Understanding menstrual disorders
In the west, we are accustomed to thinking that maladies surrounding menstruation – pain, heavy bleeding, premenstrual tension (PMT) and headaches, to name but a few – are part and parcel of the female experience. Symptoms can range from the mildly annoying to utterly debilitating, impacting all areas of one’s life. Thankfully, TCM takes a different view and teaches us that, while incredibly common, these conditions are not found in a harmonious bodily landscape and need not be silently endured.
How is menstruation understood in TCM?
In TCM, the nature of a woman’s menstrual flow and cycle is a window in to the state of her physical and emotional being. A menstrual complaint, therefore, gives us valuable insight in to where balance has been lost and how best to bring it back.
TCM holds that menstruation – tian gui or ‘heavenly water’ – is present when the ren (Conception) and chong (Penetrating) channels fill with qi and blood, respectively, and derives from jing – our core, inherited essencethat governs reproduction and growth. Jing forms the substance of a woman’s eggs and is involved, with the heart, in ovarian function.
The mind-body connection inherent to TCM philosophy is clearly illustrated in menstrual physiology, where the heart houses the shen (spirit/ mind, including the hypothalamus and pituitary glands), governs the blood and is connected to the uterus/ ovaries via a channel called the bao mai (Uterus vessel). There is, therefore, a direct correlation between TCM heart function in ovulation and the hypothalamic-pituitary-ovarian axis. As such, Chinese medicine readily appreciates how emotional strain can be a direct cause of menstrual dysfunction (1).
Menstrual cycles are governed by an intricate dance and interplay of hormones. In TCM, like the waxing and waning of the moon, a woman’s cycle follows the ebb and flow of yin and yang energy throughout her cycle where the follicular phase (day 1-14) pertains to yin and luteal phase (day 14-28) to yang.
The follicular phase is marked by the onset of menstruation as a result of a sharp drop in oestrogen and progesterone. In TCM, menstruation occurs when yang (reflected in progesterone levels) has reached its maximum and switches to yin. We then see follicular development as the pituitary gland stimulates follicle stimulating hormone (FSH) and leutinising hormone (LH). In TCM, this process relies and draws on our jing. The growing follicles, nourished by yin and blood, then secrete oestrogen. Increasing oestrogen levels reflect the growth of yin and blood and can be observed, to a degree, in the presence, quantity and quality of cervical mucus leading up to ovulation. If yin rises sufficiently, it will trigger the transformation to yang. This transition is reflected in rising progesterone (and, therefore, yang) levels and an LH surge. Under the influence of LH, the empty follicle – having released its egg – secretes progesterone and this maintains the uterine lining (endometrium) until menstruation or conception (1,2).
Understanding the root
Main disruptors of menstrual health in TCM:
A very common and readily treatable clinical presentation, qi stagnation (in particular of liver and heart qi) impedes the natural flow of qi and blood in women’s cycles, particularly at ovulation and in the lead up to menstruation. It manifests with premenstrual tension with marked breast and abdominal distension, moodiness, depression and irritability. Where stagnant qi has become errant and invaded the digestion, there may also be diarrhea before the period. Menstrual blood will be darker than the fresh red colour we would expect in a healthy cycle. Ovulatory issues are common here as it relies on the smooth flow of heart and liver qi and cycles will be irregular, delayed or even absent. There will often be pain (worse just before and during the period) that is aggravated by pressure (a sign that the pain is due to a condition of excess rather than deficiency). The flow itself might stop and start, reflecting the lack of smooth qi flow in the body. This constraint is also displayed in a wiry radial pulse; taught under the fingers, like a guitar string. This pattern is typically brought on by emotional strain but can also result from a history oral contraceptive use.
