Treatment of dysmenorrhea with Acupuncture and Chinese Herbs- A Case Study

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Yan Lu, L.Ac.
Clinical Case Study #4
Treatment of dysmenorrhea with Acupuncture and Chinese Herbs- A Case Study
ABSTRACT
Background Treatment of dysmenorrhea with pharmaceutical medicine is effective, but
may not prevent recurrence
Object To present a case that demonstrates the effectiveness of acupuncture and
Chinese herbs for dysmenorrhea
Result reliving symptoms of dysmenorrhea in a 28 year-old women using
acupuncture and Chinese herbs after 7 weeks of treatments
Conclusion The positive results in this case indicates that acupuncture and Chinese
herbs may be a viable treatment option in treating dysmenorrhea
BACKGROUND
Biomedicine Perspective
Dysmenorrhea can be divided into primary dysmenorrhea and secondary dysmenorrhea.
Primary dysmenorrhea is menstrual pain associated with ovular cycles without pathologic
findings. The pain usually begins within 1-2 years after the menarche and become more
severe with time. The frequency of cases increases up to age 20 and then decreases with
age and markedly with parity. 50 to 75 percent of women are affected at some time, and
5-6 percent has incapacitating pain. Primary dysmenorrhea is low abdomen pain which is
crampy or colicky or dull ache and radiate to the back or inner thighs. The pain may start
before or with menses, last 1 or more days and may be associated with nausea, diarrhea,
headache, and flushing. The pain is produced by uterine vasoconstriction, anoxia, and
sustained contractions mediated by prostaglandins. The pelvic examination is normal
between menses; examination during menses may produce discomfort, but there are no
pathologic findings. Nonsteroidal anti-inflammatory drugs (ibuprofen, ketoprofen,
mefenamic acid, naproxen) are generally helpful. A drug may be more effective if started
24 to 48 hours before and continued 1 or 2 days after menses begins. If pain continues to
interfere with daily life, suppression of ovulation with low dose estrogen-progesterone
oral contraceptives is advised. But when patients want to get pregnant and stop birthcontrol
pills, dysmenorrhea may come back. NSAIDs cannot prevent recurrence of
dysmenorrhea, too. Secondary dysmenorrhea is menstrual pain for which an organic
cause exists. The common causes are endometrosis and pelvic inflammation. Other
causes include submucous myoma, IUD use, cervical stenosis with obstruction, or blind
uterine horn. (1)
Traditional Chinese Medicine Perspective
Dysmenorrhea in Chinese medicine can be caused by many reasons such as excess or
deficient conditions. The excess conditions may include the following: Qi and blood
stagnations can cause this disease. Depression over period of time can cause liver qi
stagnation, which can cause blood stasis leading to obstruction of flowing of qi and
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blood, thus cause this disease. Coldness retention in the uterus is another pathogen.
Walking in the rain without a cover, swim in cold water, eating too much cold food
during menses, or living in damp-cold environment can lead to retention of coldness in
the uterus and Chong and Ren channels causing obstruction of flowing of qi and blood;
congenital yang deficiency with yin coldness-excess cause deficient coldness in the
Chong and Ren channels leading to blood stasis and dysmenorrhea. Lower jiao dampheat
disturb qi and blood can also cause dysmenorrhea. The above reasons are mainly
excess conditions that can cause dysmenorrhea (except deficient coldness).
The following reasons are deficient conditions. Deficiency of qi and blood due to
deficiency of spleen and stomach or after severe illness leads to malnourishment of uterus
and Chong and Ren channels, in addition to deficient qi will also cause blood stasis, thus
dysmenorrhea occurs. Liver and kidney deficiency due to congenital condition or overindulgence
in sex activity or giving birth many times cause deficiency of essence and
blood, leading to malnourishment of uterus, Chong and Ren channels, thus
dysmenorrhea.
The formula treatment of dysmenorrhea for qi and blood stasis include ge xia zhu yu
tang, chai hu su gan san, xiao yao san, jing ling zi san, shi xiao san. Formula for coldness
retention include shao fu zhu yu tang, wen jing tang. Formula for damp-heat include qing
jing san, qing re tiao xue tang, dan zhi xiao yao wan, long dan xie gan tang. Formula for
qi and blood deficiency include ba zhen tang, sheng yu tang, wu ji bai feng wan. Formula
for liver and kidney deficiency include tiao gan tang.
Acupuncture points for excess conditions including qi and blood stasis, coldness
retention, and damp-heat retention include CV3, BL32, LI4, SP10, SP8, LIV3, KID14
and ST28. Acupoints for deficient condition include CV4, BL20, BL23, ST36, SP6, PC6
and Sp4. (2)
Research
Wu described treating 40 women with severe dysmanorrhea with Chinese herbal
formula-Tongjing Power and obtained satisfactory result. Tonjing Power consists of 15g
each of dan shen, chi shao, pu huang, wu ling zhi, and 10g each of yan hu suo, chuan
xiong, gui zhi. The patients took Tongjing Power 30g tid three days before onset of
menstruation for 6 days during each cycle, and 3 menstrual cycles constituted a complete
course of treatment. To assess the effectiveness of the treatment, Wu use the methods of
observing clinical symptom changing, checking the blood flow parameter of uterine arties
by Doppler flow imaging and assay of hemorheologic data. Of the 40 patients treated
with Tongjing, 12 showed marked improvement, 24 were somewhat improved, and 4
showed no improvement. The total effectiveness rate was 90% (3).
