Late Menstrual Periods and Related Patterns - Exam Notes

Late Menstrual Periods (Oligomenorrhea)

• Definition: Cycles longer than $35\,\text{days}$ for at least $3\,\text{consecutive cycles}$, allowing a definitive pattern to be observed.
• In extreme cases, periods may be overdue by $3-5\,\text{months}$.
• Long cycles shorter than $35\,\text{days}$ are not considered late, nor are occasional delays.
• Late and irregular cycles are considered normal during the first year after menarche and during the perimenopausal period.
• Causes: deficiency or stasis or a complex of both. The Chong mai cannot be filled on time either due to deficiency or obstruction.
• The ensuing menstrual flow may be scanty but will flow for the normal duration or time.
• WM perspective: delayed menses indicates delayed ovulation or a concurrent condition in dysfunctional uterine bleeding (DUB).

Kidney Deficiency (Late Period pattern in Oligomenorrhea)

• Symptoms:
  • Late period, scanty, darkish, clean and thin menses, and clear discharge.
  • Aching low back and knees, dizziness and tinnitus, dull or dark complexion or dark macules on the face.
  • Pale tongue, dip at rear, thin white coat.
  • Deep and thready pulse.
  • Insufficient fire in the lower burner leaves the menses darkish, thin and clear (w/o clots).
• Pathophysiology:
  • Kidney deficiency leads to a lack of warming and transformation in the lower jiao and lack of security of Ren and Dai mai; turbid dampness may appear as a clear, thin vaginal discharge.
• Treatment Principles:
  • Supplement Kidney, nourish blood, and tiao Yue Jing.
• Herbal Formula (Gu Zhuan/Suggested for Kidney deficiency):
  • Dang Gui Di Huang Yin (代理方: Chinese formula for kidney deficiency with blood):
  • Ren Shen $10\,g$
  • Shan Yao $15\,g$
  • Shu Di Huang $10\,g$
  • Du Zhong $15\,g$
  • Dang Gui $10\,g$
  • Shan Zhu Yu $15\,g$
  • Gou Qi Zi $15\,g$
  • Zhi Gan Cao $5\,g$
• Modifications for vaginal discharge:
  • With excessive vaginal discharge: add Qian Shi and Jin Ying Zi (to astringe).
  • With deficient ministerial fire: add Rou Gui.
  • With dull pain in the lower abdomen: add Bai Shao, E Jiao, Xiang Fu.
• Acupuncture points (to secure Kidney Qi):
  • KI13, R4, R6, R5, K7, Du 4, SP6, St36
  • Address Chong, Ren, Dai, Bao Luo.

Blood Deficiency (Late menses with scanty, clear, thin, light red flow)

• Symptoms:
  • Sallow complexion or pallor; dizziness; blurred vision; palpitations and insomnia; dull lower abdominal pain that responds to pressure.
  • Pale lips and tongue with thin white coating.
  • Thready weak pulse or hollow pulse.
• Mechanism:
  • Ying-blood depletion results in inability to supplement the Chong and Ren Mai; sea of blood fails to fill on time; late period with scanty flow; light red and thin menses due to essence and blood deficiency; dull lower abdominal pain due to blood’s inability to nourish the Bao Luo.
  • Blood deficiency can cause head/eye symptoms (blurred vision, dizziness) and heart-nourishment issues (vexation, palpitation, insomnia).
• Treatment Principles:
  • Replenish Qi, supplement blood, and tiao Yue Jing.
• Herbal Formula:
  • Da Bu Yuan Jian (Major Origin–Supplementing Brew):
  • Ren Shen $10\,g$
  • Shan Yao $15\,g$
  • Shu Di Huang $10\,g$
  • Du Zhong $15\,g$
  • Dang Gui $10\,g$
  • Shan Zhu Yu $15\,g$
  • Gou Qi Zi $15\,g$
  • Zhi Gan Cao $5\,g$
• Modifications/Variants:
  • For spleen deficiency add Bai Zhu, Bai Bian Dou, Sha Ren.
  • For heart blood deficiency add Yuan Zhi, Wu Wei Zi, Suan Zao Ren.
  • For concurrent deficiency heat signs (tidal fever, night sweats, vexation) add Nu Zhen Zi, Han Lian Cao, He Shou Wu, Di Gu Pi.
• Acupuncture (to nourish blood and support Chong/Ren):
  • Points: SP6, St36, Ren Mai (R4), Sp10, Sp2, Sp3, UB17, Ht7, P6
  • Additional: moxa on UB20, UB18; attend to Bao Luo and Bao Mai.

