1. Dysmenorrhea (tong jing 痛经 ) Shuguang hospital affiliated to shanghai TCM university Doctor: zhang qin hua

2. Introduction Introduction Classification Classification Pathogenesis Pathogenesis Diagnosis Diagnosis Main points of syndrome differentiation Main points of syndrome differentiation Examples :Treatments on the types of syndrome differentiation Examples :Treatments on the types of syndrome differentiation contents

3. Introduction What is 痛经（ tong jing) ？

4. Definition: Definition: refers to painful menstrual period, characterized by cramping lower abdominal pain radiating to the back and legs, often accompanied by GI & neurological symptoms （ nausea, vomiting, diarrhea) refers to painful menstrual period, characterized by cramping lower abdominal pain radiating to the back and legs, often accompanied by GI & neurological symptoms （ nausea, vomiting, diarrhea) Affects approximately 50% of women Affects approximately 50% of women about 5-10% have severe dysmenorrhea affecting daily activities. about 5-10% have severe dysmenorrhea affecting daily activities. Introduction

5. Classification Primary or idiopathic Primary or idiopathic without pelvic pathology. without pelvic pathology. Secondary Secondary underlying pelvic pathology underlying pelvic pathology

6. Primary Spasmodic Dysmenorrhea Commonest in teens/early twenties Commonest in teens/early twenties Usually appear 1-2 yrs after menarche Usually appear 1-2 yrs after menarche ovulatory cycles are established. ovulatory cycles are established. No abnormal findings except some tenderness. No abnormal findings except some tenderness. Main physiological basis is increased endometrial prostaglandin productions. Main physiological basis is increased endometrial prostaglandin productions. The pain may lessen as the woman gets older.or after giving birth. The pain may lessen as the woman gets older.or after giving birth.

7. Secondary Dysmenorrhea secondary to pathology secondary to pathology Usually occurs many years after menarche. Usually occurs many years after menarche. Pain may begin before bleeding and last for entire duration or persist continuously upto few days after the cessation of bleeding. Pain may begin before bleeding and last for entire duration or persist continuously upto few days after the cessation of bleeding. 30s and 40s women 30s and 40s women

8. Underlying pathology in secondary dysmenorrhea 1. Endometriosis/Adenomyosis. 2. Fibroid uterus 3. Congenital uterine anomalies- bicornuate, septate etc. 4. Cervical stenosis. 5. Pelvic inflammatory disease.

13. Shall we consider all the pain with vaginal bleeding as dysmenorrhea ?

14. Differential Diagnosis pregnancy complications like abortions & ectopic pregnancy pregnancy complications like abortions & ectopic pregnancy rupture of corpus luteum rupture of corpus luteum torsion of ovarian cyst torsion of ovarian cyst urinary stones urinary stones Appendicitis Appendicitis colitis and acute gastroenteritis colitis and acute gastroenteritis

15. Symptoms of Dysmenorrhea Cramps or pain in the lower abdomen or lower back Cramps or pain in the lower abdomen or lower back Pulling feeling in the inner thighs Pulling feeling in the inner thighs Diarrhea Diarrhea Nausea Nausea Vomiting Vomiting Headache Headache Dizziness Dizziness

16. Examination Vaginal exam not essential in young female with Primary dysmenorrhea Vaginal exam not essential in young female with Primary dysmenorrhea Vagina – septum Vagina – septum cervical - moving tenderness cervical - moving tenderness Uterus- size / mobility/ position/tenderness Uterus- size / mobility/ position/tenderness Adnexa –tenderness/ enlargement Adnexa –tenderness/ enlargement

17. Investigations Transabdominal ultrasound with full bladder Transabdominal ultrasound with full bladder Transvaginal ultrasound –increased sensitivity Transvaginal ultrasound –increased sensitivity Laparoscopy –gold standard for endometriosis Laparoscopy –gold standard for endometriosis Risks versus benefits Risks versus benefits

19. TCM pathologic factor Emotional factors six exogenous malnutrition of uterus congenital defect consumption of Q i& blood QI BLOOD Sad, anger, liver depression Cold, heat, dampness serious disease and prolonged illness liver and kidney multiparity and excessive sexual life

