Chapter 3 Clinical Experience of Chen Mushan's Gynecology
Section 1 Menstrual Disorders
The Understanding of Menstrual Disorders
Menstruation is also known as monthly tide, monthly sign, or monthly water in TCM. A woman's menstrual cycle has a character of regular monthly tide and is a kind of phenomenon of natural society corresponding with human beings. It is said that “the menstrual cycle is corresponding with the wax and wane of the moon and rise and fall of the ocean”. Menstrual disorder is a common disease in gynecology. In a narrow sense, menstrual disorder refers to abnormalities in cycle, color and quality of menstrual flow and includes preceded menorrhea, delayed menorrhea, irregular menstrual cycle, long menstrual cycle, menostaxis and hypomenorrhea.
Chen's family divides the cause of menstrual disorder into two aspects, internal and external or can be a combination of both. The external pathogenic factors refer to six pathogenic qi, which attacks the body when body constitution is weak. The internal factors are disorders of the seven emotions, which impair the function of zang and fu organs. The mixed causes refer to the all above factors. The etiology is always related to the insuf ficiency of the chong and ren meridians, the disorder of qi and blood or qi and blood stagnation. Menstrual disease could also lead to other gynecologic diseases. Therefore, Chen's family believes that “regular menstruation is fundamental to women's health”.
As the 23rd generation inheritor of Chen Mushan's Genecology, Dr. Chen Shaowu believed“when women have sufficient kidney qi, tiangui appears and ren meridian is opened”. When taichong meridian becomes invigorated and the blood sea becomes full, then menstruation will begin. Regular menstruation relies on suf ficient and smooth flow of qi and blood, blood storage of liver and blood domination of spleen. The flow of menstruation should be smooth rather than obstructed. Therefore, the treatment strategy is to regulate qi and blood. Regulating qi is the priority, nourishing and invigorating blood is the method and strengthening the liver, spleen and kidney is the essential.
In regulating menstruation, Chen Mushan's Gynecology defines moving qi as the priority. He treats blood stasis by moving qi, since qi promotes blood circulation and removes obstruction. For example, the herbs used for moving blood combined with the herbs for moving qi can strengthen the overall function of blood moving herbs. Herbs for strengthening and activating spleen combined with herbs for moving qi can strengthen the regulation of spleen and stomach. Herbs used for resolving phlegm combined with herbs for moving qi can strengthen the function of removing phlegm and promote blood circulation. Moving qi at san jiao can eliminate all related qi stagnations. The commonly used formulas in clinic are Xiao Yao San (逍遥散), Xue Fu Zhu Yu Tang (血府逐瘀汤) and Tao Ren Hong Hua Jian (桃仁红花煎). They reflect the importance of moving qi in the treatment of menstrual disease.
Chen Mushan's Gynecology considers blood as another priority for regulation of menstruation, which is reflected by nourishing and harmonizing blood. Since blood is essential for women's health and menstruation, qi acts as the commander of blood and blood is the mother of qi. Smooth qi movement promotes blood circulation and qi stagnation will cause blood stasis. When blood stasis worsens, all kinds of health problems can occur. Therefore, qi and blood should be treated simultaneously. Chen Mushan's Gynecology typically uses Shen Qi Si Wu Tang(参芪四物汤) to invigorate qi and nourish blood. Dr. Chen Shaowu adds Xiao Yao San (逍遥散)to soothe liver qi, strengthen spleen, nourish blood and harmonize ying.
Chen Mushan's Gynecology also emphasizes the importance of liver, spleen and kidney in maintaining regular menstruation. It should always be considered to replenish kidney, reconsolidate the congenital root, soothe liver and nourish blood. He prefers to use a modification of Bu Zhong Yi Qi Tang (补中益气汤), Shen Ling Bai Zhu San (参苓白术散) and Ren Shen Yang Wei Tang (人参养胃汤), which are based on Si Jun Zi Tang (四君子汤). These formulas are used to tonify kidney and consolidate the root, soothe liver and nourish blood. The kidney is the congenital root while the liver stores blood and relates with chong and ren meridians and the blood sea. Dr. Chen also prefers to use Wu Zi Yan Zong Wan (五子衍宗丸), Er Zhi Wan (二至丸), Zuo Gui Yin (左归饮), You Gui Yin (右归饮) with Yin Yang Huo, Shi Nan Ye, Lu Jiao Shang and Zi Shi Ying to tonify kidney and liver.
Stage Differentiation of Menstrual Disorders
According to the physiology of the development of menstruation and the cycle of filling and emptying of sea of blood, regulating the menstrual cycle is the commonly used method of Chen's family to treat menstrual disorders. However, most menstrual disorders coexist with deficiency and excess. This may imply the body constitution is deficient, however, the manifestation is excessive. Therefore, we must differentiate the symptoms comprehensively including the cycle, blood flow quantity and quality and the color as well as the accompanied symptoms to determine an appropriate treatment for each different cycle stage. This is important so that the disease is treated from its root and its manifestation simultaneously.
Chen's family divides menstrual cycle into three stages and offers different treatments for each stage. In the stage of premenstrual period, treatment is performed by warming the kidney and regulating the liver. In the stage of menstrual period, activating blood circulation and promoting the flow of menstruation achieves treatment. In the stage of post menstrual period, treatment includes replenishing the kidney and nourishing blood, which restores the normal menstrual cycle.
1.Premenstrual period
In this stage, the treatment principle is reinforcing the deficiency and strengthening the constitution while treating the root and manifestation together. In this period, yin is profuse and yang is ascending. The activity of yang qi is exuberant and the basal body temperature shows high phase. Many patients will experience premenstrual symptoms such as moodiness, irritability, mouth ulcers, constipation, etc. which are due to kidney yin deficiency and excessive liver fire. Therefore, during this period, herbs are used to warm kidney yang and soothe liver qi, such as Shu Di Huang, Bai Shao, Yin Yang Huo and Ba Ji Tian. Simultaneously we need to nourish yin and blood and clear the liver fire by using herbs such as Han Lian Cao, Sheng Di Huang, Mu Dan Pi, Chai Hu and Chen Pi. This will reset the balance of yin and yang while regulating chong and ren meridians.
2.Menstrual period
The priority of this treatment is to promote qi and blood circulation while following the menstrual trend and targeting symptoms. During this period, yang is growing and yin is declining while yin blood is diminishing rather than growing. With the menses occurring, decreased yin impairs yang, therefore qi and blood both become deficient and the basal body temperature has declined. The treatment strategy is to nourish blood and activate blood circulation, soothe the qi, eliminate the stagnation and generate the production of new blood. The applicable formulas used to remove obstruction from channels and promote qi and blood movement are Tao Hong Si Wu Tang (桃红四物汤) and Shao Fu Zhu Yu Tang (少腹逐瘀汤).
3.Late phase of period
This strategy should target on root cause, treat from its root as well as its manifestation, rebuild the balance of yin and yang and fundamentally restore the body function. During this period, bleeding has discontinued but qi and blood are impaired. The blood sea is empty and the basal body temperature is low. The uterus starts to store, while the drainage has ceased and the body is in the extreme yin. The treatment strategy is to nourish kidney yin, replenish the chong and ren and strengthen the spleen and stomach while promoting the production of qi and blood. Commonly used herbs to nourish yin and create suf ficient kidney yin are Sheng Di Huang, Dang Gui, Chao Bai Shao, Xiang Fu, Nü Zhen Zi and Zhi Yu Zhu (prepared). Huang Qi, Bai Zhu and Fu Ling are used to strengthen the spleen and replenish blood.