PRIMARY DYSMENORRHOEA

A Comparison of East and West.

Jimi Windmills

Primary Dysmenorrhoea – An Introduction and Epidemiology

Dysmenorrhoea can be separated into two categories. Primary Dysmenorrhoea, and Secondary Dysmenorrhoea. Primary dysmenorrhoea is defined as pain in the lower abdomen beginning just prior to or during menstruation. A diagnosis of primary dysmenorrhoea is given when no specific pathological cause can be established. Secondary Dysmenorrhoea is period pain which is associated with a diagnosed condition such as PCOD, or endometriosis, which are responsible for the occurrence of pain (Coco 1999). This essay will focus on primary dysmenorrhoea, and from a TCM perspective, the three most common patterns of disharmony; Qi and Blood Stagnation, Qi and Blood Deficiency, and Cold stagnation in the Uterus.

Primary dysmenorrhoea is the most common gynecologic complaint in menstruating women. Primary dysmenorrhoea typically presents in adolescence, and is often ignored or not satisfactorily treated, since period pain in this context is considered normal. It is so common, that even though it interferes with womens daily lives, it often goes unmentioned in medical interviews (Coco 1999). Reported prevalence is as high as 90 percent. A study of college students, found that 72 percent of periods, based on menstrual diaries kept for a year, were painful, most commonly during the first day of menses. At least one episode of severe pain was reported by sixty percent of the participants (Coco 1999).

There are several risk factors associated with severe menstrual pain. The same study found an association between severe episodes of dysmenorrhoea and “earlier age at menarche, long menstrual periods, smoking, obesity and alcohol consumption” (Coco 1999).

Some Chinese Physiology

In TCM physiology we see the involvement of several organs and channels in the regulation of the menstrual cycle. The primary organs involved are the uterus, kidneys, liver, spleen, and heart. The primary channels are the Chong and Ren, along with the Bao Mai (uterus to heart), and Bao Luo (uterus to kidneys).

Uterus – The Uterus stores blood and nourishes the fetus. It is associated with the lower dan tian, the area from which the Ren, Du, and Chong vessels arise. It is closely related to the kidneys and heart and maintains a connection to them through the Bao Luo and Bao Mai channels. In Chinese medicine the Uterus as an organ, includes the Fallopian tubes and Ovaries (Maciocia 1998: 7).

Kidneys – The Kidney essence provides the physical substance for the creation of menstrual blood. The Kidney water or yin, provides a substrate for the condensation of the tian gui, which is then released monthly during the period. Futher, the kidneys play a vital role in the creation of Blood in general, through their contribution of Essence and Yuan-Qi, to the post-natal Qi extracted from food and the air by the spleen and lungs. The kidneys also generate marrow which in turn contributes to the production of blood (Maciocia 1998: 11-12).

Liver – The liver has a close relationship with the uterus and with blood. Thus, it's role in menstruation is extremely important. The liver stores and nourishes blood, and in this capacity, provides the uterus the blood it needs for its fundamental functioning. Perhaps more important, in the context of dysmenorrhoea, is Liver-Qi. Liver-Qi moves the blood, and the smooth functioning of Liver-Qi is critical pre-menstrually to ensure that Blood does not stagnate, and cause pain (Maciocia 1998: 12-13).

Spleen – The spleen makes the blood. Without the spleen, the liver and uterus would have no blood to store and release. The spleens ascending Qi also holds the uterus in place, and its Qi also holds blood in the vessels, until the appropriate time for release (Maciocia 1998: 13-14).

Heart – While the heart governs blood, and in this role has an overall effect on menstrual function, it's role in relation to dysmenorrhoea is minimal. Maciocia notes however, that the Secret Records of Master Feng's Brocade Bag tells us that the Heart and Small Intestine channels, as an interior exterior pair relate in one aspect (Yang) to the production of breast milk, and in another (Yin) to the production of menstrual blood (Maciocia 1998: 14).

The Lungs also contribute in a minor way through their function of governing Qi. The Stomach, through it's channel relationship with the chong, is influential in nourishing breast milk, and also plays a part in morning sickness. It is worth mentioning here that the stomach is also involved (along with the spleen, and the rest of the digestive system) in making Blood (Maciocia 1998: 14-15).

The Chong Mai (Penetrating Vessel) is the most important channel when it comes to menstrual function. It is the sea of blood which gathers from the zang-fu. It is the changes in this (and the Ren) channel that dictate the seven year cycles of female development (Maciocia 1998: 17-18). Maciocia also notes that when the Chong is deficient, periods may come late, be scanty, or not come at all (Maciocia 1998: 18).