Li reported treating 52 cases of primary dysmenorrhea with acupuncture and got good
results. Main acupoints included CV3, UB32, SP8 and SP6. Supplementary points for
excess condition included CV4; for deficient condition included BL23, CV4, and ST36.
Of the 52 cases, following 2 sessions of acupuncture treatment, 32 were cured, 17 were
improved and 3 were ineffective, with an effective rate of 94.2% (4).
CASE HISTORY
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Patient Identification and Chief Complaint
This patient is 28 year-old married female with severe dysmenorrhea.
History of Chief Complaint
The patient started her menses at age 12, her cycle was usually 28 days with 5 days flow.
The patient had severe menstrual cramping with heavy bleeding since June of 2000. She
described the symptoms as feeling “noodle legs”, tingling in her hands and feet, and they
made her not functional. She tried Aleve, Meclofernamate and Naproxen for couple
months (she did not remember exact how long), which did not help, she was then put on
birth control pills until two months ago-July, 2006 when the patient got married to a
TCM student and want to have children. Her dysmenorrhea came back after she stopped
taking birth control pills. Her last period lasts 7 days with severe cramping, heavy
bleeding and clotting. After rethought this case, I think the patient may have secondary
dysmenorrhea, so I asked the patient what happened then and what medical exams had
been done to her, she said nothing. I did not know it was true or she was hiding
something since her husband is my student and was always present during her treatment.
The patient did not have many symptoms according to the 10 TCM questions. Neutral
temperature, no abnormal thirst, no abnormal sweating, no headache or dizziness, no
palpation or short of breath, good appetite, no gas or bloating, no stomach discomfort,
bowel is formed, once a day, urination is fine, sleep is good, good energy, no floaters in
the eyes, no tinnitus, some stress at work.
Exam
Palpation examination reveals no tenderness or abnormal findings in her abdomen. There
is thick white coat on the sides of her tongue. The tongue color is purple and little pale
with scalloped shape. Her pulse is on the thin and weak sides.
Diagnosis
Western medicine: dysmenorrhea
TCM: the main diagnosis for dysmenorrhea is Qi and blood stagnation in liver, Chong
and Ren meridians causing severe menstrual pain. Because the patient felt some stress at
work, which could causes liver qi stagnation and lead to blood stasis in the Chong and
Ren meridians manifested as purple tongue and clotting during menses. The patient also
has mild spleen Qi deficiency with dampness manifested as thin weak pulse and pale
tongue with teeth marks. Stagnated liver qi may attack spleen and cause spleen deficiency
and dampness retention due to failure of spleen in transportation of water.
Treatment
Treatment principle is to move qi and blood and tonify spleen.
I treated the patient’s dysmenorrhea once a week for 7 weeks, after that I treated the
patient to get her ready for pregnancy.
In her first visit, herbal formula1 was given, which included wu ling zhi 6g, dang gui 6g,
tao ren 6g, hong hua 6g, chuan xiong 5g, mu dan pi 5g, wu yao 5g, xiang fu 4g, chi shao
5g, zhi ke 4g, yan hu suo 3g, gan cao 6g. It was granule. The dosage was 3 tid. In formula
1, wu ling zhi, dang gui, tao ren, hong hua, mu dan pi and chi shao moved the blood
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stasis; while chuan, wu yao, xiang fu, zhi ke and yan hu suo sooth the live and regulate
the Qi. Gan cao harmonized the herbs. Acupoints included Liv3, Li4, Pc6, Sp4, Cv17,
Cv12, Cv6, Cv3 and Zigong. Liv 3 and LI 4 were used to sooth the liver, PC6 and Sp4
were used to open the Cong channel, Cv 17, 12, 6 and 3 were used to open the Ren
channel, Zigong is an local extra point used to move stagnation in the uterus.Electroacupuncture
was applied from Cv6 to Cv3, and from Zigong to Zigong. The frequency
was mixed 100/2. The needles were retained for half an hour.
The second visit occurred 7 days later, the same points and herbal formula were given.
Her period started one day before her third visit, which happened one week after her
second visit. Herbal formula 2 was given, including wu ling zhi 7g, pu huang 7g, chuan
xiong 3g, bai shao 7g, gan cao 3g, san qi 7g, sheng jiang 5g, da zao 5g. It was granule
form. The dosage was 3g tid. In formula 2, san qi, wu ling zhi and pu huang were used to
move blood stasis and stop bleeding since the patient had dysmenorrhea with heavy
bleeding. Bai shao and gan cao were used to relax her muscle and uterus for the pain.
