The breast pathology itself shows a clear condition of Liver-Qi stagnation because the swelling of the breast is clearly premenstrual; however, the breast lump, the pronounced swelling and the pain indicate that there is also Phlegm. This is Qi-Phlegm and the lump comes and goes because of the Qi stagnation. Liver-Qi stagnation occurs against a background of Liver-Blood deficiency of which there are clear manifestations (tiredness, floaters, dizziness, Pale sides of the tongue, Fine pulse). There is also some Heart-Blood deficiency indicated by the palpitations and the anxiety in the evening. Finally, there is an underlying Spleen-Qi deficiency indicated by the weakness and the loose stools; the Spleen-Qi deficiency has given rise to Phlegm.

Box 46.2 summarizes the patterns underlying breast distension.

BOX 46.2 PREMENSTRUAL BREAST DISTENSION

• Liver-Qi stagnation: pronounced distension, irritability, Wiry pulse

• Lung-Qi stagnation: slight breast distension, sadness, Weak pulse

• Liver-Qi stagnation with Phlegm: swollen and painful breasts, Swollen tongue

• Liver-Blood stasis: painful breasts, Purple tongue

• Liver-Blood deficiency: mild breast distension, Choppy pulse

MENSTRUATION

When asking about menstruation, we should ask about the following aspects systematically:

• premenstrual symptoms

• other symptoms occurring around menstruation.

When asking questions about the menstrual cycle, I always ask the woman how her periods were about 2 years after the menarche (remember that it is normal for the period to be somewhat irregular for 2 years after menarche). This is important because it gives us an idea of the woman’s constitutional menstrual cycle, eliminating the influence of subsequent gynaecological events (e.g. pregnancy, childbirth, miscarriage, abortion, contraception, etc).

For example, a woman may have suffered heavy blood loss during childbirth and therefore develop a Blood deficiency which makes her periods scanty. The scanty period in this case shows not her constitutional menstrual cycle but the consequence of a definite cause of disease. By asking her about her menstruation 2 years after menarche, we formulate an idea of the constitutional state of her gynaecological system.

Amount of bleeding

Symptoms and Signs, Chapter 84

The loss of blood during menstruation can vary between 30 and 80 ml. A period is defined as ‘heavy’ if the loss of blood is either profuse or prolonged. It is important to ask how many days the period lasts because a period that lasts more than 5 days is normally considered excessive in Chinese medicine, while one that lasts under 4 days is normally considered scanty. While most women would describe as abnormal a period that either lasts too long or is too heavy, they would not use the same term for a period that is too short or too scanty. In other words, many women would say that their period is ‘normal’ when it lasts 3 days or even less or when the bleeding is very light.

A heavy loss of blood is due to Qi deficiency, Blood-Heat, Blood Empty-Heat, Liver- and Kidney-Yin deficiency or Blood stasis. If the period is scanty, this denotes Blood deficiency. Cold in the Uterus or Liver-Blood stasis.

In my experience, there is strong bias among practitioners to attribute heavy periods always to Qi deficiency. This is not so and, in my experience, about half the cases are due to Blood-Heat and half to Qi deficiency.

Case history 46.3 illustrates a pattern underlying heavy periods.

Case history 46.3

A 42-year-old woman had been suffering from heavy periods for 15 years: the periods came regularly, they lasted 7 days, they were not painful and the menstrual blood was dark with clots. The heaviest flow was in the first 3 days of the period. A month before her consultation a scan revealed the presence of fibroids in the uterus.

Her body build was robust, her eyes had good lustre indicating good Spirit and her general energy was good. She was rather overweight and her complexion was sallow. She had no other symptoms, apart from occasionally mucus in the stools. Questions investigating a possible Kidney deficiency revealed no symptoms of it. On palpation, her abdomen felt quite soft and the fibroids could not be palpated. Her tongue had a normal colour but was very Swollen. Her pulse was Slippery, Full and slightly Overflowing.

