Menstrual Cramps/Dysmenorrhea

Course: HTD 3 – Gynecology Date: March 24, 2011 Class #: 11 Prof: Zheng Zeng

Good link for a lot of these formulas and some acupuncture treatment suggestions: http://www.sacredlotus.com/diagnosis/obgyn/gyn_dys.cfm

Your first task is to determine whether the patient has an excess or a deficiency. Excess cramps will feel worse with pressure, but maybe better with heat. Will also have gas/bloating. Deficiency cramps prefer pressure. Another important thing, especially if they can’t determine whether they like pressure, ask the time. If early/prior or 1st day it’s probably excess. Later in the period cramps are more likely to be deficiency.

(Zheng Zeng is telling a story about trying nourishing herbs for what looked like a deficiency, but they didn’t work. Upon further investigation

Type of pain: if severe, sharp, stabbing, burning = excess. If gentle, dull, discomfort = deficiency Location of pain: center around uterus = blood stasis. If patient says pain on the sides of the lower abdomen and ovary, will be more Liver Qi stagnation. Pain on the lower back and sacral area is more kidney xu. Occasionally you will find an endometriosis patient which is blood stasis who will have pain in all of these areas.

Kidney Qi Deficiency Even though only Kidney deficiency on the handout can also be somewhat related to blood stasis. If a patient has ultrasound might see that uterus is a weird shape or small size. Kidney xu is usually seen as a lower back cramping pain, but might also be a uterine related pain. Other typical Ki xu signs will be evident as well.

Tiao Gen Tang Herb functions are nourishing mostly and nourish blood, Liver, and Kidney. This is a qi and blood boosting formula.

Qi and Blood Deficiency This is often seen in teenagers (whose uteri are still developing). Qi and blood xu patients have dull pain, prefer pressure (light weight) and warmth, and will probably have other qi and blood xu signs. Pain will often come later.

Bai Shao and Gan Cao are often used for deficiency type cramps – same number of grams in the dosage.

Whether qi and blood or Kidney qi xu – all deficiency cases – you can also use Shao Yao Gan Cao Tang

Huang Qi Jian Zhong Tang

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 1 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Dosages are different, but related to other formulas….I didn’t catch which two. Sorry. Shao jian zhong tang perhaps? Anyway. The tastes in this formula combine sweet + sour which helps reduce the urgency and the cramps. This is a good formula to nourish and stop the cramps.

White Crane doesn’t carry Huang Qi Jian Zhong Tang, so start with Shao jian zhong tang and modify. Ba Zhen Tang is another option, but it doesn’t stop the cramps, just nourishes the qi and blood xu. You will see results, but much slower

Final: discussion of cases with menstrual cramps. This is the formula you need to choose for the deficiency type: Huang Qi Jian Zhong Tang.

Liver Qi Yu with Stagnant Heat Stress and menstrual cramps. Might have a burning cramping pain, but not always. Pain likely to be on the lower ab on the sides in line with the ovary. Might also see pain on the uterus area – blood doesn’t exit easily and this can cause pain there.

Bleeding with stagnant heat will show as bright red, probably small clots, possibly will have bloating and gas, and of course the other fun Liver Qi stagnation signs – throw in the heat signs of aggravation, irritability, etc. Qi stagnation can cause no tongue changes, but might see dusky, possibly some yellow coating. Usually will have a thin pulse.

Jiao Wei Xiao Yao San You could also add chuan lian zi and yan hu suo. Jing Ling Zi San is a formula with just these 2 herbs. Old rx’s use 30g for each – chuan lian zi and yan hu suo ground into powder. Now you can add this to Jia Wei XYS – 10g for raw, 6g for powder. Can also be used for ovulation pain.

If your patients have clots that are larger you can add pu huang and wu ling zi.

Qi Stagnation and Blood Yu Endometriosis is common for this differentiation. Really bad, severe cramps. Usually have to take some kind of pain killer to stop the pain or they can’t function. Sharp pain is common, so it stabbing pain. Location can be all over the lower part of the body – abdomen, back, etc. Worse with bowel movements sometimes if the endometriosis is implanted between the uterus and rectum. Urination may be burning and sharp too.

