五味调经散 Wu Wei Tiao Jing San Five Flavor Synchronize the Menstruation Powder

“He substituted Mu Dan Pi for Zhi Zi and Shan Zha for Liu Qu.  He did this because Mu Dan Pi and Shan Zha enter the blood level while Zhi Zi and Liu Qu do not.  Brilliant! ”

Todays entry includes the next section in Dr. Xia Guisheng’s chapter on opening through menstruation.  He uses his formula Wu Wei Tiao Jing Tang (Five Flavor Synchronize the Menstruation Decoction) as a jumping off point to discuss some basic ideas about the treatment of irregular menstruation due to congealed blood.   Wu Wei Tiao Jing Tang is a simple and small formula.  It’s design represents some of the basic principles of working with blood stasis in relation to menstruation and it’s size makes it ideal for combining with other formulas or for adding other herbs.

What are some of these basic principles Dr. Xia is illustrating here?

  1. There are light and heavy manifestations of a pathological presentation and formulas can be adjusted for this.
    Wu Wei Tiao Jing Tang is a formula for light presentations of blood stasis while the previous formula Jia Jian Tong Jing San was for a somewhat heavier presentation.  We will be looking at other formulas that are used to treat different degrees of pathology in up-coming entries here.  In school we do not generally learn to take the degrees of seriousness into account.
  2. Some herbs have the function of synchronizing the menstruation and these should be used in gynecology.
    In the materia medica, the function of herbs is listed.  For some herbs the function of Tiao Jing 调经 “synchronizing the menstruation” is listed.  This refers to an innate characteristic of the herb to help regulate the menstrual cycle.  The herbs that have this function within them are the ones most used in the gynecology clinics.
  3. Warmth helps move blood.
    Warmth is a quality that promotes movement.  Cold slows movement down.  Because of this, even if there is no cold present in a blood stasis presentation, unless warmth is contra-indicated, it can and should be used.
  4. We must pay attention to other characteristics of the presentation besides the disease factor of blood stasis in the womb.
    In this case, Dr. Xia is encouraging us to pay attention to the amount of bleeding.  As we go through these sections we will see that scanty bleeding will cause Dr. Xia to use herbs like Hong Hua, Tao Ren and Dan Shen while heavier bleeding will cause him to use herbs like Wu Ling Zhi and Pu Huang.  He also makes a point in this essay, to help us pay attention to the stool quality because it is so common for a woman to have a loose or sticky stool at menstruation.  These subtle observations and ability to modify are the kinds of skills that make so much difference in the clinical accuracy of our treatments.
  5. I think it is also very useful to note how Dr. Xia modified the formula Yue Ju Wan (Escape Restraint Pill) and to look at why he made these modifications.  He substituted Mu Dan Pi for Zhi Zi and Shan Zha for Liu Qu.  He did this because Mu Dan Pi and Shan Zha enter the blood level while Zhi Zi and Liu Qu do not.  Brilliant!

I hope you enjoy his writings as much as I do….

Formula Name:

Regulating the Jing is regulating the menstruation, promoting menstruation and causing the amount of the menstruation to become normal.  Generally I use light dosages of herbs to vitalize the blood and I use 5 flavors.  So, this formula is made up of the 5 herbs I use most often in the clinic.  I gathered them together to form Wu Wei Tiao Jing San and this is exactly why I named it Wu Wei Tiao Jing San.

Formula Constituents:

Dang Gui            10 gm

Chi Shao             10

Wu Ling Zhi        10

Ai Ye                    6

Yi Mu Cao            15-30

Method of Application

This formula is to be decocted in water, one package each day.  It should be stopped when the menses come.

Function:

Vitalizes blood and transforms stasis, regulates the menstruation

Presentation for Use:

Irregular menstruation, late menstruation, scanty menstruation, lack of free flow with menstruation and even amenorrhea or prolonged cycle.

Formula explanation:

This is a light formula for vitalizing the blood and transforming stasis and it uses the most frequently used herbs to regulate the menstruation.  Dang Gui and Chi Shao are the two common herbs from Si Wu Tang (Soup of Four Things).  One is Yang and one is Yin and yet both are herbs that vitalize blood and transform stasis.  These are the principle herbs of Wu Wei Tiao Jing Tang.  Wu Ling Zhi enters the Liver channel, transforms stasis and stops pain.  It is able to transform while stopping [bleeding].  When it is under the guidance of Dang Gui and Chi Shao, it is able to vitalize the blood and regulate the menstruation without forcing the blood to flow excessively.  This is assisted with Ai Ye, whose warm character heats the womb.  When the menstrual blood is warm it will move and therefore Ai Ye warms and helps to make the blood flow smoothly. Finally there is Yi Mu Cao, which transforms stasis and generates the new.  It also contracts the uterus, which helps the Dang Gui, Chi Shao and Wu Ling Zhi discharge the menstrual blood fully.  When the blood goes out, the new will be generated and the deficiency of the sea of blood will become abundant.  This way the uterine lining becomes newly generated.  This is the function of Wu Wei Tiao Jing Tang.

