Menstrual disorders refer to conditions characterized by abnormalities in the menstrual cycle, duration of menstruation, menstrual flow, color, or consistency, or by symptoms that occur in conjunction with the menstrual cycle. Common conditions include premature menstruation, delayed menstruation, irregular menstrual cycles, menorrhagia (heavy menstrual bleeding), hypomenorrhea (scant menstrual bleeding), prolonged menstrual periods, intermenstrual bleeding, metrorrhagia, dysmenorrhea (menstrual cramps), amenorrhea (absence of menstruation), menstrual dizziness, menstrual diarrhea, menstrual edema, menstrual hives, menstrual breast tenderness, menstrual headaches, menstrual body aches, emotional disturbances during menstruation, and various symptoms occurring before and after the cessation of menstruation.
I. Intermenstrual Bleeding
Any cyclic bleeding that occurs between two menstrual periods—that is, during the ovulatory phase—is referred to as intermenstrual bleeding. The ovulatory phase is what is now known as the ovulation period.
Etiology and Pathogenesis of Intermenstrual Bleeding: Most experts believe that this condition is related to constitutional factors. After menstruation has completely ceased, the Blood Sea becomes depleted, and the Chong and Ren meridians weaken. Menstrual energy gradually accumulates, transitioning from a state of deficiency to one of abundance. Between two menstrual cycles, this marks the turning point from deficiency to abundance: Yin essence becomes replenished, functions strengthen, and Yang energy stirs internally, giving rise to the period of ovulation—the ovulatory phase. At this time, if the body’s Yin-Yang regulatory functions are normal, it can adapt to these changes without exhibiting any specific symptoms. However, conditions such as kidney yin deficiency, internal accumulation of damp-heat, or the presence of stagnant blood may all lead to vaginal bleeding.
(1) Kidney Yin Deficiency: Congenital insufficiency, or damage to the kidneys caused by excessive sexual activity or frequent childbirth, resulting in kidney yin deficiency, essence depletion, and blood deficiency, can lead to bleeding during the ovulation period. This occurs because the internal movement of yang qi damages the yin collaterals, causing the Chong and Ren meridians to become unstable.
(2) Damp-Heat: Emotional distress may lead to liver qi stagnation, which in turn impairs the spleen and stomach’s ability to transform the essence of food and drink into essence and blood. Instead, this essence accumulates as dampness; as the damp pathogen descends, it generates heat, which damages the Chong and Ren meridians, thereby causing intermenstrual bleeding.
(3) Blood Stasis: In patients with a weak constitution, residual blood stasis from menstruation or childbirth may obstruct the uterine vessels. Alternatively, internal injury caused by the seven emotions (joy, anger, worry, overthinking, sadness, fear, and shock) may lead to qi stagnation in the Chong and Ren meridians, which over time develops into blood stasis. During ovulation, when yang qi stirs internally, it damages the uterine vessels, potentially causing bleeding.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Intermenstrual Bleeding
(1) Kidney Yin Deficiency: Patients present with light bleeding between menstrual periods—bright red in color, without clots or abdominal pain—but may experience lower back soreness, dizziness, restless sleep, difficulty with bowel movements, dark yellow urine, a red tongue, and a thin, string-like, or slightly rapid pulse. The treatment principle is to nourish yin and stop bleeding. The formula Liangdi Decoction combined with Erzhi-Jiu, with appropriate modifications, may be used.
(2) Damp-Heat: Patients present with bleeding between menstrual periods that may be light or heavy, with bright red, sticky blood containing no clots, or discharge resembling reddish-white leukorrhea. They may experience fatigue, aching joints, chest tightness, irritability, poor appetite, scanty and reddish urine, and generally excessive, sticky leukorrhea. The tongue coating is yellow or white and greasy, with a thick coating at the base of the tongue, and the pulse is fine and taut. The treatment principle should be to clear heat and drain dampness. The formula “Liver-Clearing and Urinary-Tract-Regulating Decoction” (Qinggan Zhilin Tang), with appropriate modifications, may be used for treatment.