Sharp, stabbing pain is the most important sign. Will probably also have clots, but not always. Clots will be dark and large, heavier bleeding is common. Blood is often darker in color. Patient will also tell you about lower back pain too.

Tongue and pulse will help: tongue is usually dusky red, though you may see pale and dusky (this is the root of the problem). Darker spots with uterine fibroids. Vein often enlarged underneath. Pulse could be wiry, theoretically should be choppy but clinically doesn’t always work that way.

Ge Xia Zhu Yu Tang

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 2 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Cool in nature due to mu dan pi. If no yang xu sx, this is the formula you use. Tastes like hell. Might want to give a patent, can even + the dose – 12-15 pills 3-4 times daily or so. Depends on their weight.

Shao Hu Zhu Yu Tang Use this for cold symptoms, yang xu Tong Jing Tang (Tong Jing = painful menses/dysmenorrhea) Soothe the liver, clear heat and eliminate stagnation. This TCM Herbal signs accompanying. Apply castor oil formula is best suited for dysmenorrhea (painful periods) due to liver Qi on the lower abdomen, put a towel on stagnation turning into fire. it, then place a heating pad on top of Indications and Symptoms for Xuan Yu Tong Jing Tang it.Can do this even not on the period. Abdominal pain before or during period, dark menstrual blood, heavy period, irritability, outbursts of yelling or anger, thirsty, general feeling of heat, dry stools, dry sore eyes Tongue - red body (redder on sides), If not trying to get period, give 3-5 yellow coating Pulse - rapid, wiry days away from period. If trying to get Herbal Ingredients of Xuan Yu Tong Jing Tang period, take the herbs only when they Bai Shao Yao (Radix Paeoniae Lactiflorae, White Peony Root, Peony) start bleeding. Give other herbs during 15g. -soothe liver, nourish blood the rest of the month depending upon Dang Gui (Radix Angelicae Sinensis, Chinese Angelica Root, tang -kuei) their differentiation. If patient has 15g. -soothe liver, nourish blood, invigorate blood dusky tongue, constant cramps, etc Mu Dan Pi (Cortex Moutan Radicis, Peony Tree Root Cortex, Moutan) indicating strong stagnation signs and 15g. -clears liver heat such you could give these formulas Shan Zhi Zi (Fructus Gardeniae Jasminoidis, Cape jasmine Fruit, throughout the month. Gardenia) 9g. -clears liver heat Huang Qin (Radix Scutellariae Baicalensis, Baical Skullcap Root, Scutellariae, Scute) 3g. -clears liver heat Bai Jie Zi (Semen Sinapis Albae, White Mustard Seed) 6g. -regulate Qi in the diaphragm and soothe liver Qi Chai Hu (Radix Bupleuri, Hares Ear Root, Thorowax Root) 3g. -soothe liver, regulate Qi, eliminate stagnation Xiang Fu (Rhizoma Cyperi Rotundi, Nut Grass Rhizome, Cyperus) 3g. -soothe liver, regulate Qi, eliminate stagnation Yu Jin (Tuber Curcumae, Tumeric Tuber Curcuma) 3g. -soothe liver, regulate Qi, eliminate stagnation Gan Cao (Radix Glycyrrhizae Uralensis, Licorice Root) 3g. -harmonize all herbs within this TCM formula Cooking Preparation of Xuan Yu Tong Jing Tang This natural chinese medicine Herbal formula is generally prepared as a decoction. Additional Information on Xuan Yu Tong Jing Tang This type of dysmenorrhea (painful periods) is due to liver fire deriving from long term stagnation of liver Qi. This pattern is NOT treated by draining fire with bitter cold herbs but by clears heat through eliminating stagnation! This alternative medicine Herbal formula is able to follow this treatment principle to alleviate the symptoms mentioned above.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 3 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Cold Accumulation and Blood Stasis Cold accumulation with blood stasis is rare in Austin Texas, but could be more common in colder areas. This can be related to external pathogens rather often. Repeat cold exposure and not covering up in your teens….that has some ramifications for later on! So take that you rebellious little hippies and your scantily clad offspring! Barton Springs and Deep Eddy swimmers (especially during the period), women who eat cold foods, etc are susceptible to this as well.