20. TCM Pathogenesis sthenia ( 实） Bu tong er tong 不通而痛 sthenia ( 实） Bu tong er tong 不通而痛 Qi stagnation and blood stasis into uterus Qi stagnation and blood stasis into uterus Asthenia ( 虚） Bu rong er tong 不荣而痛 Asthenia ( 虚） Bu rong er tong 不荣而痛 Malnutrition of the uterus and meridian Malnutrition of the uterus and meridian

21. Syndrome differentiation How to revealing the nature of dysmenorrhea? How to revealing the nature of dysmenorrhea? Pain Pain the time the time Location Location Degree Degree Menses Menses the quantity the quantity Color Color Texture Texture Complications Complications tongue and pulse conditions. tongue and pulse conditions.

22. Sthenia: Sthenia: before and during the mens before and during the mens unpressable and violent pain unpressable and violent pain Asthenia: Asthenia: After the menstruation After the menstruation dull pain with preference of pressure dull pain with preference of pressure Cold: Cold: pain alleviated with warmth pain alleviated with warmth colic or cold pain colic or cold pain Heat: Heat: pain worsened with warmth pain worsened with warmth burning pain burning pain Syndrome differentiation Blood stasis: Blood stasis: pain severer than distension pain severer than distension pain alleviate after the removal of blood clot pain alleviate after the removal of blood clot Pain is fixed and sting Pain is fixed and sting Qi stagnation: Qi stagnation: distension severer than pain distension severer than pain With breast tenderness With breast tenderness liver disorders: liver disorders: pain in the sides of abdomen pain in the sides of abdomen kidney disorders: kidney disorders: pain involving the loins pain involving the loins

23. Therapeutic principle key:regulating Qi and blood in the thoroughfare and conception vessels key:regulating Qi and blood in the thoroughfare and conception vessels regulating Qi regulating Qi activating blood activating blood dissipating cold dissipating cold Clearing away heat Clearing away heat supplementing asthenia supplementing asthenia purging sthenia purging sthenia

24. Two step principles Firstly : during the menstruation Firstly : during the menstruation regulating the blood to stop the pain regulating the blood to stop the pain treat branch (biao 标） treat branch (biao 标） Secondly : at other time Secondly : at other time syndrome differentiation syndrome differentiation treat root （ ben 本） treat root （ ben 本）

25. Syndrome of dysmenorrhea qi stagnation and blood stasis qi stagnation and blood stasis coagulation of cold in uterus coagulation of cold in uterus Coagulation of cold and dampness Coagulation of cold and dampness intern-cold caused by Yang asthenia intern-cold caused by Yang asthenia liver and kidney asthenia liver and kidney asthenia Qi and blood asthenia Qi and blood asthenia

26. Examples from ”Zhu nansun” clinical examples of gynecology from ”Zhu nansun” clinical examples of gynecology 14 jan Miss Huang, 22 year-old, soldier.unmarried 14 jan Miss Huang, 22 year-old, soldier.unmarried Main symptoms: Main symptoms: The 3rd day of the menses The 3rd day of the menses severe lower abdominal pain since the menses comes severe lower abdominal pain since the menses comes prolonged period,scanty menorrhea,with blood clots prolonged period,scanty menorrhea,with blood clots accompanied with backpain accompanied with backpain Tongue: thin and white fur, Tongue: thin and white fur, Pulse: deep, thready and a little taut. Pulse: deep, thready and a little taut.

27. Syndrome analyse The 3rd day of the menses — treat branch The 3rd day of the menses — treat branch severe lower abdominal pain since the menses comes severe lower abdominal pain since the menses comessthenia prolonged period,scanty menorrhea,with blood clots prolonged period,scanty menorrhea,with blood clots Qi and blood stagnation or cold coagulation accompanied with backpain accompanied with backpain Asthenia –kidney ‘s yang asthenia Tongue: thin and white fur, Tongue: thin and white fur, Cold or qi stagnation Pulse: deep, thready and a little taut. Pulse: deep, thready and a little taut. Cold and qi stagnation