The Ren Mai (Directing Vessel) is the Sea of the yin channels, and relates to yin, essence, and fluids, and provides these substances as well as blood for all physical and hormonal function. While the Chong Mai is more closely related menstruation (and its dysfunction), the Ren Mai has more to do with menarche, fertility, conception, pregnancy, and menopause (Maciocia 1998: 19).

Aetiology and Pathogenesis – East vs West.

From a western medical perspective, primary dysmenorrhoea (while not completely understood) is a result of increased production of endometrial prostaglandin, resulting in increased uterine tone and stronger, more frequent uterine contractions. In the day leading up to menstruation, the blood flow to the endometrium is restricted by contracting blood vessels. This starves the endometrium, which, as the period begins, starts to breakdown and release prostoglandins. The combined effect of local ischaemia, as well as new nerve endings being exposed, is the primary cause of pain (Coco 1999; French 2005; Lyttleton 2004: 30-31).

From a TCM perspective, Dysmenorrhoea is essentially a condition of stagnation. Since Qi and Blood are essentially the same substance (although polar opposites), they have a very close synergistic relationship. The Qi is the commander of Blood, and Blood is the mother of Qi. When Qi is deficient it will not lead the Blood in the Uterus. If Blood is deficient it will not nourish Qi, which will stagnate. For painless menstruation to occur, there must be abundant Liver-Blood, to fill the Chong Mai, and an unimpeded flow of Liver-Qi, this will enable the menstrual cycle to function smoothly. Stagnation may arise in response to several different aetiological factors.

Emotional Strain – Causes Liver-Qi to stagnate, which in turn can lead to Liver-blood Stasis. Both result in pain. In severe cases Liver-Qi stagnation may develop into Liver-fire, which may lead to Blood-heat and combine in the Uterus with damp-heat (Maciocia 1998: 235-236).

Cold and Damp – Cold may invade the Uterus either at puberty or around the time of menstruation. At these times times the body is particularly susceptible to invasion of cold. Cold constricts and stagnates Qi and Blood which obstructs the passages and leads to pain (Maciocia 1998: 236).

Overwork and Chronic Illness – Both impact the stomach and spleen and limit their capacity to produce Qi and Blood. This in turn causes deficiency of blood in the Chong and Ren, which then pools and stagnates, since there is not enough volume to flow correctly (Maciocia 1998: 236).

Excessive Sexual Activity and Childbirth – Excessive sex, sex from a young age, and multiple childbirths close together, impact the Liver and Kidneys. Deficient Liver and Kidneys causes emptiness in the Chong and Ren, causing stagnation due to inadequate flow in the vessels (Maciocia 1998: 236).

From these aetiological factors we derive several patterns of disharmony which give rise to painful periods. According to Maciocia, there are eight patterns; Qi Stagnation, Blood Stagnation, Damp-Heat with Blood-Heat, Stagnant Liver-Qi turning into Live-Fire, Stagnation of cold in the Uterus (May be excess or deficient cold), Qi and Blood deficiency, Yang and Blood deficiency, Kidney and Liver-Yin deficiency (1998: 236).

Qi and Blood stagnation most frequently present together. They are also usually present in some form in each of the deficient type patterns (Maciocia 1998: 236). Qi Stagnation pain by itself usually occurs before the period, and is dull, with a feeling of distention in the lower abdomen. There may also be symptoms of PMS, irritability or depression and a wiry pulse. When Blood is also stagnant the pulse may become choppy or fine, and the tongue will become purple. In Blood stasis the pain becomes intense and stabbing, and the menstrual blood is dark in colour. The pain generally subsides after the passing of large dark clots (Maciocia 1998: 237).

Stagnation of Cold is a common cause of period pain. Cold obstructs the uterus and vessels, and impedes the flow of blood. The result is Blood Stasis, and with it, clots and intense cramping pain. Cold stagnation pain is relieved by heat and is further differentiated from Blood stagnation by the quality of the blood. Like Blood stagnation, the pain with ease with the passing of clots, but the blood will be red rather than dark. Cold stagnation clots will be dark, but small or stringy (Maciocia 1998: 237).