Feel the lower abdominal area – if it feels colder than the upper or side areas, that’s a cold accumulation.

With cold often see dark bleeding with clots. Tongue will be pale/dusky and pulse is often weak and/or slow.

Wen Jing Tang Moves and nourishes.

Shao Fu Zhu Yu Tang More directly moving the blood, not so much nourishing.

Damp Heat Now this is an Austin favorite. Hx of pelvic infections and/or inflammation is common and may be month long ab cramps and pelvic pain. Important sx is tongue – always have a thick or thin yellow coating. Digestive problems are very likely – ab cramps, gas and bloating, etc.

Qing Re Tiao Xue Tang Clear damp heat formula. Add hong teng, bai jiang cao, yi yi ren to clear damp heat in the lower jiao! They can put yi yi ren in the diet too. Job’s Tears of pearl barley, for the record.

For clinical practice, know to use the Golden Flower patent Dan Shen Hua Yu Pian. This is a great clear damp heat formula for these cases.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 4 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Dysfunctional Uterine Bleeding

Vaginal bleeding not related to ovulation. Teenagers may not ovulate, but have a period and perimenopausal women may not ovulate but will have uterine bleeding. Some px will bleed very heavily and/or bleed longer time. Dysfnx ut bleed includes flooding and leaking. Flooding and leaking is longer bleeding, no cycle pattern. This is not heavy bleeding within the period! Flooding and leaking is irreg menstruation!

Regardless, tx may be the same.

NOTE: If the px is post menopause – like haven’t been bleeding for a full year – you must refer them to an MD. There’s a very very high risk of cancer here in most cases.

Kidney Deficiency This can be yin or yang xu. Symptoms will fall in line with what we already know.

Yin Xu Red colored bleeding, not necessarily with clots. Heat makes the blood flow faster, will make blood thinner. Look for other yin xu signs. Pulse is thin rapid. Tongue is red less coating.

Zuo Gui Wan, can be modified – take out niu xi and add han lian cao, chao di yu or other cool blood/stop bleeding herbs as appropriate. There’s a Golden Flower patent called San Qi Formula. Might be a good one.

Yang Xu Heavy bleeding, but not bright red so often. Possible clots. Other ki xu signs….but may not! If you have a perimenopause age patient you might be looking at this also. Tongue will be damp/prob pale, cold slow type pulse.

Da Bu Yuan Jian – remove dang gui and add herbs like bu gu zhi, lu jiao jiao, ai ye tan, pao jiang, etc. By itself it will somewhat help stop bleeding, but mostly tonifies kidney.

Spleen Qi Deficiency Gu Chong Tang is your formula for this fun manifestation of Spleen Qi Xu. Add astringent herbs. Moxa on SP 1 to stop bleeding if they are doing so actively. Only use the formula when they are bleeding. Once it stops, switch to Gui Pi Tang or Xiang Sha Liu Jun Zi Tang.

Blood Heat See this in clinic a lot – heat and heavy bleeding with bright red color. San Qi Formula (Golden Flower) works well for this as well as it has both san qi and cool blood herbs. Don’t confuse this with San Qi Tablet. That’s not the same – just san qi in this pill. Help the px figure out where the heat is coming from. Could be from stagnation, stress, food they are eating, etc.

If you choose something else, be sure you are using a non-cooked version of san qi! Uncooked will stop bleeding, cooked will nourish. You can also use Yunnan Baiyao for this. Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 5 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Qing Re Gu Jing Tang is the standard formula from more classical sources – no q’s about this on the test.

Blood Stasis Again with the Yunnan baiyao.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 6 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Menopause

Rarely is menopause Kidney yin xu only…often with Liver Qi Stagnation. Know the difference for these formulas – there’s more than 1 question on this! Know both the names and the ingredients of these rx’s.