28. answer Syndrome differentiation: Syndrome differentiation: asthenic uterine cold, Qi stagnation in Chong and Ren vessels( 胞宫虚寒，冲任气滞 ) asthenic uterine cold, Qi stagnation in Chong and Ren vessels( 胞宫虚寒，冲任气滞 ) Treatment: warm meridians and regulating Qi Treatment: warm meridians and regulating Qi Drug: Drug: Aiye6 Xiangfu9 Danggui6 Xuduan9 Baishao6 Shoudi9 Muxiang4.5 Wuyao6 Chuanlianzi9 Huangqi9 Rougui2.4

29. prognosis One month late One month late patient felt the pain obviously illeviated, and less blood clots, more volume of menses. patient felt the pain obviously illeviated, and less blood clots, more volume of menses. Treatment: Soothing the liver to regulate qi nourishing blood and warming the middle Treatment: Soothing the liver to regulate qi nourishing blood and warming the middle Drug: Drug: Xiangfu9 Yujin9 Danshen9 Aiye9 Wuyao6 Chuanlianzi9 Zhike4.5 Shoudi9 Chenpi6 Wuzhuyu6 Baishao6 After the treatment, dysmenorrhea disappeared,and the period became regular. After the treatment, dysmenorrhea disappeared,and the period became regular.

30. summarize Dr. Zhu said:“ When treating dysmenorrhea, doctors should not only pain attention to the syndrome differentiation, but also the proper moment. In this case, because there is Qi stagnation and blood stasis in the patient, we should give drugs at the first of the menses, especially patient felt severe lower abdominal pain,scanty menorrhea, with blood clots. We usually use “Shanzha, Zhike, Danggui, Ruxiang, Moyao” to dissipate the stagnation,smooth the menstruation, then the pain will disappear.” Dr. Zhu said:“ When treating dysmenorrhea, doctors should not only pain attention to the syndrome differentiation, but also the proper moment. In this case, because there is Qi stagnation and blood stasis in the patient, we should give drugs at the first of the menses, especially patient felt severe lower abdominal pain,scanty menorrhea, with blood clots. We usually use “Shanzha, Zhike, Danggui, Ruxiang, Moyao” to dissipate the stagnation,smooth the menstruation, then the pain will disappear.”

31. Examples from ”Zhu nansun” clinical examples of Gyn from ”Zhu nansun” clinical examples of Gyn Miss Wang, 23 year-old, doctor Miss Wang, 23 year-old, doctor Main symptoms: Main symptoms: Dysmenorrhea since the 1st, in recent years,aggressive pain Dysmenorrhea since the 1st, in recent years,aggressive pain advanced menorrhea, normal quantity, with clots, advanced menorrhea, normal quantity, with clots, there was signs before the menstruation there was signs before the menstruation distending pain in the chest, hypochondria and breasts distending pain in the chest, hypochondria and breasts poor appetite, fatigue, backpain,leucorrhea poor appetite, fatigue, backpain,leucorrhea when the menses came,severe lower abdominal pain lead to vomiting and diarrhea, even to coma when the menses came,severe lower abdominal pain lead to vomiting and diarrhea, even to coma Tongue: white and thin fur Tongue: white and thin fur Pulse: thready and taut. Pulse: thready and taut.

32. analyse advanced menorrhea, with clots advanced menorrhea, with clots Qi asthenia ， blood stasis Qi asthenia ， blood stasis distending pain in the chest, hypochondria and breasts distending pain in the chest, hypochondria and breasts Liver depression and qi stagnation Liver depression and qi stagnation poor appetite, fatigue, backpain,leucorrhea poor appetite, fatigue, backpain,leucorrhea Liver ‘s qi affect the Spleen’s function Liver ‘s qi affect the Spleen’s function Dampness invased the belt vessel because of the spleen’s weekness Dampness invased the belt vessel because of the spleen’s weekness severe lower abdominal pain lead to vomiting and diarrhea, even to coma severe lower abdominal pain lead to vomiting and diarrhea, even to coma Liver ‘s qi rising,spleen’s qi descending Liver ‘s qi rising,spleen’s qi descending Tongue: white and thin fur Tongue: white and thin fur Pulse: thready and taut. Pulse: thready and taut.