Clinical Application

This formula is a light formula for vitalizing the blood and regulating the menstruation.  It is also relatively harmonious and therefore it is appropriate for late or light menses or menstruation that does not flow smoothly.  However, it is also appropriate for profuse or prolonged menstruation when there is blood stasis.

1. Heavy menstruation: When there is heavy, purple red menstruation with relatively large blood clots.  There may also be paroxysmal lower abdominal pain and distention, chest and stomach focal distention, thirst without a desire to drink, dark colored stool, back and waist soreness.  The pulse may be thin and wiry or thin and rough.  The tongue may be purplish or have stasis spots and may have a thin white moss that is thick and sticky at the root.  In this case you would add herbs such as Chao Pu Huang, Qian Cao Tan, Da Xiao Ji or Chao Xu Duan.

2. Prolonged menstrual cycle:  In this kind of situation, though the bleeding amount is not heavy, the bleeding goes on without stopping or the amount is relatively profuse with episodes in which the blood contains relatively large clots.  The blood is a purple red color and menstruation is accompanied by lower abdominal distention, discomfort in the chest and thirst without a desire to drink.  The tongue will be pale red and the moss will be thin white.  The pulse will be thin but not smooth.  In this kind of case one should also add herbs such as Chao Pu Huang, Jing Jie and Zhi Xiang Fu.
Modifications:

This formula has a very broad application for any menstrual illness in which there is blood stasis.  However, if the pathology is combined with fire heat, Ai Ye should be removed and one should add herbs such as Mu Dan Pi, Ling Xiao Hua or Gou Teng.  If there is waist and back soreness then add herbs such as Chao Xu Duan, Sang Ji Sheng and Du Zhong.  If the Spleen and Stomach are lacking, with abdominal distention, flatulence and sticky stool, add herbs such as Zao Mu Xiang, Zhi Cang Zhu and Jiao Shan Zha.

Clinical Experience

Wu Wei Tiao Jing Tang is the formula I use most often in the clinic.  I often use Dan Shen in place of Dang Gui.  Why?  Dang Gui and Dan Shen are both herbs that regulate the menstruation.  However, Dang Gui has the function of moistening the large intestine and it easily induces a sticky stool.  In my clinical practice, it is common for women to develop a sticky or loose stool during menstruation so I substitute Dang Gui with Dan Shen.  Our predecessors said “The single herb Dan Shen is the same as Si Wu Tang (Soup of Four Things)”.  So, in terms of regulating menstruation formulas it seems to be good to make this substitution.  But, it should be kept in mind that when the menstruation is heavy or prolonged, this substitution is not suitable because it is easy to cause excessive bleeding or increase bleeding with Dan Shen.  This comes from my many years of experience.  Therefore, when the stool is not sticky or the menstrual discharge is profuse, keep Dang Gui in the formula.  If the stool is sticky or soft, it is appropriate to use Dan Shen.

Clinically one should pay attention to the particular characteristics of the differential diagnosis and the pathological changes.  When the menstruation is irregular, I consider this to be related to Liver depression, Spleen deficiency, Kidney deficiency, blood stasis or phlegm turbidity.  Therefore the methods I apply will open the flow of the Liver, fortify the Spleen, supplement the Kidney dispel stasis and transform phlegm.  I will use the formula to fit the method.

When there is Liver depression, I will smooth the flow of the Liver and regulate menstruation, using Si Zhi Xiang Fu Wan (Tang)(Four Prepared Cyperus Pill (Decoction)) or Qi Zhi Xiang Fu Wan (Tang) Seven Prepared Cyperus Pill (Decoction)) with Wu Wei Tiao Jing Tang.

When there is Spleen Qi deficiency with irregular menstruation, I will fortify the Spleen and regulate the menstruation.  If this appears with sticky stool I will use Xiang Sha Liu Jun Zi Tang (Six-Gentlemen Decoction with Aucklandia and Amomun) with Wu Wei Tiao Jing Tang. If there is focal distention with rebellious burping or nausea and vomiting then I will use Xiang Sha Ping Wei San (Calm the Stomach Decoction with Auklandia and Amomum) with Wu Wei Tiao Jing Tang.

When there is Kidney deficiency causing irregular menstruation, I will supplement the Kidneys and regulate the menses.  When there is Yang deficiency irregular menstruation use Xiao Wen Jing Tang (Minor Warm the Menses Decoction) with Wu Wei Tiao Jing Tang.

When there is Yin deficiency irregular menstruation, the menstruation will often be profuse.  You can use Er Zhi Di Huang Wan (Two-Solstice Rehmannia Decoction) with Wu Wei Tiao Jing Tang.

When there is phlegm damp causing irregular menstruation you can use Cang Fu Dao Tan Tang (Grey Atractylodes Guide Out the Phlegm Decoction). If this tends more to damp heat you can use Si Miao Wan (Four-Miracle Pill) with Wu Wei Tiao Jing Tang.

When there is blood stasis causing menstrual irregularity with a tendency to cold fatigue, you can use Wen Jing Tang (Warm the Menses Decoction) from the Fu Ren Liang Fang (Effective Formulas for Women) with Wu Wei Tiao Jing Tang.  If there is more of a tendency to heat blood stasis, this can easily give rise to heavier bleeding and you can use Si Cao Tang (Four Grass Decoction) with Wu Wei Tiao Jing Tang.

