The Five Stagnations in Gynecology

9/18/16

Four broad mechanisms that lead to The Five Stagnations most gynecological disorders 1. Insufficient blood affects the regularity and in Gynecology volume of menses. 2. Insufficient qi or yang fails to contain blood and fluids or leads to cold that impedes the flow Jill Blakeway, DACM, L.Ac. of blood. 3. Blood heat causes the blood to move frenetically outside the vessels. 4. Stagnation of qi or blood or fluids leads to obstruction of the free flow of the menstruate.

What is the difference between stagnation, depression, The Six Stagnations of Zhu Dan-xi constraint & stasis? yù = Constraint or Depression Qi Often speciﬁc to the liver, or has an emotional Fire component. Blood zhì = Stagnation Often more general or referring to stagnation Stagnations unrelated to the liver. yū = Stasis Damp Often refers to a condition where there is a Food component of blood stasis. Phlegm

Liu Wan-su’s The Five Stagnations Theory of Similar Transformation

1. Evil qi will Food Blood 2. Life is 3. become qi Qi is Guest qi FIRE Stagnations warm matches host qi

Phlegm Damp

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Yue Ju Wan(Escape Restraint Pill) Ban Xia Xi Xin Tang (Pinelliae Treats each of the five stagnations Decoction to Drain the Epigastrium) plus the resulting heat How addressing stagnation in the middle jiao can treat a GYN disorder in the lower jiao. • Cang Zhu (Rz. Atractylodes) • Chuan Xiong (Rz. Chuanxiong) • Zhi Ban Xia (Rz. Pinelliae Preparatum) • Xiang Fu (Rz. Cyperi) • Gan Jiang (Rz. Zingiberis) • Zhi Zi (Fr. Gardeniae) • Huang Qin (Rx. Scutellariae) • Shen Qu (Massa Medicata Fermentata) • Huang Lian (Rz. Coptidis) • Ren Shen (Rx. Ginseng) • Da Zao (Fr. Jujube) • Zhi Gan Cao (Rx. Glycyrrhizae Preparata)

Sample Acupuncture Prescriptions The take home… to Move GYN Stagnation

• To move liver qi and calms the heart Zhu Dan-xi identified 6 Of the six stagnations, qi HT7, GB 34, LV14, Ren17 stagnations stagnation leads to stagnation of blood, phlegm, damp and • To move blood in the lower jiao “10,000 illnesses all food (all of which are yin start with Yu” substances) Ren9, Ren4, SP6, SP10, LI4 • To move damp in the lower jiao Ren5, SP9, LU7, KI7, SP3, 13 According to Liu Treat stagnation Wan-su’s Theory Zhu Dan-xi’s where you find it • To move damp-heat in the lower jiao of Similar formula Yue Ju to correct the Ren5, SP9, LV8, LI11, LV5 Transformation – Wan treats all six ascending and Evil Qi will stagnations descending become fire mechanism of qi

Qi Stagnation: PMS PMS Possible Causes and Cofactors A recurring cyclic cluster of physical and behavioral v Elevated estrogen symptoms, developing 7-14 days prior to v Estrogen/progesterone imbalance menstruation (during the luteal phase) and v Elevated prolactin dissipating when menstruation or the follicular v phase begins. Symptoms are only present during Hormone allergy the luteal phase. v Hypoglycemia (McPhee & Papadakis, 2010) v Vitamin B6 deﬁciency v Lowered neurotransmitters Beyond Xiao Yao Wan (and the 4 gates!)…. v Stress v Family history of PMS

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Chinese Medical Etiology Xiao Yao Wan (Free Wanderer Powder) Deficiency Stagnation of yang or of Qi and or qi Blood Chai Hu (Bupleuri Radix) Dang Gui (Angelicae Sinensis Radix) Leads to or Leads to Bai Shao (Paeoniae Radix Alba) stagnation weak yang Bai Zhu (Atractylodis Macrocephalae Rh) of qi or qi Fu Ling (Poria) Bo He (Mentha H) stagnation fluid Sheng Jiang (Zingiberis RH) accumulation of blood Gan Cao (Glycyrrhizae Radix) or fluids Deficiency of yang or qi Leads to stagnation of qi Which leads to stagnation of blood or fluids. Or Stagnation of qi and/ or blood Leads to weak yang or qi Leading to fluid accumulation. Si Ni San Dao Shui Fu Ling Tang (Poria (Frigid Extremities Powder) Decoction to Drain Water)