If left untreated, qi stagnation can lead to Blood stasis. Here, pain will be more significant, fixed and stabbing in nature and relieved with the passing of clots (a hallmark feature of blood stasis). As with qi stagnation, it will be worse for pressure and blood will be very, usually with clots. Periods can be both light (the blood is simply not flowing) or long and heavy as the body attempts to flush out stagnant blood and clots. The cycle will be irregular or even absent and there may be spotting in between. The tongue will be purple with distended veins underneath and, again, the pulse will be wiry. We see blood stagnation in conditions such as amenorrhea, endometriosis, fibroids, tumors and PMT, where mental restlessness is pronounced. Aside from qi stagnation, blood stagnation can also stem from cold in the uterus, obstruction from phlegm-damp and qi deficiency, where there is simply not enough energy to guide the blood out. It is a common presentation after childbirth and surgery.
Heat may arise if qi and, or, blood stagnation continues or from a deficiency of yin and manifests with short cycles as heat can trigger early ovulation. Heat also results in the reckless movement of blood, so we will typically see heavy periods with fresh, bright red blood. However, where heat has injured the fluids, menstrual blood may be thick and dry and where it stems from yin deficiency, it will be scanty. Depending on the source of the heat, we might also see accompanying symptoms such as intense irritability, headaches with red eyes, nosebleeds (liver qi stagnation with liver fire or yang rising), insomnia, anxiety, palpitations, mouth ulcers, red tongue tip (heart qi stagnation with heart fire) or reflux, acne and mucus in the blood (phlegm-damp).
Yin deficiency is a common cause of heat, especially in women over 35 years, and the primary cause of amenorrhea. Yin deficiency signs in the absence of heat might include long cycles (weak yin, reflected in oestrogen levels, is slow to nourish developing follicles and, therefore, ovulation is delayed), vaginal dryness, dry skin and hair, insomnia, hot palms and soles, a red, cracked, dry tongue and a weak, ‘floating’ (at the surface) pulse. Where yin deficiency has generated deficient heat, we may also see scanty yellow urine, red lips, nightsweats and a strong libido. As with yin deficiency, the tongue is red and cracked but here it will also have a thin yellow coat. The pulse is still weak and at the surface but the heat has made it rapid.
Heat may come from a variety of sources, both internal and external, excess and deficient. Common sources include overwork, lack of rest, excessive heating food and drink and prolonged emotional turmoil.
In TCM, a warm womb is of great importance and necessary for healthy menstruation and fertility. However, cold is a very common clinical pattern with menstrual disorders and can emerge from either excess or deficient sources. Cycles are generally late, often with pain that is relieved with warmth. Blood will be red with small, dark clots in excess cases or pale in deficient ones. The tongue will be pale and the pulse slow.
Cold food and drink as well as exposure to cold (cold environments, swimming or wearing tops that expose the midriff) can lead to cold in the uterus and these are to be avoided during menstruation. Cold can also enter the uterus via the leg channels if we walk barefoot on cold surfaces or expose our legs to cold. It is also vitally important to keep warm after childbirth to prevent cold invading the uterus and we often suggest treatment with warming, blood invigorating herbs and moxibustion over the lower abdomen and lower back in the post-partum to chase out lingering cold, a technique known as ‘mother warming’.
In the case of yang deficiency, we will see issues in the luteal phase, notably low progesterone, which can result in spotting before the period. This will be accompanied by symptoms such as diarrhea and low back pain at the onset of menses, late or no ovulation, oedema, low libido, cold hands feet and abdomen, a pale, wet tongue and a slow pulse. Hypothyroidism is a classic example of a yang deficient condition that can impact menstruation and endometriosis often has its roots in weak yang. Yang deficiency can come about from constitutional weakness, overwork, inadequate rest, chronic illness, yin deficiency (yin and yang are mutually-engendering) or external cold invasion that is left untreated.
A diet of excessive damp foods (e.g. greasy, sweetened, dairy) and/ or improper metabolism and circulation of fluids can lead to phlegm-damp. This has a tendency to sink and settle in the lower part of the body, disrupting menstrual function, resulting in absent, irregular and long cycles. Here we will have symptoms such as mucus in the menstrual blood, thick, copious discharge, oedema, a feeling of heaviness, weight gain, acne, sinus issues, a phlegmy cough and might see conditions such as polycystic ovarian syndrome (PCOS) and thrush. The tongue will be swollen with a thick coat, the pulse full and ‘slippery’ under the fingers.
Spleen qi is said to hold the blood. Where qi is weak, there will be early periods, long flows, bleeding in between and heavy periods. Blood will be brown, pale and watery. It will often be accompanied by symptoms such as easy bruising, tiredness, poor appetite, loose bowels, a pale tongue and weak pulse. As qi engenders blood, it often goes hand in hand with blood deficiency. It can arise from excessive worry or mental taxation, poor diet and inadequate rest.
In addition to qi deficiency, blood may be deficient as a result of short cycles (and, therefore, frequent menstruation), heavy periods, blood loss from trauma or childbirth or a poor diet. The period may be late or even absent and light. The blood will be pale and dilute, the tongue pale and the pulse thin. Accompanying signs and symptoms may include anaemia, pallor, dizziness, dry skin and nails and insomnia (especially getting to sleep).
At the extreme end of jing deficiency, we might see delayed puberty, primary amenorrhea (periods have not started by age 15) and even underdeveloped uterus and ovaries. Milder forms of jing weakness will manifest with conditions such as irregular periods, early menopause and fertility issues. This type of deficiency may be inherited (especially in the youngest of many children or offspring from older parents) or due to lifestyle factors – living large, using recreational drugs or overworking without adequate rest. It can also result from many pregnancies close together and simply aging as our stores of essence deplete naturally over time and with each menstrual cycle (1-4).
Signs and symptoms
- Premenstrual tension (PMT)
- Premenstrual dysphoric disorder (PMDD)
- Dysmenorrhea (painful periods)
- Amenorrhea (absent periods)
- Menorrhagia (heavy periods, prolonged periods)
- Oligomenorrhea (light or irregular periods)
- Metrorrhagia (irregular bleeding, bleeding between periods)
- Symptoms surrounding menstruation include: breast distension, headaches, bowel changes, muscular aches, fever, blood noses/ blood in sputum, acne, dizziness, nausea
TCM herbal therapy for menstrual health typically takes a few cycles to have a real impact but you should start to see some improvements after the first month. There are a great many TCM herbs and formulas to promote menstrual health depending on the presenting signs and symptoms and it is common to use different herbs and formula modifications for each stage of the cycle. The following are examples of common herbs used at each of these phases:
Herbs that invigorate blood
chuan xiong (Ligisticum chuanxiong, Szechuan lovage root), tao ren (Prunus persica, peach kernel) and hong hua (Carthamus tinctorius, safflower flower) are all brilliant blood-invigorators and a popular choice at this stage in the cycle when we want to promote a smooth and complete discharge of blood. Pungent, and, therefore, moving herbs, chuan xiong is the gentler of the three, used to revitalise blood. hong hua and tao ren, in particular, can strongly dispel blood stasis. They are often used together during menstruation in cases of blood stagnation or when regulating the cycle and are found in the most popular formula for this purpose – Tao Hong Si Wu Tang (Four Substance Decoction with Safflower and Peach Pit), an extrapolation of the classic blood tonic formula, Si Wu Tang (Four Substances Decoction: shu di (Rehmannia), bai shao (white Peony root), dang gui (Chinese angelica root), chuan xiong). This is a wonderful formula for this time of the month as it both nourishes and invigorates blood.
Where blood stagnation is pronounced, such as in cases of endometriosis, stronger blood stasis breaking herbs such as san leng (Sparganium stoloniferum, bur-reed rhizome) and e zhu (Curcuma zedoaria, zedoaria) may be added.
In cases where pain is significant, yan hu suo (Cordyalis yanhusuo, Cordyalis rhizome), a blood-invigorator with great analgesic effect, is often used.
Herbs that stop bleeding
For heavy periods, san qi (or tian qi, Panax notoginseng, Notoginseng root) is a fantastic choice as it both stops bleeding and invigorates blood, meaning that it can arrest heavy bleeding without creating stagnation. It also has analgesic properties, making it an invaluable herb for menstrual complaints, in particular, those from blood stagnation with heavy, long and painful flows.
Herbs that nourish yin and blood
After menstruation, we help to rebuild yin and blood, particularly in individuals where these are deficient. For this, we often use Gui Shao Di Huang Tang (Angelica Paeonia and Rehmannia Decoction); a variation on the classic yin tonic formula, Liu Wei Di Huang Tang (Six Ingredient Pill with Rehmannia: shu di, shan zhu yu (Cornus), shan yao (Wild yam), fu ling (Poria), mu dan pi (Peony tree), ze xie (Alisma)), where chief blood tonics dang gui and bai shaohave been added, making it especially useful for this stage of the cycle.
Herbs that regulate the qi and calm the spirit
Smooth qi flow is especially important mid-cycle to support the release of the egg and herbs that regulate heart and liver qi and benefit the spirit are thus employed. chai hu (Bupleurum chinense, Bupleurum) and yuan zhi (Polygala tenuifolia, polygala) are common choices. chai hu is a bitter, pungent, cool herb and a primary herb for soothing liver qi. Yuan zhi enters the heart and is used in cases of shen disturbance with palpitations, anxiety and insomnia.
Herbs that tonify the yang
In this yang phase of the cycle, it is important to support the yang energy where it is weak and in these cases we will use herbs such as rou gui (Cinnamomum cassia, cinnamon bark), a chief medicinal in classic yang tonic formula, You Gui Wan (Restore the Right [Kidney] Pill), to strongly warm yang, disperse cold, alleviate pain and support the luteal phase.
Herbs that regulate the qi and clear heat
As at ovulation, before the period is a crucial time to ease constraint and spread liver qi, particularly where there is PMT. chai hu is again an excellent herb for this and a chief herb in Xiao Yao San, one of the most popular TCM formulas and the go-to formula for PMT. Xiao Yao San translates as‘Free and Easy Wanderer’ or ‘Rambling Powder’ for its ability to smooth the flow of our energy and moods. Alongside chai hu are dang gui, bai shao, bai zhu (white Atractylodes), fu ling, bo he (mint), wei jiang (roasted ginger), and zhi gan cao (honey-fried licorice root). This combination regulates qi, strengthens the digestion and tonifies blood. Where there is qi contraint with heat, as there so often is at this time of the month, we may use the modification, Jia Wei Xiao Yao San. Bitter and cold, mu dan pi and zhi zi (Gardenia jasminoides, Gardenia) are added to the original formula to quell liver fire (1-6).
TCM tips for menstrual health:
- Keep the lower belly, lower back, legs and feet warm and avoid cold food and drink during menstruation. Opt instead for warm, well-cooked, nourishing foods such as soups, stews and congees (a Chines rice/porridge dish).
- Rest and avoid stress and emotional upset as much as possible while menstruating and around ovulation.
- Avoid intercourse and inverted yoga poses while bleeding to promote the downward flow of blood and to avoid creating blood stagnation in the uterus.
- Tonify blood after the period with TCM blood foods: beef, lamb, bone marrow, liver, bone broth (chicken/ beef – aim for a cup a day), eggs, sardines, oysters, mussels, dark leafy greens, beetroot, kelp, shiitake mushroom, parsley, avocado, nettle tea, raspberry leaf, almonds, molasses, dried apricot and fig.
- Relieve qi stagnation before the period with gentle exercise, relaxation techniques and sex.
- Avoid heating food and drink where there are heat signs, especially pre-menses. These include spices (think chilli, pepper, garlic, cinnamon etc), red meat (especially lamb), fried foods, sugar, caffeine and alcohol.
- Qi gong and yoga have specific exercises and postures to enhance menstrual health. Seek a knowledgeable practitioner to incorporate these in to your routine.
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