Diagnosis:

Her body build, the good Spirit and general energy indicate a good constitution, although being overweight indicates Phlegm. The presence of Phlegm is confirmed by the presence of occasional mucus in the stools, her being overweight, the swelling of the tongue and the Slippery pulse; the fibroids could also be partly due to Phlegm. The dark menstrual blood with clots and the presence of the fibroids themselves indicates Blood stasis localized in the Uterus and not severe enough to turn the tongue Purple. In this case, we can therefore conclude that the fibroids are due to a combination of both Phlegm and Blood stasis; the softness of her abdomen on palpation indicates that Phlegm is the predominant pathogenic factor in the formation of the fibroids.

The two major causes of heavy menstrual flow are usually Qi deficiency or Blood-Heat and in this case it is due to Blood-Heat; there are not many signs of this because the tongue is not Red, but it is shown primarily by the Overflowing pulse. On the other hand, there are no signs of a Spleen or Kidney deficiency even though the Spleen must be deficient for Phlegm to form. In her case, there are probably not many symptoms of deficiency because of her good constitution, which is also shown by the Full pulse; this, while it does indicate the presence of pathogenic factor also indicates that the Upright Qi has not been severely affected.

In this case, it is necessary to treat her three main conditions (i.e. Phlegm, Blood-Heat and Blood stasis) simultaneously and the treatment principle is therefore to resolve Phlegm, cool and invigorate Blood and stop bleeding.

Box 46.3 summarizes the patterns underlying abnormal amounts of bleeding.

Colour

Observation, Chapter 20; Symptoms and Signs, Chapter 84

The colour of the menstrual blood varies slightly during the period. In general, it is usually dark red, being lighter at the beginning, deep red in the middle, and pinkish at the end of the period. Box 46.4 summarizes the main areas of questioning and patterns with regard to colour.

BOX 46.4 COLOUR OF MENSTRUAL BLOOD

• Blood-Heat: dark red or bright red

• Blood deficiency: pale

• Stasis of Blood: blackish, very dark

• Full-Cold: purplish

• Empty-Cold: brownish like soya-bean sauce and dilute

• Empty-Heat in Blood: scarlet red

Consistency

Observation, Chapter 20; Symptoms and Signs, Chapter 84

The normal flow does not coagulate and there are no clots; the blood is neither dilute nor thick. Box 46.5 summarizes the main areas of questioning and patterns with regard to the consistency of menstrual blood.

BOX 46.5 CONSISTENCY OF MENSTRUAL BLOOD

• Stasis of Blood or Cold in the Uterus: clotted, with dark, dull clots

• Heat: clotted, with dark but fresh-looking clots

• Stasis of Blood: large clots

• Cold in the Uterus: small dark clots, but blood not dark

• Blood or Yin deficiency: watery

• Dampness or Damp-Heat in the Uterus: sticky

Cycle

Symptoms and Signs, Chapter 84

The length of the cycle is ideally 28 days, but it may vary from this norm. The regularity of the cycle is somewhat more important than its absolute value; thus, if the cycle is consistently of 32 days, this can be deemed normal and would not be considered as ‘late periods’. Moreover, an occasional deviation from a regular cycle should not be considered abnormal as the menstrual cycle is influenced by many factors such as travelling, emotional stress, etc.

There are several main areas of questioning with regard to the cycle. Periods that are always early (i.e. more than 7 days early) may be due to Qi deficiency, Blood-Heat or Empty-Heat in the Blood from Blood or Yin deficiency. Periods that are always late (i.e. more than 7 days late) may be due to Blood deficiency, stasis of Blood or stasis of Cold. Periods that are irregular (sometimes late, sometimes early) may be due to stagnation of Liver-Qi, stasis of Liver-Blood, Spleen deficiency or Kidney deficiency. Periods that stop and start, or that start or end with a brownish discharge, may be due to Liver-Blood stasis. If there is mid-cycle bleeding then this may be due to Damp-Heat, especially if there is also some pain, Qi deficiency, or Liver- and Kidney-Yin deficiency.

Amenorrhoea may be due to severe Blood deficiency (as often happens in women athletes), Blood stasis or Cold in the Uterus.

Box 46.6 summarizes the patterns underlying menstrual cycle irregularites.

