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.
Menstrual disorders are the most common gynecological conditions. Their etiology and pathogenesis primarily stem from damage caused by the “Seven Emotions”—joy, anger, worry, overthinking, sadness, fear, and shock—or from external invasion by the “Six Excesses”—wind, cold, heat, dampness, dryness, and fire. Other causes include congenital deficiency of kidney qi, frequent childbirth and postpartum exhaustion, excessive fatigue—all of which damage the vital energy of the zang organs, disrupt the functions of the kidney, liver, and spleen, and cause imbalances in qi and blood. This leads to damage to the Chong and Ren meridians; conditions such as deficiency, excess, cold, and heat can also result in menstrual disorders.
The treatment principle for menstrual disorders emphasizes regulating the menstrual cycle. Specific methods for regulating the menstrual cycle include regulating blood, tonifying the kidneys, strengthening the spleen, and soothing the liver. When regulating qi and blood, one must first clearly distinguish whether the pathology lies in qi or blood. If the disorder lies in qi, treatment should focus primarily on regulating qi, supplemented by nourishing and invigorating the blood; if the disorder lies in the blood, treatment should focus primarily on regulating the blood, supplemented by tonifying and promoting the flow of qi. Tonifying the kidneys primarily involves replenishing essence and blood, supplemented by herbs that assist yang—in accordance with the principle that “to nourish water, one must first nourish heaven”—so that yin and yang in the kidneys are balanced, essence and blood are both vigorous, and menstruation will naturally regulate itself. Nourishing the spleen focuses on strengthening the source of blood, with an emphasis on fortifying the spleen and raising yang; regulating the liver focuses on smoothing liver qi to facilitate its dispersing and draining functions. Furthermore, when regulating menstruation, one must distinguish between primary and secondary conditions: if menstrual irregularities result from another underlying illness, that illness should be treated first. At the same time, one must adhere to the principle of “treating the symptoms in urgent cases and the root cause in non-urgent cases.” Only by comprehensively considering the situation and applying treatment flexibly based on the physician’s clinical experience can effective results be achieved. The following is a discussion of common menstrual disorders.
I. Premature Menstruation
A menstrual cycle that occurs more than 7 days earlier than expected—or even as early as 10 or more days ahead—is termed “premature menstruation,” also known as “advanced menstrual period,” “early menstruation,” or “early period.” If the period arrives 3–5 days early without other obvious symptoms, it falls within the normal range; similarly, an occasional early occurrence should not be classified as premature menstruation.
Causes and Manifestations of Premature Menstruation: The primary etiology and pathogenesis of this condition are qi deficiency and blood heat. Since qi is responsible for containing and regulating blood, qi deficiency leads to an inability to control and contain it, causing the Chong and Ren meridians to lose their stability; blood heat circulates and overflows, resulting in unrest in the Blood Sea and causing menstruation to arrive prematurely.
(1) Qi Deficiency: Irregular diet, excessive physical exertion, or excessive mental worry can damage spleen qi. Consequently, central qi becomes deficient, losing its ability to contain and regulate; the Chong and Ren meridians become unstable; and menstrual blood loses its control, resulting in early menstruation. Symptoms include an earlier-than-usual menstrual cycle, increased menstrual flow that is pale in color and thin in consistency, fatigue and weakness in the limbs, a sensation of emptiness or heaviness in the lower abdomen, poor appetite, loose stools, a pale tongue, and a fine, weak pulse.
(2) Blood Heat: This can be further divided into Excess Heat and Deficient Heat.
① Excess Heat: Common types include Yang-Excess Blood Heat and Liver-Qi Stagnation with Blood Heat.
Excess Yang with Blood Heat: In individuals with a constitutional excess of Yang or those who have overconsumed pungent and drying foods that stimulate Yang, heat becomes latent in the Chong and Ren meridians, forcing the blood downward and resulting in early menstruation. Symptoms include early onset of menstruation, heavy flow, dark red or purple color, thick and sticky consistency, and may be accompanied by restlessness in the heart and chest, flushed face, dry mouth, scanty and yellow urine, dry and hard stools, a red tongue with a yellow coating, and a rapid pulse.
Liver Qi Stagnation with Blood Heat: Suppressed anger injures the liver, causing the Wood and Fire elements to act erratically and disturb the Blood Sea below, forcing the blood downward and resulting in early menstruation. Symptoms include early onset of menstruation; flow may be heavy or light, with a purplish-red color and clots; may be accompanied by lower abdominal distension and pain, chest tightness and rib-side distension, breast distension and pain, restlessness and irritability, a bitter taste in the mouth and dry throat; a red tongue with a thin yellow coating; and a string-like, rapid pulse.
② Deficiency-Heat: Constitutional yin deficiency, yin depletion due to chronic illness, or yin injury from blood loss can lead to water deficiency and fire excess. This heat disturbs the Chong and Ren meridians, causing unrest in the Blood Sea and resulting in the premature descent of menstrual blood, thus leading to early menstruation. Manifestations include early onset of menstruation, with flow that may be scant or heavy, red in color, and thick in consistency; may be accompanied by flushed cheeks and heat in the palms and soles; red tongue, sparse coating, and a fine, rapid pulse.
Treatment for Premature Menstruation
(1) Qi Deficiency: For cases of premature menstruation caused by qi deficiency, treatment should focus on tonifying qi, retaining blood, and regulating the menstrual cycle. The formula Bu Zhong Yi Qi Tang with appropriate modifications is used.
(2) Blood Heat
① Excess Heat
Excess Yang and Blood Heat: For cases of early menstruation caused by excess Yang and real heat, treatment should focus on clearing heat, cooling the blood, and regulating the menstrual cycle. The formula Bu Zhong Yi Qi Tang with appropriate modifications is used.
Liver Qi Stagnation with Blood Heat: For cases of early menstruation caused by liver qi stagnation and blood heat, treatment should focus on clearing the liver, resolving stagnation, and regulating the menstrual cycle. The formula Dan Zhi Xiao Yao San with appropriate modifications is used.
② Deficiency Heat: For menstrual periods that occur earlier than expected due to deficiency heat, treatment should focus on nourishing yin, clearing heat, and regulating the menstrual cycle. The formula Liangdi Decoction with appropriate modifications can yield good results.
II. Delayed Menstruation
A menstrual cycle delayed by 7 days or more, or even occurring only once every 40 to 50 days, is referred to as “delayed menstruation.” It is also known as “late menstrual flow,” “delayed menstrual period,” or “menstrual delay.” If the delay is only three to five days and there are no other discomforts, it is not considered a pathological condition of delayed menstruation. If a delay occurs only once and the next menstrual period arrives on schedule, or if menstruation is delayed within a few months after menarche during adolescence or during menopause without accompanying symptoms, it is generally not considered a pathological sign.
Etiology and Pathogenesis of Delayed Menstruation
(1) Cold in the Blood: During menstruation, consuming raw or cold foods, being exposed to rain, or wading through water may lead to exposure to cold pathogens. Alternatively, exposure to cold during childbirth or the postpartum period may cause cold pathogens to invade the uterus. Cold constricts the blood, causing it to congeal; this obstructs the flow of qi and blood, preventing the Blood Sea from filling and overflowing as scheduled. If the body is weak, yang deficiency can generate internal cold; this cold causes blood to congeal, resulting in delayed menstruation.
(2) Qi Stagnation: Chronic worry, overthinking, or depression impedes the smooth flow of qi. Blood becomes stagnant due to qi stagnation, leading to impaired blood circulation and blockages in the Chong and Ren meridians, resulting in delayed menstruation.
(3) Blood Deficiency: Constitutional weakness, severe or chronic illness leading to internal depletion of body fluids and blood, excessive lactation causing prolonged chronic blood loss, or poor diet, overwork, and excessive worry damaging the spleen—all of which deplete the source of blood generation. This results in blood deficiency in the Chong and Ren meridians, causing delayed menstruation.
(4) Deficiency-Cold: Prolonged illness damages yang, leading to both yang and yin deficiency. The zang-fu organs are deprived of proper warmth and nourishment, which impairs the generation and circulation of blood. Consequently, the Blood Sea cannot fill and overflow on schedule, resulting in delayed menstruation.
Differential Diagnosis and Treatment of Delayed Menstruation
(1) Cold in the Blood: Delayed menstruation with scant flow; dark red menstrual blood containing clots; cold pain in the lower abdomen relieved by warmth; a pale, sallow complexion; aversion to cold and cold extremities. White tongue coating; deep and tight pulse. Treatment should focus on warming the meridians, dispelling cold, and regulating the menstrual cycle. The formula “Warming the Meridians Decoction” (温经汤) with appropriate modifications may be used.
(2) Qi Stagnation: Delayed menstruation, scant menstrual flow that is dark red in color, possibly with small clots; distension in the lower abdomen; depressed mood; breast distension and pain; chest fullness and discomfort; dark red tongue with a thin yellow coating; and a string-like and涩 pulse. Treatment should focus on promoting the flow of qi and dispelling stagnation, or regulating qi to normalize menstruation. Formulas such as the Delayed Menstruation Decoction with modifications or the Wuyao Decoction with modifications may be used.
(3) Blood Deficiency: The patient experiences delayed menstruation, scant menstrual flow that is pale red in color with no clots, a sensation of emptiness or pain in the lower abdomen, dizziness, blurred vision, palpitations, and insomnia. The complexion is pale or sallow; the tongue is pale red with no coating; and the pulse is fine and weak. Treatment should focus on tonifying qi and nourishing blood or tonifying blood and regulating menstruation. The formula may be Ren Shen Yang Ying Decoction with modifications or Da Bu Yuan Decoction with modifications.
(4) Deficiency-Cold: The patient’s menstrual period is delayed, with scant menstrual flow that is pale red in color and thin in consistency, without clots. There is a dull ache in the lower abdomen that is relieved by warmth and pressure, accompanied by dizziness, shortness of breath, lower back soreness, and weakness. The complexion is pale, with clear and copious urine and loose stools. The tongue is pale with a thin white coating, and the pulse is deep, slow, and weak. Treatment should focus on supporting yang, dispelling cold, and regulating the menstrual cycle. The formula should be Ai Fu Nuan Gong Wan or Da Ying Decoction with appropriate modifications.
III. Irregular Menstrual Cycle
A menstrual cycle that is more than 7 days earlier or later than usual is referred to as an “irregular menstrual cycle,” also known as “menstrual irregularity” or “menstrual disorder.”
Etiology and Pathogenesis of Irregular Menstrual Cycle
(1) Liver Qi Stagnation: The liver stores blood, thrives on smooth flow, and governs the free flow of qi. If emotional depression or anger injures the Liver, causing dysfunction in its dispersing and draining functions, leading to disharmony of Qi and blood and agitation of the Blood Sea, this results in an irregular menstrual cycle.
(2) Kidney Deficiency: A constitutional deficiency of Kidney Qi, or damage to Kidney Qi due to prolonged illness and lack of proper nourishment, or due to multiple childbirths and postpartum exhaustion, leads to a deficiency of Kidney Qi. This disrupts the functions of storage and discharge, causes disharmony in the Chong and Ren meridians, and results in abnormal accumulation and overflow of the Blood Sea, thereby causing menstrual cycle irregularities.
Traditional Chinese Medicine Differential Diagnosis and Treatment
(1) Liver Qi Stagnation: The patient has an irregular menstrual cycle, with menstrual flow that varies in volume, a purplish-red color, and the presence of blood clots. Menstrual flow is obstructed, accompanied by breast distension, distending pain in the chest, flanks, and lower abdomen, and a depressed and unhappy mood. The tongue coating is normal, and the pulse is string-like. Treatment should focus on regulating the liver, harmonizing qi, and regulating the menstrual cycle, using modified Xiaoyao San.
(2) Kidney Deficiency: Menstrual periods occur at irregular intervals; menstrual flow is scant, pale in color, and thin in consistency. There may be unbearable aching pain in the lumbar and sacral regions, a sensation of emptiness and heaviness in the lower abdomen, and frequent urination at night; or a sallow complexion, dizziness, tinnitus, a pale tongue with a thin coating, and a deep, weak pulse. Treatment should focus on tonifying the kidneys and regulating the menstrual cycle, using the Gu Yin Decoction or Ding Jing Decoction with appropriate modifications.
IV. Menorrhagia
When the menstrual cycle is normal or essentially normal, but menstrual flow is significantly heavier than usual and accompanied by symptoms of anemia resulting from excessive blood loss, the condition is termed “menorrhagia,” also known as “excessive menstrual flow.”
Etiology and Pathogenesis of Menorrhagia: The primary causes and mechanisms of this condition are qi deficiency leading to an inability to contain and regulate the blood, or blood heat causing the blood to flow and spill, resulting in instability of the Chong and Ren meridians and the leakage of blood during menstruation. In addition, internal obstruction by blood stasis can also lead to excessive menstrual flow.
(1) Qi Deficiency: Due to a constitutionally weak constitution, or factors such as poor diet, overwork, prolonged illness damaging the spleen, or excessive worry damaging the heart and spleen, the central qi becomes deficient and loses its ability to contain and retain blood, resulting in instability of the Chong and Ren meridians. During menstruation, qi is expelled along with the blood, further exacerbating the deficiency; thus, the body is unable to retain blood or stabilize the Chong meridian, leading to excessive menstrual flow.
(2) Blood Heat: This results from a constitutional excess of yang and internal heat. Heat causes the blood to overflow, lose its containment, and flow erratically; or from extreme emotional disturbances that transform into fire; or from excessive consumption of pungent, spicy, and drying foods; or from an external invasion of heat pathogens, causing latent heat in the blood to disturb the Sea of Blood, thereby increasing menstrual flow.
(3) Blood Stasis: Due to long-standing blood stagnation or the retention of stagnant blood following a miscarriage, induced abortion, or abortion, which accumulates in the Chong and Ren meridians. If the stagnant blood is not eliminated, fresh blood cannot return to its proper channels, resulting in heavy menstrual flow.
Differential Diagnosis and Treatment of Menorrhagia in Traditional Chinese Medicine
(1) Qi Deficiency: Patients with qi deficiency primarily present with heavy menstrual flow that is pale red in color and thin and clear in consistency. They may also exhibit a pale complexion, shortness of breath, reluctance to speak, limp and weak limbs, aversion to cold, a sensation of emptiness and heaviness in the lower abdomen, and palpitations. The tongue is pale red or pale and swollen, with a thin, white, and moist coating; the pulse is fine and weak or slow and weak. The treatment principle is to tonify qi, consolidate blood, and stabilize the Chong Meridian. The formula used is Ju Yuan Decoction with modifications.
(2) Blood Heat: Patients with blood heat primarily present with heavy menstrual flow that is bright red or dark red in color and thick and sticky in consistency, possibly containing small blood clots. This is often accompanied by distending pain in the lower back and abdomen, restlessness and thirst, a flushed face and dry lips, scanty and reddish urine, and dry, hard stools. The tongue is red with a yellow coating, and the pulse is slippery, rapid, and forceful. The treatment principle should be to clear heat, cool the blood, and stop bleeding. The formula Bao Yin Tang with appropriate modifications is used for treatment.
(3) Blood Stasis: Patients with blood stasis primarily present with increased menstrual flow or prolonged bleeding that is difficult to stop, with a purplish-black color accompanied by blood clots. This may be accompanied by aching pain in the lower back and abdomen, tenderness in the lower abdomen, stasis spots on the tongue, or a dark purple tongue, with a fine and涩 pulse. The treatment principle should be to invigorate blood circulation, resolve blood stasis, and stop bleeding. The formula Shi Xiao San, with appropriate modifications, may be used for treatment. Based on the author’s experience, pattern differentiation and treatment are particularly important; pattern differentiation must be integrated with the patient’s overall condition to achieve optimal results.
V. Oligomenorrhea
When the menstrual cycle is normal but menstrual flow is reduced, or the duration of menstruation is shortened to less than two days with scant flow, this is referred to as “oligomenorrhea,” also known as “scant and sluggish menstrual flow.”
Etiology and Pathogenesis of Oligomenorrhea: This condition can be classified as either deficiency or excess. Deficiency cases result from an insufficiency of the source of transformation, leading to deficiency of the Blood Sea, or from a decline in essence and blood, causing the Blood Sea to remain unfilled. Excess cases are often due to the internal stagnation of blood stasis or obstruction by phlegm-dampness, which blocks the meridians and impedes the smooth flow of blood.
(1) Blood Deficiency: The patient may have a constitutional blood deficiency, or yin blood deficiency following a serious or chronic illness; alternatively, excessive fatigue from overwork or mental worry may damage the spleen, leading to spleen deficiency that fails to transform and transport food and drink to generate blood. Consequently, the Blood Sea becomes depleted, resulting in scant menstrual flow. Blood is the mother of qi; when blood is deficient, qi is also deficient. Qi deficiency causes a sensation of emptiness and heaviness in the lower abdomen. Blood deficiency fails to nourish the meridians, leading to symptoms such as cold hands and feet, dizziness, and palpitations.
(2) Kidney Deficiency: The patient may have a constitutionally weak constitution, or kidney qi may be insufficient in youth; alternatively, repeated childbirths and the physical strain of labor may have injured the kidneys. This results in insufficient kidney qi, deficiency of essence and blood, and an empty Blood Sea, leading to a reduced menstrual flow.
(3) Blood Stasis: The patient may have been exposed to cold pathogens, causing cold to invade the uterus and causing blood to congeal due to cold; or qi stagnation and blood stasis may obstruct the uterine vessels. Both conditions can impede the smooth flow of blood, resulting in a reduced menstrual flow.
(4) Phlegm-Dampness: Due to an excess of phlegm-dampness or impaired spleen function, dampness accumulates to form phlegm. When phlegm obstructs the meridians, it impedes the smooth flow of blood, leading to a reduced menstrual flow.
TCM Differential Diagnosis and Treatment of Scanty Menstruation: Scanty menstruation should be diagnosed as either a “deficiency” or “excess” pattern based on the color, consistency, and presence or absence of abdominal pain. Generally, pale color, clear consistency, scant flow, and no abdominal distension or pain indicate a deficiency pattern; dark purple color mixed with blood clots and abdominal pain that worsens with pressure indicate blood stasis; and pale red color with a sticky, phlegm-like consistency indicate phlegm-dampness. A sudden decrease in menstrual flow is typically classified as an excess pattern, while a gradual decrease is typically classified as a deficiency pattern. Oligomenorrhea is often accompanied by delayed menstruation; in middle-aged women, it may progress to amenorrhea and should be treated proactively.
(1) Blood Deficiency: Patients with blood deficiency present with scant menstrual flow or spotting that ceases quickly, with pale-colored blood and no clots. When blood deficiency fails to nourish the brain, symptoms such as dizziness and blurred vision may occur; if blood fails to nourish the heart, palpitations and anxiety may occur; if blood fails to nourish the skin and muscles, the complexion may appear sallow and the hands and feet may feel cold; if blood deficiency leads to inadequate nourishment of the uterine vessels, a sensation of emptiness and heaviness in the lower abdomen may result. The tongue is pale red, and the pulse is fine, weak, and lacking in strength. The treatment principle should be to nourish the blood and regulate the menstrual cycle. The formula “Blood-Nourishing Decoction” (Zi Xue Tang), with appropriate modifications, may be selected for treatment.