Fu ling (Poria Rubra) Zi Su Ye (Fol. Perillae) Chai Hu (Rx. Bupleuri) Ze Xie (Rz. Alismatis) Deng Xin Cao (Medulla Junci) Bai Shao (Rx. Paeoniae Lactiﬂorae) Bai Zhu (Rz. Atractylodis) Chen Pi (Per. Citri Reticulatae) Zhi Shi (Fr. Citri seu Ponciri Immaturus) Mu Gua (Fr. Chaenomelis) Mu Xiang (Rx. Aucklandiae) Gan Cao (Rx Glycyrrhizae Uralensis) Bing Lang (Sm. Arecae) Sha Ren (Fr. Amomi) Mai Men Dong Sang Bai Pi (Cx. Mori) (Rx. Ophiopogonis) Da Fu Pi (Per. Arecae)

Wen Dan Tang Developing a Point (Warm the Gallbladder Decoction) Prescription for PMS Look for the root stagnation in this patient Ban Xia (Rhizoma Pinelliae Ternatae) Eg. Epigastric stagnation PC6, R13, SP4 Chen Pi (Pericarpium Citri Reticulatae) Identify the kind of stagnation and treat the cause Fu Ling (Sclerotium Poriae Cocos) Damp stagnation SP3, SP9, R6 Zhu Ru (Caulis Bambusae in Taeniis) Qi stagnation LV3, LI4, ST36 Zhi Shi (Fructus Citri seu Ponciri Immaturus) Treat the manifestations of stagnation Sheng Jiang (Rhizoma Zingiberis) For breast tenderness LV3, R17, PC6 Gan Cao (Radix Glycyrrhizae Uralensis) Headache LI2, LI4, R6 Da Zao (Fructus Zizyphi Jujubae)

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PMS: The take home… Blood Stagnation: Dysmenorrhea

PMS symptoms are Damp stagnation is a factor in Primary dysmenorrhea often caused by many PMS symptoms such as deﬁciency of qi and breast tenderness, fatigue, Normal menstrual cramps that are recurrent yang as well as cloudy mind, weight gain and and are not due to other diseases stagnation clumsiness Secondary dysmenorrhea Pain that is caused by a disorder in the woman's PMDD is often reproductive organs, - endometriosis, Don’t forget caused by adenomyosis, uterine ﬁbroids, or infection (PID) Look beyond about Ban Xia Xi stagnation of cervical stenosis. Xiao Yao Wan Xin Tang and the 4 gates! blood and (or Si Ni San) phlegm with heat from stagnation

What Causes the pain? Dysmenorrhea in TCM

• Uterine contractions Stagnation of blood is always a branch Due to excessive prostaglandin production diagnosis. • Passing clots Look for the root! • Structural abnormalities • Trauma, cold, heat • Diet and lifestyle exacerbate the pain • Qi stagnation, qi deﬁciency • Deﬁciency of blood, yin or yang

The relationship between Wen Jing Tang cold and blood stagnation (Menses Warming Formula) Ren Shen (Ginseng Radix) Warmth moves and Dang Gui (Angelicae Sinensis Radix) cold stops movement. Chuan Xiong (Chuanxiong Rhizoma) Bai Shao (Paeoniae Radix Alba) That means that warming can be a helpful Niu Xi (Achyranthis Bidentatae Radix) part of any general prescription for pain from E Zhu (Curcumae Rhizoma) stagnation. Rou Gui (Cinnamomi Cortex) Mu Dan Pi (Moutan Cortex) Gan Cao (Glycyrrhizae Radix)

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Shao Fu Zhu Yu Tang Regulating the cycle (Lower Abdomen Stasis Expelling Formula) to treat dysmenorrhea

Dang Gui (Angelicae Sinensis Radix) • During the menses (days 1 - 7) - Move qi and Chi Shao (Paeoniae Radix) blood and relieve pain. Chuan Xiong (Chuanxiong Rhizoma) SP10, LI4, LV3, R4, SP6 Xiao Hui Xiang (Foeniculi Fructus) Gan Jiang (Zingiberis Rhizoma) • After the menses (days 8 - 21) - Supplement Rou Gui (Cinnamomi Cortex) qi and nourish blood. Yan Hu Suo (Corydalis Rhizoma) KI3, ST36, Zi Gong Xue, R3, R4 Wu Ling Zhi (Trogopteri Faeces) • Before the menses (days 22 - 28) - Move qi to Pu Huang (Typhae Pollen) prevent stagnation. Mo Yao (Myrrha) ST36, LI4, LV3, SP6, DU20

Endometriosis Endometriosis Symptoms

• Often asymptomatic • Dysmenorrhea The presence of endometrial • Dyspareunia tissue outside the uterus. • Painful bowel movements

• Painful urination Two types: • Menorrhagia or menometrorrhagia • Pigmented (bleeding) • Infertility • Non - pigmented (not bleeding) • Other (fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods).

