月经病治疗重在调经，调经之法首当调理肝气。李老推崇《医宗金鉴》所云“内因经病多忧愁忿郁伤情”，即言七情过度为月经病之内在因素，其最多见者为忧思、忿怒、郁气所伤。女子性情要强，稍有失望即悲伤痛哭、郁郁寡欢而成肝气不舒的种种证候。肝藏血，主疏泄，主一身之气机，气机以条达为顺，气机郁滞，阻碍血行，则冲任失调，经血疏泄失常，导致月经不调。调肝理气使气机调畅，血行和调，经脉通利，则经病自愈。
2。调和饮食不可或缺
“先天天癸始父母，后天经血水谷生”。胃主受纳，腐熟水谷，脾主运化，“血为水谷之精微，若伤脾胃何以生”，可见饮食对于月经的重要性。如若饮食失当，损伤脾胃，则精微不足，脾失统摄，冲任气血不和，形成种种月经病，故调理和节制饮食为治疗月经病所不可或缺。
月经不调析因 当重全身兼症
月经病，为月经的期、量、色、质及味的异常，或伴随月经周期出现的症状为特征的疾病，亦称“月经不调”。前者为月经病本症，后者为月经病兼症，辨证当重视全身兼症并结合月经症状审因论治。．临证不外虚、实、寒、热四种：寒证者，必喜热恶寒，不喜冷性饮食，四肢厥冷，下腹凉，脉沉迟，常见经迟而来，痛经，色晦，质清澈，臭味轻；热证者，必喜冷恶热，喜热饮，口干舌燥，舌红，苔黄，脉数，常先期而来，色鲜明，味臭，量多；虚证者，神疲乏力，气短懒言，肢倦脉虚，常见闭经，经期吐泻，经色浅淡，量多；实证者，必呈邪气有余之证，当分别气郁、血瘀、痰湿的不同而各异。其辨证特色不同于多数医家。而以月经的量、色、质、味为辨证要点。
痛
经
寒多于热 实多于虚
痛经为妇科常见病，为伴随月经周期而出现的下腹疼痛。李老认为，临证寒多于热，气滞血瘀证多，故多表现为胀痛、冷痛，其痛有轻有重，疼痛剧烈者伴手足厥冷，冷汗淋漓，恶心呕吐，甚或虚脱或昏厥。正如《格致余论》中所云：“将行而痛者，气之滞也，来后作痛者，气血俱虚也。”故当根据疼痛发生的时间、性质辨其寒、热、虚、实属性及在气、在血的不同。痛在经前有实、有寒，痛在经后有虚、有寒；痛如针刺者为热、为血瘀，绞痛为寒，隐痛为虚；持续痛者为血瘀，时痛时止为气滞；喜按为虚，拒按为实；得热痛减为寒，得热痛增为热。并据胀与痛之轻重辨气血并病之因果，胀甚于痛者为气滞阻血之证，痛甚于胀者为血凝碍气之证，反映了气血相互为用的生理机制。然临证不可以一项为凭，应结合月经色、量、全身兼症、舌脉及体质情况加以分析归纳，知常达变，务求于本，意即“此当于形气禀质兼而辨之，当以察意，言不能悉也”。
痛经之治 调气和血
痛经之发病，乃因六淫、七情、饮食起居失调所伤等致病因素乘经期或经行前后气血骤变之时影响冲任胞宫，使得经血流通受碍，不通则痛，或胞脉失于濡养，不荣而痛，皆为气血失于调畅之故。治疗视其寒、热、虚、实及轻重缓急的偏重，在温补攻清总则的指导下，或温经散寒，或清热活血，使血行畅利；或补气养血活血，使气行血行。血凝碍气者，活血为主；气滞阻血者，理气为主。理气药物多用柴胡、乌药、香附、砂仁等，养血活血多用四物汤及失笑散等。痛在经前或经期，为气血凝滞，治宜疏通气血，方用活络效灵丹加元胡、香附，兼寒者，酌加官桂等温性药。经期腹胀甚于腹痛者，为气滞碍血证，治宜理气活血，方用加味乌药汤，药物组成有乌药、砂仁、木香、元胡、香附、槟榔各等份，生姜作引；腹痛甚于腹胀者，以活血为主，方用失笑散或琥珀散，琥珀散药物组成有熟地、赤芍、当归、三棱、莪术、刘寄奴、丹皮、元胡、乌药、官桂、生姜。经前下腹冷痛，为寒邪入侵，经血被阻，治宜祛寒行血，方用桂枝汤或《证治准绳》吴茱萸汤，后者药物有当归、肉桂、吴茱萸、丹皮、半夏、麦冬、防风、细辛、藁本、干姜、茯苓、木香、炙草；经后下腹冷痛者，为血虚兼寒，治宜补血祛寒，方用当归建中汤或金匮温经汤。
附案：
张某，女，36岁。门诊号：19026。
1959年6月12日初诊：患者经前少腹、乳房胀痛，大腿憋困有冷感10余年，经色紫有块，便干，舌苔薄白，脉弦。处方：
乌药7．5克 砂仁4．5克 草蔻4。5克 元胡6克 木香4．5克 香附6克 槟榔7。5克 生蒲黄4。5克 五灵脂4．5克 甘草3克 水煎，经前服。 按：病发于经前属实，为厥阴气滞，络脉不疏，故其经脉所过之少腹、乳房胀痛；气郁遏阳，则肢体有冷感；气滞血行不畅，故见经色紫有块；脉弦为肝郁之候。综观脉症，为气滞血瘀，故治以加味乌药汤理气疏肝开郁，失笑散活血止痛。全方重理气，辅以活血止痛而达气顺血和痛止之功效。
闭
经
闭经八证 少虚多实
审征求因 各施其术
闭经病症当排除妊娠、乳子、歇经、断经等生理现象及石女、暗经等先天畸形。因其病因多样，病机复杂，故临证首辨其寒、热、虚、实，次辨其表、里、气、血及在脏、在腑之不同，据全身兼症及脉症审因论治。李老从脾虚、血枯、热结、寒凝、气滞、血瘀、痰湿、食积八型论治。
脾虚者，由于摄人不足，或劳倦过度，或误服汗下攻伐药，损伤脾胃，化源不足，血海不能满溢，致月经久闭不行，如《兰室秘藏》所谓：“妇人脾胃久虚，或形羸气血俱衰老，而致经水断绝不行。”症见月经数月不潮，神疲肢倦，胸腹胀满，饮食不化，消瘦，大便溏泻，舌淡苔薄，脉细。脾虚又有脾气虚及脾阳虚之异，脾气虚者，健脾益气，方用归脾汤加鹿茸；脾阳虚者，健脾温阳，方用参苓白术散加当归、川芎、附子、肉桂，或八珍汤去白芍、川芎，加黄芪、补骨脂、香附、山药。
血枯者，为血虚之重证，“枯者竭也，血虚极矣”，生化血液的机能障碍，血液匮乏，渐而枯竭，如源断流，则无血可见。症见月经经年累月不至，饮食日减，肌肉渐消，面黄发落，甚且骨蒸潮热，舌淡，脉细。轻者人参养荣汤，重者资生通脉汤，后者药物有炒白术9克，生山药30克，生鸡内金6克，元肉18克，山萸12克，枸杞12克，元参9克，生白芍9克，桃仁3～6克，红花3～4．5克，甘草6克。
热结者，由于心胃积热，蕴于中焦，经血为热所结，血海无血可行。症见经闭，喜冷恶热，口舌干燥，大便秘结，舌红苔黄燥，脉数有力。治宜养血清热调经，当分上、中、下三焦何处结热而用药偏倚。方用玉烛散，即四物汤合调胃承气汤或加黄芩、栀子、连翘、薄荷、竹叶、蜂蜜。
寒凝者，为经产之时血室正开，感风受寒，或伤于生冷，血为寒凝，经血被阻不行。症见月经不至，喜热性饮食，恶寒，小腹冷痛，口不干，脉沉迟或紧。当辨表寒、里寒轻重，分别用吴茱萸汤或琥珀散，以温散攻逐通经。
气滞者，七情郁结，气机失于调畅，经脉阻塞，经血被阻。症见闭经，胸腹胀痛，喜太息，时嗳气，头晕，两目干涩，左脉沉弦。方用逍遥散加香附、泽兰、丹皮、生地、郁金、黑栀、黄芩等疏肝解郁，活血调经。
血瘀者，为经期产后余血未尽，继外感内伤，致宿血停滞，凝结经脉，胞脉被阻，经血不得下行。症见经闭而小腹疼痛拒按，舌紫有瘀，脉沉涩。临证视其体质盛衰用泽兰汤(泽兰、当归、白芍、甘草)合柏子仁丸(柏子仁、牛膝、卷柏各15克，泽兰、续断各60克，熟地75克)或通瘀煎。
痰湿壅阻者，其人必素体阳虚，水湿不化，聚而阻胞，致经闭不行。症见闭经肥胖，恶心痰多，胸脘满闷，舌苔白腻，脉滑。治宜祛痰通经。方用芎归二陈汤。
食滞者，由于积食，饮食不进，不能生化经血。症见月经闭而不行，脐腹胀痛拒按，恶食，嗳腐吞酸，舌胀苔厚，脉滑，右关明显。方用大承气汤荡涤肠胃，排除积食。
因病致闭者 宜治其病
由闭致病者 但调其经
闭经一病与他病并见者，当别病之先后。如陈素庵所论：血分因经闭，血壅不行，流于四肢而形成浮肿，为经病而致他病，不必治肿，但调其经。方用小调经散加红花、丹皮、牛膝，调经活血则肿自消。小调经散原治产后水肿，组成药物有白芍、当归、没药、琥珀、桂心各3克，细辛、麝香各1．5克，共为细末，每服9克，姜汁温酒调服。先浮肿而后经水断绝不行，称之水分。“膀胱者，州都之官，气化出焉”，膀胱气化不行，水饮溢于肌肤，从而影响丫月经的正常来潮，治疗但治其肿。脾升清降浊，为运化水湿之枢纽，故治宜健脾行水，理气利尿。方用茯苓导水汤，药物有茯苓、槟榔、猪苓、砂仁、木香、陈皮、泽泻、白术、木瓜、大腹皮、桑白皮、苏梗各等份。
血滞、血枯均有变证，妇人经闭咳嗽，宜从速治疗，否则病久体衰，感受风邪，虚实夹杂，终成血分痨证。症见经闭，久嗽，骨蒸，潮热， 自汗，盗汗，消瘦食少，脉虚数等，为气、血、阴俱虚之证。宜据其脉证，辨其虚之在气、血、阴之偏重而施补脾益气、滋阴宁嗽、退蒸止汗之侧重不同。李老据其多年临床经验认为，此证阴虚最重，治宜滋阴为主，方用劫劳散，药物组成有白芍、炙芪、人参、五味子、阿胶珠、茯苓、当归、生地、半夏、生姜、大枣，水煎服。
经行身痛
辨表里虚实 治经行身痛
经行身痛，是伴随月经周期而出现的身体疼痛证候，证分表里虚实，由“外亏卫气之荣养”而感邪，适经潮乘虚而作，脉络失和，“内乏荣血之灌溉”，筋脉失养，或因故气血运行失畅，经脉不利，故经行则痛。临床上，李老常以身痛发生时间辨虚实，以是否兼有恶寒发热之症辨表里，并据此进行治疗。
有表证的身痛：痛在经前或经期，恶寒，发热，脉浮。治宜发表解肌，调和营血。表实者麻黄汤，表虚者桂枝汤，体虚者兼用四物汤养血。
无表证的身痛：经前或经期身痛，无恶寒发热，经血色黯有血块，行而不畅，舌淡红或黯，边有瘀点，苔薄白，脉沉或兼弦涩。此为血脉壅滞不通之候。治宜疏通经络。方用羌桂四物汤。
经后身痛：痛在经后，肢软乏力，月经量少色淡，面色淡，舌淡红，苔薄，脉细弱。为血虚筋脉失荣之证。治宜补益血脉。方用黄芪建中汤。
经期便血
经期使血当从虚论治
月经前或行经期间大便下血、经量减少，称为“经期便血”，古谓之“血走肠道”。故亦称“错经”。证分虚热及肝脾肾并虚二证，当从虚论治。
虚热证，即阴虚火盛，责之肠道积热灼伤阴津，经行之际则热迫血走于肠道。症见经期便血，月经量少，血色鲜红，渴喜冷饮，饮而不解，大便燥结，舌红，苔黄，脉虚数。治宜清热凉血，养阴生津。方用《景岳全书》约营煎，药物有生地4．5～15克，白芍7．5～9克，黄芩4．5～6克，地榆6～9克，续断6～9克，槐花4．5～9克，乌梅4．5～6克，黑芥穗3～4．5克，甘草3～4．5克。如大便燥结甚者，去乌梅之收敛，加麻仁7．5～9克，郁李仁4．5～7.5克；热盛者，加栀子4．5～6克，黄连3～4．5克。
肝脾肾三脏并虚者，责之于劳倦过度。症见经前大便下血，月经量少，色淡红，面色苍白，头晕，神疲，小便频数，大便稀薄，舌淡红，脉细无力，尺脉更弱。治宜补肝肾，益气血，止血升陷。方用《傅青主女科》顺经两安汤，药物有人参9克，熟地15克，山萸6克，当归15克，白芍15克。白术15克，巴戟天3克，黑芥穗6克，升麻1．5克，水煎服。
带下病
带下病治疗四法
带下病为妇科常见病、多发病，属子宫阴道疾患，其形成如《医宗金鉴》所云：“带下劳伤冲与任，邪人胞中五色分，青肝黄脾白主肺，虾血黑肾赤属心。”可见带下病与冲任带脉劳伤、胞宫感受风寒湿热邪气及脏腑气血偏盛偏衰相关，内因为脏腑气血失调，外因为感邪，不内外因则属醉饱房劳、膏粱厚味或服燥性药太过，阴血虚亏，阳气下陷。故审因论治或调理脏腑气血，或祛邪，或调理冲任，必要时收敛固涩并化瘀通滞。
1．调理脏腑气血 包括补气健脾、补肾、调肝。 白带属气虚，补气健脾乃治法之大纲。仲淳云：“崩中日久为白带，漏下多时肾水枯。”带下日久不愈，量多，兼见肾虚证者，必补肾以利气化。肝属木，脾属土，肝郁则脾土受伤，湿气失于运化则带证转甚，故凡带证兼见肝气郁滞者，须兼理肝气。 2．除湿调寒热 夫带下俱是湿证，带证系湿证中的主要疾病之一，故除湿为带下病主要治法。除湿有利水渗湿，健脾燥湿，温阳化湿，兼热者清热，兼寒者祛寒。分别寒、湿、热之轻重多少，治疗时也有所偏重。 3．理冲任之气 凡带证多系脾湿，初病无热，但补脾土，兼理冲任气血，其病自愈。胞络者系于肾，若湿久生热，必得清肾火而湿始有去路，如易黄汤中黄柏、车前子是也。
4．升提固涩，化瘀通滞
凡带证服滲利药太多，湿热虽解而气往下陷而不愈者，必当佐以升阳之品方效，如葛根、白芷、升麻、柴胡之类。
带证曰久不愈，排泄量多且有滑脱不禁现象者，宜于健脾、补肾之时予以收敛固涩，如芡实、白果、龙牡、赤石脂等。
The treatment of menstrual disorders focuses on regulating menstruation, and the primary method for regulating menstruation is to regulate Liver Qi. Elder Li advocates the view from *Yi Zong Jin Jian* (Golden Mirror of Medicine): "Internal causes of menstrual diseases often involve emotional distress such as sorrow, anger, and depression," indicating that excessive seven emotions are internal factors for menstrual disorders, with worry, anger, and stagnation being the most common. Women tend to have strong personalities; slight disappointment can lead to weeping, depression, and various syndromes of stagnant Liver Qi. The Liver stores blood and governs free flow (Shu Xie), controlling the Qi mechanism of the whole body. Qi mechanism should be smooth and unobstructed; if Qi stagnates, it hinders blood circulation, leading to disharmony of the Chong and Ren meridians, abnormal discharge of menstrual blood, and resulting in irregular menstruation. By regulating the Liver and moving Qi to ensure smooth Qi movement, harmonious blood circulation, and patent meridians, menstrual disorders will heal naturally.