This is all to say that when you use Wu Wei Tiao Jing Tang alone or in combination, you must consider the characteristics of the illness.

Detailed analysis of the principle herbs in this formula:  Dang Gui and Chi Shao.

Dang Gui

Dang Gui is sweet, pungent and warm.  It enters the 3 channels: Heart, Liver and Spleen.  It can supplement blood and vitalize blood.  It moistens dryness of the Large intestine.  The primary applications for Dang Gui are irregular menstruation, painful menstruation, bleeding, blood deficiency constipation and traumatic injury.

The Ming Yi Bie Lu (Separate Records of Famous Physicians) considers Dang Gui to “produce warmth in the middle and to stop pain.  It dispels cold that is lodged in the blood, treats stroke, spasms, inhibited sweat, Qi deficiency type cold and damp obstructed evil.  It can supplement the 5 Zang and generate the muscles and flesh”.   I consider Dang Gui to supplement the blood and regulate the menstruation.  Everyone in the world knows that Dang Gui is the important herbs for presentations of irregular menstruation, blood deficiency amenorrhea, and pathology before and after birth. For example, the He Ji Ju Fang (Official Formulas for Harmony) tells us that Si Wu Tang (Soup of Four Things) is Dang Gui combined with Shu Di, Chuan Xiong and Bai Shao and that this is an important formula in the gynecology clinic.  Dang Gui has the function of regulating Qi and vitalizing blood.  It is able to treat congealed static Qi and blood, abdominal pain from lack of harmony in the luo vessels, rib-side pain, traumatic injuries as well as numbness and pain presentations.  In general, Qi stasis will, over time cause the luo vessels to become congealed and the blood will not flow through easily.  When Dang Gui is combined with herbs to regulate Qi, the effect for this type of condition is really good.  When blood stasis causes pain, Dang Gui can be combined with herbs to regulate blood.  When there is blood deficiency with interior cold and abdominal pain, Dang Gui can be combined with herbs to benefit the Yang.  When there is lack of harmony in the Luo vessels due to wind damp, Dang Gui can be used with wind damp herbs.  Keep in mind that Dang Gui can make the intestines slippery.  It is used for blood deficiency constipation but you should use caution when there is Spleen deficiency with diarrhea.

Chi Shao

Chi Shao is sour and bitter and slightly cold.  It enters the 2 channels Liver and Spleen.  It discharges the Liver and clears heat, scatters stasis, vitalizes the blood and stops pain.  It is able to treat static blood that is congealed and stuck causing abdominal pain, rib-side pain, amenorrhea, blood obstruction, masses and painful swelling presentations.  Miao Xi-yong considers this herb to crack and scatter, open through and disinhibit and to enter the Liver blood level for evil Qi abdominal pain.  When it is combined with Dang Gui, it primarily treats abdominal and rib-side pain very effectively and so it is good for painful menstruation and irregular menstruation.  It has a good and lasting effect.

Practical Experience

When I use Wu Wei Taio Jing Tang in the clinic to regulate the menstruation, up until the menstruation arrives or 1-2 days before menstruation, I often combine it with Yue Ju Wan (Escape Restraint Pill). Yue Ju Wan (Escape Restraint Pill) contains Shan Zhi Zi for which I substitute Dan Pi.  It also contains Liu Qu for which I substitute Shan Zha.  This becomes one of my frequently used formulas in the clinic and the effect is quite good. Yue Ju Wan (Escape Restraint Pill) helps the smooth flow of the Liver and regulates Qi.  Wu Wei Tiao Jing San (Tang) regulates the menstruation from within the blood.  One formula is for the blood and one is for the Qi.  Each formula makes the other shine more brightly.  Honestly these are good herbs and good formulas for regulating the menstruation.

Case Example

I had a patient named Wang who was 32 years old.  Her menstruation was late and scanty and now had not come for 3 months.  She began menstruating at age 12 and bled for 3-5 days every 30 days.  The color was red and there were small clots in it.  She had menstrual pain.  After she was married, she used mechanical birth control.  She often had vaginal discharge.  At ovulation time she had bright stringy discharge for 3 days.  Gynecology check-up: There was a mild degree of cervical inflammation but otherwise there were no abnormalities.  In the last half year she had gotten very keyed up in relation to her work situation.  She felt emotional discomfort and her menstruation became irregular.  Gradually her menstruation came later, 50 days between menstruations, and the amount was scanty.  The color was purple red and there were clots in the blood.  She felt acute lower abdominal pain and premenstrually she felt chest oppression, agitation, breast distention and insomnia.  Her pulse was thin and wiry and the tongue moss was thin and white and sticky.  I gave her Yue Ju Wan (Escape Restraint Pill) and Wu Wei Tiao Jing Tang.  From 2 days before her menstruation until it had stopped she took the herbs.  We worked this way for about 2 months.  Her menstruation regulated to come every 35-17 days and the amount became normal.  On the whole she came back around to health.


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