Dysmenorrhea Treatment with Chinese Medicine Dr. Jeffrey(Ji Fei) Wang DOM, L.Ac & CH Wang’s Acupuncture & Herbal Clinic

Dysmenorrhea Treatment with Chinese Medicine Overview in Western Medicine 1.Signs and symptoms 2.Causes and mechanism 3.Screening and diagnosis 4.Complications 5.Treatment Dysmenorrhea Treatment with Chinese medicine 1.Concept 2. Causes and Mechanisms 3. Clinical manifestations 4. Diagnosis and Differential diagnosis 5.Patterns and Treatments

Overview in Western Medicine Dysmenorrhea is simply the medical term for menstrual cramps, that dull or throbbing pain in the lower abdomen many women experience just before and during their menstrual periods. For some female, it can be severe enough to interfere with everyday activities for a few days every month. Dysmenorrhea occurs in conjunction with the menstrual cycle. For many sufferers, it occurs during menstruation, though it can occur at other times in a woman's cycle, as well, such as during ovulation. Dysmenorrhea can be primary or secondary. Primary dysmenorrhea involves no physical abnormality and usually begins within three years after you begin menstruating. Primary dysmenorhea is the term used to describe pain related to menstruation, but not related to any pelvic disorder or injury. The pain of primary dysmenorrhea is often identified as waves of lower abdominal pain or cramping, which may be associated with the contractions of the uterus during menstruation. The abdominal pain of primary dysmenorrhea in some cases can be accompanied by leg cramps or back ache, nausea, vomiting, and bowel problems such as diarrhea or constipation, as well. Additionally, daughters of mothers who suffered primary dysmenorrhea frequently suffer from primary dysmenorrhea themselves. Secondary dysmenorrhea involves an underlying physical cause, such as endometriosis or uterine fibroids. Secondary dysmenorrhea refers to pain related to menstruation and caused by pelvic inflammation or lesions from disease, surgical scarring, injuries to the reproductive tract, and sometimes implanted types of birth control (IUDs). While the pain of primary dysmenorrhea is often symmetrical, begins just before the onset of menstrual bleeding, and lasts only one or two days, the pain of secondary dysmenorrhea is often concentrated around the area effected by the lesions, begins several days before bleeding, and lasts for several days after the onset of bleeding.

Signs and symptoms Most women experience menstrual cramps at some time in their lives. Cramps become problem when they're severe enough to keep you from going about your day-to-day routine. Signs and symptoms of dysmenorrhea, whether primary or secondary, may include: Dull or throbbing pain in the lower abdomen Pain that radiates to the lower back and thighs Less common signs and symptoms include: Nausea and vomiting Loose stools Sweating Dizziness

Causes and mechanism For primary dysmenorrhea: No one knows for sure, but many experts believe that prostaglandins cause menstrual cramps. To create a nourishing environment for a fertilized egg, the female sex hormone estrogen causes the uterine lining (endometrium) to thicken every month. Soon after, a follicle — a tiny sac in the ovary that contains a single egg (ovum) — ruptures and releases its egg (ovulation). If the egg becomes fertilized by contact with a sperm on its way to the uterus, the egg implants in the lining of the uterus. However, most often the unfertilized egg passes through the uterus and out of the body. Shortly thereafter, the uterus releases the lining, and the menstrual flow begins. To help expel its lining, the uterus contracts. Prostaglandins, hormone-like substances involved in pain and inflammation, trigger the uterine muscle contractions. For Secondary dysmenorrhea: The following are main causes for secondary dysmenorrhea. They include: Endometriosis. In this painful condition, the type of tissue that lines the uterus becomes implanted outside the uterus, most commonly on the fallopian tubes, ovaries or the tissue lining the pelvis. Pelvic inflammatory disease (PID). This infection of the female reproductive organs is usually caused by sexually transmitted bacteria. Use of an intrauterine device (IUD). These small, plastic, T-shaped birth control devices are inserted into the uterus. They may cause increased cramping, particularly during the first few months after insertion. Uterine fibroids and uterine polyps. These noncancerous tumors and growths protrude from the lining of the uterus. Risk factors Early onset of puberty (age 11 or younger) A family history of painful periods

Screening and diagnosis Review the medical history Perform a physical examination, including a pelvic exam. During the pelvic exam, the doctor will check for any abnormalities in the reproductive organs and look for indications of infection. Diagnostic tests: To rule out other causes of the symptoms or to identify the cause of secondary dysmenorrhea, which include: Imaging tests. Noninvasive tests that enable the doctor to look for abnormalities inside the pelvic cavity include ultrasound, computerized tomography (CT) and magnetic resonance imaging (MRI). Laparoscopy. This surgical procedure involves the doctor viewing the pelvic cavity by making tiny incisions in the abdomen and inserting a fiber-optic tube with a small camera lens. Hysteroscopy. In this procedure, the doctor inserts an instrument through the vagina and the cervical canal to examine the cervical canal and the inside of the uterus.