Chuan xiong was used to move qi stagnation. Sheng jiang and da zao were used to
harmonize her stomach. Acupoints given then included Gv20, Bl18, Bl20, Bl23, Bl32,
Sp6, Liv5 and Li4. Electro-acupuncture was connected from Bl23 to Bl32 with frequency
of 100/2 Hz. Gv 20 was used to calm her shen, BL18 was used to sooth her liver, BL20 to
tonify her spleen, EAC from BL23 to BL32 help to move stagnation in the Ren meridian
to ease the pain, Liv5 and LI4 help to move the Qi.
During her 4th visit, the patient described her recent period was less heavy , there was no
clotting, and the pain level was about half as before, herbal formula 1 was given with
modification of sheng jiang 4g, da zao 4g and ban xia 4g for her nausea. The same
formula was given during her 5th and 6th visit. Acupoints in her first visit and her third
visit were used alternatively once a week during her 4th, 5th and 6th visits.
During her 7th treatment, she felt little cramp and her period could start any day. Formula
2 was prescribed and acupoints in her first visits were used. The patient reported her
period started next day. She was also seen at OCOM program one week after her 7th visit
for her dysmenorrhea, both Misha cohen and the patient were happy with her progress.
The same formulae were suggested. The points given then included Pc6, Sp4, Liv3, Li4,
Kid3 and moxa over Cv3 and Cv6. Pc6 Sp 4 to open Cong meridian, Liv3 and LI4 to
sooth the liver, Kid3 to tonify the kidney, Moxa over Cv3 and Cv6 to warm the uterus.
Case management
Because the patient want to get ready for pregnancy and dysmenorrhea did not really
bother her much, I started to tonify qi, blood, liver and kidney. I think her dysmenorrhea
may disappear after she has her babies. If dysmenorrhea returns in the future, I may use
similar protocol by adding ba zhen tang to tonify qi and blood or liu wei di huang wan to
tonify kiver and kidney. Because her pulse is on the thin and weak side suggesting
underline deficiency.
Result
After 3 visits once per week, the patient did not have clotting during her period, the pain
level is about half as before, 4-5/10, and the bleeding is less heavy. After another 4
treatment once per week, her pain level was reduced to 3-4/10 during the following
period and her menses lasted 5 days with moderate bleeding instead of 7 days of heavy
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bleeding. Her pain level continues to be 3-4/10 during the following 2 cycles, even
though I changed to focus on her pregnancy. Her prognosis is not clear at this point,
because she had unclear biomedical diagnosis. For example, if her dysmenorrhea was
caused by PID, her prognosis was good with proper TCM treatment. If her dysmenorrhea
was caused by endometriosis, her prognosis was fair with proper TCM treatment.
DISCUSSION
Birth control pills can be effective in treating dysmenorrhea, but once it is stopped,
dysmenorrhea may returns. Chinese medicine appears to be of benefit as a
complementary modality in treating dysmenorrhea with less severe symptom recurrence.
This patient was diagnosed with qi and blood stagnation, modified ge xia zhu yu tang was
used after her period stopped until onset of her next period. Modified shi xiao san with
herbs moving blood stasis and stopping bleeding due to her heavy bleeding was used
during her period. Acupoints in the front and back were selected to move qi and blood
with little tonification. Electro-acupuncture over Zigong and BL32 are important to move
stagnation, increase blood flow to the uterus by affecting blood vessels and sacrum
plexus. Pc6 and Sp 4 are the master points for the Chong meridian, which is the key extra
meridian for dysmenorrhea. Of course, the four gates are important to move qi and blood
in the liver channel.
While the result of TCM treatment is encouraging, further biomedical testing is necessary
to differentiate the cause of her dysmenorrhea, which may help her future treatment.
CONCLUSION
Dysmenorrhea treated with birth control pill may return once patients stop taking the
pills. The result in this case with acupuncture and Chinese herbal treatment suggests that
Chinese medicine may be an effective treatment option. Also, in this case, even though I
started to treat the patient for her pregnancy later, acupuncture and Chinese herbs may
still have some effects on her dysmenorrhea. While this result is encouraging, further
high quality clinical trials with larger numbers of objects and adequate follow-up period
are needed.
REFERENCE
(1) Lawrence M. Tierney, jr. Current Medical diagnosis and treatment 2003, Lange
Medical Books; 702.
(2) Class notes from misha cohen L.Ac. for OCOM-DAOM 2005 class.
(3) Wu, Qing-qing. Clinical Observation of Adolescent Dysmenorrhea treated with
Traditional Chinese Medicine. International Journal of Oriental Medicine V2 N1
P49-51, March 1999.
(4) Li, yun-bo. Acupuncture Treatment of 52 cases of Primary Dysmenorrhea.
Internal Journal of Clinical Acupuncture V15 N3 P155-156, 2006.

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