By Jake Paul Fratkin, OMD, L.Ac.
Discussion has been given to pre-menstrual syndromes, according to traditional Chinese medicine, but the postmenstrual syndromes are equally important, and are often overlooked. Understanding the postmenstrual syndromes in fact clarifies the various differentiations applicable to premenstrual syndromes. It is necessary to evaluate the pulse both before and after the period. Commonly a wiry pulse exists before the period in PMS patients, but the status of the pulse after the period may vary from excessive to deficient. Before an accurate assessment of the patient can be made, the pulses should be taken at both times of the cycle.
Premenstrual syndrome is usually a variation on a common foundation. This foundation is, of course, stagnation of Liver Qi. It is the stagnation of Qi in the Liver, and Liver channel, that account for the four predominant premenstrual symptoms:
- Irritability. When the Liver fails to smooth the Qi, the body becomes physically tense; this in turn leads to emotional tension. Anger that has been internalized, often an originating cause of Liver stagnation, may express itself at this time, or manifest as depression, which I feel is internalized anger
- Breast distension. This is due to stagnation of Liver Qi, since the Liver channel affects the breast
- Headache. Stagnation affects the Liver channel in its internal routing into the head and behind the eyes, and through its partner channel, the Gallbladder
- Abdominal water retention. In this symptom stagnation affects the Liver channel as it connects to Ren 3 and 4; coexisting Kidney deficiency contributes to the water retention
The premenstrual symptoms may appear one day before the period, indicating a mild case, and up to 14 days prior to the period, indicating a severe case. Patients may exhibit any one, or any combination, of the four dominant symptoms.
PREMENSTRUAL PRESENTATIONS
- Liver Qi stagnation. Liver Qi stagnation is common to all premenstrual types. However, the degree of stagnation may vary with each person, and it certainly may vary during the course of the whole cycle. Prior to the onset of the period in a woman affected with PMS, we expect to see a wiry pulse. This may exhibit in both left and right pulses, just the left, or just the Liver position. The strength of the pulse will indicate the degree of excess, or the degree of stagnation. This is a relative value, of course, measured against the strength of the whole pulse. But in the main, we expect the Liver pulse to be wiry and excessive. The Gallbladder pulse may be more wiry and excessive than the Liver position: this indicates rising Liver Yang affecting the head, usually as headache or migraine, or an accompanying deficiency of Liver Blood or Yin. It is important to differentiate at this point the status of Liver Yin and of Liver Blood. This is often overlooked by practitioners, who are content with treating stagnated Liver Qi only. Better results, and less reactions to herbal products and prescriptions, can he had by further delineating the differentiations.
- Liver Qi stagnation, with deficiency of Liver Yin. The pulse is wiry, but more thin, and slightly weaker than Liver Qi stagnation when it exists alone. The tongue may appear normal, perhaps with more red on the sides, which is characteristic of most Liver Qi stagnation types due to stagnant heat in the Liver. It should he noted that the tongue is not pale. A key symptom is dry eyes, or eyes that itch, which is exacerbated during premenstrual time. Other signs may include blurry vision, ringing in the ear(s), and dry throat. In this type, it is helpful to nourish the Yin while smoothing the Liver. Postmenstrually, this type usually manifests as Liver Yin deficiency standing alone.
- Liver Qi stagnation, with deficiency of Liver Blood. The pulse is very similar to the previous type described, in that there is a wiry, thin pulse. In fact, the two pulses cannot he easily distinguished. It is necessary to look at other signs and symptoms to make the differentiation. The tongue will he characteristically pale. This paleness may he slight, or extreme. It is my experience that many students and inexperienced practitioners have difficulty distinguishing a pale tongue, especially when the tongue is only slightly pale. This is a skill acquired only by seeing many patients. Often the paleness can he seen on the sides of the tongue, however it should be noted that with premenstrual Liver Qi stagnation, the sides of the tongue can he reddish, or purple, masking the paleness. Other Blood deficient signs are dry skin, spots in the field of vision, dry hair, scanty menses, or a long time between periods. Postmenstrually, this type usually manifests as Liver Blood deficiency, alone.
- Liver Qi stagnation with heat. The pulse is again wiry, but slightly rapid. If the pulse seems particularly thin, evaluate for accompanying Yin deficiency or Blood deficiency. The tongue will have characteristic red, or dark red, along the sides in the Liver area. Rarely will the entire tongue be red. Other signs might include red eyes, excessive menstrual flow, early menses. This type can also manifest herpes sores, either genitally or orally. Heat presentation prior to the period is the most common type of the PMS differentiations. Xiao Yao San (Bupleurum and Tang Kuei Formula) has been the main formula used for premenstrual syndrome, yet many practitioners discover that their patients react adversely, the most common reaction being aggravation of the symptoms. This is usually due to an advanced degree of congestion in the Liver, combined with the overly strong effect of Bupleurum. If the differentiation is correct, the formula may he too strong a dose for the patient. I recommend reducing the dosage or frequency of dosing. Do not give the prescription throughout the month, instead switch formulas postmenstrually depending on the presenting postmenstrual differentiation.
If there are side effects, more than likely the differentiation was not correct. This formula is incorrect for patients exhibiting strong Liver Yin deficiency, or Liver Yin deficiency with heat. Some sources feel that Bupleurum depletes Yin others feel that in severe Yin deficiency Bupleurum can have too strong an invigorating effect.
In heat signs the classical formula is Dan Zhi Xiao Yao San which adds gardenia and Moutan to Xiao Yao San. The addition of Gardenia and Moutan acts to cool the Liver and Liver Blood. My experience is that this presentation is the most prevalent in premenstrual syndrome, and that this prescription is more appropriate than Xiao Yao San. The precautions regarding Xiao Yao San addressed above still apply to this formula, namely that there is potential for overdosing which can lead to an aggravation of symptoms.
Another Bupleurum formula useful in Liver Qi stagnation is Xiao Chai Hu Tang (Minor Bupleurum Decoction). Like Xiao Yao San, this formula smoothes Liver Qi and tonifies Spleen Qi. Instead of Mentha to cool the Liver, Scutellaria is used. Pinellia and Zingiberis clear the phlegm in the stomach which results from the combining of Liver heat with Spleen dampness. For some patients, especially where Liver Blood deficiency is not an issue, this formula can he very effective for premenstrual tension. An embellished prescription for premenstrual tension which combines Minor Bupleurum with Xiao Yao San is Heavenly Water formulated by Dr. Bob Flaws, who feels that a significant presentation in PMS is stagnation of phlegm accompanying Liver Qi stagnation.
POSTMENSTRUAL PRESENTATIONS
Many practitioners erroneously persist in giving one formula throughout the cycle, usually a premenstrual formula such as Xiao Yao San. However, because the differentiation has probably changed it is better to switch to another formula. It is relatively rare (though not unknown) that Liver Qi stagnation persists after the period. Often the stagnation is not diagnostically obvious: not only are the premenstrual symptoms gone, but the pulse is no longer wiry or excessive. Usually, the pulse is weak after the period. The most common postmenstrual differentiations are the following, in order of frequency:
1. Deficiency of Liver Blood.
Pulse: Thin, or thin in liver position.
Tongue: Pale.
Symptoms: Dry skin or hair, amenorrhea, or scanty or early periods, spots before eyes, cold limbs.
2. Deficiency of Kidney Qi or Jing.
Pulse: Weak in Kidney positions.
Tongue: Occasionally pale.
Symptoms: Weak or sore low back or knees.
3. Deficiency of Kidney Yang.
Pulse: Weak in kidney positions.
Tongue: Occasionally pale.
Symptoms: Cold knees or limbs, sore low back.
4. Deficiency of Qi, Blood, and Yang.
Pulse: Weak and thin.
Tongue: Pale.
Symptoms: Cold knees or limbs, sore low back, fatigue, amenorrhea or scanty periods.
5. Deficiency of Spleen Qi.
Pulse: Weak, especially in Spleen position.
Tongue: Occasionally swollen or damp.