(3) Blood Stasis: The patient presents with bleeding between menstrual periods that is light or slightly heavy, with a purplish-black color or the presence of blood clots. This is accompanied by distending or stabbing pain on both sides of the lower abdomen, possible breast distension and dull pain, chest tightness, irritability, a tongue with stasis spots, and a fine, taut pulse. The treatment principle should be to resolve blood stasis and stop bleeding. The formula “Decoction for Expelling Blood Stasis and Stopping Bleeding” (Zhu Yu Zhi Xue Tang), with appropriate modifications, can be used to achieve good results.
II. Menstrual Breast Distension and Pain
When breast distension, discomfort, or itchy and painful nipples occur before, during, or after menstruation—to the extent that the nipples cannot even bear contact with clothing—this is referred to as “menstrual breast distension and pain.”
Etiology and Pathogenesis of Menstrual Breast Distension and Pain: This condition is often caused by internal injury from the “Seven Emotions,” stagnation of Liver Qi, and impaired circulation of Qi and Blood; or it may result from deficiency of Liver and Kidney essence and Blood, leading to inadequate nourishment of the meridians.
(1) Stagnation of Liver Qi: Anger and worry lead to stagnation that injures the liver, causing the liver to lose its smooth flow. During menstruation, yin blood descends into the Chong and Ren meridians; the Chong Meridian belongs to the Yangming channel and is associated with the liver, while the nipples belong to the liver and the breasts to the stomach. When liver qi fails to disperse properly and the milk vessels become obstructed, this results in menstrual breast tenderness.
(2) Deficiency of Liver and Kidney Yin: Patients with deficiency of Liver and Kidney Yin may have a constitutional yin deficiency, or their yin and blood may have been depleted due to chronic or acute illness, blood loss, or fluid depletion. During menstruation, yin and blood become even more deficient, further exacerbating the insufficiency of Liver and Kidney essence and blood. As a result, the mammary collaterals fail to receive proper nourishment, leading to breast distension and pain during menstruation.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Menstrual Breast Distension and Pain: Clinically, this condition is categorized into deficiency and excess patterns. In deficiency patterns, pain typically occurs after menstruation, and the breasts feel soft with no palpable lumps upon palpation; in excess patterns, pain often occurs before menstruation, with palpable lumps upon palpation, and the breast distension and pain gradually subside after menstruation. The condition occurs cyclically.
(1) Stagnation of Liver Qi: Patients with this pattern experience breast distension, itching, hardness, and pain before menstruation, accompanied by chest tightness, distension in the flanks, depression, and frequent sighing. The tongue coating is thin and white, and the pulse is string-like. The treatment principle should focus on soothing the liver, resolving stagnation, regulating qi, and alleviating pain. The formula Chaihu Shugan San, with appropriate modifications, may be used for treatment.
(2) Liver-Kidney Yin Deficiency: Due to a deficiency of essence and blood in the Liver and Kidney, the breast meridians do not receive proper nourishment. Consequently, patients experience distension and dull pain in both breasts during or after menstruation, soreness and weakness in the lower back and knees, dry and gritty eyes, dry throat and mouth, heat in the palms and soles, a red tongue with little coating, and a thin, rapid pulse. The supports principle should be to nourish the Kidney and Liver. The author frequently uses Modified Yiguan Decoction based on specific signs of imbalance, which has consistently produced good results.
III. Amenorrhea
A woman over the age of 18 who has not yet experienced menarche, or who has had a menstrual cycle but has experienced an interruption of menstruation for three months or longer, is diagnosed with amenorrhea. The former is referred to as primary amenorrhea, while the latter is secondary amenorrhea. Temporary cessation of menstruation during pregnancy or lactation, menopause, or occasional absences of menstruation in some adolescent girls for a period of time after menarche are all normal physiological phenomena and are not classified as amenorrhea. There are also some women who experience amenorrhea due to changes in living conditions, psychological factors, or exposure to cold pathogens, with no other symptoms. If menstruation has not resumed after six months of observation, treatment should be administered. However, congenital reproductive organ malformations—such as absence of the vagina, uterus, or ovaries, or hymenal atresia—are not within the scope of this discussion.