Causes of Endometriosis The most common patterns I observe in my patients with endometriosis

• Retrograde menstruation • Embryonic cell growth Root deﬁciency Stagnant • Post-surgical scars Heat from of Spleen qi, blood stagnation • Cell transport qi and/ or or (which may • Immune dysfuction Kidney phlegm/ rise) yang. damp

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Xiao Zheng Fang Days 25 - 4 (Concretion Dispersing Formula)

Use blood moving herbs Menstrual Formula (days 25 – 4) Ji Xue Teng (Spatholobi Caulis) Acupuncture San Leng (Sparganii Rhizoma) E Zhu (Curcumae Rhizoma) SP6, R4, SP8, SP10, Bai Liao, LV8, LI 4, PC5, Mu Dan Pi (Moutan Cortex) abdominal ashi (ST28, ST29, SP12, SP13) Dan Shen (Salviae Miltiorrhizae Radix) Moxa Chi Shao (Paeoniae Radix Rubra) Tao Ren (Persicae Semen) Zhi Ke (Qiao) (Aurantii Fructus) Fu Ling (Poria) Bai Zhu (Atractylodis Macrocephalae Rhizoma)

HuoJjing Zhong Zi Fang (Quicken the Days 5 - 24 Channels to Plant Seeds Decoction) Post Menstrual Formula for Tonify qi and yang, move qi and supplement blood Endometriosis (days 6 – 28) Dang Gui (Angelicae Sinensis Radix) Chai Hu (Bupleuri Radix) Acupuncture Dan Shen (Salviae Miltiorrhizae Radix) KI3, St36, SP6, DU20, R3, R4, Zi Gong Xue, Yin Bai Shao (Paeoniae Radix Alba) Tang Fu Ling (Poria) Moxa Bai Zhu (Atracrylodis Macrocephalae Rhizoma) Zhi Ke (Qiao) (Aurantii Fructus) Gan Cao (Glycyrrhizae Radix)

Dysmenorrhea and Endometriosis. Damp Stagnation: The take home… Chronic Pelvic Inflammatory Disease PID is caused by a bacterial infection in the upper female genital tract. Warmth moves and cold stops There are 3 main ways that an infection can occur. Stagnation of blood is movement. That means that always a branch warming can be a helpful part 1. From the lower genital tract to the upper: Often from diagnosis. Look for the sexually transmitted bacterias, but also from root! of any general prescription for pain from stagnation gynecological procedures such as insertion of IUD, D&C, abortion and endometrial biopsy. 2. From infection of surrounding organs: Infection of In fact warmth Non-pigmented When treating the bladder, appendix or other surrounding organs can moves so well endometriosis is endometriosis also lead to Pelvic Inﬂammatory Disease more likely to that you may give blood 3. From transfer of bacteria through the circulatory or need less blood cause infertility moving herbs movers – think because of the during the lymphatic system: Bacteria from the respiratory Wen Jing Tang. presence of damp menses. system such as pneumonia can travel through the body and cause PID.

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Chinese Medicine’s View on the The Three Stages of PID Etiology of Chronic PID Deﬁciency of External evils righteous qi (hot or cold) Early stage, acute PID • Damp-heat-toxin Evils accumulate in the lower jiao and obstruct the qi dynamic, Leading to qi and blood stagnation obstructing the Chong and the Ren. Middle stage, chronic PID Damp-heat and blood stagnation The qi and blood stagnation, combined with the external pathogen, causes damp stagnation, Late stage, chronic PID which can become damp-heat due to stagnation. Spleen qi and yang vacuity with All of which is exacerbated by underlying spleen qi qi and blood stagnation and deﬁciency (which leads to more damp) or kidney yang either damp-heat or damp-cold vacuity (which leads to more blood stagnation).