2. Harmonizing diet is indispensable.
"The congenital Tian Gui originates from parents, while postnatal menstrual blood is generated from food and fluids." The Stomach governs receiving and rotting/ripening food and fluids, and the Spleen governs transportation and transformation. "Blood is the refined essence of food and fluids; if the Spleen and Stomach are damaged, how can blood be generated?" Thus, diet is crucial for menstruation. Improper diet damages the Spleen and Stomach, leading to insufficient essence, loss of Spleen's control over blood, disharmony of Qi and Blood in the Chong and Ren meridians, and formation of various menstrual disorders. Therefore, regulating and moderating diet is indispensable in treating menstrual disorders.
Analyzing Causes of Irregular Menstruation: Emphasis on Systemic Accompanying Symptoms
Menstrual disorders refer to abnormalities in the timing, volume, color, quality, and taste of menstruation, or diseases characterized by symptoms accompanying the menstrual cycle, also known as "irregular menstruation." The former refers to the primary symptoms of menstrual disorders, while the latter refers to accompanying symptoms. In syndrome differentiation, one must emphasize systemic accompanying symptoms and combine them with menstrual symptoms to analyze causes and treat accordingly. Clinically, there are essentially four types: deficiency, excess, cold, and heat.
In Cold syndromes, patients prefer warmth and dislike cold, avoid cold foods/drinks, have cold extremities, a cold lower abdomen, and a deep, slow pulse. Common manifestations include delayed menstruation, dysmenorrhea, dark/dull color, clear/thin consistency, and mild odor.
In Heat syndromes, patients prefer cold and dislike heat, desire hot drinks (note: text says hot drinks, typically heat prefers cold, but translating literally), dry mouth and tongue, red tongue, yellow coating, and rapid pulse. Common manifestations include early menstruation, bright/red color, foul odor, and heavy volume.
In Deficiency syndromes, patients show mental fatigue, shortness of breath, reluctance to speak, limb weakness, and a deficient pulse. Common manifestations include amenorrhea, vomiting/diarrhea during menstruation, pale/light color, and heavy volume.
In Excess syndromes, there are signs of pathogenic excess, differentiated into Qi stagnation, Blood stasis, and Phlegm-dampness. Its differentiation features differ from many other physicians, focusing on the volume, color, quality, and taste of menstruation as key points.
Dysmenorrhea: More Cold than Heat, More Excess than Deficiency
Dysmenorrhea is a common gynecological disease characterized by lower abdominal pain accompanying the menstrual cycle. Elder Li believes that clinically, cold syndromes are more common than heat, and Qi stagnation with Blood stasis is frequent. Thus, it often presents as distending pain or cold pain, varying in severity. Severe pain may be accompanied by cold extremities, profuse cold sweat, nausea, vomiting, syncope, or fainting. As stated in *Ge Zhi Yu Lun*: "Pain before onset indicates Qi stagnation; pain after onset indicates both Qi and Blood deficiency." Therefore, one should differentiate cold, heat, deficiency, and excess, and determine whether the pathology lies in Qi or Blood based on the timing and nature of the pain. Pain before menstruation indicates excess or cold; pain after menstruation indicates deficiency or cold. Pricking pain indicates heat or Blood stasis; cramping pain indicates cold; dull pain indicates deficiency. Continuous pain indicates Blood stasis; intermittent pain indicates Qi stagnation. Preference for pressure indicates deficiency; aversion to pressure indicates excess. Relief with heat indicates cold; aggravation with heat indicates heat. Furthermore, the relative severity of distension and pain helps distinguish the causal relationship between Qi and Blood pathology: distension exceeding pain indicates Qi stagnation obstructing Blood; pain exceeding distension indicates Blood coagulation hindering Qi, reflecting the physiological mechanism of mutual reliance between Qi and Blood. However, clinical diagnosis cannot rely on a single sign; it must be analyzed comprehensively considering menstrual color, volume, systemic symptoms, tongue/pulse, and constitution, adhering to principles while adapting to changes, seeking the root cause, meaning "one must differentiate based on form, Qi, constitution, and intent, which words cannot fully express."
Treatment of Dysmenorrhea: Regulating Qi and Nourishing Blood
The etiology of dysmenorrhea involves pathogenic factors such as Six Evils, Seven Emotions, and improper diet/lifestyle affecting the Chong and Ren meridians and Uterus during the sudden changes of Qi and Blood around menstruation. This obstructs menstrual flow causing "blockage leads to pain," or fails to nourish the uterine collaterals causing "lack of nourishment leads to pain," both due to dysfunction of Qi and Blood regulation. Treatment depends on the predominance of cold, heat, deficiency, excess, and urgency. Guided by general principles of warming/nourishing and attacking/clearing, methods include warming meridians and dispersing cold, clearing heat and invigorating blood to promote flow, or tonifying Qi and Blood to move Qi and Blood. For Blood stasis hindering Qi, invigorate Blood primarily; for Qi stagnation hindering Blood, regulate Qi primarily. Qi-regulating herbs include Chai Hu, Wu Yao, Xiang Fu, Sha Ren. Blood-nourishing and invigorating formulas include Si Wu Tang and Shi Xiao San.
For pain before or during menstruation due to Qi/Blood stagnation, use Huo Luo Xiao Ling Dan plus Yuan Hu and Xiang Fu; add Guan Gui if cold is present.
If abdominal distension exceeds pain during menstruation (Qi stagnation hindering Blood), use Jia Wei Wu Yao Tang (Wu Yao, Sha Ren, Mu Xiang, Yuan Hu, Xiang Fu, Bing Lang equal parts, Ginger as guide).
If abdominal pain exceeds distension (Blood stasis primary), use Shi Xiao San or Hu Po San. Hu Po San contains Shu Di, Chi Shao, Dang Gui, San Leng, E Zhu, Liu Ji Nu, Dan Pi, Yuan Hu, Wu Yao, Guan Gui, Ginger.
For pre-menstrual lower abdominal cold pain due to Cold invasion blocking blood, use Gui Zhi Tang or Wu Zhu Yu Tang from *Zheng Zhi Zhun Sheng*. The latter contains Dang Gui, Rou Gui, Wu Zhu Yu, Dan Pi, Ban Xia, Mai Dong, Fang Feng, Xi Xin, Gao Ben, Gan Jiang, Fu Ling, Mu Xiang, Zhi Cao.
For post-menstrual lower abdominal cold pain due to Blood deficiency with Cold, use Dang Gui Jian Zhong Tang or Jin Gui Wen Jing Tang.
Case Study:
Patient Zhang, Female, 36. Outpatient No. 19026.
First visit June 12, 1959: Patient had lower abdominal and breast distending pain before menstruation, and a sensation of tightness and cold in the thighs for over 10 years. Menstrual blood was purple with clots, stool was dry, tongue coating thin white, pulse wiry. Prescription:
Wu Yao 7.5g, Sha Ren 4.5g, Cao Kou 4.5g, Yuan Hu 6g, Mu Xiang 4.5g, Xiang Fu 6g, Bing Lang 7.5g, Sheng Pu Huang 4.5g, Wu Ling Zhi 4.5g, Gan Cao 3g. Decoct in water, take before menstruation.
Commentary: Onset before menstruation indicates excess, specifically Jue Yin Qi stagnation and unpatent collaterals, causing pain in the lower abdomen and breasts along the meridian pathway. Qi stagnation suppresses Yang, causing cold sensations in limbs. Qi stagnation hinders blood flow, causing purple clots. Wiry pulse indicates Liver depression. Overall, this is Qi stagnation and Blood stasis. Treatment uses Jia Wei Wu Yao Tang to regulate Qi, soothe Liver, and resolve depression, combined with Shi Xiao San to invigorate Blood and stop pain. The formula emphasizes regulating Qi, assisted by invigorating Blood and stopping pain, achieving smooth Qi, harmonious Blood, and cessation of pain.
Amenorrhea: Eight Syndromes, Less Deficiency More Excess
Analyze Causes, Apply Appropriate Methods
Amenorrhea diagnosis must exclude physiological phenomena like pregnancy, lactation, menopause, and congenital anomalies like stone girls or hidden menstruation. Due to diverse causes and complex pathogenesis, first differentiate cold, heat, deficiency, excess; then exterior/interior, Qi/Blood, Zang/Fu. Treat based on systemic symptoms and pulse/syndrome analysis. Elder Li treats eight patterns: Spleen deficiency, Blood exhaustion, Heat accumulation, Cold coagulation, Qi stagnation, Blood stasis, Phlegm-dampness, Food retention.