33. answer Syndrome differentiation: Syndrome differentiation: liver depression and asthenia of spleen, weekness of Belt vessel liver depression and asthenia of spleen, weekness of Belt vessel Treatment: Treatment: Before the menstruation, when patient felt the signs Before the menstruation, when patient felt the signs soothing liver and harmonizing stomach soothing liver and harmonizing stomach In the middle of menses In the middle of menses invigorating spleen and tightening up the Belt vessel invigorating spleen and tightening up the Belt vessel

34. Drug: Before the menstruation Drug: Before the menstruation Xiangfu9 Yujin6 Danggui6 Baishao6 Yanhusuo6 Wuyao9 Chuanlianzi6 Ruxiang6 Moyao6 Sugeng6 Muxiang4.5 Shanzha9 Xiangfu9 Yujin6 Danggui6 Baishao6 Yanhusuo6 Wuyao9 Chuanlianzi6 Ruxiang6 Moyao6 Sugeng6 Muxiang4.5 Shanzha9 Drug: in the middle of menses Drug: in the middle of menses Baishu6 Chenpi6 Fuling9 Huangqi9 Danggui6 Yiyiren12 Ebaipi9 Haipiaoxiao9 Xianhecao9 Diyutan12 Huangbai6 Baishu6 Chenpi6 Fuling9 Huangqi9 Danggui6 Yiyiren12 Ebaipi9 Haipiaoxiao9 Xianhecao9 Diyutan12 Huangbai6

35. summarize PS: Dr. Zhu said:” in the case of liver depression, we should treat dysmenorrhea when signs appears, by using drugs of soothing liver and regulating Qi” PS: Dr. Zhu said:” in the case of liver depression, we should treat dysmenorrhea when signs appears, by using drugs of soothing liver and regulating Qi”

36. Syndrome of qi stagnation and blood stasis Main symptoms: Main symptoms: unpressable lower abdominal pain or distention pain before or during menstruation unpressable lower abdominal pain or distention pain before or during menstruation profuse or scanty menstruation,dripping and unsmooth menorrhea, purplish and blacking color menses with blood clots profuse or scanty menstruation,dripping and unsmooth menorrhea, purplish and blacking color menses with blood clots distending pain in the chest, hypochondria and breasts distending pain in the chest, hypochondria and breasts purplish tongue or with ecchymosis on the edge purplish tongue or with ecchymosis on the edge deep and taut pulse. deep and taut pulse. Therapeutic methods: Therapeutic methods: Soothing the liver to regulate Qi and resolving stasis to stop pain. Soothing the liver to regulate Qi and resolving stasis to stop pain. Prescription: Prescription: Modified Xuefu Zhuyu Tang Modified Xuefu Zhuyu Tang

37. example from ”Qian bo xuan” clinical examples of gynecology from ”Qian bo xuan” clinical examples of gynecology 23 /2 Miss Jin, 21 year-old 23 /2 Miss Jin, 21 year-old unmarried,LMP: 3 feb unmarried,LMP: 3 feb Main symptoms: Main symptoms: dysmenorrhea for six years dysmenorrhea for six years lower abdominal pain before menses lower abdominal pain before menses accompanied with stomach pain accompanied with stomach pain felt cold in abdomen with preference of pressure felt cold in abdomen with preference of pressure Tongue: white and thin fur Tongue: white and thin fur Pulse: thready and slippery Pulse: thready and slippery

38. analyse lower abdominal pain before menses lower abdominal pain before menses sethnia sethnia accompanied with stomach pain accompanied with stomach pain Qi stagnation(liver) Qi stagnation(liver) felt cold in abdomen with preference of pressure felt cold in abdomen with preference of pressure Asthenia of spleen yang(why not kidney) Asthenia of spleen yang(why not kidney) Tongue: white and thin fur Tongue: white and thin fur Pulse: thready and slippery Pulse: thready and slippery

39. answer Syndrome differentiation: Syndrome differentiation: coagulation of cold and Qi stagnation; disharmony between liver and stomach coagulation of cold and Qi stagnation; disharmony between liver and stomach Treatment: Treatment: Warming meridians and dissipate coldness; harmonizing liver and spleen Warming meridians and dissipate coldness; harmonizing liver and spleen Drug: Drug: Danggui9 Chuanxiong4.5 Chishao9 Baishao9 Rougui3 Danggui9 Chuanxiong4.5 Chishao9 Baishao9 Rougui3 Wuzhuyu3 Gouji12 Wuyao6 Qingpi6 Chenpi6 Banxia6 Muxiang6 xiaohuixiang Wuzhuyu3 Gouji12 Wuyao6 Qingpi6 Chenpi6 Banxia6 Muxiang6 xiaohuixiang