Base differentiations

Kidney Yin Xu Estrogen levels are low in this differentiation. Use acupuncture as well as herbs. Hot flashes and all that fun stuff. Insomnia, DDS, etc will also be present. The difference between the 3 rx’s.

Yin xu only – LWDHW, but Zhi Bai DHW might be better. Add gui ban, mu li, shi jue ming. These are heavy herbs and will bring the spirit downward and calm pretty quickly. Also takes down the hot flashes and night sweats. Can also use Da Bu Yin Wan.

Tian Wan Bu Xin Dan – heart/kidney disharmony. Blah blah blah.

Yi Guan Jian – all the fun Yin xu plus the Liver Qi Stagnation sx. Likely will have hypochon pain also. Pulse is thin and wiry/tense. Tongue – peeled on the edges in the liver area…no coating at all. Could work in a tincture version also.

Beware the estrogen sensitive px – like breast cancer survivors. Dang gui and xiang fu will boost estrogen. If they are on suppressant therapies you don’t want to work against that.

Kidney Yang Xu Don’t see that much. Often mixed with Yin and Yang xu.

You Gui Wan

Er Xian Tang. 1) Created for hypertension around periomenopause time. 2) “Disharmony of chong and ren and kidney yin and kidney yang xu.” There are a lot of questions on the boards about this. 3) Skin problems around menstrual cycle.

Easy to adjust dosages: the column to the far left on ZZ’s handout tonify yang. Middles nourish blood. Right side clears heat. Increase or decrease to meet needs of patients. Start small with the huang bai – can damage the spleen. Increase as needed.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 7 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Accompanying differentiations

Liver Qi Yu Lots of px will deny stress either because they don’t wanna talk about it or because they’ve had it so long it feels normal.

XYS or JWXYS can be added to Da Bu Yin Wan or others. Or you could use Yi Guan Jian instead. Depends on the degree.

Calcium and magnesium – that’s basically what mu li is made of. Calms the px. Can got to Target, get the oyster shell calcium instead of adding it in. Except Target has been all anti-gay lately, so I can’t do that. B@stards. 1000-1200mg Calcium to calm.

Watch out for estrogen sensitive px. No dang gui, xiang fu.

Blood Stasis Hx of fibroids or endometriosis. During meno will have some sx of ab pain, chest tightness, chest pain, etc. Possible migraine HA even w/o period - add Qi Ju Di Huang Wan for these peeps.

Xue Fu Zhu Yu Tang

Phlegm Related to perimeno time – vertigo, dizziness. Foggy mind, hot flashes too. Acupuncture and herbs help a lot.

Ban Xia Bai Zhu Tian Ma Tang – this is the phlegm/wind retention formula you use for Meniere’s.

Also know: perimeno with hormone changes can cause circulation issues. Use blood moving herbs like yin guo ye, chuan xiong which ascends and guides upward for the poor memory/concentration issues.

Depression during this time with crying and sensitivity - Gan Mai Da Zao Tang with XYS.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 8 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Final Exam Review:

Periomenopause rx’s – gotta memorize, know how to modify if you can’t remember ‘em for some credit. Know diagnoses – what is early, what is late, what is common, what’s abnormal and such. Differentiations – gotta be able to do that diagnosis Formulas –

100 pts total.  45 pt for MC – diagnoses and differentiations.  45 pt for 15 questions worth 3 pts – 15 cases, 12 formulas to choose from. Will use more than once. All rx’s will be used. This is the case and then a formula to choose from the 12. Will prob curve this part somewhat. If you can’t come up with the formula, at least put your differentiation down.  10 pts – 2 cases. Give disease dx (early, late, delayed, PMS, perio sx, etc.), differentiation, what rx you’d choose and write the ingredients. You can do powder or raw forms. Give directions – how many grams each day/dosage.

Herbal Treatment of Disease 3 – Gynecology – Class 11 www.CatsTCMNotes.com Page 9 of 9 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replacement for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you 1) do not charge for it and 2) attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun