Dysmenorrhea ( tong jing 痛经 )

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

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

3. Introduction What is 痛经（tong jing)？

4. Introduction • 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.

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

6. Primary Spasmodic Dysmenorrhea • Commonest in teens/early twenties • Usually appear 1-2 yrs after menarche • 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.

7. Secondary Dysmenorrhea • 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

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

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

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

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

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

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

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

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

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

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

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

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

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

26. Examples • from ”Zhu nansun” clinical examples of gynecology • 14 jan Miss Huang, 22 year-old, soldier.unmarried • Main symptoms: • 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.

27. 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

28. answer • Syndrome differentiation: • 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 Danggui6 Xuduan9 Baishao6 Shoudi9 Muxiang4.5Wuyao6 Chuanlianzi9 Huangqi9 Rougui2.4

29. prognosis • One month late • 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 Danshen9 Aiye9 Wuyao6 Chuanlianzi9 Zhike4.5 Shoudi9 Chenpi6 Wuzhuyu6 Baishao6 • 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.”

31. Examples • from ”Zhu nansun” clinical examples of Gyn • Miss Wang, 23 year-old, doctor • Main symptoms: • 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.

32. analyse • advanced menorrhea, with clots • Qi asthenia ， blood stasis • distending pain in the chest, hypochondria and breasts • Liver depression and qi stagnation • poor appetite, fatigue , backpain ,leucorrhea • 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 • Liver ‘s qi rising ,spleen’s qi descending • Tongue: white and thin fur • Pulse: thready and taut.

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

34. Drug: Before the menstruation Xiangfu9 Yujin6Danggui6 Baishao6 Yanhusuo6Wuyao9 Chuanlianzi6 Ruxiang6 Moyao6 Sugeng6 Muxiang4.5 Shanzha9 • Drug: in the middle of menses 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”

36. Syndrome of qi stagnation and blood stasis • Main symptoms: • 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: • Soothing the liver to regulate Qi and resolving stasis to stop pain. • Prescription: • Modified Xuefu Zhuyu Tang

37. example • from ”Qian bo xuan” clinical examples of gynecology • 23 /2 Miss Jin, 21 year-old • unmarried ,LMP: 3 feb • Main symptoms: • 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

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

39. answer • Syndrome differentiation: • coagulation of cold and Qi stagnation; disharmony between liver and stomach • Treatment: • Warming meridians and dissipate coldness; harmonizing liver and spleen • Drug: Danggui9 Chuanxiong4.5Chishao9 Baishao9Rougui3 Wuzhuyu3 Gouji12 Wuyao6 Qingpi6 Chenpi6 Banxia6 Muxiang6xiaohuixiang

40. Syndrome of coagulation of cold dampness • Main symptoms: • 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: • Warming meridians to disperse cold and draining dampness to eliminate stagnation. • Prescription: • Modified Shaofu Zhuyu Tang

41. example • from ”Qian box uan” clinical examples of gynecology • 6.25 Miss lin ,20 year-old, unmarried LMP: 6.15 • Main symptoms: • 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.

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

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

44. prognosis • 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. • Treatment: nourishing blood and regulating Qi,; warming meridians and dissipating stagnation

45. 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 • 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, • Syndrome differentiation: • blood asthenia and stagnation of Qi and blood • Treatment: • nourishing blood and regulating Qi to regulate menstruation and dissipate stagnation. • Drug: • Chinese patent drug: Bazhen Yimu Wan+Hupo San

47. Syndrome of Qi and blood asthenia • 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. • Therapeutic methods: • Strengthening the spleen and nourishing Qi ,invigorating blood and stopping bleeding. • Prescription: • Modified Bazhen Tang

48. example • 7.22 Miss Teng ,27 year-old, unmarried • 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

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

50. Syndrome of liver and kidney asthenia • 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. • Analyse: