CMAC311 Session 4 MENSTRUATION DISORDERS Pre-menstrual Syndrome (PMS) Dysmenorrhea (painful periods) Chinese Medicine Department www.endeavour.edu.au
Session Contents o Explain the aetiology factors & pathological process of PMS and dysmenorrhea from TCM & biomedical perspectives. o Discuss the pattern differentiation & the treatments principle & methods, precautions & prevention of PMS and dysmenorrhea. Endeavour College of Natural Health www.endeavour.edu.au 2
Learning Outcomes After this session study, students should be able to: Describe and explain the aetiology & pathology of each disorder in this session. Outline the patterns differentiation and treatments principles & methods accordingly. Endeavour College of Natural Health www.endeavour.edu.au 3
PRE MENSTRUAL SYNDROME (PMS) Endeavour College of Natural Health www.endeavour.edu.au 4
PRE MENSTRUAL SYNDROME (PMS) Definition? (IN WESTERN MEDICINE PERSPECTIVE) Emotional and physical symptoms occurring before period Varies in intensity, from mild to very severe Varies in duration from 1 day to 2 weeks before period may be experienced even after period (but rarely) Signs and symptoms may include: depression, sadness, irritability, anxiety, lethargy, loss of concentration, aggressiveness, changes in libido, changes in bowels, skin eruptions, food cravings, crying, angry outbursts, distension of breasts and abdomen, insomnia, oedema. Endeavour College of Natural Health www.endeavour.edu.au 5
How does TCM explain and manage PMS? Endeavour College of Natural Health www.endeavour.edu.au 6
TCM Aetiology and Pathogenesis of PMS Anger, frustration, resentment Liv Qi Stag Fire Excess dairy & greasy foods Phlegm Phlegm Fire combine Obstructs orifices of the Heart PMS Overwork; excess sex Weakens Kid & Liv Yin Liv Qi Stag Endeavour College of Natural Health www.endeavour.edu.au 7
Notes o The liver is not the only organ causing PMS. Lungs, heart, spleen and kidneys are all the organs which could be involved in the PMS pathological process. o In case of Liver Qi stagnation, if it arises independently from emotional problems it is a purely full condition, in this case, the pulse will be wiry, either in all positions or just on the left. If it is secondary to a deficiency of liver blood or liver yin deficiency or liver and kidney yin deficiency, the condition is based on deficiency, liver Qi is deprived of its root and stagnates. Endeavour College of Natural Health www.endeavour.edu.au 8
DIFFERENTIATIAL DIAGNOSIS OF PMS o What are the common differentiation diagnosis of PMS? o what are the treatment principle and TCM treatment methods? o Outline and explain the acu-points used in each acupuncture treatment. Endeavour College of Natural Health www.endeavour.edu.au 9
Treatment of PMS o TCM treatment principles based on your TCM pattern identification o What TCM treatment methods you will choose or combine based on your TP? Acupuncture? Moxibustion? Cupping? Gua sha? Tui Na? Electro acupuncture? Laser acupuncture? Endeavour College of Natural Health www.endeavour.edu.au 10
Identification pattern Liver Qi Stagnation Liver Heat Liv Qi stagnation with phlegm PMS Clinical manifestation Main s/s: Abdominal and breast distension before period, irritability, moodiness, hypochondria pain or distension. Accompanying S/S: tongue may be red on sides, wiry pulse Main s/s: pre-menstrual tension, irritability, anxiety, agitation, abdominal and breast distension, feeling heat, red eyes, thirst. Accompanying S/S: Red sides tongue; wiry and rapid pulse Main s/s: premenstrual tension, irritability, depression, sadness, swollen, distended and painful breasts, abdominal distension, sighing, expectoration of sputum in the morning. Accompanying S/S: swollen tongue, sticky coating; wiryslippery pulse Treatment Principle & methods Principle-- Soothe liver, eliminate stagnation, calm the mind, settle the ethereal soul Acu-points LIV3, GB34, GB 41, SP6, SJ6, PC 6 Herbs Yue Ju Wan Principle Move Qi, pacify liver, clear liver heat, calm the mind, settle ethereal soul Acu-points LIV3, GB34, GB41, SP6, SJ6, PC6, LIV2, PC7 Herbs Jia wei (Dan Zhi) Xiao Yao San Principle Move qi, pacify the liver, resolve phlegm, tonify the spleen Acu-points LIV3, GB34, GB41, SP6, TB6, PC6, BL22, ST40 Herbs Wen Dan Tang Endeavour College of Natural Health www.endeavour.edu.au 11
Identification pattern Lung Qi Stagnation with phlegm Heart Heat Phlegm Fire harassing upwards PMS Clinical manifestation Main s/s: pre-menstrual tension, worrying, crying, depression, a feeling of tightness or oppression of the chest, expectoration of phlegm. Accompanying S/S: swollen tongue, slippery pulse,slightly tight on he lung position Main s/s: pre-menstrual tension, irritability, anxiety, insomnia, depression, agitation, thirst, a feeling of heat, palpitation. Accompanying S/S: red tip tongue, rapid, overflowing pulse Main s/s: pre-menstrual tension, agitation, depression, slightly manic behaviour, aggressiveness, a feeling of oppression of the chest, red face, blood shot eyes. Accompanying S/S: tongue : red with a sticky yellow coating pulse: overflowing-slippery-rapid Treatment Principle & methods Principle Move lung qi, restore the descending of lung qi, resolve phlegm, calm the mind Acu-points Lu7, LI4, REN17, PC6, REN12, ST28, BL22 Herbs Ban Xia Hou Po Tang Principle Clear heart heat, calm the mind Acu-points HE7, REN15, DU24, PC6, 7. Herbs Dao Chi San Principle Clear heat, resolve phlegm, calm the mind, settle the ethereal soul Acu-points PC6, 7; ST40, ST8, DU24, LI11,SP4,9; REN12, BL20 Herbs Sheng Tie Luo Yin Wen Dan Tang Endeavour College of Natural Health www.endeavour.edu.au 12
Identification pattern PMS Clinical manifestation Liver Blood Deficiency Main s/s: Depression and weepiness before period, slight abdominal and breast distension, scanty periods, tired ness, poor memory, poor sleep, slight dizziness, pale complexion. Accompanying S/S: pale tongue ; choppy/fine pulse, possible slightly wiry on the left Liver and Kidney deficiency Spleen and Kidney Yang deficiency Main s/s: Slight breast distension and irritability before the period and occasionally after, sore back and knees, dizziness, blurred vision, poor memory, night sweating, dry eyes and thorat Accompanying S/S: tongue without coating; fine-empty pulse Main s/s: slight premenstrual tension with depression and weeping, slight abdominal and breast distension, tiredness, sore back, feeling cold, frequent and pale urination, low sexual desire Accompanying S/S: pale tongue; deep and weak pulse Treatment Principle & methods Principle nourish liver blood, move liver qi Acu-points REN 4, LU7, KI6, SP6, GB34, PC6, LIV8, BL18,20. Herbs Xiao Yao San Principle Nourish liver and kidney yin, move liver Qi Acu-points LIV8, REN4, SP6, LIV3 Herbs Yi Guan Jian Principle Tonify yang, strengthen the kidneys Acu-points BL20, 23, REN4, ST 36, SP6, KI3, LU7 Herbs You Gui Wan Endeavour College of Natural Health www.endeavour.edu.au 13
Updates o Premenstrual syndrome (PMS) is characterized by recurrent, moderate-to-severe affective, physical, and behavioral symptoms that develop during the luteal menstrual cycle and disappear within a few days of menstruation. Premenstrual dysphoric disorder (PMDD) is a severe and disabling condition that can affect personal relationships and occupational activities. PMS occurs in 30 40% of reproductive-age females; PMDD affects 3 8% of this population. The diagnostic method of PMS is the Daily Record of Severity of Problems, which women with PMS can use to self-report several symptoms and their severity. Premenstrual syndrome: A mini review. https://www-sciencedirect-com.ezproxy.endeavour.edu.au/science/article/pii/s0378512215300451?_rdoc=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb&ccp=y o Acupressure is effective for decreasing the symptoms of premenstrual syndrome (PMS) http://eds.b.ebscohost.com.ezproxy.endeavour.edu.au/eds/detail/detail?vid=2&sid=f851df2c-4135-442c-8008-7fbc9cc29bb0%40sessionmgr104&bdata=jnnpdgu9zwrzlwxpdmumc2nvcgu9c2l0zq%3d%3d#an=126511495&db=rzh o Good RCT protocol for Acupuncture for premenstrual syndrome http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd005290/full Endeavour College of Natural Health www.endeavour.edu.au 14
Share Your relevant research updates? https://link.springer.com/article/10.1007%2fs00404-001-0270-7 http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2011.02994.x/full https://www.sciencedirect.com/science/article/pii/s096522990900082x Endeavour College of Natural Health www.endeavour.edu.au 15
Dysmenorrhea (Painful Periods) Endeavour College of Natural Health www.endeavour.edu.au 16
Painful Periods / Dysmenorrhea Definition? characterized by continual pain or even acute pain in the lower abdomen and lumber region before, during or after menstruation, usually accompanied with pallor, profuse cold sweat on the head, cold limbs, nausea and vomiting. Note: A light distending pain or discomfort in the lower abdomen or lumbar region is a frequent occurrence and is not diagnosis as dysmenorrheal. Endeavour College of Natural Health www.endeavour.edu.au 17
Aetiology & Pathology of Dysmenorrhea What are the common aetiological factors? Emotional strain External Cold & Dampness Overwork/ chronic illness/too many childbirth, etc What patterns are the most important factors in painful periods pathology? Stagnation of Qi Stasis of Blood Stagnation of Cold Endeavour College of Natural Health www.endeavour.edu.au 18
Dysmenorrhea Diagnosis Pain differentiation characteristics: Nature of the pain? Time of onset? Location of pain? Deteriorating and / or relieving factors? Period cycle? Menstruation blood? Endeavour College of Natural Health www.endeavour.edu.au 19
Class Discussion o The four TCM diagnosis methods should be applied properly for an appropriate TCM diagnosis. Abdomen palpation is very important in the diagnosis process for dysmenorrhea except for asking questions about the menstruation and pain. Discuss in class: how would you do the abdomen palpation for such a patient. Endeavour College of Natural Health www.endeavour.edu.au 20
Dysmenorrhea Patterns Identification The differential patterns include: Full-Conditions (Stagnation of Qi / Blood / cold and Damp-Heat) & Empty-conditions (Qi & Blood xu, Yang & Blood xu, kid & Liv-Yin xu) The most important differentiation is that between Full & Empty types of painful periods, is to differentiate clearly between Heat, Cold, deficiency and excess. Clinically, the full types are much more common than empty types. Endeavour College of Natural Health www.endeavour.edu.au 21
Qi stagnation Low abdominal pain during period or 2 days pre-menses; distended feeling in lower abdomen & breasts; sluggish flow initially; dark flow; no clots Blood stasis Stagnation of cold (either full or empty) Damp heat Intense, fixed, stabbing pain during or before menses, pulling pain, bearing down pain pre-menses; dark flow with large clots; relief after discharging clots Low abdominal pain pre or post menses; warmth relieves; cramping pain; scanty bright red flow with small dark clots; feels cold Hypogastric pain pre menses & at times ovulation; burning feeling radiates to sacrum; red flow with small clots; leucorrhoea Endeavour College of Natural Health www.endeavour.edu.au 22
Qi Stagnation turning into Fire Qi and Blood Xu Yang and blood deficiency Kid & Liv Yin Xu Abdominal pain pre or during menses; dark heavy flow Dull hypogastric pain near end or post menses; dragging sensation in lower abdomen; pain relieved by pressure/massage; scanty flow Dull abdominal pain after the period, scanty with pale blood, no clots, abdominal pain relieved by pressure and heat, dull headache, blurred vision, feeling cold, dizziness Dull hypogastric pain near end or post menses; relieved by pressure/massage; scant flow
Treatment of Dysmenorrhea o TCM treatment principles based on your TCM pattern identification o What TCM treatment methods you will choose or combine based on your TP? Acupuncture? Moxibustion? Cupping? Gua sha? Tui Na? Electro acupuncture? Laser acupuncture? Endeavour College of Natural Health www.endeavour.edu.au 24
Treatment of Dysmenorrhea Note: The treatment principle is changed according to the time of the menstrual cycle (i.e. 4 phases treatment principles)and the patterns, but the main treatment principle is to regulate the Qi and blood of the penetrating Vessel. Endeavour College of Natural Health www.endeavour.edu.au 25
Qi Stagnation TP: Move Qi & Blood, eliminate stagnation, stop pain LIV3, REN6, GB34, SP8, ST29, SP10, SP6, SP4&P6 even Xiao Yao Wan (Bupleurum & Dang Gui) Blood Stasis TP: invigorate Blood, eliminate stasis, stop pain LIV3, REN6, GB34, SP8, ST29, SP10, SP6, SP4&P6, BL17, KI14, ST25 reduce Tong Jing Wan (Dysmenorrhoea Pill) Cold Stagnation TP: warm Uterus, expel Cold, invigorate blood, stop pain LU7&KI6, REN4, REN6, ST29, SP8, SP6, ST36, ST28 reduce & moxa (reinforce St36) Wen Jing Wan (Dang Gui & Evodia) Endeavour College of Natural Health www.endeavour.edu.au 26
Damp-Heat Stagnant Liver Qi turning into Fire TP: clear Heat, resolve Damp, eliminate stasis SP9, SJ6, LU7&KI6, REN3, ST28, BL32, BL22, REN9, CO11, SP10, KI2,LIV3 reduce Long Dan Xie Gan Wan (Gentiana Combination) TP: clear Heat, pacify Liver, eliminate stagnation, stop pain LIV3, LIV2, LIV14, REN6, REN4, KI14, SP10, CO11, TB6, GB34 even method Jiao Wei Xiao Yao Wan (Bupleurum & Peony) Endeavour College of Natural Health www.endeavour.edu.au 27
Qi & Blood deficiency Yang and blood deficiency Kidney & Liver Yin deficiency TP: tonify Qi, strengthen Spleen, nourish Blood REN4, REN6, ST36, SP6, SP8, BL20, SP10 reinforce BL54, BL32 even method Ba Zhen Wan (Ginseng & Dang Gui 8) BL20, REN 12,ST 36, SP 6, REN 4, LIV 8, LU7 and KI6, reinforcing; BL54,BL32 even; Moxa should be used. Dang Gui Jian Zhong Tang TP: nourish Yin, benefit Kidneys, nourish Liver BL23, BL18, REN4, SP6, KI3, ST36, LU7&KI6 reinforce BL54, BL32 even method Liu Wei Di Huang Wan (Rehmannia 6)
Research about dysmenorrhea, acupuncture, cupping and moxa Acupuncture for dysmenorrhoea(review). http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd007854.pub3/epdf Clinical Report: Acupuncture and moxibustion combined with cupping for primary dysmenorrhea in 66 cases. http://eds.b.ebscohost.com.ezproxy.endeavour.edu.au/eds/detail/detail?vid=11&sid=bfdfb226-4d11-494a-9031-0f71da241618%40sessionmgr103&bdata=jnnpdgu9zwrzlwxpdmumc2nvcgu9c2l0zq%3d%3d #AN=S1003525712600324&db=edselp Effects of acupoint-stimulation for the treatment of primary dysmenorrhoea compared with NSAIDs: a systematic review and meta-analysis of 19 RCTs. http://eds.a.ebscohost.com.ezproxy.endeavour.edu.au/eds/detail/detail?vid=3&sid=c92b4a57-8953- 4be9-9e33-520e7292570d%40sessionmgr4006&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3 d#an=28859645&db=mdc Endeavour College of Natural Health www.endeavour.edu.au 29
Break Endeavour College of Natural Health www.endeavour.edu.au 30
Practical section Endeavour College of Natural Health www.endeavour.edu.au 31
Session 4 Practical Activity o Session review questions: assessment, diagnosis and management plan for PMS and dysmenorrhea. o Practise abdomen palpation skills o Case study based practical skills building up Endeavour College of Natural Health www.endeavour.edu.au 32
Case: A 27-year-old woman had been suffering from pre-menstrual tension for 13 years (more or less ever since her menarche). She had two children and the pre-menstrual tension became worse after each birth. Her main symptoms were abdominal distension, severe irritability, anger and aggressiveness. She had been given a progesterone pill but this had not helped and had only given her headaches. Her periods were regular, lasted 4 days and were heavy; the menstrual blood was bright red. She also suffered from constipation and, on interrogation, it transpired that she experienced backache and dizziness, she often felt cold, she had cold feet and her urination was frequent and pale. She did not sleep well and occasionally experienced some tingling of her limbs. Her tongue was pale and slightly thin with teeth marks. Her pulse was wiry. P362 Giovanni Maciocia
Case study o Campus Lecturer prepared relevant case and activities for students practical tutorial. Or o See Case for session 3 in Practical case studies which was sent to all lecturer and students via the loop. Endeavour College of Natural Health www.endeavour.edu.au 34
References o Lyttleton J, 2004 The Treatment of Infertility with Chinese Medicine Churchill Livingstone o West Z, 2008 Acupuncture in Pregnancy and Childbirth, 2 nd edition Churchill Livingstone o Maciocia, G 2011 Obstetrics and Gynecology in Chinese Medicine 2 nd Ed, Elsevier, London o Betts, D 2006 The essential guide to Acupuncture in Pregnancy and Childbirth, Eastland Press, USA Endeavour College of Natural Health www.endeavour.edu.au 35