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An Overview of the Pathogenisis and Therapeutics of Dysmenorrhea

by John Ryan Wahnish, D.Ac., L.Ac.

Western Overview and Approach

Dysmenorrhea is a menstrual condition characterized by severe and frequent menstrual cramps and pain associated with menstruation. Dysmenorrhea may be classified as primary or secondary.

primary dysmenorrhea - Primary dysmenorrhea is menstrual pain associated with ovular cycles in the absence of pathological findings. From the beginning and usually lifelong; manifestation is severe and frequent menstrual cramping caused by severe and abnormal uterine contractions. Pain generally develops one or two years after the first menarche and may progressive get worse with time.

secondary dysmenorrhea - due to some organic cause and usually of later onset; painful menstrual periods caused by another medical condition present in the body (i.e., pelvic inflammatory disease, endometriosis).

The cause of dysmenorrhea depends on whether the condition is primary or secondary. In general, women with primary dysmenorrhea experience abnormal uterine contractions as a result of a chemical imbalance in the body (particularly prostaglandin and arachidonic acid -- both chemicals which control the contractions of the uterus). Secondary dysmenorrhea is caused by other medical condition. Most often endometriosis is the root problem. This is a condition in which tissue that looks and acts like endometrial tissue becomes implanted outside the uterus, usually on other reproductive organs inside the pelvis or in the abdominal cavity -- often resulting in internal bleeding, infection, and pelvic pain. Other possible causes of secondary dysmenorrhea include pelvic inflammatory disease (PID), uterine fibroids, abnormal pregnancy, infection, tumors, or polyps in the pelvic cavity.

While any woman can develop dysmenorrhea, the following women may be at an increased risk for the condition: women who smoke, women who drink alcohol during menses (alcohol tends to prolong menstrual pain), women who are overweight, women who started menstruating before the age of 11.

The following are the most common symptoms of dysmenorrhea. However, each individual may experience symptoms differently. Symptoms may include cramping in the lower abdomen, pain in the lower abdomen, low back pain, pain radiating down the legs, nausea, vomiting, diarrhea, fatigue, weakness, fainting, and headaches. The symptoms of dysmenorrhea may resemble other conditions or medical problems.

Western Diagnosis begins with a gynecologist evaluating a patient’s medical history and a complete physical examination including a pelvic examination. A diagnosis of dysmenorrhea can only be certain when the physician rules out other menstrual disorders, medical conditions, or medications that may be causing or aggravating the condition. In addition, diagnostic procedures for dysmenorrhea may include:

Ultrasound - a diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs.

Magnetic resonance imaging (MRI) - a non-invasive procedure that produces a two-dimensional view of an internal organ or structure.

Laparoscopy - a minor surgical procedure in which a laparoscope, a thin tube with a lens and a light, is inserted into an incision in the abdominal wall. Using the laparoscope to see into the pelvic and abdomen area, the physician can often detect abnormal growths.

Hysteroscopy - a visual examination of the canal of the cervix and the interior of the uterus using a viewing instrument (hysteroscope) inserted through the vagina.

Counseling with your physician regarding symptoms may increase understanding and lead to activities for stress management. Other possibilities include surgical and medical treatment protocols for managing dysmenorrhea. This treatment may include: prostaglandin inhibitors (i.e., nonsteroidal anti-inflammatory medications, or NSAIDs, such as aspirin, ibuprofen) - to reduce pain, acetaminophen, oral contraceptives (ovulation inhibitors), progesterone (hormone treatment), dietary modifications to increase protein and decrease sugar and caffeine intake, vitamin supplements, regular exercise, heating pad across the abdomen, hot bath or shower, abdominal massage, endometrial ablation - a procedure to destroy the lining of the uterus (endometrium), endometrial resection - a procedure to remove the lining of the uterus (endometrium), hysterectomy - surgical removal of the uterus . In the future it is my hope that more and more physicians will refer patients to an Acupuncturist/Herbalist before resorting to their other possibilities.