Late Stage, Chronic PID Treatment Wan Dai Tang Strategy in Order of Priority (Discharge Ceasing Decoction) 1. Treat the underlying deﬁciency For PID with underlying Spleen Qi Vacuity Ren Shen (Rx Ginseng) Spleen qi vacuity Shan Yao (Rh. Dioscoreae) Kidney yang vacuity Bai Zhu (Rh. Atractylodis Macrocephalae) 2. Treat the stagnation Bai Shao (Rx Paeoniae Alba) Qi stagnation Chai Hu (Rx. Bupleuri) Blood stagnation Cang Zhu (Rh Atracylodis) Chen Pi (P. Citri) Damp stagnation Che Qian Zi (S. Plantaginis) 3. Clear heat and toxicity (if appropriate) Jing Jie (H. Schizonepetae) Gan Cao (Rx. Glycyrrhizae)

Nei Bu Wan Liu Jun Zi Tang (Internal Supplementation Pill) (Six Gentlemen Decoction) For PID with underlying kidney yang vacuity To support the spleen, if the patient is Lu Rong (Cervi Cornu) receiving antibiotic treatment. Tu Si Zi (S. Cuscutae) Ren Shen (Rx Ginseng) Sha Yuan Zi (S. Astragali) Bai Zhu (Rh. Atractylodis Macrocephalae) Rou Cong Rong (H. Cistanches) Fu Ling (Poria) Rou Gui (C. Cinnamomi) Gan Cao (Rx. Glycyrrhizae) Huang Qi (Rx. Astragali) Chen Pi (P. Citri) Ci Ji Li (Fr. Tribuli) Ban Xia (Rh. Pinelliae) Sang Piao Xiao (Ootheca Mantidis) Zhi Fu Zi (Rx. Aconite preap.)

Zi Wan (Rx Asteris)

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Vaginal Douche for Chronic PID Acupuncture for Chronic PID

Hong Teng 15g (Caulis Sargentodoxae) • Open the Dai, Ren and or Chong Bai Jiang Cao 15g (Herba Patriniae) GB41, SJ5, LU7, KI6, PC6, SP4 Pu Gong Ying 15g (Herba Taraxaci) • Support the spleen and kidney Ru Xiang 6g (Gummi Olibani) KI7, SP3, ST36, R6 Mo Yao 6g (Myrrh) • Move blood and qi San Leng 5g (Rhizoma Sparganii) SP10, LV5, SP6 E Zhu 5g (Rhizoma Curcumae ) • Clear damp and heat Mu Dan Pi 3g (Cortex Moutan) LV8, SP9, ST44 Cook the herbs in water to make a 100ml thick decoction and use as a retained douche (retain • Local points for 20 minutes 1 x a day) Zi Gong Xue, R3, R4 • Moxibustion

Phlegm Stagnation: Chronic PID. The take home… Polycystic Ovarian Syndrome (PCOS)

Early stage = Damp-heat-toxin The Rotterdam Criteria PID is the most common Middle stage = Damp-heat and Two out of three of the following cause of female infertility blood stagnation and ectopic pregnancy. Late stage = Spleen qi and yang About 1 million women a vacuity with qi and blood biochemical signs of year suffer from it stagnation and either damp-heat hyper-androgenism or damp cold

Chronic PID is Chronic PID If there is ongoing PCOS resistant to responds best to a antibiotic treatment antibiotic therapy because the formula like Wan use Liu Jun Zi spleen qi and Dai Tang because Tang to support the kidney yang have it supports the spleen and clear irregular and/or appearance of small been compromised spleen damp no ovulation cysts in the ovaries

Biomedical Understanding of PCOS What causes phlegm? • Fluids become phlegm when they are unable to prompt the ovary to move. ü Excess insulin increase androgen • Therefore phlegm can have it’s roots in: ü Low grade inﬂammation production ü Ovarian cysts • Qi or yang vacuity or • Qi or blood stagnation elevated androgens • Phlegm thickens due to block follicular development • Cold constricting or alter HPO Axis feedback Impedes • Heat congealing ovulation and • Blood and ﬂuids move together makes endometrium elevated estrogen “To treat phlegm it is essential to treat the blood. less Decreased FSH Quickening the blood leads to transformation of phlegm” hospitable Increased LH & testosterone - Zhu Lian-chun

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Chinese Medicine and PCOS PCOS Treatment Principals

Kidney Jing Deﬁciency Tonify Kidney jing, qi and/or yang Kidney yang vacuity Disrupts ﬂow in Ren and Chong to regulate the Ren and the Chong Spleen qi vacuity Support the Spleen Ø Damp to address damp and phlegm Ø Phlegm Liver qi stagnation Move liver qi and harmonize the spleen and liver Ø Blood stagnation to clear heat from stagnation Ø Heat Ø Congeals phlegm Stagnation of qi, phlegm and blood disrupt the Chong and Ren leading to irregular menses and anovulation.