Complications The complications of secondary dysmenorrhea depend on the underlying cause. Ectopic pregnancy Infertility For instance, pelvic inflammatory disease can scar your fallopian tubes and compromise reproductive health. The scarring can lead to an ectopic pregnancy, in which the fertilized egg stays in the fallopian tube rather than traveling through the tube to implant in your uterus, or it implants somewhere else outside your uterus. Endometriosis, another possible cause of secondary dysmenorrhea, can lead to impaired fertility.

Treatment For primary dysmenorrhea: While there is no cure for primary dysmenorrhea, many steps can be taken to reduce or eliminate symptoms. an over-the-counter nonsteroidal anti-inflammatory drug (NSAID), such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen (Aleve). Some over-the-counter remedies are designed especially for combating the pain of primary dysmenorrhea, and contain a combination of pain-killing agents and diuretics to stop pain and reverse bloating and water retention. For those with especially painful, heavy or long periods, prescription pain killers, muscle relaxants, or hormonal therapies may be used to alleviate symptoms or normalize the menstrual cycle; For severe cramping, low-dose oral contraceptives to prevent ovulation, which may reduce the production of prostaglandins and therefore the severity of the cramps. Other possible remedies include heat application, dietary modification, and exercise. Some patients report that herbal remedies help to decrease their symptoms, as well, although it is recommended that patients check with their health care provider before beginning any such products. For secondary dysmenorrhea, Depending on the cause, treatment could include antibiotics to treat infection or surgery to remove fibroids or polyps. Many women suffer from mild cramping and discomfort at the time of their menstrual periods. However, for others, the pain can be intense and disruptive.

Dysmenorrhea Treatment with Chinese Medicine Dysmenorrhea refers to the pain that occurs around or during the menses. Commonly seen. It occurs periodically / regularly per month. Primary dysmenorrhea starts w/ the first menses. Secondary dysmenorrhea occurs later or post surgery / abortion May diagnose if occurs X 2. Common sx’s – abdominal pain, lower back pain, fainting, N/V. The abdominal pain is dt excess or def. in the sudden change of qi & blood in the chong or ren during the period. In Chinese medicine, dysmenorrhea like other forms of pain is the symptom of a deeper problem. The location of the disease is in the Chong & Ren & Uterus; It is caused by abnormal changes of qi & blood which manifests as pain in the lower abdomen.

Causes and machenisms Stagnation of Qi and Blood: Emotional Factors - strong emotions (depression, anger) may lead to stagnation of the LV Qi which may lead to a stagnation of Qi & Blood manifesting as painful menstruation. Cold(Damp) in Chong/Ren/Uterus: contact with cold(damp) environments (climates, climate controlled buildings, basements) a/or excessive consumption of cold/damp foods (fruit juices, ice cream) may lead to an accumulation of cold/damp in the Chong/Ren and Uterus which may lead to a stagnation of Qi & Blood manifesting as painful menstruation. Damp-heat in Lower Jiao: contact with damp-heat during menses period or consuming too much damp-heat food, etc. Existing Qi/Blood Deficiencies: def.of sp and st. or chronic disease. symptoms may be exacerbated during menstruation leading to dysmenorrhea. Existing LV/KD Deficiencies - constitutional weaknesses a/or in women who have had multiple child-births, thus depleting the KD Jing, worsened by the loss of Blood during menstruation.

Diagnosis and differentiation Key points for diagnosis: 1. cramping, dull or throbbing pain in the lower abdomen just before or during or after their menstrual periods. It relates with menstrual cycle. 2. Accompanied with other symptoms: lower back pain, nausea, vomiting, sweating, etc. The Key points for differentiation: Pain/ conditions of menses/ accompanied symptoms, tongue, pulse/ constitution 1.Pain symptoms: The nature of the pain: throbbing/shooting/sharp/stabbing/dislike pressure--- Excess dull/empty/aching/hollow/ prefer pressure---Deficiency The time of the pain: Prior/or during--- Excess; after or during---Deficiency The location of the pain: Central/Sides/Back/etc The degree of the pain: Severe---Excess; mild---Deficiency 2.Conditions of menses: Cycle, amount, color, quality 3.Accompanied signs and sym.+ tongue and pulse conditions 4.Constitutions