40. Syndrome of coagulation of cold dampness Main symptoms: Main symptoms: unpressabe lower abdominal pain, cold pain before or during menstruation unpressabe lower abdominal pain, cold pain before or during menstruation alleviation of pain with warmth alleviation of pain with warmth scanty menorrhea with purplish color menses and clot or like juice of black soybean scanty menorrhea with purplish color menses and clot or like juice of black soybean cold sensation in the body and aversion to cold,loose stool cold sensation in the body and aversion to cold,loose stool light purplish tongue with white and moist or white and greasy fur light purplish tongue with white and moist or white and greasy fur deep and tense pulse. deep and tense pulse. Therapeutic methods: Therapeutic methods: Warming meridians to disperse cold and draining dampness to eliminate stagnation. Warming meridians to disperse cold and draining dampness to eliminate stagnation. Prescription: Prescription: Modified Shaofu Zhuyu Tang Modified Shaofu Zhuyu Tang

41. example from ”Qian box uan” clinical examples of gynecology from ”Qian box uan” clinical examples of gynecology 6.25 Miss lin,20 year-old, unmarried LMP: 6.15 6.25 Miss lin,20 year-old, unmarried LMP: 6.15 Main symptoms: Main symptoms: Dysmenorrhea for 4 years. Less volume of menses with light color. Dysmenorrhea for 4 years. Less volume of menses with light color. lower abdominal pain appeared 2 days before the menses; at the first day of menstruation, lower abdominal pain became more serious lower abdominal pain appeared 2 days before the menses; at the first day of menstruation, lower abdominal pain became more serious accompanied with cold limbs, palpitation, dizziness, alleviated with warmth. accompanied with cold limbs, palpitation, dizziness, alleviated with warmth. LMP: 6.15, scanty menses purplish color with clots, serious lower abdominal pain even to faint, constipation LMP: 6.15, scanty menses purplish color with clots, serious lower abdominal pain even to faint, constipation Tongue : white fur, exfoliate fur in the middle of the tongue Tongue : white fur, exfoliate fur in the middle of the tongue Pulse: deep and taut. Pulse: deep and taut.

42. Less volume of menses with light color. Less volume of menses with light color. Asthenia of qi and blood Asthenia of qi and blood accompanied with cold limbs, palpitation, dizziness, alleviated with warmth. accompanied with cold limbs, palpitation, dizziness, alleviated with warmth. Cold and blood deficiency( heart and spleen) Cold and blood deficiency( heart and spleen) scanty menses purplish color with clots, serious lower abdominal pain even to faint, constipation scanty menses purplish color with clots, serious lower abdominal pain even to faint, constipation Blood stasis (cold and qi asthenia) Blood stasis (cold and qi asthenia) Tongue : white fur Tongue : white fur Pulse: deep and thready. Pulse: deep and thready.

43. Syndrome differentiation: Syndrome differentiation: Qi and blood asthenia Qi and blood asthenia Treatment: Treatment: Warming and nourishing Qi and blood Warming and nourishing Qi and blood Drug: Drug: Chinese patent drug :Shiquandabu Wan Chinese patent drug :Shiquandabu Wan siwutang+sijunzi tang +rougui huangqi siwutang+sijunzi tang +rougui huangqi

44. prognosis 2 w After treatment, the patient felt all kinds of symptoms alleviated. 2 w After treatment, the patient felt all kinds of symptoms alleviated. Tongue: white and thin fur, Pulse : thready and deep.Now the menses was coming. Tongue: white and thin fur, Pulse : thready and deep.Now the menses was coming. Treatment: nourishing blood and regulating Qi,; warming meridians and dissipating stagnation Treatment: nourishing blood and regulating Qi,; warming meridians and dissipating stagnation