Symptoms: Poor digestion, gas, distension, erratic stools.
6. Deficiency of Kidney Yin.
Pulse: Thin, weak in Kidney position.
Tongue: Occasionally dry, or slightly red.
Symptoms: Dry eyes, heat in feet.
7. Deficiency of Liver Yin.
Pulse: Thin, or thin in Liver position.
Tongue: Occasionally dry, or slightly red on sides and tip.
Symptoms: Dry eyes, blurry vision.
I hope this article helps practitioners to differentiate various presentations that occur during both the pre- and postmenstrual phases of a woman’s cycle. The principle of dispersing the stagnation of Liver Qi is applicable when some or all of the four predominant symptoms of PMS occur: irritability, breast distention, headache, and abdominal water retention. The appropriate time to address these issues is from the time of ovulation to the time of menstruation, i.e., during premenstruation.
From the time menstruation is completed, to the time ovulation occurs is postmenstruation. During this time deficiencies are most likely to be manifested. At this time tonifying Blood, Jing, Qi Yin, and Yang is most often appropriate. With careful attention to both phases of the cycle and proper pulse, tongue, and syndrome differentiation, your treatments will be highly effective and rewarding to your patients.
Jake Fratkin. OMD, L.Ac., is the author of “Chinese Herbal Patent Formulas” and is a popular lecturer in the U.S. and Europe.
PREPARED FORMULAS FOR PRE- AND POSTMENSTRUAL PRESENTATIONS
Premenstrual Liver Qi Stagnation
Women’s Balance addresses the most commonly found PMS syndrome which is Liver Qi stagnation with heat signs. The formula is based on Xiao Yao San with the addition of Moutan and Gardenia. The formula is called Dan Zhi Xiao Yao San and is described in the previous article.
Heavenly Water combines elements of both Xiao Yao San and Xiao Chai Hu Tang to resolve stagnation of phlegm and Liver Qi Stagnation. The formula, designed by Dr. Bob Flaws, replaces
Bupleurum with Gotu Kola to create an effective formula that is less likely to cause irritability.
Ease 2 is based on the formulas Xiao Chai Hu Tang. Pueraria and Cinnamon twig have been added to assist with muscle and shoulder tension.
Nine Flavor Tea may be used in conjunction with the above formulas to address Liver Qi stagnation with deficiency of Liver Yin.
POSTMENSTRUAL PRESENTATIONS
Eight Treasures is composed of two complementary formulas. The Four Substances tonifies the Blood. The Four Gentlemen tonifies Qi. Eight Treasures is one of the most frequently prescribed postmenstrual formulas used to build Blood and address fatigue.
Astra Essence is a formula designed to tonify Kidney Yin, Yang, Qi, and Jing. It omits the warm herbs present in some other formulas, thus it is appropriate and safe for long term use.
Two Immortals addresses deficiency of Kidney Qi and/or Jing during menopause. The formula can also he used for false menopause or when menopause-like symptoms are present. The formula contains both warming and cooling herbs to resolve the complex syndrome seen clinically.
Rehmannia 8 is the classic formula for Kidney Yang deficiency. The formula is available from Health Concerns in a concentrated form. The herb Eucommia is substituted for Aconite, while Cinnamon bark is kept in the formula. This retains the hot qualities of the formula without making it excessively so.
Eight Treasures is also appropriate for deficiency of Qi, Blood, and Yang. It is a warming and tonifying formula for insufficient Qi and Blood. The formula is aimed at resolving postmenstrual fatigue, anemia, reduced appetite, and cold limbs. Milletia is added to increase the formula’s tonifying and circulation promoting properties.
Astra 8 is a warming formula which tonifies Spleen Qi. If assimilation problems are also present, this formula may be combined with Quiet Digestion. If heat signs are present, Astra Isatis may be the more appropriate formula.
Nine Flavor Tea is based on the classic Liu Wei Di Huang Wan formula. By adding other Yin tonifying herbs, Health Concerns has produced a formula that is excellent for both Liver and Kidney Yin Deficiency.