Etiology and Pathogenesis of Amenorrhea: The etiology and pathogenesis of this condition are relatively complex and can be categorized into deficiency and excess patterns. Deficiency patterns are often caused by insufficiency of the liver and kidneys, deficiency of essence and blood, emptiness of the Blood Sea (Xuehai) resulting in a lack of blood to be discharged, weakness of qi and blood, or yin deficiency leading to dryness of the blood, all of which result in amenorrhea. Excess patterns are often caused by qi stagnation and blood stasis, obstruction by phlegm-dampness, blockage of the meridian channels, and the inability of menstrual blood to descend, leading to amenorrhea.
(1) Deficiency of the Liver and Kidneys: Congenital insufficiency, where kidney qi is not yet robust and essence qi is not yet abundant; deficiency of liver blood; failure to adequately nourish the Chong and Ren meridians, resulting in an inability to transform essence into menstrual blood; or amenorrhea caused by multiple childbirths, excessive sexual activity, abortions, or chronic illness that depletes essence and blood, leading to an insufficient Blood Sea.
(2) Spleen Deficiency: Weakness of the spleen and stomach; dietary imbalances or excessive physical exertion; excessive worry or overthinking damaging the heart and spleen; severe or chronic illness; or the use of diaphoretic, purgative, or aggressive medications damaging the spleen and stomach—all of which lead to spleen deficiency, an insufficiency in the source of generation and transformation, and an inability of the Blood Sea to be filled, thus resulting in amenorrhea.
(3) Yin Deficiency with Blood Dryness: This is often caused by blood loss damaging yin, blood depletion due to a chronic illness, or excessive consumption of pungent and drying foods that scorch body fluids and blood, leading to dryness,涩ness, and desiccation of the Blood Sea, which results in amenorrhea.
(4) Qi Stagnation and Blood Stasis: This results from internal emotional trauma causing liver qi stagnation and impaired circulation, leading to stagnation of qi and blood; or from exposure to wind, cold, or chill pathogens during menstruation or the postpartum period when the “Blood Chamber” is open, causing the blood to congeal due to cold and form stasis, which obstructs the uterine vessels and leads to amenorrhea.
(5) Phlegm-Dampness Obstruction: Obese individuals often have excessive phlegm and dampness, which obstruct the menstrual channels; or, due to impaired spleen yang function, dampness accumulates to form phlegm, and this phlegm-dampness obstructs the Chong and Ren meridians, causing the uterine meridian to close and menstruation to cease.
Differential Diagnosis and Treatment of Amenorrhea in Traditional Chinese Medicine
(1) Deficiency of the Liver and Kidney: Menarche has not occurred by the age of 18; or menstruation gradually becomes delayed and scant, eventually leading to amenorrhea. Patients present with a weak constitution, soreness in the lower back and weakness in the legs, dizziness, blurred vision, and tinnitus. Married women often experience low libido. The tongue is pale red with a thin coating, and the pulse is deep and fine.
The treatment principle should be to tonify the Kidney, nourish the Liver, and regulate the menstrual cycle. The formula Gui Shen Wan, with appropriate modifications, may be used for treatment.
(2) Spleen Deficiency: Patients present with progressively delayed menstruation, scant flow, pale and thin menstrual blood, eventually leading to amenorrhea. Symptoms may include dizziness, blurred vision, a pale-yellow complexion, mental fatigue, cold limbs, and in severe cases, edema, palpitations, shortness of breath, poor appetite, loose stools, abdominal distension, and a bland taste in the mouth. The tongue appears pale with a thin coating, and the pulse is slow and weak. The treatment principle is to tonify the spleen, nourish the blood, and regulate menstruation. Formulas such as Shenling Baizhu San or Ren Shen Yangying Tang, with appropriate modifications, may be selected for treatment.
(3) Yin Deficiency with Blood Dryness: Patients present with menstruation that gradually ceases after initially being scant, flushing on both sides of the face, heat in the palms and soles, or bone-steaming fever, or coughing up blood. The tongue is red with a sparse coating, and the pulse is fine and rapid. The treatment principle should be to nourish yin, clear heat, and regulate menstruation. The formula Yinyin Jian with modifications may be used for treatment.