45. Drug: Drug: Danggui9 Chuanxiong6 Danshen9 Xiangfu6 Zelan9 Wuyu3 Guizhi4.5 Yanhusuo9 Heidou12 And Chinese patent drug: Hupo San 6g/every night Huposan: Sanleng30 Eshu30 Chishao30 Liujinu30 Mudanpi30 Shoudihuang30 Danggui30 Guangui30 Wuyao30 Yanhusuo30

46. 8.3 After this period treatment 8.3 After this period treatment LMP:7.27,the pain and poor appetite disappeared,just felt distending in the abdomen. The volume of menses became large, but still accompanied with headache, backpain LMP:7.27,the pain and poor appetite disappeared,just felt distending in the abdomen. The volume of menses became large, but still accompanied with headache, backpain white thin fur, Pulse: deep and slippery, white thin fur, Pulse: deep and slippery, Syndrome differentiation: Syndrome differentiation: blood asthenia and stagnation of Qi and blood blood asthenia and stagnation of Qi and blood Treatment: Treatment: nourishing blood and regulating Qi to regulate menstruation and dissipate stagnation. nourishing blood and regulating Qi to regulate menstruation and dissipate stagnation. Drug: Drug: Chinese patent drug: Bazhen Yimu Wan+Hupo San Chinese patent drug: Bazhen Yimu Wan+Hupo San

47. Syndrome of Qi and blood asthenia Main symptoms: Main symptoms: Dull pain or continuous pain or prolapsing sensation in the lower abdomen during or after menstruation, alleviation with pressure, profuse or scanty menses with light color and thin texture but without clot, pale complexion, dizziness, palpitation, lassitude, light-colored tongue with tooth print and thin fur as well as thin pulse. Dull pain or continuous pain or prolapsing sensation in the lower abdomen during or after menstruation, alleviation with pressure, profuse or scanty menses with light color and thin texture but without clot, pale complexion, dizziness, palpitation, lassitude, light-colored tongue with tooth print and thin fur as well as thin pulse. Therapeutic methods: Therapeutic methods: Strengthening the spleen and nourishing Qi,invigorating blood and stopping bleeding. Strengthening the spleen and nourishing Qi,invigorating blood and stopping bleeding. Prescription: Prescription: Modified Bazhen Tang Modified Bazhen Tang

48. example 7.22 Miss Teng,27 year-old, unmarried 7.22 Miss Teng,27 year-old, unmarried Main symptoms: Main symptoms: Dysmenorrhea for six years; delayed menorrhea with a few blood clots,; dull abdominal pain during the menstruation accompanied with backpain, hot sensation in palms; Tongue: red tongue with teeth print, white fur Dysmenorrhea for six years; delayed menorrhea with a few blood clots,; dull abdominal pain during the menstruation accompanied with backpain, hot sensation in palms; Tongue: red tongue with teeth print, white fur

49. Syndrome differentiation: liver and kidney asthenia Syndrome differentiation: liver and kidney asthenia Drug: Drug: Danggui9 Huainiuxi9 Shengdi9 Chishao9 Nuzhengzi4.5 Danggui9 Huainiuxi9 Shengdi9 Chishao9 Nuzhengzi4.5 Xuduan9 Gouji9 Fuling12 Zexie9 Danpi9 Xuduan9 Gouji9 Fuling12 Zexie9 Danpi9

50. Syndrome of liver and kidney asthenia Main symptoms: Main symptoms: Scanty menses with dull light color but without blood clot, dull pain in the lower abdomen after menstruation, aching sensation in the lions and knees, dizziness and tinnitus, light-red tongue with thin fur, deep and thin pulse. Scanty menses with dull light color but without blood clot, dull pain in the lower abdomen after menstruation, aching sensation in the lions and knees, dizziness and tinnitus, light-red tongue with thin fur, deep and thin pulse. Analyse: Analyse:

51. Therapeutic methods: Therapeutic methods: Nourishing blood and regulating the liver, replenishing the kidney and enriching essence Nourishing blood and regulating the liver, replenishing the kidney and enriching essence Prescription: Prescription: Modified TiaoGan Tang Modified TiaoGan Tang Shanyao15 ejiao 9 danggui9(wine) baishao9(wine) shayurou9 baji3 gancao3 sangjisheng15 Shanyao15 ejiao 9 danggui9(wine) baishao9(wine) shayurou9 baji3 gancao3 sangjisheng15 Duzhong15 gouji15 shoudi12 shayuanzi15 Duzhong15 gouji15 shoudi12 shayuanzi15