Diagnosis and differentiation Differentiation of the Pain: time, location, nature, intensity to the interview, along w/ condition of the menses, T & P,+ accompanying sx’s. Key Points: Time – if before the menses – excess If after the menses – deficiency If during the menses – either Location – If both sides of lower abd – Liver If central / middle lower abdomen – indicates blood stasis or Kidney def. Nature or Character/and Intensity – Excess: severest, stabbing, fixed, distention, dislike pressure Def: dull, hollow, empty, bearing down sensation, prefer pressure Heat / Burning – blood heat Cold pain / prefer warmth – Cold – may be def or excess. General treatment Principle: Regulate Qi & Blood Regulate Chong & Ren During the Bleeding Period: Regulate Qi & Blood Stop Pain Other time of the month: Treat the Root Regulate Chong & Ren Best time to treat to stop pain is 1 week to 10 days prior to onset of menses**

Treatment Principle General treatment Principle: Regulate Qi & Blood Regulate Chong & Ren During the Bleeding Period: Regulate Qi & Blood Stop Pain Other time of the month: Treat the Root Regulate Chong & Ren Best time to treat to stop pain is 1 week prior to onset of menses**

Patterns and treatment 1.Qi Stagnation w/ Blood Stasis 2. Cold in the Uterus 1) Yang Deficiency 2) Damp-Cold accumulation 3.Damp-heat Accumulate in the Chong & Ren 4.Qi & Blood Deficiency 5.Kidney & Liver Deficiency

Patterns and treatment 1.Qi Stagnation w/ Blood Stasis Liver qi stag. causes obstruction of chong & ren leading to painful periods. Dt strong emotions Occurs prior to onset of menses, May occur up to 1 week prior menses. Amount: Normal, scanty, un-smooth flow. Color; Purple Quality: w/ clots Abdominal pain & distention, dislike pressure,w/ breast distention/ pain.Pain relieved w/ discharge of clots; Pain disappears at end of period T/P:Normal or Slightly purple, may have dark spots/ ecchymosis Wiry or wiry & rolling Move the Qi, Soothe the Liver Invigorate the Blood Relieve the pain Pts: LIV 3, SP 6, SP 8 SP10, Ren 6, UB 17 Tao Hong Si Wu Tang or Ge Xia Zhu Yu Tang or Xue Fu Zhu Yu Tang + 5 herbs Chai Hu Zhi Ke Nui Xi Jie Jeng Gan Cao + Modify w/Shi Xiao San – sudden smile powder Pu HunagWu Ling Zhi Modifications:If increased heat sx’s – fresh red blood+ Mu Dan Pi & Zhi Zi If have bearing down sensation in genitalia (sx of endometriosis)+ Chai Hu* or Xiang Fu, Chuang Lian If lower abd pain w N/V dt LIV OA ST+ Huang Lian & Wu Zhu Yu

2. Cold in the Uterus Yang Deficiency or Damp-Cold accumulation Dt outside on cold, rainy days, eat too much raw, cold food, C-D accumulates in Chong & ren 1) yang qi def. failing to promote circulation of qi & blood in chong & ren leading to pain. Occurs at end of menses or during Amount; Scanty Color; Slightly light or dim Abdominal w/ cold sensation, likes warmth & pressure, likes hot water bottle.W/ soreness/weakness of low back/knees Poly urine T/P Pale, Moist Pale body or normal White, greasy coat Deep, Weak Warm the Channels Warm the Uterus Relieve the Pain Pts: UB 23, DU 3, DU 4Ren 4, Ren 6, SP 6, SP 8, KI 6Omit SP 6 Ai Fu Nuan Gong Wan Artemisia-Cyperus Warming the Uterus Pill Ai Ye Xiang Fu‘Si Wu Tang’Shu di Huang Bai Shao Dang Gui Chuan Xiong+ Huang Qi Rou Gui Xuan Duan Wu Zhu Yu Indicated for Dysmenorrhea & delayed menses 2) Cold accumulation: Occurs prior or during mensesAmount; ScantyColor; Dark, dim Quality; w/ clots - small, dark Lower abdominal pain – centralW/ cold sensation Prefers warmth / dislikes pressure T/P Deep, Tense Warm the Channels Eliminate Dampness Remove Blood stasis, Relieve Pain Pts: SP 6, SP 9, Ren 3 ST 29, ST 28, SP 8, DU4 Shao Fu Zhu Yu TangLower (Abdominal Eliminating Stasis Decoction) Cang Zhu Xiang fu 1st 2 herbs for damp Fu Ling Mo yao Invigorate blood Ru Xiang Remove stasis Dang Gui Chuan Xiong Wu Ling Zhi Pu Huang Yan Hu Suo Rou Gui* Xiao Hui Xiang * Warm the channels Chi Shao Yao Expel cold Gan Jiang *Modifications:If exterior cold w severe pain+ Fu Zi