Spleen deficiency: Caused by inadequate intake, overwork, or misuse of purgatives/sweats damaging Spleen/Stomach, reducing source of transformation, failing to fill the Sea of Blood. As per *Lan Shi Mi Cang*: "Long-term Spleen/Stomach deficiency in women... leads to cessation of menses." Symptoms: No period for months, fatigue, fullness, poor digestion, emaciation, loose stools, pale tongue, thin coating, fine pulse. For Spleen Qi deficiency, tonify Qi with Gui Pi Tang plus Lu Rong. For Spleen Yang deficiency, warm Yang with Shen Ling Bai Zhu San plus Dang Gui, Chuan Xiong, Fu Zi, Rou Gui, or Ba Zhen Tang minus Bai Shao, Chuan Xiong, plus Huang Qi, Gu Gu Zhi, Xiang Fu, Shan Yao.
Blood exhaustion: Severe Blood deficiency ("exhaustion means depletion"). Obstruction in blood generation leads to scarcity and eventual depletion. Symptoms: Amenorrhea for years, decreased appetite, muscle wasting, sallow complexion, hair loss, bone-steaming tidal fever, pale tongue, fine pulse. Mild cases: Ren Shen Yang Rong Tang. Severe cases: Zi Sheng Tong Mai Tang (Chao Bai Zhu, Sheng Shan Yao, Sheng Ji Nei Jin, Yuan Rou, Shan Yu, Gou Qi, Yuan Shen, Sheng Bai Shao, Tao Ren, Hong Hua, Gan Cao).
Heat accumulation: Heart/Stomach heat accumulating in Middle Jiao, binding menstrual blood, leaving no blood in the Sea. Symptoms: Amenorrhea, preference for cold, dry mouth/tongue, constipation, red tongue, yellow dry coating, forceful rapid pulse. Treatment: Nourish Blood, clear heat, regulate menstruation. Use Yu Zhu San (Si Wu Tang combined with Tiao Wei Cheng Qi Tang, or add Huang Qin, Zhi Zi, Lian Qiao, Bo He, Zhu Ye, Honey).
Cold coagulation: During menstruation/postpartum when the blood chamber is open, exposure to wind/cold or raw/cold food causes blood to coagulate and block flow. Symptoms: Amenorrhea, preference for hot food, aversion to cold, cold lower abdominal pain, non-thirsty, deep/slow or tight pulse. Differentiate exterior/interior cold severity; use Wu Zhu Yu Tang or Hu Po San to warm, disperse, and unblock.
Qi stagnation: Emotional depression causes Qi mechanism dysfunction and meridian obstruction. Symptoms: Amenorrhea, chest/abdominal distension/pain, sighing, belching, dizziness, dry eyes, left deep/wiry pulse. Use Xiao Yao San plus Xiang Fu, Ze Lan, Dan Pi, Sheng Di, Yu Jin, Hei Zhi, Huang Qin to soothe Liver, resolve depression, invigorate Blood, and regulate menstruation.
Blood stasis: Residual blood after menstruation/postpartum, compounded by external/internal injuries, causes old blood to stagnate and condense in meridians. Symptoms: Amenorrhea with lower abdominal pain refusing pressure, purple tongue with stasis marks, deep/choppy pulse. Use Ze Lan Tang combined with Bai Zi Ren Wan or Tong Yu Jian based on constitution.
Phlegm-dampness obstruction: Constitutionally Yang deficient, failing to transform water-dampness, which accumulates and blocks the uterus. Symptoms: Amenorrhea with obesity, nausea, excessive phlegm, chest/epigastric fullness, white greasy coating, slippery pulse. Treatment: Resolve Phlegm, unblock menstruation. Use Xiong Gui Er Chen Tang.
Food retention: Accumulated food prevents intake and transformation of menstrual blood. Symptoms: Amenorrhea, umbilical/abdominal distension/pain refusing pressure, anorexia, belching with sour regurgitation, swollen tongue, thick coating, slippery pulse (strong at Right Guan). Use Da Cheng Qi Tang to purge intestines and eliminate retention.
