Blood stasis is either due to trauma or it is a branch symptom. This is important because we have to resist the urge to simply vitalize blood when we see blood stasis. Our effectiveness is much stronger if we ask ourselves to identity the root. Often the root is Qi stasis but not always. Qi deficiency, blood deficiency, Yin or Yang deficiency, heat, cold, damp etc..all can be a factor in the root of the blood stasis. Of course the location of the blood stasis is very important to identify and treat but, in addition, if the root is not addressed, the results will be far from adequate.
In this post I look at cold as a root of blood stasis. I identify cold as a root factor in almost half of my dysmenorrhea cases. In my experience, there are some unique characteristics to treating blood stasis as the root cause of dysmenorrhea and these are the same characteristics for treating other types of pain in which cold is a factor.
Cold causes blood stasis very intensely and quickly. The pain from blood stasis due to cold is also relatively intense. Think of a child swimming in cold water and how they start to shiver and develop blue-purple lips, fingers and toes. I have a small spring fed pond behind my clinic. The water is very cold all year round. If I dip my feet into it, within 2 minutes they start to ache. Cold causes blood stasis and this blood stasis causes pain. However, as soon as the child is warmed up, the lips, fingers and toes turn pink again!
The good news about pain due to blood stasis is that warming the area of pain is very often enough to vitalize the blood and stop the pain.
As we saw in the last post, Dr. Xia wrote:
There is the principle that when the blood is warm it will move. When there is dysmenorrhea, there is a relationship with blood stasis. For this it is appropriate to warm the Yang and vitalize the blood and this is not really because there is cold there. Generally blood stasis does not manifest with Heart and Liver fire flourishing. The transformation of stasis and the opening through of the collaterals must be assisted with herbs to warm the Yang.
Dr. Xia is talking about the importance of using warmth to vitalize blood regardless of the root pattern. Warmth moves and cold stops. This is a general principle for treating pain. Even in cases in which pain has a strong heat component, the herbs for clearing heat are combined with herbs that warm. This means that if the root cause of the blood stasis is cold or if the patient has a Yang deficiency constitution, you will be able to use warming herbs very liberally. Very often there is no need to use any herbs to vitalize the blood. Simply melting the iceberg is enough.
When a patient comes to me with dysmenorrhea that is improved with warmth accompanied by, a cold butt, pale tongue body, a general aversion to cold and a particular aversion to cold in the lower body I know that cold is a factor in the pain. The next step for me is to determine if there are other root factors involved as well.
If the only cause of the blood stasis is cold or yang deficiency, there will be no need for any blood vitalizing herbs. Simply warming the womb will renew circulation and stop the pain. If the patient is thin and tending to dryness, I use Wen Jing Tang. This formula can be modified to be relatively more warming or relatively more enriching. By combining warm and pungent herbs with sweet blood enriching herbs, warmth is directed into the blood. This will stop pain without adding any herbs to stop pain or strongly vitalize the blood.
Ai Fu Nuan Gong Tang is also a wonderful and effective formula. Again it can be seen that there are no herbs here to strongly vitalize blood or to stop pain.
For robust patients with rough or dry skin, I often use Ma Huang in combination with herbs to direct the formula to the womb and to the blood. If there is Kidney Yang deficiency herbs such as Fu Zi, Xian Mao or Ba Ji Tian can be added. I often notice that my patients with cold womb pain also have a very red tipped tongue combined with agitation and insomnia. For this I often integrate Jiao Tai Wan by adding a good dose of Huang Lian. This not only calms the spirit but also directs the fire downward.
Of course there is a relationship between cold womb dysmenorrhea and infertility and habitual miscarriage. Dr. Qiu writes:
“When the Kidney Yang is insufficient, the Ming Men Fire wanes, the uterus is cold and vacuous and a woman is unable to receive Jing and become pregnant the treatment to use is Gui Xian Tang Cinnamon Immortals Soup with added flavors. This prescription warms the Yang and heats the uterus, replenishes the Jing and boosts the Kidneys so that the Chong and Ren Mai will be abundant and so the fetal wrapper can receive and sprout life. The Qi will then be warm and harmonious like the springtime, the container of creation will transform and become and there will be pregnancy”.