TCM Overview

Dysmenorrhea (Tong Jing) is a gynecological disorder characterized by cramping pains in the lower abdomen proceeding, during or following menstruation. At times, the pain may radiate to the lower back or sacral region. Fainting may occur with severe pain. The pathology of dysmenorrhea is the impairment of Qi and Blood. The main organs involved are the Liver, Kidney and Spleen. The main channels involved are the Ren and the Chong. Patients with vacuous patterns will experience more pain after the period. The pain will be have a dull quality that is better with pressure. Patients with excess patterns will have more severe pain before the period. The pain is severe and worse with pressure. Frequently patients with excess patterns can have underlying vacuous issues. Although your point selection will be determined by the person in front of you these are some general points used for dysmenorrhea: Ren3, 4, 6, St25(qi), St28(damp), St29 (stasis), Ub32, Ki13, Ki14, Shi Qi Zhui (17^th vertebrae point, located below Lumber 5), Pc6, Li4, St36.

TCM Pattern Differentiation

Dysmenorrhea may present as one of these patterns or in combination. Other pattern maybe displaying depending on the individual.

Excess Patterns: More severe pain at the beginning of the period.

Coagulation of Cold-Damp: most common.
Liver Qi Stagnation and Blood Stagnation
Descent of Damp-Heat: uncommon, possibly related to PID (Pelvic Inflammatory Disorder).

Vacuity Patterns: More severe pain following period.

Yang Deficiency with Internal Cold: Kidney and Spleen.

Liver and Kidney Deficiency: Liver (blood), Kidney (essence and qi).

Qi and Blood Deficiency: Mostly Liver and Spleen but can also relate to Lung Heat. Origin may relate to loss of nourishment to the Ren and Chong.

EXCESS

Coagulation of Cold-Damp
Indications	Cold and Pain of the lower abdomen either proceeding or during menstruation; aggravation of pain upon external pressure and some relief with external application of heat; scanty menstrual discharge that is dark in color and contains blood clots; aversion to cold and, occasionally, body aches and pains.
Tongue/Pulse	Tongue may present with a white slimy coat. Pulse is deep and tight.
Treatment Method	Warm the vessels, dissipate cold, dispel dampness, dispel blood stasis, and relieve pain.
Formulas	Shao Fu Zhu Yu Tang: Lesser Abdomen Stasis Expelling Decoction.
Point Prescription	Ren3- excess, St28 – damp, Sp8- xi cleft, Sp6, Ub32, Shi Qi Zhui, Severe pain add: Ub32, St29.

Liver Qi Stagnation and Blood Stagnation
Indications	Distending pain in the lower abdomen preceding or during menstruation, aggravation of pain with external pressure, difficult menstruation, scanty menstrual discharge that is dark purple in color and contains blood clots, decrease in pain upon expulsion of clots and disappearance of pain with termination of the menstrual period. Some cases may be accompanied by a distended sensation in the chest, hypochondria and breasts.
Tongue/Pulse	Tongue is dark with thin whit coat with possible sublingual vein distention. The pulse is deep, wiry, or slippery wiry or choppy.
Treatment Method	Soothe the liver, rectify qi, dispel blood stasis, and relieve pain.
Formulas	Ge Xia Zhu Yu Tang: Infra-diaphragmatic Stasis Expelling Decoction
Point Prescription	Ren6, Lv3, Sp6, Sp8- pain, Sp10-blood, Ki13-Qi, Ki14-blood, St25-qi, St29-blood, Ub32, Shi Qi Zhui.

Descent of Damp-Heat
Indications	Lower abdomen pain preceding menstruation, aggravation of pain with external pressure accompanied by a burning sensation or distention pain in the lower sacrum. In some cases, there is a recurrent pain in the lower abdomen that becomes more severe with the onset of menstruation. Accompanying symptoms include thick blackish red menstrual discharge containing blood clots, thick yellow leukorrhea, scanty concentrated urine and, in many cases a mild fever.
Tongue/Pulse	Tongue is red with yellow slimy coat. The Pulse is rapid and wiry or rapid and slippery.
Treatment Method	Clear Heat, dispel dampness, dispel blood stasis, and relieves pain.
Formulas	Qing Re Tiao Xue Tang: Heat Clearing Blood Regulating Decoction.
Point Prescription	Ren3, Sp8, St29, Lv3, Ub23, Li4, Ub32, Shi QI Zhui.