BOX 46.6 CYCLE IRREGULARITIES

• Always early: Qi deficiency, Blood-Heat, Blood Empty-Heat, Liver- and Kidney-Yin deficiency

• Always late: Blood deficiency, Liver-Blood stasis, Cold in the Uterus

• Irregular: Liver-Qi stagnation, Liver-Blood stasis, Spleen deficiency, Kidney deficiency

• Hesitant start: Liver-Blood stasis

• Starting or ending with brownish discharge: Liver-Blood stasis

• Mid-cycle bleeding: Damp-Heat, Qi deficiency, Liver- and Kidney-Yin deficiency

• Amenorrhoea: severe Blood deficiency, Blood stasis, Cold in the Uterus

Case histories 46.4–46.6 illustrate some patterns underlying menstrual pain.

Case history 46.4

A 15-year-old girl had been suffering from severe abdominal pain for just over a year, beginning 18 months after menarche. The pain was on the right side of her abdomen and she described it as a continuous, dull ache. However, it would become sharp and stabbing in nature during her period and also at other times. The pain was relieved by the application of heat.

Three months before she came for treatment, the patient had had an ovarian cyst removed from her left side and one on her right side had been drained. She had also had recurrent attacks of oral and genital ulcers since the age of 9. These had been relieved by treatment with steroids. On questioning, the patient revealed that she was prone to constipation, specifically that she had infrequent bowel actions.

Her tongue body was Swollen and slightly Red on the sides. It had a white-sticky coating, particularly in the Gall-Bladder area, and was peeled in the centre. Her pulse was Wiry on the right and slightly Wiry on the left, where it was also Empty at the Deep level.

Diagnosis:

The stabbing nature of the abdominal pain, together with its alleviation by the application of heat, seems to suggest Cold in the Uterus as the main cause. The abdominal pain began shortly after menarche, which also would suggest the presence of Cold in the Uterus as this is a very common pathogenic factor in young girls suffering from dysmenorrhoea. The Wiry quality of the pulse seems also to confirm the presence of stagnation. However, this initial hypothesis is not confirmed by the other clinical manifestations.

Ovarian cysts are usually characterized by Dampness, which is the case in this patient, as the presence of Dampness is confirmed by the swelling of the tongue and the sticky coating.

The recurrent oral and genital ulcers are caused by Damp-Heat in the Girdle and Directing Vessels. A disharmony of the Girdle Vessel is a frequent cause of the accumulation of Dampness in the genital system, especially in women: a disharmony of this Vessel is confirmed by the distribution of the tongue coating in the Gall-Bladder areas (Fig. 46.4) This disharmony of the Directing Vessel is shown clearly by the distribution of oral and genital ulcers as this vessel starts from Ren-1, flows through the external genitalia and, on the face, it wraps around the mouth. In this case, Dampness is combined with Heat, which is evident from the redness of the sides of the tongue.

Fig. 46.4 Patient’s tongue

Therefore, we can conclude that the abdominal pain is caused by Damp-Heat and not by Cold as it would appear on first impression. The long-standing retention of Dampness in the Lower Burner (it started when she was aged 9) also led to Qi and Blood stasis and therefore the aggravation of the pain during the period. From a Western medicine point of view, recurrent oral and genital ulcers, which are inflammatory and non-infectious, are known as Behçet’s disease.

The peeling of the central area of the tongue indicates Stomach-Yin deficiency, which was probably caused by Heat injuring Yin. The pulse being Empty at the Deep level confirms the Yin deficiency; however, it is Empty on the left side (rather than the right side as it would be expected in Stomach-Yin deficiency) and this may be due to a deficiency of Liver-Yin. This is all the more likely owing to the disharmony of the Girdle Vessel, which affects the Gall-Bladder and Liver channels.

Case history 46.5

A 49-year-old woman had been suffering from menstrual flooding for 11 years. Since the birth of her second child, when she was 35, her cycle had been irregular, varying in length between 17 and 45 days; the period lasted 7 days in total, was painful, the menstrual blood had clots and she had a brown discharge for 1 day after the period. Her periods had been painful also in the years following the menarche at 12. Her gynaecological history was rather complicated as she had been on the contraceptive pill from the age of 18 to 30, she had a miscarriage at 30, the first child at 31, another miscarriage at 34, a second child at 35 and the periods became very heavy at 38. In complicated histories such as these it is helpful to draw two diagrams, one outlining the main gynaecological events of her life and the other depicting the menstrual cycle (Figs 46.5 and 46.6).

Fig. 46.5 Diagram of gynaecological events

Fig. 46.6 Diagram of menstrual cycle

Apart from the gynaecological problem, she has also had difficulty in controlling her bladder and also her bowel since the second pregnancy.

Her pulse was slightly Overflowing and Rapid and very Weak on both Rear positions; her tongue was Red and slightly Purple.

Diagnosis:

The menstrual flooding is caused by Blood-Heat, which is evidenced by the Red tongue and Overflowing-Rapid pulse. There is also some Blood stasis indicated by the painful period, menstrual clots, irregular cycle and slightly Purple tongue. There is, thirdly, an underlying Kidney deficiency, which is indicated by the weakness of the pulse in both Rear positions and by the fact that the menstrual flooding started after the second childbirth and that she had two miscarriages.

The treatment principle is therefore to cool Blood, stop bleeding, invigorate Blood and tonify the Kidneys. In gynaecological problems, it is often appropriate to apply different treatment principles in each phase of the menstrual cycle. There are four phases in the menstrual cycle, the first being the period itself during which Blood is moving, the second being the postmenstrual phase during which there is a relative Blood deficiency, the third being ovulation during which the Penetrating and Directing Vessels are active and the fourth being the premenstrual phase during which Liver-Qi moves. In this case, we can therefore cool and invigorate Blood during the premenstrual phase and the period itself and tonify the Kidneys after the period for about 2 weeks.

Case history 46.6

A 28-year-old woman had been suffering from painful periods ever since the menarche. The periods came regularly and lasted 9 to 10 days; the menstrual blood was dark with occasional clots. The pain was stabbing in nature at times but at other times it was a dull, deep ache rather than a pain and with a pronounced feeling of heaviness: she said ‘my whole lower body feels thick, heavy and stodgy’, which was clearly her way of expressing what, in Chinese medicine, is called ‘a feeling of heaviness’. The pain was situated in the central-lower abdominal area and was alleviated by a hot bath. Recently, she had been experiencing pain on intercourse which was sharp in nature and also located in the central-lower abdominal area. Apart from painful periods, she had also been experiencing a dull, mid-cycle ache on the right-lower abdominal area for the past 2 years; this ache was also accompanied by a dark-brown discharge. She also suffered from premenstrual tension, manifesting with irritability and distension of the breasts and abdomen. On the basis of an internal examination and an ultrasound scan, she had been diagnosed as suffering from endometriosis.

Other symptoms elicited from interrogation included cold limbs, occasionally a feeling of heat in the face, palpitations, anxiety and tightness of the chest.

The tongue was Red on the tip and the pulse was slightly Slippery in general and slightly Tight on the left rear position.

Diagnosis:

The stabbing character of the pain and the dark colour of the menstrual blood with clots clearly indicates Blood stasis which most probably derives from Cold in the Uterus. We can deduce the presence of Cold in the Uterus from the alleviation of the pain by a hot bath and also by the history: in fact, if the periods are painful from the time of menarche, the most common aetiological factor is invasion of the Uterus by external Cold owing to playing games wearing shorts in cold and damp weather. In this case, therefore, Cold in the Uterus obstructs the circulation of blood and causes Blood stasis.

In addition to Blood stasis, there is also a clear pattern of Dampness in the Lower Burner, which is manifested by the occasional dull ache during the periods, the pronounced feeling of heaviness and the mid-cycle pain. There is also some Liver-Qi stagnation causing the premenstrual symptoms.

An occasional feeling of heat in the face, cold limbs, palpitations, anxiety and tightness of the chest can all be explained as manifestations of rebellious Qi in the Penetrating Vessel. In fact, given these symptoms and the menstrual symptoms, we can say that all her symptoms reflect a disharmony of the Penetrating Vessel.

The main treatment principle is therefore simply to regulate the Penetrating Vessel by warming the Uterus, invigorating Blood and resolving Dampness from the Lower Burner.

Box 46.7 summarizes the patterns underlying menstrual pain.

Premenstrual symptoms

Symptoms and Signs, Chapter 85

The most common cause of premenstrual tension is Liver-Qi stagnation which manifests with irritability, depression and moodiness, a tendency to crying, impatience and a Wiry pulse; these emotional states are often accompanied by abdominal or breast distension.

However, many other patterns may cause premenstrual tension. Liver-Fire or Heart-Fire, or both, may cause premenstrual tension manifesting with a propensity to outbursts of anger, irritability and agitation, together with shouting, anxiety, insomnia and dream-disturbed sleep. Phlegm-Fire harassing upwards may also cause premenstrual tension manifesting with similar symptoms, as well as mental confusion and hyperactivity; with Phlegm-Fire there is also premenstrual breast swelling and pain.

Premenstrual tension may also be caused by Deficiency, and primarily Liver-Blood deficiency, Liver- and Kidney-Yin deficiency, Spleen- and Kidney-Yang deficiency, and Spleen-Qi deficiency with Dampness. In Deficiency premenstrual tension manifests primarily with depression, crying, lack of motivation, feelings of heaviness, tiredness and lassitude, and only a mild irritability.

Premenstrual tension is not always due to Liver-Qi stagnation.

Nausea or vomiting before the period denotes stagnant Liver-Qi invading the Stomach, whereas premenstrual constipation with bitty stools and abdominal distension indicates stagnant Liver-Qi invading the Intestines and Spleen. It is always important to ask whether there is a change in bowel movements around period time because such changes reflect the state of the Yang organs in a woman. Loose stools or constipation are frequent symptoms appearing at period time. Constipation at period time may be due to stagnant Liver-Qi invading the Intestines, Liver-Blood deficiency (with dry stools) or Kidney-Yang deficiency (with infrequent movements), whereas loose stools may be due to Spleen-Qi deficiency, stagnant Liver-Qi invading the Spleen (with abdominal distension) or Kidney-Yang deficiency (with diarrhoea).

Headaches before the period indicate Liver-Qi stagnation or Liver-Yang rising. Distension of the breasts denotes Liver-Qi stagnation, but if the breasts become very swollen and painful this may denote Phlegm (which, in premenstrual problems, usually combines with Qi stagnation). Acute breast pain may be due to Toxic Heat in the breast, such as happens in acute mastitis after childbirth.

Retention of water with oedema before the period indicates Spleen-Yang or Kidney-Yang deficiency, or both.

Box 46.8 summarizes patterns underlying premenstrual symptoms.

BOX 46.8 PREMENSTRUAL SYMPTOMS

• Irritability, depression, moodiness, propensity to outbursts of anger/crying, abdominal/breast distension, impatience, Wiry pulse: Liver-Qi stagnation

• Propensity to outbursts of anger, irritability, mental restlessness, shouting, feeling of agitation, anxiety, insomnia: Liver- and Heart-Fire

• Mental restlessness, anxiety, insomnia, dream-disturbed sleep: Heart-Fire

• Mental restlessness, anxiety, insomnia, hyperactivity, dream-disturbed sleep, mental confusion: Phlegm-Fire harassing upwards

• Weepiness, crying, depression, mild irritability: Liver- Blood deficiency with secondary Liver-Qi stagnation

• Weepiness, crying, depression, lack of motivation, insomnia: Liver- and Kidney-Yin deficiency

• Weepiness, crying, depression, lack of motivation, tiredness, lassitude: Spleen- and Kidney-Yang deficiency

• Weepiness, tiredness, lassitude, feeling of heaviness, swollen breasts: Spleen-Qi deficiency with Dampness and secondary Liver-Qi stagnation

• Nausea, vomiting: Liver-Qi invading the Stomach

• Constipation with bitty stools and abdominal distension: Liver-Qi invading the Intestines