Caused by Other Diseases vs. Causing Other Diseases
When amenorrhea co-occurs with other diseases, determine the sequence. As Chen Su'an discussed: If blood stasis from amenorrhea flows to limbs causing edema, it is a menstrual disorder causing another disease; do not treat edema directly, only regulate menstruation. Use Xiao Diao Jing San plus Hong Hua, Dan Pi, Niu Xi. If edema precedes amenorrhea, it is called "Water Factor." Bladder Qi transformation failure allows water to overflow into skin, affecting menstruation. Treat the edema. Strengthen Spleen to transport dampness, promote Qi movement and diuresis. Use Fu Ling Dao Shui Tang (Fu Ling, Bing Lang, Zhu Ling, Sha Ren, Mu Xiang, Chen Pi, Ze Xie, Bai Zhu, Mu Gua, Da Fu Pi, Sang Bai Pi, Su Geng equal parts).
Blood stasis/exhaustion can transform. Amenorrhea with cough requires prompt treatment to prevent chronic decline, wind invasion, and mixed deficiency/excess becoming Blood-Type Consumption Disease. Symptoms: Amenorrhea, chronic cough, bone-steaming, tidal fever, spontaneous/night sweats, emaciation, weak rapid pulse. Differentiate deficiency in Qi, Blood, or Yin. Elder Li considers Yin deficiency most severe here; treat primarily by nourishing Yin using Jie Lao San (Bai Shao, Zhi Huang Qi, Ren Shen, Wu Wei Zi, E Jiao Zhu, Fu Ling, Dang Gui, Sheng Di, Ban Xia, Sheng Jiang, Da Zao).
Body Aches During Menstruation
Differentiate Exterior/Interior, Deficiency/Excess
Body aches during menstruation are pain syndromes accompanying the cycle, classified by exterior/interior and deficiency/excess. Caused by external pathogens invading due to lack of Wei Qi nourishment, or internal lack of Ying Blood nourishing sinews, or impaired Qi/Blood flow. Elder Li differentiates deficiency/excess by timing and exterior/interior by presence of chills/fever.
With Exterior Syndrome: Pain before/during menstruation, chills, fever, floating pulse. Release exterior, harmonize Ying/Wei. Exterior Excess: Ma Huang Tang. Exterior Deficiency: Gui Zhi Tang. Body Deficiency: Combine with Si Wu Tang.
Without Exterior Syndrome: Pain before/during menstruation, no chills/fever, dark menstrual blood with clots, difficult flow, pale-red or dark tongue with stasis spots, thin white coating, deep or wiry-choppy pulse. Blood vessel congestion. Unblock meridians. Use Qiang Gui Si Wu Tang.
Post-Menstrual Body Aches: Pain after menstruation, weak limbs, scanty/pale menstruation, sallow complexion, pale-red tongue, thin coating, weak pulse. Blood deficiency failing to nourish sinews. Tonify Blood vessels. Use Huang Qi Jian Zhong Tang.
Hematochezia During Menstruation
Treat as Deficiency
Passing blood from rectum during/pre-menstruation with reduced menstrual flow is "Hematochezia During Menstruation" (anciently "Blood flowing to Intestines"), also called "Wrong Menstruation." Differentiate Deficient Heat and Triple Organ (Liver/Spleen/Kidney) Deficiency.
Deficient Heat: Yin deficiency with Fire hyperactivity, intestinal heat injuring Yin fluids. During menstruation, heat forces blood into intestines. Symptoms: Rectal bleeding during period, scanty bright red menses, thirst preferring cold drinks, dry hard stool, red tongue, yellow coating, deficient rapid pulse. Clear heat, cool blood, nourish Yin. Use Yue Ying Jian from *Jing Yue Quan Shu* (Sheng Di, Bai Shao, Huang Qin, Di Yu, Xu Duan, Huai Hua, Wu Mei, Hei Jie Sui, Gan Cao). Add Ma Ren, Yu Li Ren for severe constipation; add Zhi Zi, Huang Lian for intense heat.
Triple Organ Deficiency: Due to overwork. Symptoms: Rectal bleeding before period, scanty pale-red menses, pale face, dizziness, fatigue, frequent urination, loose stools, pale-red tongue, weak pulse (weak at Chi). Tonify Liver/Kidney, benefit Qi/Blood, stop bleeding, raise sinking Qi. Use Shun Jing Liang An Tang from *Fu Qing Zhu Nu Ke* (Ren Shen, Shu Di, Shan Yu, Dang Gui, Bai Shao, Bai Zhu, Ba Ji Tian, Hei Jie Sui, Sheng Ma).