(4) Qi Stagnation and Blood Stasis: Patients present with amenorrhea, depressed mood, irritability, dry mouth, distension and fullness in the chest and epigastrium, or distending pain in the flanks, lower abdominal distension or tenderness on palpation, a purple tongue with stasis spots, and a string-like and涩 pulse. The treatment principle is to regulate qi, activate blood circulation, remove blood stasis, and unblock the menstrual channels. The formula Xuefu Zhuyu Decoction with modifications may be used for treatment. For milder cases, modified Dan Zhi Xiao Yao San may be used.
(5) Phlegm-Dampness Obstruction: The patient is obese, with amenorrhea, fullness and oppression in the chest and flanks, nausea, vomiting, and excessive phlegm; fatigue and lethargy; possibly accompanied by facial puffiness and foot edema; or cold pain in the lower abdomen that is relieved by warmth; loose stools; profuse, white vaginal discharge; a greasy tongue coating; and a slippery pulse. The treatment principle should be to eliminate phlegm and dampness, and to invigorate blood circulation to unblock the menstrual channels. The formula Cangfu Daotan Pills combined with Foshou Powder, with appropriate modifications, can yield good results.
IV. Menstrual Headache
When headaches are the primary symptom occurring during menstruation, or before or after menstruation, this is referred to as “menstrual headache.”
Etiology and Pathogenesis of Menstrual Headaches: This condition primarily stems from disorders of qi and blood. It may result from constitutional blood deficiency, leading to insufficient nourishment during menstruation and failure of blood to ascend to nourish the brain; from internal obstruction by blood stasis, causing blockage of the collateral vessels; or from emotional distress causing qi stagnation that transforms into fire—all of which can lead to menstrual headaches.
(1) Blood Deficiency: Due to constitutional weakness, severe or chronic illness, prolonged chronic blood loss, or spleen deficiency resulting in insufficient production of essence and blood, during menstruation, essence and blood flow downward to the Chong and Ren meridians, further depleting yin blood. Consequently, the brain is deprived of nourishment, leading to headaches.
(2) Blood Stasis: This is often caused by emotional distress, which impairs the smooth flow of the liver, hinders the proper dispersion of qi, and obstructs blood circulation. During menstruation, qi and blood descend to the uterus; however, since the Foot Jueyin Liver Meridian runs along the crown of the head and connects to the brain, if blood stasis blocks the internal channels and impedes the flow of meridians, pain results.
(3) Liver Fire: This is often caused by emotional trauma, pent-up anger, and qi stagnation transforming into fire. During menstruation, the Chong Qi becomes excessively vigorous, and qi and fire easily rise against the flow of the Chong Qi, causing pain.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Menstrual Headaches: Menstrual headaches are categorized as either “excess” or “deficiency” types. Clinically, the timing and nature of the pain are used to distinguish between these two patterns. In cases of “excess,” headaches typically occur before or during menstruation and are often characterized by a distending or stabbing pain; in cases of “deficiency,” headaches usually occur after menstruation or as menstruation is nearing its end, accompanied by dizziness and headache. A detailed analysis is provided below:
(1) Blood Deficiency: The main symptoms include dizziness and headache during or after menstruation, palpitations, insomnia, mental fatigue, and physical weakness; the tongue is pale with a thin coating, and the pulse is weak and fine. The treatment principle is to nourish the blood and tonify qi, using Ba Zhen Tang with appropriate modifications.
(2) Blood Stasis: The main symptoms include headaches before or during menstruation, dark purple menstrual blood with clots, accompanied by lower abdominal pain that worsens with pressure; a dark tongue or a tongue with stasis spots on the tip or edges; and a fine and涩 or string-like and涩 pulse. The treatment principle is to regulate qi, activate blood circulation, resolve stasis, and unblock the meridians. The formula Tongqiao Huoxue Decoction with appropriate modifications may be used.