52. Relief tips Exercise Exercise Exercising most days of the week can make you feel better. Exercising most days of the week can make you feel better. Aerobic workouts, such as walking, jogging, biking, or swimming, help produce chemicals that block pain. Aerobic workouts, such as walking, jogging, biking, or swimming, help produce chemicals that block pain. Apply heat Apply heat A warm bath or a heating pad or hot water bottle on your abdomen can be soothing. A warm bath or a heating pad or hot water bottle on your abdomen can be soothing. Sleep Sleep Make sure you get enough sleep before and during your period. This can help you cope with any discomfort. Make sure you get enough sleep before and during your period. This can help you cope with any discomfort. Relax Relax Meditate or practice yoga. Relaxation techniques can help you cope with pain. Meditate or practice yoga. Relaxation techniques can help you cope with pain.

53. Food treat Mutton soup: Mutton soup: Danggui 60g raw jinger 5 huangqi30g Danggui 60g raw jinger 5 huangqi30g Mutton 500g Mutton 500g Reinforce qi and blood,regulating menses stop pain Reinforce qi and blood,regulating menses stop pain Hawkthorn soup: Hawkthorn soup: Shanzha(hawkthorn)30g brown sugar 60g guizhi5g Shanzha(hawkthorn)30g brown sugar 60g guizhi5g Activing blood and disperse stasis,stop pain Activing blood and disperse stasis,stop pain Brown sugar soup Brown sugar soup Brown sugar 30g ganjiang 30g dazao 30g Brown sugar 30g ganjiang 30g dazao 30g Warming meridian disperse cold stop pain Warming meridian disperse cold stop pain

54. External therapy Navel stuffing with baiyao Navel stuffing with baiyao Baiyao 20g, make paste use white wine and stuffing into navel,fasten with adhesive plaster, iron on it with the hot-water bag,twice a day,10-15min avery time. Baiyao 20g, make paste use white wine and stuffing into navel,fasten with adhesive plaster, iron on it with the hot-water bag,twice a day,10-15min avery time. Drug-wine massage Drug-wine massage Yunnan baiyao wine,daub on the guanyuan 、 qihai acupoint ， and massage until you feel hot. Yunnan baiyao wine,daub on the guanyuan 、 qihai acupoint ， and massage until you feel hot.

55. Foot bath Foot bath Yimucao 20g xiangfu 20g ruxiang 20g moyao 20g xiakucao 20g Yimucao 20g xiangfu 20g ruxiang 20g moyao 20g xiakucao 20g take decoction2000ml and make foot bath erery day,15-20min take decoction2000ml and make foot bath erery day,15-20min External therapy

56. 清 · 王清任 wang qing ren qing dynasty ( 公元 1768 - 1831 年 ) 。

57. Zhu yu tang Xue fu zhu yu tang Xue fu zhu yu tang Ge xia zhu yu tang Ge xia zhu yu tang Qi stagnation and blood stasis Qi stagnation and blood stasis Shao fu zhu yu tang Shao fu zhu yu tang Cold lodging into uterus or low energizer Cold lodging into uterus or low energizer

58. Warm uterus : Warm uterus : huixiang aiye rougui paojiang fuzi wuyu huixiang aiye rougui paojiang fuzi wuyu Clear heat Clear heat Danpi chishao shengdi huangqin shanzhi huangbai zhimu Danpi chishao shengdi huangqin shanzhi huangbai zhimu Disperse stasis ： Disperse stasis ： chishao sanleng ezhu honghua Taoren danpi chishao sanleng ezhu honghua Taoren danpi dibiechong shuizhi shengpuhuang wulingzhi dibiechong shuizhi shengpuhuang wulingzhi Active qi: Active qi: Zhixiangfu chuanxiong zhike qingpi yanhusuo chaihu Zhixiangfu chuanxiong zhike qingpi yanhusuo chaihu Stop pain Stop pain Quanxie wugong xuejie Ruxiang moyao Quanxie wugong xuejie Ruxiang moyao

59. rebalance yourself TCM’s treatment focuse on th body, not on the diease Aim to rebalance the yin and yang of the body