Notes on Early Menstruation and Pattern Differentiation (TCM)

Early Menstruation - Shortened Cycle

• Period begins more than $7$ days in advance of regular cycle ( <21 days)
• Common patterns and pathophysiology:
  • 1. Blood Heat
  • a. deficiency of Yin
  • b. Excess of Yang
  • 2. Qi Deficiency
  • Qi not containing the blood
• Aetiology (causes):
  • Stress, overwork/strain, successive pregnancies close together
  • Irregular diet
  • Internal heat d/t emotional constraint
  • External heat - heat contracted from environment
  • ‘Menopause’, medications, etc.

Blood Heat due to deficiency of Yin

• Clinical presentation:
  • Cycle is <21 days
  • Flow is red, sticky, scanty
  • Yin-deficient signs: five-centered heat, afternoon fever, night sweating, etc.
  • Tongue: peeled, no coat or rootless moss, small or thin red body
  • BBT chart: shortened luteal phase
• Treatment goals: Nourish Yin and clear heat
• Herbal prescriptions:
  • Zhi Bai Di Huang Wan, Liang Di Tang (key herb - Sheng di huang)
  • Afternoon fever: Yin chai hu, Qing hao, di gu pi
  • Night sweating: wu wei zi, fu xiao mai
  • Dry stool: he shou wu
  • Liang Di Tang (Rehmannia and Lycium Root-Bark Decoction):
  • Sheng di Huang $15\,g$
  • Di gu pi $10\,g$
  • Xuan shen $10\,g$
  • Mai dong $10\,g$
  • e jiao $10\,g$
  • Bai shao $10\,g$
  • Bai wei $10\,g$
  • Gui ban $30\,g$
• Acupuncture/points:
  • K6, Sp6, GB39, K2, R3, Ht 6, P7, LV 8

Blood Heat due to Yang excess

• Clinical presentation:
  • Cycle <21 days
  • Blood flow scarlet, deep red; may be scanty due to heat or profuse; sticky due to heat; may have clots due to heat consuming fluids
  • Heat signs: strong thirst, dry stools, red face/skin, dark urine, agitation, sensations of heat
• Treatment: clear heat and cool blood
• Herbal prescriptions:
  • Qin Lian Si Wu Tang ji a jian, Qing Jing San

LV Qi stagnation builds heat/fire in blood

• Pattern evidence:
  • Dan Zhi Xiao Yao san / jia wei xiao yao san
  • Long dan xie gan tang
• Bleeding-stop herbs (due to heat): Mu Dan Pi, Sheng Di, Qian Cao, Di Yu
• Acupuncture/points for cooling by circulating ying and wei:
  • Sp10, Li4/Lv3, Lv2, Li11, St44, Du14, UB40, R3, Lu7/Li4

Qi Deficiency

• Clinical features:
  • Period <21 days
  • Blood flow light in color / watery
  • Volume is profuse (unless concurrent blood deficiency; flow may be scanty)
  • May have lengthy spotting or dribbling (Qi fails to contain blood)
  • Spleen Qi deficiency signs: fatigue, poor/dull appetite, SOB, loose stool, weakness of the limbs, soft spongy abdomen, hardness in epigastrium, water retention, loose stool or diarrhea, easy bruising
  • Tongue: scalloped teeth marks, possibly puffy, possibly wet or large
• Treatment: Nourish Qi and Blood
  • Ba Zheng Tang, Bu Zhong Yi Qi Tang, Shen Ling Bai Zhu San, Ju Yuan Jian, Gu Yin Jian
• Single herb to astringe Qi and blood: Xian He Cao
• Notes on blood and qi relationship:
  • Qi is the mother of blood; concurrent blood deficiency is common or predictable
• Spleen Qi and Heart Blood deficiency overlay:
  • May have a gushing flow at start of period with Qi xu signs
  • Dream-disturbed sleep, heart palpitations, poor memory, anxiety
  • Formula: Gui Pi Tang
• Kidney/Qi aspects:
  • Kidney Qi Deficiency – Qi deficiency signs +
  • Sunken tongue at rear, palpable tension along linea alba
  • Low back and knee weakness
  • Sunken low belly or extremely tight erector spinae ("bow-tie" pattern) in low abdomen
  • May have Kidney or UB channel pain or weakness with period; leakage of fluids (urine, blood, stool)
  • Add herbs to nourish kidneys to above formulas (e.g., shan yao, ci wu jia, huang jing, gou ji, nu zhen zi, han lian cao)

Page 3: Gu Yin Jian and review points

• Warming/moxa points:
  • Sp6, R4, R5, Ki13, K7, K3
  • moxa K1
  • moxa (UB 23/22 and Du4/Du5)
  • UB17, UB11
• Gu Yin Jian (Yin-Securing Brew):
  • Tu si zi $10\,g$
  • Shu di huang $15\,g$
  • Shan zhu yu $15\,g$
  • Ren Shen $10\,g$
  • Shan yao $15\,g$
  • Wu wei zi $6\,g$
  • Yuan zhi $6\,g$
  • Zhi gan cao $6\,g$
• Review: what causes Spleen Qi deficiency?
  • Constitutional weakness, dietary irregularity, overwork, prolonged illness
  • Impairing Qi, excessive thinking/worry → Spleen Qi damage
  • Can lead to failure to control blood → instability of Chong and Ren Mai → early menses
• What causes Kidney Qi Deficiency?
  • Youth (not firmed up yet), gradual decline with aging toward menopause
  • Multiple pregnancies
  • Kidney Qi injury due to prolonged illness
  • All can lead to Kidney Qi Deficiency → instability of Chong and Ren Mai → early bleeding from failure to control blood
• What causes blood heat due to Yang exuberance?
  • Constitutional Yang exuberance, environmental heat, overeating spicy foods
  • Leads to heat accumulation → harasses Chong and Ren Mai → blood moves erratically and downward → early menses
  • Constitutional depression; internal damage from unresolved emotions can bind Liver Qi → transforms into heat over time
  • Heat disturbs Chong and Ren Mai → frenetic blood flow and early menses
• What causes blood heat due to Yin deficiency?
  • Constitutional Yin deficiency, yin injury from blood loss, multiparity consuming essence and blood, excessive thinking impairing ying/yin
  • Yin-blood deficiency heat → drives yin fluid loss
  • Internal deficiency heat causes instability of Chong and Ren; restlessness in the sea of blood; failure to contain blood → early menses

Differential Diagnosis

• Menstruation arriving 10 or more days early should be distinguished from intermenstrual bleeding
• Intermenstrual bleeding (ovulatory bleeding in Western medicine) usually occurs during the $12^{th}$ to $16^{th}$ days of a menstrual cycle
• The bleeding is typically:
  • very light flow or spotting that lasts from a few hours to a few days
  • may appear as sticky transparent discharge tinged with blood
• Diagnosis can be made by confirming ovulatory timing via:
  • verifying against BBT charts or ovulation test kits

Page 4 - Intermenstrual bleeding continuation (summary)

• Recap: Intermenstrual bleeding is distinct from early/precocious menses and is characterized by timing around ovulation rather than a shortened overall cycle
• Practical implication: track cycle timing with BBT or ovulation tests to differentiate patterns and guide treatment