Stasis Types: Cold in the Blood (Excess type)

• Symptoms:
  • Late menstrual period with scanty, dark flow with clots.
  • Lower abdominal pain aggravated by pressure and improved with warmth.
  • Pale bluish complexion, aversion to cold, cold limbs.
  • Dark tongue with white coating.
  • Deep, wiry or tight pulse.
• Pathophysiology:
  • External cold or overconsumption of cold-natured foods can lead to blood coagulation.
  • Blood circulation in Chong and Ren may be obstructed; sea of blood fails to fill or empty on time; loss of right timing → dark, scanty, clotted flow.
  • Internal cold lodges in uterus, disrupting Qi and Blood flow; Yang cannot circulate externally; limbs cold.
• Treatment Principle:
  • Warm the channels, dissipate cold, tiao Yue Jing.
• Herbal Formula:
  • Wen Jing Tang (Flow-Warming Decoction) from Fine Formulas for Women (1237):
  • Ren Shen $10\,g$
  • Dang Gui $6\,g$
  • Chuan Xiong $6\,g$
  • Rou Gui $6-10\,g$
  • E Zhu $6\,g$
  • Mu Dan Pi $6\,g$
  • Chuan Niu Xi $10\,g$
  • Gan Cao $10\,g$
  • Variations when menses flow is not scanty or becomes heavy:
  • Remove E Zhu and Niu Xi during menses.
  • Add Pao Jiang, Ai Ye Tan, and Qian Cao.
  • Bai Shao can be added to ease cramping with Gan Cao; Chi Shao and Bai Shao can be used interchangeably if blood stagnation persists.
• Acupuncture:
  • Move blood and warm channels: P6, Sp4, Sp6, Sp2, Sp8, Lv5, Gb38, Ht5, Zi Gong, K13.
  • Assess Chong Mai at St30; Ren Mai; K6 and all Ren Mai points.
• Additional assessment references:
  • Assess/activate Dai Mai at GB26, GB41.

Deficiency Cold Type (Late menstrual period with scanty flow)

• Symptoms:
  • Scanty flow, light red in color, thin, no clots.
  • Dull lower abdominal pain with preference for warmth and pressure; lumbar aching and weakness.
  • Copious clear urine and loose stools.
  • Pale tongue with white coat.
  • Deep and slow or thready and weak pulse.
• Diagnosis:
  • Yang Qi is deficient, so internal cold develops; internal organs cannot function properly.
  • A lack of Yang means that the fundamental processes of Qi and Blood creation/transformation fail.
  • Deficiency of Yang and warmth in the Blood and uterus leads to scanty, thin, light-red flow with dull lower abdominal pain; kidney yang deficiency may manifest as back pain; copious urine and loose stools.
• Treatment Principle:
  • Warm the channels, reinforce yang, nourish blood, tiao Yue Jing.
• Herbal Formula:
  • Wen Jing Tang (Channel-Warming Decoction):
  • Wu ZHU Yu $6\,g$
  • Dang Gui $10\,g$
  • Chuan Xiong $10\,g$
  • Bai Shao $15\,g$
  • Gui Zhi $6\,g$
  • Ren Shen $10\,g$
  • Mu Dan Pi $10\,g$
  • Ban Xia $10\,g$
  • Mai Dong $10\,g$
  • E Jiao $10\,g$
  • Sheng Jiang $10\,g$
  • Gan Cao $10\,g$
• Modifications:
  • If unresolved abdominal pain during menses: add Ba Ji Tian, Xiao Hui Xiang, Xiang Fu; if sloppy diarrhea: add Chao Bai Zhu, Shen Qu, Pao Jiang; for kidney yang support: add Tu Si Zi, Bu Gu Zhi, Yi Zhi Ren.
• Acupuncture:
  • As above with emphasis on nourishing and warming kidney.

Qi Stagnation Type (Late menstrual period with clots, dark red, mentally depressed)

• Symptoms:
  • Late period with slightly reduced or normal flow that is sluggish, dark red with clotting.
  • Mental depression; lower abdominal distention and pain; breast swelling and discomfort.
  • Tongue: Normal or red; possibly thin yellow coat.
  • Pulse: Wiry or choppy.
• Pathophysiology:
  • Liver injury from depression impairs free flow of Qi and disturbs Blood circulation, preventing Chong Mai from filling on time.
  • Flow is not smooth and may be clotty; if not complicated by hot/cold, the amount may be normal.
  • Liver constraint causes distention in breasts, hypochondrium/ribs, and lower abdomen.
• Treatment Principles:
  • Regulate Qi, move stagnation, activate blood, tiao Yue Jing.
• Herbal Formula:
  • Wu Yao Tang (Secrets from the Orchid Chamber):
  • Wu Yao $10\,g$
  • Xiang Fu $10\,g$
  • Mu Xiang $10\,g$
  • Dang Gui $10\,g$
  • Gan Cao $5\,g$
  • Modifications for period pain: add E Zhu and Yan Hu Suo.
  • If constraint turning to fire: add Mu Dan Pi, Zhi Zi.
  • Severe distension/pain in breasts, ribs, low abdomen: add Chai Hu, Yu Jin, Chuan Lian Zi, Wang Bu Liu Jing.
  • Scanty menses: add Ji Xue Teng and Dan Shen.
  • Cold in lower abdomen: add Ai Ye, Rou Gui.
• Acupuncture:
  • Move Liver Qi and Blood: Lv14, P6 (to regulate liver and move jueyin outward);
  • Lv2/Lv5 as Ying and Luo points to soothe liver and regulate Qi;
  • Engage Chong and Ren Mai: Tiao Yue Jing; K13, Sp6, St30 or Sp4.