Qi and Blood deficiency pain occurs at the end of, or after the period. While Qi and Blood deficiency pain is relatively mild according to Maciocia, there is nevertheless, some element of Qi and Blood stagnation. This happens because the Qi and Blood are deficient and thus do not flow properly. Qi and Blood deficiency pain tends to be dull, and is relieved by pressure and massage. The period will be scanty, the complexion pale, and there will also be tiredness and loose stool. The tongue will be pale, and the pulse choppy (Maciocia 1998: 252)

Damp-heat with Blood-Heat does not cause intense pain, and is associated with a heavy period. Other signs of damp and heat will also be present such as: Red tongue, yellow coat, rapid pulse, feeling heavy, and yellow vaginal discharge (Maciocia 1998: 237). Yang and Blood deficiency will cause pain which is better for pressure and heat. The pain occurs after a period which was scanty with pale blood, accompanied by a dull headache, feeling cold, pale swollen tongue and a fine deep pulse (Maciocia 1998: 254). Kidney and Liver-Yin deficiency pain comes toward the end, or after the period. It is differentiated by sore lower back, dizziness, tinnitus and blurred vision, and is better for pressure and massage (Maciocia 1998: 256).

Western management of primary dysmenorrhoea.

In current western medicine, a diagnosis of primary dysmenorrhoea is given when period pain is so bad that it interferes with the routines of a woman's daily life. Other causes of pain must be investigated to eliminate them as aetiological factors, and thus differentiate primary, from secondary dysmenorrhoea.

Western medical science, for the most part, relies on non-steroidal anti-inflammatory drugs (NSAID's). These provide analgesic relief from the symptoms of primary dysmenorrhoea, by inhibiting prostaglandin synthesis (Coco 1999). Less prostaglandin equates to less frequent and intense uterine contractions, and decreased menstrual flow. In cases where this symptomatic treatment is ineffective, it is often supplemented with the addition of the oral contraceptive pill (OCP). The OCP also acts to reduce prostaglandins by suppressing ovulation and thereby lessening the endometrial lining, reduces the menstrual volume and reducing uterine cramps during menstruation (Proctor, Roberts & Farquhar 2001). Between 10 and 20 percent of women who suffer dysmenorrhoea do not respond to these treatments (Hendrix and Alexander 2002). In these cases surgery may be considered an option, and has been utilised increasingly in recent years. There are two main methods; Uterine nerve ablation (UNA) and presacral neurectomy (PSN), both of which interrupt the sensory nerves near the cervix to block pain (Proctor et al. 2010). However, a systematic review of these methods conducted by Proctor et al. found that there was little evidence to support the use of surgery for pain management, in either primary or secondary dysmenorrhoea (Proctor et al. 2010).

None of these treatments address the underlying cause of the pain. This may be due to the fact that western medicine considers pain during the period to be a relatively normal part of the process. Primary dysmenorrhoea is considered to be little more than particularly bad period pain, and the period itself is the “pathology”. This, in the authors opinion, is due to the male-centric development and current domination of the modern western medical system. If men suffered period pain, there would be a lot more research on the topic, and the underlying mechanisms (from a western sense) would be better understood.

TCM Treatment

In Chinese medicine, the ultimate aim in treating a condition is to identify the underlying pattern of disharmony, and treat it to effect the greatest outcome possible, while at the

same time, provide symptomatic relief. This is treating the root and branch (ben and biao), and is typically a stark contrast to western management of similar conditions.

As mentioned above there are three predominating causes of primary dysmenorrhoea; Qi and Blood stagnation, Qi and Blood deficiency, and Cold stagnation in the Uterus. Each with clear differentiating signs and symptoms. Once a diagnosis is reached, a treatment principle is formulated, to address the key elements of the condition. The treatment principle is then used in conjunction with palpation of the involved channels to select appropriate points and therapeutic techniques. See appendix for treatments.

Supporting Studies

A clinical review of 27 studies (dated up until 2008), involving 2960 subjects, found that in 22 of the studies acupuncture was significantly more effective at reducing pain than pharmacological treatment, and concluded that there was “promising evidence in the form of [randomised controlled trials] for the use of acupuncture in the treatment of primary dysmenorrhoea compared with pharmacological treatment ” (Cho & Hwang 2010: 519). In another clinical review of research released up until 2010, including 10 trials, and 944 patients, showed in all cases that acupuncture was effective in reducing the effects of dysmenorrhoea, and two of the trials specifically showed acupuncture to be more effective than the use of NSAID's (Smith et al. 2010: 14-15). A 1984 preliminary trial demonstrated a complete absence of pain for three consecutive periods in 86% of women treated with acupuncture (Yuqin 1984). A randomized controlled trial in 2003, involving 30 women with primary dysmenorrhoea, showed a success rate of 93.3% within one year of treatment (Habek et al. 2003).

Appendix

Treatment of Common patterns of Primary Dysmenorrhoea

- From Maciocias Obstetrics and Gynecology in Chinese Medicine 1998 -

Qi Stagnation

Pain in the lower abdomen, or distention of the lower abdomen and breasts, hesitant start of period, dark menstrual blood, no clots, PMS, and irritability.