(3) Liver Fire: The main symptoms include headaches during menstruation, or even a pulling pain at the crown of the head, dizziness and vertigo, irritability and short temper, a bitter taste in the mouth and dry throat, a red tongue with a thin yellow coating, and a string-like, fine, and rapid pulse. The treatment principle should be to nourish yin, clear heat, soothe the liver, and subdue wind. The formula Qi Ju Di Huang Wan with appropriate modifications may be used for treatment.
V. Menstrual Body Pain
When physical pain is the primary symptom occurring before, during, or after menstruation, it is referred to as “menstrual body pain.”
Etiology and Pathogenesis of Menstrual Body Pain: This condition is primarily caused by a constitutional deficiency of Zheng Qi, an imbalance between the Ying and Wei Qi, and inadequate nourishment of the tendons and vessels; or it may result from pre-existing stagnation of cold and dampness, which takes advantage of a state of vulnerability during menstruation to trigger the symptoms.
(1) Blood Deficiency: Due to constitutional blood deficiency, or following a serious or prolonged illness resulting in deficiency of both qi and blood, during menstruation, yin blood descends into the uterus, and qi is discharged along with the blood. This further exacerbates the deficiency of qi and blood, leading to inadequate nourishment of the tendons and vessels and resulting in body pain.
(2) Blood Stasis: Caused by cold and dampness stagnating in the meridians and joints, which causes the blood to congeal due to cold and dampness. During menstruation, when qi and blood flow down the Chong and Ren meridians, cold causes blood stasis and impedes circulation, resulting in menstrual pain.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Menstrual Pain
(1) Blood Deficiency: The main symptoms include pain and numbness in the limbs during menstruation, accompanied by weakness and fatigue in the limbs; the pain gradually subsides after menstruation ends. This differs from bi syndrome, which does not occur in conjunction with the menstrual cycle. Menstrual flow is scant, pale in color, and thin in consistency; the tongue is pale red with a white coating, and the pulse is fine and weak. Treatment should focus on nourishing blood, tonifying qi, and alleviating pain. The formula Danggui Bu Xue Tang, with appropriate modifications, may be used for treatment.
(2) Blood Stasis: This condition primarily manifests as pain in the lower back and knee joints during menstruation, which is alleviated by heat and exacerbated by cold. Menstrual flow is scant, dark in color, and may contain clots. This occurs because cold pathogens obstruct the meridians, impeding the smooth flow of qi and blood, leading to pain in the lower back and knee joints. Blood flows when warmed but stagnates when exposed to cold; thus, pain is relieved by heat, and the menstrual flow is scant, dark, and clotted due to blood coagulation caused by cold. The tongue coating is thin and white, and the pulse is deep and tight. The treatment principle should be to nourish the blood, dispel wind, disperse cold, and relieve pain. The formula “Chentong San” with appropriate modifications may be used for treatment.
VI. Menstrual Edema
Edema appearing in the head, face, and limbs before, during, or immediately after menstruation is referred to as menstrual edema, or “generalized edema during menstruation.”
Etiology and Pathogenesis of Menstrual Edema: This condition is often caused by deficiency of Spleen and Kidney Yang, leading to impaired Qi transformation; combined with Liver Qi stagnation and impaired blood circulation, the stagnation results in distension.
(1) Spleen-Kidney Yang Deficiency: Excessive worry, overthinking, and fatigue damage the spleen and kidneys. As menstruation approaches, essence and blood are directed to the uterus, further depleting the spleen and kidneys. Yang qi fails to circulate, causing dampness and fluid to accumulate and overflow into the skin and muscles, resulting in generalized edema, particularly severe in the head, face, and limbs.
(2) Qi Stagnation and Blood Stasis: Emotional disturbances (the “Seven Emotions”) cause the liver to lose its ability to regulate and disperse, leading to impaired qi circulation and obstructed blood flow. When qi stagnates and blood flow is impaired, stagnation leads to swelling, which is particularly evident in the skin and muscles.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Menstrual Edema
(1) Spleen-Kidney Yang Deficiency: Patients present with facial and limb edema during menstruation, which gradually subsides after menstruation ends. Symptoms include abdominal distension, reduced appetite, soreness and weakness in the lower back and knees, loose stools, heavy menstrual flow that is pale red and thin in consistency, a pale tongue with a white, greasy coating, and a deep, slow pulse. The treatment principle should focus on warming the Kidneys, strengthening the Spleen, and promoting diuresis. The modified Ling Gui Zhu Gan Decoction is prescribed for this condition.