3. Damp-heat Accumulate in the Chong & Ren D-H accumulates in chong & ren dt living in a Damp, humid area, post surgery D-H attacks, D-H constitution. D-H flow into chong & ren, flows into uterus & fighting w/ qi & blood 6pain. Occurs prior or during menses Color: Fresh red Quality: Sticky w clots Lower abdominal pain w heat or burning sensation, LBPPain may occur mid cycle, increases w period Yellow Leukorrhea 6T/P:Red Yellow, greasy coatWiry, Rapid or Moderate, rapid 6Clear Heat, Eliminate Damp Remove Blood Stasis Relieve Pain Pts:SP 6, SP 9, UB23, UB 22, LI 11,SP 10, Ren 3, ST28, LIV 3, LIV 8,SP 4, LU 7 & KI 6 Dan Bai Si Ni Miao San Mu Dan Pi Huang Bai Chai Hu Bai Shao Yao Zhi Ke Gan Cao‘Si Ni San’for pain dt qi stag.(Huang Bai)Cang Zhu Niu XiYi Yi Ren‘Si Miao San’cl D-H Hong Teng Bai Jiang Lian Qiao Clear heat, detoxify Chuan Xiong Chi Shao Yao Invigorate blood Remove stasis Modifications:If Distention abd/costal/breast area+ Chuang Lian Zi, Xiang Fu & Yan Hu Suo

4. Qi & Blood Deficiency Physical overwork or chronic disease consume qi & blood; especially SP. The menses consumes more qi & blood failing to nourish chng & ren & failing to nourish the uterus causing pain. Pain occurs during the menses or at the end Amount: Scanty Color: Pale Quality: Thin ;Abdominal pain that is dull, empty, hollow, Prefer pressure Dragging sensation in lower abdomen w lassitude, tiredness, poor appetite, diarrhea T/P:Pale Thready, Weak Tonify Qi Nourish Blood Relieve Pain Pts: Ren 4, Ren 6, ST 36, SP 10,UB 20, UB 17, UB 32, UB 54 Ba Zhen Tang* – best choiceComposed of Shen Qi Si Wu Tang and Sheng Yu Tang minus bai shao yao+ Sheng di Huang+ herbs to move qi Xiang Fu Yan Hu Suo Modifications:If breast distention/ pain/ costal dt blood def causing liver qi stag.+ Ju Ye or Ju He If w dizziness, vertigo, palpitations+ Shan Zao Ren, Ji Xue Teng If LBP and knees sore+ Chuan Xiong, Xu Duan, Shan Ji Sheng Also for:Scanty menses, Amenorrhea

5. Kidney & Liver Deficiency Over sex / too many pregnancies consume yin & blood, essence so fail to nourish chong & ren, fail to nourish the uterus leading to pain.*commonly seen patterns Occurs towards the end or after menses Amount: Scanty Color: Pale Quality: Thin Dull, hollow abdominal pain, relieved by pressure / massage Soreness/ weakness low back / knees+ Yin def Sx’s, Essence def Sx’s:tinnitus, blurred vision, tidal fever, T/P: Pale (essence def) or Red (yin def.)Thin, may be yellowish Thready, weak Tonify Kidney & Liver Relieve Pain Pts: Ren 4, Ren 6, UB 18, UB 23 ST 36, UB 32, UB 54 Tiao Gan Tang*(Regulating the Liver Decoction) Dang Gui ) Tonify blood &Bai Shao Yao ) Nourish yin Shan Zhu Yu – tonify KI & LIV Huai Shan Yao – Strengthen Spleen E Jiao – Nourish yin, Tonify blood Ba Ji Tian – Tonify KI Gan Cao Or Yi Guan Jian Sha Shen Gou Qi Zi Shu di Huang Mai men Dong Dang Gui Chuan Lian Zi Modifications:If sore low back+ Xu Duan & Du Zhong If Distention/ pain sides of lower abdomen / costal area++ Xiang Fu, Chuang Liang Zi, Yu Jin If breast distention, breast cysts+ Ju Ye, Ju He