Below are some discussion on this topic with case studies written by my teacher Dr. Qiu Xiao-Mei. She uses formulas such as modified Wu Zhu Yu Tang and Dang Gui Jian Zhong Tang, which also follow the ideas discussed above.
Often a woman will receive a cold evil because she wades in cold water, gets caught in the rain or she eats too many cold foods during menstruation.
This causes stasis in the uterus. When blood meets cold the blood becomes congealed, the blood is unable to move freely and this causes pain. As Zhang Jing-Yue wrote “When a woman eats cold or toxic foods, if there is cold stasis in the channels, external cold gets in or she is not cautious with cold, the effect is congealed knotting and lack of movement. When this stays and gathers, there is pain”.
Principle Pattern: The patient may feel cramping or gripping pain before or during menstruation, the application of warmth will ease the pain, she may vomit clear liquid, have coldness in her four limbs. The menstrual liquid may be dark red and scanty or irregularly pour or drip with no ease of flow. The blood may contain clots. Her pulse may be deep and slow or deep and tight. Tongue moss may be thin and white.
Treatment method: Warm the menses and scatter cold
Principle formulas: Wu Zhu Yu Tang Jia Jian (Wu Zhu Yu, Rou Gui, Fang Feng, Xi Xin, Dang Gui, Qi Ye, Chaun Xiong, Gan Jiang).
Case Example: Ms. He was already married and 36 when she came for her first visit in June of 1962. In the past, during her menstruation she had waded in water and three days before her menses she had experienced abdominal pain and felt cold. When she had her menses for 3-5 days the pain became severe though was slightly relieved with the application of warmth. She was unable to eat and vomited clear liquid. She had spontaneous sweating, dizziness, inability to leave her bed, back soreness and down bearing pain in her abdomen. Her menses were late, the color was murky and the amount scanty. Her facial color was dull white, wan and thin and she felt worried and depressed. During her menses she was unable to work. Her pulse was deep and rough. Her tongue moss was thin white. Western medical diagnosis was endometriosis. She did not want to have surgery but wanted to try Chinese herbs for treatment so she switched from the other hospital to my clinic.
Differential diagnosis: Cold damp congealing and static.
Treatment method. Benefit the Yang and expel stasis.
Gui Zhi 4.5
Chao Bai Shao 9
Dang Gui 12
Chuan Xiong 4.5
Zhi Gan Cao 3
Ai Ye 4
Dan Shen 15
Xiang Fu 9
Yu Jin 6
Mu Xiang 9
Pao Jiang 4.5
Rou Gui Wei 2.4 (make into a pill and take)
Second Visit: After taking the abover formula the abdominal pain lightened, she was able to eat and did not vomit. The sweating also stopped, her facial color was more luminous and her spirit was happy. Her pulse was slow and moderate and her tongue moss thin and white. The previous formula had been effective so I continued with the same method with a few changes:
Gui Zhi 4.5
Dang Gui 9
Dan Shen 12
Chuan Xiong 3
Chao Bai Shao 9
Xiang Fu 9
Ai Ye 3
Xu Duan 9
Pao Jiang 3
Rou Gui Wei 1.5 (make into a pill)
Third visit: Warming, opening through and moving the blood, the congealed cold in the uterus was warmed and scattered. The abdominal pain was gone. After this, she would take 5 packages of this formula before her menses and there was no sign of a problem. She was able to return to her normal activities.
Discussion: In this case, the western diagnosis was endometriosis but, based on my differential diagnosis she had cold damp congealed stasis in the uterus. Because of the cold, the blood did not move. This caused the menses to come late and the cold Qi stagnating in the lower Jiao caused extreme pain that was slightly relieved by the application of warmth. I used Gui Zhi Tang with Rou Gui. The idea was to aide the Yang to expel the congealed as well as to regulate and harmonize the luxuriant Wei. This way the heat dispels the cold.
Many cases of dysmenorrhea are caused from a vacuity of Yang and uterine vacuity cold. The blood looses its warm movement and the menses do not flow smoothly. Lack of openness causes pain and leads to dysmenorrhea.
Principle pattern: The patient may have pain before or during menstruation that feels cold. The patient may like pressure and warmth on her abdomen. The menses may be scanty and pale. She may fear cold, lack warmth in her 4 limbs, have a sticky thin bowel movement, a deep slow pulse and a pale tongue.
