Transcript Syndrome differentiation

Dysmenorrhea
(tong jing 痛经)
Shuguang hospital affiliated to
shanghai TCM university
Doctor: zhang qin hua
contents
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Introduction
Classification
Pathogenesis
Diagnosis
Main points of syndrome differentiation
Examples :Treatments on the types of
syndrome differentiation
Introduction
What is 痛经（tong jing)？
Introduction
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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)
 Affects approximately 50% of women
 about 5-10% have severe dysmenorrhea affecting
daily activities.
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Classification
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Primary or idiopathic
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without pelvic pathology.
Secondary
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underlying pelvic pathology
Primary Spasmodic
Dysmenorrhea
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Commonest in teens/early twenties
Usually appear 1-2 yrs after menarche
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ovulatory cycles are established.
No abnormal findings except some
tenderness.
Main physiological basis is increased
endometrial prostaglandin productions.
The pain may lessen as the woman gets
older.or after giving birth.
Secondary Dysmenorrhea
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secondary to pathology
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.
30s and 40s women
Underlying pathology
in secondary dysmenorrhea
1.
2.
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5.
Endometriosis/Adenomyosis.
Fibroid uterus
Congenital uterine anomalies- bicornuate,
septate etc.
Cervical stenosis.
Pelvic inflammatory disease.
Shall we consider all
the pain with vaginal
bleeding as
dysmenorrhea ?
Differential Diagnosis
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pregnancy complications like abortions &
ectopic pregnancy
rupture of corpus luteum
torsion of ovarian cyst
urinary stones
Appendicitis
colitis and acute gastroenteritis
Symptoms of Dysmenorrhea
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Cramps or pain in the lower abdomen or
lower back
Pulling feeling in the inner thighs
Diarrhea
Nausea
Vomiting
Headache
Dizziness
Examination
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Vaginal exam not essential in
young female with Primary
dysmenorrhea
Vagina – septum
cervical - moving tenderness
Uterus- size / mobility/
position/tenderness
Adnexa –tenderness/
enlargement
Investigations
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Transabdominal ultrasound with full
bladder
Transvaginal ultrasound –increased
sensitivity
Laparoscopy –gold standard for
endometriosis
Risks versus benefits
TCM pathologic factor
Emotional
factors
multiparity and
excessive sexual life
malnutrition
of uterus
liver and kidney
congenital
defect
QI
BLOOD
Sad, anger, liver depression
six
exogenous
consumption
of Q i& blood
Cold, heat, dampness
serious disease and
prolonged illness
TCM Pathogenesis
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sthenia (实）Bu tong er tong 不通而痛
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Qi stagnation and blood stasis into uterus
Asthenia (虚） Bu rong er tong 不荣而痛
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Malnutrition of the uterus and meridian
Syndrome differentiation
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How to revealing the nature of dysmenorrhea?
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Pain
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Menses
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the time
Location
Degree
the quantity
Color
Texture
Complications
tongue and pulse conditions.
Syndrome differentiation
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Sthenia:
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After the menstruation
dull pain with preference of
pressure
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pain alleviated with warmth
colic or cold pain
Heat:
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Blood stasis:
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Cold:
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before and during the mens
unpressable and violent pain
Asthenia:
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Qi stagnation:
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pain worsened with warmth
burning pain
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pain severer than distension
pain alleviate after the
removal of blood clot
Pain is fixed and sting
distension severer than pain
With breast tenderness
liver disorders:
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pain in the sides of abdomen
kidney disorders:
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pain involving the loins
Therapeutic principle
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key:regulating Qi and blood in the
thoroughfare and conception vessels
regulating Qi
 activating blood
 dissipating cold
 Clearing away heat
 supplementing asthenia
 purging sthenia
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Two step principles
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Firstly : during the menstruation
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regulating the blood to stop the pain
treat branch (biao 标）
Secondly : at other time
syndrome differentiation
 treat root（ben 本）
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Syndrome of
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dysmenorrhea
qi stagnation and blood stasis
coagulation of cold in uterus
Coagulation of cold and dampness
 intern-cold caused by Yang asthenia
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liver and kidney asthenia
Qi and blood asthenia
Examples
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from ”Zhu nansun” clinical examples of
gynecology
14 jan Miss Huang, 22 year-old,
soldier.unmarried
Main symptoms:
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The 3rd day of the menses
severe lower abdominal pain since the menses comes
prolonged period ,scanty menorrhea ,with blood clots
accompanied with backpain
Tongue: thin and white fur,
Pulse: deep, thready and a little taut.
Syndrome analyse
The 3rd day of the menses — treat branch
 severe lower abdominal pain since the menses comes
sthenia
 prolonged period ,scanty menorrhea ,with blood clots
Qi and blood stagnation or cold coagulation
 accompanied with backpain
Asthenia –kidney ‘s yang asthenia
 Tongue: thin and white fur,
Cold or qi stagnation
 Pulse: deep, thready and a little taut.
Cold and qi stagnation
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answer
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Syndrome differentiation:
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asthenic uterine cold, Qi stagnation in Chong and Ren
vessels(胞宫虚寒，冲任气滞)
Treatment: warm meridians and regulating Qi
Drug:
Aiye6
Xiangfu9
Shoudi9 Muxiang4.5
Rougui2.4
Danggui6
Wuyao6
Xuduan9
Chuanlianzi9
Baishao6
Huangqi9
prognosis
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One month late
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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
Drug:
Xiangfu9
Yujin9
Chuanlianzi9 Zhike4.5
Baishao6
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Danshen9
Shoudi9
Aiye9
Wuyao6
Chenpi6 Wuzhuyu6
After the treatment , dysmenorrhea
disappeared ,and the period became regular.
summarize
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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.”
Examples
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from ”Zhu nansun” clinical examples of Gyn
Miss Wang, 23 year-old, doctor
Main symptoms:
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Dysmenorrhea since the 1st, in recent years,aggressive pain
advanced menorrhea, normal quantity, with clots,
there was signs before the menstruation
distending pain in the chest, hypochondria and breasts
poor appetite, fatigue , backpain ,leucorrhea
when the menses came ,severe lower abdominal pain lead to
vomiting and diarrhea, even to coma
Tongue: white and thin fur
Pulse: thready and taut.
analyse
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advanced menorrhea, with clots
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distending pain in the chest, hypochondria and breasts
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Liver ‘s qi affect the Spleen’s function
Dampness invased the belt vessel because of the spleen’s
weekness
severe lower abdominal pain lead to vomiting and diarrhea,
even to coma
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Liver depression and qi stagnation
poor appetite, fatigue , backpain ,leucorrhea
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Qi asthenia ， blood stasis
Liver ‘s qi rising ,spleen’s qi descending
Tongue: white and thin fur
Pulse: thready and taut.
answer
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Syndrome differentiation:
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liver depression and asthenia of spleen, weekness of
Belt vessel
Treatment:
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Before the menstruation, when patient felt the signs
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soothing liver and harmonizing stomach
In the middle of menses
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invigorating spleen and tightening up the Belt vessel
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Drug: Before the menstruation
Xiangfu9
Yujin6
Yanhusuo6 Wuyao9
Moyao6
Sugeng6
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Danggui6
Chuanlianzi6
Muxiang4.5
Baishao6
Ruxiang6
Shanzha9
Drug: in the middle of menses
Baishu6
Chenpi6
Danggui6 Yiyiren12
Xianhecao9 Diyutan12
Fuling9
Huangqi9
Ebaipi9
Haipiaoxiao9
Huangbai6
summarize
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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”
Syndrome of
qi stagnation and blood stasis
Main symptoms:
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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
distending pain in the chest, hypochondria and breasts
purplish tongue or with ecchymosis on the edge
deep and taut pulse.
Therapeutic methods:
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Soothing the liver to regulate Qi and resolving stasis to stop pain.
Prescription:
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Modified Xuefu Zhuyu Tang
example
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from ”Qian bo xuan” clinical examples of
gynecology
23 /2 Miss Jin, 21 year-old
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unmarried ,LMP: 3 feb
Main symptoms:
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dysmenorrhea for six years
lower abdominal pain before menses
accompanied with stomach pain
felt cold in abdomen with preference of pressure
Tongue: white and thin fur
Pulse: thready and slippery
analyse
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lower abdominal pain before menses
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accompanied with stomach pain
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sethnia
Qi stagnation(liver)
felt cold in abdomen with preference of pressure
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Asthenia of spleen yang(why not kidney)
Tongue: white and thin fur
 Pulse: thready and slippery
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answer
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Syndrome differentiation:
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Treatment:
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coagulation of cold and Qi stagnation; disharmony between
liver and stomach
Warming meridians and dissipate coldness; harmonizing liver
and spleen
Drug:
Danggui9 Chuanxiong4.5 Chishao9
Baishao9 Rougui3
Wuzhuyu3 Gouji12
Wuyao6 Qingpi6
Chenpi6 Banxia6
Muxiang6
xiaohuixiang
Syndrome of
coagulation of cold dampness
Main symptoms:
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unpressabe lower abdominal pain, cold pain before or during
menstruation
alleviation of pain with warmth
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
light purplish tongue with white and moist or white and greasy fur
deep and tense pulse.