VACUITY

Yang Deficiency with Internal Cold
Indications	Cold and Pain of the lower abdomen either during or following menstruation, some relief from pain with external pressure or the application of heat, small volume of dark colored menstrual discharge, weak aching lower back and legs, copious clear urine. The pain has a dull quality. Patients maybe overweight or present with bloating. This pattern is more common with elderly patients.
Tongue/Pulse	Tongue has a white moist coat. The pulse is deep.
Treatment Method	Warm the channels, warm the uterus, and relieves pain.
Formulas	Wen Jing Tang: Menses warming decoction. Two formulas in this case do share the same name. One of the Wen Jing Tangs is commonly used for amenorrhea nd menstral irregularity. This particular Wen Jing Tangwas first recored in the Jin Gui Yao Lue Fang Lun (Synopsis of Prescriptions of the Golden Chamber).
Point Prescription	Ub23, Ren4, St36, Sp6, 10, Ren3, Sp8, Ub32, Moxa.

Liver and Kidney Deficiency
Indications	Indistinct lower abdominal pain either proceeding or following menstruation, some relief from pain with external pressure, thin light colored menstrual discharge, aching lower back and spine, general fatigue, dizzy spells and tinnitus and in some cases tidal fever. Additional signs may present as pail nails, scanty urination or an aching lower back.
Tongue/Pulse	The tongue is pale and the pulse is deep and thready or weak and thready.
Treatment Method	Supplement the Liver and the Kidney, regulate and rectify the Chong and the Ren, and relieve pain.
Formulas	Tiao Gan Tang: Liver Regulating Decoction
Point Prescription	Ub18, 23, Ren4, St36, Ki6, Lv3, 8, St25, Sp6,10.

Qi and Blood Deficiency
Indications	Indistinct lower abdominal pain either proceeding or following menstruation, some relief from pain with external pressure, empty and bearing down sensation in the lower abdomen and pubic regions, scanty menstrual discharge that is light in color and thin in texture, tiredness, fatigue and occasionally dull complexion, loss of appetite or diarrhea.
Tongue/Pulse	The tongue is pale and the pulse is weak and thready.
Treatment Method	Supplement qi and blood, and relieve pain.
Formulas	Sheng Yu Tang: Additional this formula is good for infertility due to Qi and Blood Deficiency.
Point Prescription	Ub23, Ren4, St36, Sp6, Ub32, Du20, Moxa.

Conclusion

       When treating a patient with Tong Jing (dysmenorrhea) , do not let all the factors and patterns confuse you. Keep it simple and treat what you see. A highly respected Doctor once told me, "It's simple. If they are hot use cold herbs and if they are cold use hot herbs". I knew it might not be this simple but over thinking the situation can make treating this syndrome tricky as patients tend to manifest with mixed patterns.

        Generally, regardless of what pattern you may link to your patient, there will be an emotional factor. Emotional factors or underlying emotional issues might cause the patterns. It is also possible for the pain itself to create an emotional factor. Calming the shen as well as treating the excess or deficiency pattern will benefit your patient. One may achieve this with the use of herbs, tuina or acupuncture. Also, when your patient is describing their pain, don't just listen to what they are telling you. Listen to how they are tell you. When people describe their pain they are always telling us more than just the quality of the pain. A patient's voice change while they are giving you details is a key to tune into. For example, a patient say's, "I have pain with my cycle" in a monotone voice. Then you ask the quality of the pain and they reply, "The pain is unbearable." in a singing, laughing tone. Inappropriate laugher is a sign of the element fire relating to the heart. Now you are tuning into the patients constitution as well as their pathology.

Sources:

Wu, Yan. Practical Therapeutics of Traditional Chinese Medicine. Brookline Massachusetts: Paradigm Publications, 1997.

Maciocia, Giovanni. Obstetrics & Gynecology in Chinese Medicine. New York: Churchill Livingstone, 1999.

Tierney, McPhee, Papadkis. 2001 Medical Treatment and Diagnosis. New York: Lange Medical Books/McGraw-Hill, 2001.

Benskey, D., and Gamble, A.. Chinese Herbal Medicine: Materia Medica Revised Edition. Seattle: Eastland Press, 1993.

Benskey, D., and Barot, R.. Chinese Herbal Medicine: Formulas and Strategies. Seattle: Eastland Press, 1990.

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