Tongue: normal colour or slightly red on the sides

Pulse: Wiry

Treatment Principle – Move Qi and Blood, eliminate stagnation, stop pain.

Acupuncture

LR3 – move qi and blood, stops pain

REN6 – moves qi in the lower abdomen

GB34 – in combination with REN6, moves qi in the lower abdomen

SP8 – regulates blood in the uterus and stops pain.

ST29 – Regulates blood in the uterus

SP10 – invigorates blood

SP6 – helps to invigorate blood and stops pain

SP4 – (on the right) and PC6 (on the left) regulate the chong mai, and regulate blood in the uterus

SP14 – moves qi and blood in the lower abdomen.

Herbal Prescription

Xiao Yao San (variation) – add Wu Yao, Xiang Fu, Zhi Ke, Yan Hu Suo – to move qi strongly and stop pain.

(Maciocia 1998: 239-240)

Blood Stagnation

intense, stabbing pain before or during the period, dark menstrual blood with large clots, mental restlessness, pain relieved after passing clots.

Tongue: Purple

Pulse: Wiry

Treatment principle

Invigorate Blood, eliminate stasis, stop pain.

Acupuncture

LR3 – moves Qi and Blood, stops pain, and regulates the sea of blood of the penetrating vessel

REN6 – moves qi in the lower abdomen

GB34 - in combination with REN6, moves qi in the lower abdomen

SP8 – regulates blood in the uterus and stops pain.

ST29 – Regulates blood in the uterus

SP10 and BL17 – invigorates blood

SP6 – helps to invigorate blood and stop pain

SP4 – (on the right) and PC6 (on the left) regulate the chong mai, and regulate blood in the uterus

KI14 – a point of the penetrating vessel, moves qi and blood in the abdomen and eliminates stasis from this vessel

ST25 – Front-Mu of the stomach, invigorates blood in the penetrating vessel. The bright Yang is full of Qi and Blood and, because of its relationship with the penetrating vessel, can invigorate blood.

Herbal treatment

Tao Hong Si Wu Tang (variation) – add Yan Hu Suo, Xiang Fu, Niu Xi to move Qi and Blood in the lower abdomen and stop pain.

Ge Xia Zhu Yu Tang – invigorate blood in the lower abdomen – stonger than Tao Hong Si Wu Tang, use when there is more intense pain.

Tong Jing Yin – Use if there is some cold with the Blood stasis.

(Maciocia 1998: 241-242)

Cold Stagnation in the Uterus

Lower abdominal pain before the period, pain is central, relieved by heat, menstrual blood scanty and bright red with small dark clots. Feeling cold, sore back.

Tongue: Pale bluish, or bluish purple.

Pulse: Deep and Choppy or Deep and Wiry.

Treatment Principle

Warm the Uterus, expel Cold, invigorate Blood

Acupuncture

LU7 and KI6 – Regulate the directing vessel and strengthen the Uterus

REN4 with Moxa – warms the Uterus

REN6 with Moxa – moves the Qi and expels cold from the lower abdomen

ST29- and KI14 – invigorate Blood

SP8 and SP6 – invigorate blood and stop pain

ST36 – tonifies Qi and helps to scatter cold

ST28 with moxa cones – expels cold from the Uterus.

Herbal treatments

Shao Fu Zhu Yu Tang – warms the uterus, expels cold and invigorates blood in the lower abdomen.

(Maciocia 1998: 245-246)

Qi and Blood Deficiency

Dull hypogastric pain toward the end of, or after the period, dragging sensation in the lower abdomen, pain relieved by pressure and massage, scanty bleeding, pale complexion, tiredness, slight dizziness, loose stools.

Tongue: Pale

Pulse: choppy

Treatment Principle

Tonify Qi, strengthen the spleen, nourish blood.

Acupuncture

REN4 – Nourishes Blood and the Uterus

REN6 – Tonifies and moves Qi in the lower abdomen

ST36 and SP6 – tonify Qi, strengthen the spleen, and nourish Blood

SP8 – stops pain

BL20 – strengthens the spleen and nourishes blood

SP10 – invigorates blood and stops pain

BL54 and BL32 – invigorate Blood and effect the lower genital system. Indicated when period pain is in the sacral region.

Herbal Treatment

Sheng Yu Tang – Tonify Qi, nourish and invigorate Blood.

Shi Quan Da Bu Tang – Qi and Blood Xu with Cold.

(Maciocia 1998: 252-253)

Bibliography

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