromes causing dysmenorrhea? How are they treated?