Irregular Menstrual Cycle

• Definition: A cycle length that differs from a standard monthly cycle by more than $7\,\text{days}$ for at least $3\,\text{consecutive periods}$.
• Characteristics:
  • May present as early periods for several cycles followed by late cycles, or two to three cycles of late periods followed by early cycles.
  • Most often presents as early menstruation and may present as heavy and prolonged bleeding and may develop into flooding and spotting.
  • If characterized by long cycles with scant bleeding, it may progress to amenorrhea.
• Causes and WM view:
  • Usually due to liver constraint or kidney deficiency, leading to unregulated storage/discharge from the sea of blood.
  • In Western Medicine context, may be associated with dysfunctional uterine bleeding (DUB).
• Liver Constraint pattern (as a common cause):
  • Symptoms: irregular cycle with variable flow, menses dark red or purplish red with clots; liver constraint signs: breast and ribs pain, lower abdomen pain; frequent sighing, belching, reduced appetite due to liver constraint affecting lung and spleen/stomach.
  • Tongue: normal or red; coat: thin white or thin yellow; Pulse: wiry.
  • Etiology: chronic depression/anger damages liver, causing disharmony of Chong and Ren Mai; variable volume/pace of discharge from the sea of blood.
• Pattern and Formula:
  • Xiu Yao San (Free Wanderer Powder) variant: Chai Hu $10\,g$, Dang Gui $15\,g$, Bai Shao $10\,g$, Bai Zhu $15\,g$, Fu Ling $15\,g$, Pao Jiang $6\,g$, Bo He $5\,g$, Gan Cao $10\,g$.
  • Additional modifications depending on symptoms:
  • With vexation and bitter mouth: Mu Dan Pi and Zhi Zi.
  • With menstrual pain: Xiang Fu and Yan Hu Suo.
  • Blood clots with menses: Ze Lan and Yi Mu Cao.
  • Epigastric fullness and poor appetite: Zhi Qiao, Hou Po, Chen Pi.
  • With kidney xu: Tu Si Zi, Shu Di Huang, Xu Duan.
  • With dizziness/blurred vision: Shi Jue Ming, Ju Hua, Gou Teng.
  • If both kidney and liver deficiency involved, treat together with Ding Jing Tang (Menstruation-Stabilizing Decoction).
• Acupuncture:
  • In-class exercise (no specific points listed here).

Kidney Deficiency Irregular Menstrual Cycle

• Pattern: Irregular cycle can be short or long with a scanty flow of light red blood.
• Symptoms:
  • Aching weak low back and knees, dizziness and tinnitus, dull complexion or macula.
  • Pale tongue with moist white coating and a posterior dip; thin or thready weak pulse.
• Pathophysiology:
  • Kidney is the root of Chong and Ren Mai; when Qi is insufficient, the storing function is impaired, causing disharmony in Chong/Ren Mai and irregular release of blood from the sea of blood.
  • Scanty flow due to deficiency of essence and blood; light red thin, clear flow due to kidney qi insufficiency and yang deficiency failing to warm blood.
• Treatment Principle:
  • Supplement Kidney and regulate menstruation.
• Herbal Formula:
  • 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 $6\,g$
• Acupuncture:
  • In-class exercise.

Notes on key concepts and connections

• Chong Mai, Ren Mai, and Dai Mai are central channels involved in regulating menstrual blood and its timing; deficiencies or blockages in these vessels lead to irregularities in filling and emptying the Sea of Blood (Bao Luo).
• Patterns reflect a holistic framework where organ systems (kidney, liver, spleen, heart) interact with Qi, Blood, and Body Fluids to govern menstruation.
• Treatments blend herbs that tonify deficiency (e.g., Kidney qi/blood), move stagnation (Qi/Blood), warm cold, and secure vessel function, often with targeted acupuncture to regulate the same networks (Chong/Ren/Dai, Liver Qi, Kidney yang, etc.).
• If both kidney and liver are involved, combined formulas like Ding Jing Tang are recommended, highlighting pattern overlap and the need for integrated treatment.
• Ethical/practical note: These notes summarize Traditional Chinese Medicine patterns and suggested formulas; professional medical evaluation is advised for any menstrual irregularities, especially when heavy bleeding, severe pain, or systemic symptoms are present.