(2) Qi Stagnation and Blood Stasis: Patients present with swelling of the limbs during menstruation, epigastric fullness, distension of the flanks, and a tendency to sigh. The tongue coating is thin and white, and the pulse is string-like and fine. The treatment principle should focus on regulating Qi and activating blood circulation. The modified Ba Wu Decoction is prescribed for this condition and yields good results.
VII. Menstrual Dizziness
Dizziness occurring before, during, or after menstruation—characterized by dizziness, blurred vision, or visual haze, and recurring cyclically with the menstrual cycle—is referred to as “menstrual dizziness.”
Pathogenesis of Menstrual Dizziness: This condition is classified into deficiency-type and excess-type causes. Deficiency-type cases are primarily due to blood deficiency or yin deficiency; excess-type cases are primarily caused by internal obstruction of phlegm-dampness, which prevents the rise of clear yang.
(1) Blood Deficiency: Due to a constitutional blood deficiency or an insufficiency in the source of essence transformation, blood becomes even more deficient during menstruation. As blood cannot ascend to nourish the head and eyes, dizziness and blurred vision result.
(2) Yin Deficiency with Excessive Yang: Resulting from a constitutional yin deficiency, prolonged illness, a history of febrile diseases, or excessive physical or sexual exertion—all of which repeatedly deplete yin essence—yin blood becomes increasingly deficient during menstruation. Yin deficiency fails to restrain yang, thereby triggering this condition.
(3) Spleen Deficiency with Phlegm: Due to constitutional spleen deficiency, impaired transport and transformation functions, and the accumulation of dampness that forms phlegm. During menstruation, qi and blood descend, further depleting qi; clear yang fails to rise, and phlegm-dampness disturbs the clear orifices.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Menstrual Dizziness
(1) Blood Deficiency: Patients with blood deficiency primarily experience dizziness and vertigo during or after menstruation because the blood is insufficient to nourish the upper body. Insufficient blood supply results in scanty menstrual flow that is red in color and thin in consistency. Since blood deficiency fails to nourish the face, the complexion appears sallow or pale and lackluster; when blood deficiency fails to nourish the heart, palpitations and insomnia may occur. The tongue is pale with a thin white coating, and the pulse is fine and weak. The treatment principle should focus on nourishing the heart and strengthening the spleen. The formula Gui Pi Tang with appropriate modifications may be used.
(2) Yin Deficiency with Excessive Yang: This condition arises from yin deficiency and excessive yang, where wind-heat disturbs the clear orifices, leading to dizziness and vertigo during menstruation. Yin deficiency generates internal heat; when heat becomes excessive, it forces the blood to flow erratically, resulting in heavy menstrual flow with a bright red color. Since yin deficiency fails to restrain the liver, patients experience restlessness and irritability; and because yin deficiency prevents body fluids from ascending to nourish the upper burner, dryness of the mouth and throat occurs. The tongue is red with a yellow coating, and the pulse is string-like, fine, and rapid. The treatment principle should be to nourish yin and subdue yang. The formula Tianma Gou Teng Decoction with modifications may be used, adjusted according to the patient’s specific condition and the clinician’s experience.
(3) Spleen Deficiency with Phlegm: Patients with this condition experience dizziness and a heavy sensation in the head, chest tightness, and nausea before and after menstruation, along with poor appetite and excessive sleepiness. This is caused by phlegm-dampness obstructing the middle jiao, impeding the flow of qi, and weakening spleen yang. The tongue coating is white and greasy, and the pulse is soft and slippery. The treatment principle should be to strengthen the spleen, warm yang, transform dampness, and eliminate phlegm. The formula Banxia Baizhu Tianma Decoction with modifications may be used; however, the formula must be tailored to the patient’s specific condition and the clinician’s experience to achieve optimal therapeutic results.