Therapeutic methods:
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Warming meridians to disperse cold and draining dampness to
eliminate stagnation.
Prescription:
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Modified Shaofu Zhuyu Tang
example
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from ”Qian box uan” clinical examples of gynecology
6.25 Miss lin ,20 year-old, unmarried LMP: 6.15
Main symptoms:
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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
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
Tongue : white fur , exfoliate fur in the middle of the tongue
Pulse: deep and taut.
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Less volume of menses with light color.
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accompanied with cold limbs , palpitation ,
dizziness , alleviated with warmth.
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Asthenia of qi and blood
Cold and blood deficiency( heart and spleen)
scanty menses purplish color with clots, serious
lower abdominal pain even to faint, constipation
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Blood stasis (cold and qi asthenia)
Tongue : white fur
 Pulse: deep and thready.
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Syndrome differentiation:
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Treatment:
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Qi and blood asthenia
Warming and nourishing Qi and blood
Drug:
Chinese patent drug :Shiquandabu Wan
siwutang+sijunzi tang +rougui huangqi
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prognosis
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2 w After treatment , the patient felt all kinds of
symptoms alleviated.
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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
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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
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8.3 After this period treatment
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Syndrome differentiation:
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blood asthenia and stagnation of Qi and blood
Treatment:
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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,
nourishing blood and regulating Qi to regulate menstruation
and dissipate stagnation.
Drug:
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Chinese patent drug: Bazhen Yimu Wan+Hupo San
Syndrome of
Qi and blood asthenia
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Main symptoms:
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Therapeutic methods:
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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.
Strengthening the spleen and nourishing Qi ,invigorating
blood and stopping bleeding.
Prescription:
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Modified Bazhen Tang
example
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7.22 Miss Teng ,27 year-old, unmarried
Main symptoms:
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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
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Syndrome differentiation: liver and kidney
asthenia
Drug:
Danggui9 Huainiuxi9
Nuzhengzi4.5
Xuduan9 Gouji9
Danpi9
Shengdi9
Chishao9
Fuling12
Zexie9
Syndrome of
liver and kidney asthenia
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Main symptoms:
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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:
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Therapeutic methods:
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Nourishing blood and regulating the liver,
replenishing the kidney and enriching essence
Prescription:
Modified TiaoGan Tang
 Shanyao15 ejiao 9 danggui9(wine) baishao9(wine)
shayurou9 baji3
gancao3
sangjisheng15
Duzhong15 gouji15 shoudi12
shayuanzi15
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Relief tips
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Exercise
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Apply heat
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A warm bath or a heating pad or hot water bottle on your abdomen can
be soothing.
Sleep
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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.
Make sure you get enough sleep before and during your period. This can
help you cope with any discomfort.
Relax
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Meditate or practice yoga. Relaxation techniques can help you cope with
pain.
Food treat
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Mutton soup:
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Hawkthorn soup:
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Danggui 60g raw jinger 5 huangqi30g
Mutton 500g
Reinforce qi and blood,regulating menses stop pain
Shanzha(hawkthorn)30g brown sugar 60g guizhi5g
Activing blood and disperse stasis,stop pain
Brown sugar soup
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Brown sugar 30g ganjiang 30g dazao 30g
Warming meridian disperse cold stop pain
External therapy
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Navel stuffing with baiyao
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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
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Yunnan baiyao wine ,daub on the guanyuan 、qihai
acupoint， and massage until you feel hot.
External therapy
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Foot bath
Yimucao 20g xiangfu 20g ruxiang 20g moyao 20g
xiakucao 20g
 take decoction2000ml and make foot bath erery
day ,15-20min
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清·王清任
wang qing ren
qing dynasty ( 公元1768 1831年 )。
Zhu yu tang
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Xue fu zhu yu tang
Ge xia zhu yu tang
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Qi stagnation and blood stasis
Shao fu zhu yu tang
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Cold lodging into uterus or low energizer
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Warm uterus :
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Clear heat
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chishao sanleng ezhu honghua Taoren danpi
dibiechong shuizhi shengpuhuang wulingzhi
Active qi:
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Danpi chishao shengdi huangqin shanzhi huangbai zhimu
Disperse stasis：
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huixiang aiye rougui paojiang fuzi wuyu
Zhixiangfu chuanxiong zhike qingpi yanhusuo chaihu
Stop pain
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Quanxie
wugong
xuejie Ruxiang
moyao
rebalance yourself
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TCM’s treatment
focuse on th body,
not on the diease
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Aim to rebalance the
yin and yang of the
body