Treatment method: Warm the menses and supplement vacuity
Principle formulas: Wen Jing Tang and Dang Gui Jian Zhong Tang
Case Example: Ms. Li was 32 and already married when she came to see me on August 12, 1954. She complained of 10 years of dysmenorrhea. It was worst when the menses began, liked pressure and warmth and year by year had become worse. Her menses arrived late by 9-15 days and was pale in color and thin. She bled for 6-7 days without a lot of blood and stayed in bed 3-4 days. She also experienced low back soreness, weak legs, fear of cold and eating made it worse. After she had been married for 8 years, she still had not become pregnant. Her pulse was deep and thin and her tongue moss was thin white.
Differential diagnosis: Liver and Kidney vacuity cold
Treatment method: warm the menses and scatter cold, regulate and supplement liver and Kidney
Dang Gui 12
Chuan Xiong 6
Chi Shao 9
E Zhu 6
Wu Zhu Yu 3
Niu Xi 9
Gou Qi Zi 9
Pao Jiang 3
Rou Gui Wei 3
Tu Si Zi 9
Gou Ji 9
Second Visit: August 24, 1954: After 10 packages of the above formula her menses were 5 days late and the color had changed to red though the quality was still thin and the pain had decreased so that she stayed in bed just two days. She had no problem eating. She still had back soreness and abundant discharge and her menses lasted just 2 days. Her pulse was thin and her tongue moss was thin and white. I gave her 9 packages of Ba Zhen Tang and Si Zhi Xiang Fu Wan. I advised her to take 9 gms of the pills and 1 package of the soup each day.
Third Visit: December 12, 1954: Ms. Li reported that after 10 years of dysmenorrhea, after the herbs the pain was gone. Her menses had normal color and regularity had been normal for 3 months. Her pulse was moderate and her tongue body was red. I gave her the following formula:
Dang Shen 15
Bai Zhu 9
Fu Ling 9
Zhi Gan Cao 3
Dang Gui 9
Bai Shao 9
Shu Di Huang 30
Chuan Xiong 1.5
Du Zhong 30
Tu Si Zi 15
Ba Ji Tian 12
Zi He Che 3 gm swallowed with each dose
I advised her to take it before sleep.
Forth visit: March 25, 1955. She took the above formula for more than a month. Her last menstruation was January 20 and it lasted 5 days. She reported feeling dizzy with an aversion to cold. She also had a bland taste and poor appetite with vomiting. Her pulse was thin and slippery and her tongue moss was thin and white. A pregnancy test was positive and she was suffering from morning sickness.
Discussion: This patient had dysmenorrhea for more than 10 years that responded favorably to heat and touch. Her period was late, pale in color and scanty in amount. Her back and legs were sore and weak. Her pulse was deep and thin. The differential diagnosis focused on Liver and Kidney vacuity cold. The Chong mai is the sea of blood and the Ren governs the Bao Tai. The Ren and Chong are both subordinate to the Liver and Kidneys. This Liver and Kidney insufficiency, Chong and Ren not nourished, and vacuity cold of the uterus lead to an inability to absorb Jing and become pregnant. In this case the dysmenorrhea is connected to the infertility. At her first visit I gave her Wen Jing Tang modified. Dang Gui, Chuan Xiong, Chi Shao, E Zhu, Wu Zhu Yu, Rou Gui and Pao Jiang nourish blood, vitalize blood and scatter cold so that the cold can be dispelled and the uterus can then be warm. Niu Xi, Tu Si Zi, Gou Qi Zi and Gou Ji assist the insufficiency of the Liver and Kidney. At the second visit I gave her Ba Zhen Tang to fortify the Spleen and regulate the menses. I added Si Zhi Xiang Fu Wan to rectify the Qi. This way I worked with the Qi and Blood at the same time. When the Qi is moving in the proper way the blood is harmonized and the menstrual cycle becomes normal and the pain is gone. At the third visit I changed to using Yu Lin Zhu San to fortify the Spleen and Stomach, reglate the Ying and Wei, supplement the Liver and Kidney so the Qi and Blood can be abundant and the sea of blood full. The result was pregnancy.