(2) Kidney Deficiency: Patients with kidney deficiency present with scant menstrual flow that is pale red or dark red in color and thin in consistency. They may experience dizziness, tinnitus, soreness and weakness in the lower back and waist, heel pain, coldness in the lower abdomen, or frequent urination at night. The tongue is pale, and the pulse is weak or deep and slow. The treatment principle should be to tonify the kidneys, nourish the blood, and regulate the menstrual cycle. The formula Gui Shen Wan may be used for treatment.
(3) Blood Stasis: Due to the retention of stagnant blood, obstruction of the menstrual channels, and impaired blood circulation, patients present with scanty menstrual flow containing clots and distending pain in the lower abdomen that is tender to pressure. Abdominal pain may subside after the clots are expelled. The tongue may appear normal or have small ecchymoses, and the pulse may be fine and涩 or string-like and涩. The treatment principle should be to activate blood circulation and regulate menstruation. The formula Taohong Siwu Decoction may be used for treatment.
(4) Phlegm-Dampness: Patients with this condition present with scant menstrual flow; the menstrual blood is red in color and viscous like phlegm; they may be obese and experience chest tightness, nausea, or vomiting, or have excessive, sticky vaginal discharge. The tongue is pale with a white, greasy coating, and the pulse is slippery. The treatment principle should be to resolve phlegm, dry dampness, and regulate menstruation. The formula Cangfu Daotan Pills with appropriate modifications may be used for treatment.
VI. Prolonged Menstrual Period
“Prolonged menstrual period” refers to a situation where the menstrual cycle is essentially normal, but menstruation lasts for more than 7 days, or even continues as spotting for half a month before ceasing. It is also known as “prolonged menstruation,” “unending menstrual flow,” or “continuous menstrual flow.” If bleeding persists throughout the entire month, it is classified as “menorrhagia.”
Etiology and Pathogenesis of Prolonged Menstrual Period: The pathogenesis of this condition involves both deficiency and excess patterns. Deficiency cases are often due to yin deficiency with internal heat, which disturbs the Blood Sea, leading to a prolonged menstrual period; excess cases are often due to blood stasis obstructing the Chong and Ren meridians, preventing fresh blood from returning to the menstrual channels, thus prolonging the menstrual period.
(1) Yin Deficiency with Internal Heat: Due to a constitutional yin deficiency, severe illness depleting yin, or excessive childbirth and postpartum exhaustion, yin and blood become depleted, leading to yin deficiency with internal heat. This heat disturbs the Chong and Ren meridians, causing unrest in the Blood Sea, and preventing menstrual blood from flowing according to its normal course, resulting in a menstrual period lasting 7 days or longer.
(2) Qi Stagnation and Blood Stasis: Qi stagnation and blood stasis, or external pathogenic factors invading the uterus, obstruct the flow of qi and blood, leading to stasis. Stagnant blood obstructs the uterine vessels, preventing fresh blood from returning to the meridians, causing the menstrual flow to persist and not cease.
Traditional Chinese Medicine Differential Diagnosis and Treatment of Prolonged Menstruation
(1) Yin Deficiency with Internal Heat: Patients present with menstruation lasting eight to nine days or more, up to ten or more days, characterized by scant, bright red, and thick menstrual blood, accompanied by a dry throat and mouth, flushed cheeks, hot flashes, or a burning sensation in the palms. The tongue is red with little saliva, the coating is sparse or absent, and the pulse is fine and rapid. Treatment should focus on nourishing Yin, clearing heat, and stopping bleeding. The formula “Liangdi Decoction” combined with “Erzhi-Jiu Decoction,” with appropriate modifications, may be used.
(2) Qi Stagnation and Blood Stasis: Patients present with menstrual bleeding that drips continuously for 8–9 days or more before ceasing, with scant, dark-colored blood containing clots. They may experience lower abdominal pain that worsens with pressure, or lower back soreness and weakness. The tongue is dark purple with stasis spots, and the pulse is string-like and涩 (thready and涩). The treatment principle should be to invigorate blood circulation, remove blood stasis, and stop bleeding. The formula Taohong Siwu Decoction combined with Shixiao Powder, with appropriate modifications, is used for treatment. Adjustments based on the patient’s condition and the clinician’s experience can yield good results.