Acupuncture Points for PCOS Dietary Therapy for PCOS

During menses • Swap sugar and reﬁned carbohydrates for Sp10, LI4, LV3, R4, SP6, Yin Tang, SP9 small portions of complex whole grains. Follicular phase • Avoid sweeteners PC6, SP4, ST36, DU20, Zi Gong Xue, SP9, LI4, Yin • Eat lean protein Tang • Plenty of slightly cooked vegetables Ovulation LI4, SP6, KI7, Zi Gong Xue, R3, R4, Yin Tang, SP9 • Avoid cold foods and dairy products Luteal phase • Eliminate alcohol and caffeine St 36, SP9, KI7, DU20, Yin Tang

Zhong Yao Ren Gong Tiao Qi Zu Fang Zhong Yao Ren Gong Tiao Qi Zu Fang (Formula to Regulate the Menstrual (Formula to Regulate the Menstrual Cycle) Number 1 (for after the period) Cycle) Number 2 (for ovulation)

Xian Mao (Rhizoma Curculiginis orchioidis) Dang Gui (Radix Angelicae sinensis) Yin Yang Huo (Herba Epimedii) Dan Shen (Radix Salviae miltiorrhizae) Dang Gui (Radix Angelicae sinensis) Tao Ren (Semen Persicae) Shan Yao (Radix Dioscoreae oppositae) Hong Hua (Flos Carthami tinctorii) Tu Si Zi (Semen Cuscutae chinensis) Ji Xue Teng (Radix et Caulis Jixueteng) Ba Ji Tian (Radix Morindae ofﬁcinalis) Yi Mu Cao (Herba Leonori heterophylli) Rou Cong Rong (Herba Cistanchis deserticolae) Xu Duan (Radix Dipsaci) Shu Di Huang (Radix Rehmanniae) Xiang Fu (Rhizoma Cyperi rotundi) Gui Zhi (Ramulus Cinnamomi cassiae)

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Zhong Yao Ren Gong Tiao Qi Zu Fang Zhong Yao Ren Gong Tiao Qi Zu Fang (Formula to Regulate the Menstrual (Formula to Regulate the Menstrual Cycle) Number 3 for the luteal phase Cycle) Number 4 (during the period)

E Jiao (Gelatinum Corii Asini) Dang Gui (Radix Angelicae sinensis) Gui Ban Jiao (Colla Plastri testudinis) Shu Di Huang (Radix Rehmanniae praeparata) Dang Gui (Radix Angelicae sinensis) Dan Shen (Radix Salviae miltiorrhizae) Shu Di Huang (Radix Rehmanniae praeparata) Chi Shao (Radix Paeoniae rubrae) Wu Yao (Radix Linderae strychnifoliae) Ze Lan (Herba Lycopi lucidi) Tu Si Zi (Semen Cuscutae chinensis) Chuan Xiong (Radix Ligustici Chuanxiong) Xu Duan (Radix Dipsaci) Yi Mu Cao (Herba Leonori heterophylli) Xiang Fu (Rhizoma Cyperi rotundi) Xiang Fu (Rhizoma Cyperi rotundi) Gui Zhi (Ramulus Cinnamomi cassiae)

Food Stagnation PCOS. The take home… Hypothalamic Amenorrhea

Rotterdam Criteria is two out HA occurs when the hypothalamus, slows or stops of three of the following: PCOS is a complex releasing gonadotropin-releasing hormone (GnRH), the syndrome affecting the Signs of hyperandrogenism hormone that starts the menstrual cycle. Common endocrine system and Irregular and/or no ovulation characteristics of women suffering from HA include: metabolism A chain of small cysts in the • Low body weight or low percentage of body fat ovaries • Very low intake of calories or fat • Strenuous exercise that burns more calories than are A 5-7% weight taken in through food Disruption to the reduction can reduce This disruption is hyperandrogenism, • Deﬁciency of leptin, a protein hormone that regulates Ren and the the result of weak Chong causes improve insulin appetite and metabolism anovulation and kidney function sensitivity, and and stagnation restore ovulation in • Emotional stress and some medical conditions irregular menses 75% of women with PCOS

Bao He Wan (Preserve Harmony Pill) The Five Stagnations Can be used to help underweight women gain weight and therefore restore the menses in Gynecology Shan Zha (Fr. Crataegi) Shen Qu (Massa Medicata Fermentata) Lai Fu ZI (Sm. Raphani) Chen pi (Per. Citri Reticulatae) Jill Blakeway, DACM, L.Ac. Ban Xia (Rz. Pinelliae Preparatum) Fu Ling (Poria) Lian Qiao (Fr. Forsythiae)