• Constipation with dry stools: Liver-Blood deficiency

• Constipation with infrequent bowel movement: Kidney-Yang deficiency

• Loose stools: Spleen-Qi deficiency

• Loose stools with abdominal distension: stagnant Liver-Qi invading the Spleen

• Diarrhoea: Kidney-Yang deficiency

• Headaches, Liver-Yang rising or Liver-Qi stagnation

• Breast distension and pain: Liver-Qi stagnation and/or Phlegm

• Breast pain (acute): severe Liver-Qi stagnation or Toxic Heat

• Oedema: Spleen- and Kidney-Yang deficiency

Other symptoms occurring around menstruation

Symptoms and Signs, Chapter 85

Headaches that occur during the period are usually due to Liver-Yang rising or Liver-Fire blazing, occurring against a background of Blood-Heat. Headaches occurring after the period indicate Liver-Blood deficiency.

Constipation during the period may be due to Liver-Fire, whereas constipation after the period is due to Blood or Kidney deficiency.

Insomnia during the period indicates Blood-Heat, often with Liver-Fire or Heart-Fire, or both. Insomnia after the period denotes Blood deficiency.

Diarrhoea after the period indicates Spleen-Yang or Kidney-Yang deficiency, or both.

Box 46.9 summarizes the patterns underlying other miscellaneous symptoms occurring around menstruation.

PREGNANCY AND CHILDBIRTH

Fertility

Symptoms and Signs, Chapters 86 and 89

Infertility can be due to many different deficient or excess conditions. These are:

A slight feeling of nausea in the first 3 months of pregnancy is normal; persistent vomiting during the first 3 months of pregnancy, or even continuing over the following months, is a pathological sign which usually indicates rebellious Qi in the Penetrating Vessel affecting the Stomach channel. This can occur against a background of Stomach deficiency or Stomach-Heat.

Oedema during pregnancy indicates Kidney-Yang deficiency. High blood pressure denotes a Kidney deficiency with Liver-Yang rising: this may herald a pre-eclampsia state which is also characterized by headache, dizziness and blurred vision. A full eclampsia state manifests with convulsions which, from a Chinese perspective, indicate the development of Liver-Wind from Liver and Kidney deficiency.

An aggravation or an amelioration of certain symptoms by pregnancy both indicate a Kidney deficiency. Most people think that pregnancy is a weakening event in a woman’s life: in my opinion this is not so and a pregnancy can be weakening only if there is a pre-existing Kidney deficiency and the woman does not look after herself. If any pre-existing Kidney deficiency is not very severe and the woman looks after herself during pregnancy, this event may actually strengthen the Kidneys (because menstruation itself is moderately weakening and therefore its cessation can increase Blood and strengthen the Kidneys). For this reason, an aggravation of certain symptoms during pregnancy indicates that the Kidneys have been weakened by it, while an amelioration indicates that the Kidneys have been strengthened. Common examples of diseases that may get better or worse during pregnancy are asthma, migraine and rheumatoid arthritis.

Pregnancy is not necessarily-weakening to a woman’s organism. It may have a neutral effect or it may even have a strengthening effect.

Case histories 46.7–46.9 illustrate some patterns underlying problems with fertility.

Case history 46.7

A 45-year-old woman had been trying to conceive for 7 years; she did have an 18-year-old child. Her periods were scanty lasting only 2 or 3 days, she suffered from premenstrual tension and from abdominal distension after the period; she also suffered from constipation and a dragging feeling in the lower abdomen during the periods. Other symptoms elicited from interrogation included backache, occasional dizziness, frequent urination and nocturia. She also suffered from insomnia and anxiety. She was slightly overweight and her eyes lacked sparkle to a severe degree.

She had seen a gynaecologist and had had various tests and the Western medicine diagnosis was endometriosis and ovarian cysts.

Her tongue was slightly Pale and, although it had a sticky yellow coating in the centre and root, it was Peeled on the sides and the front; her pulse was Slippery in general, slightly Moving on the left Front and Middle positions, Weak on both Rear positions and Rapid (112 b.p.m.).

Diagnosis:

This patient presents with a complex picture of patterns. There is definitely Dampness as evidenced by her being overweight, the dragging feeling in the abdomen, the sticky tongue coating and the Slippery pulse. Dampness is associated with Heat because the tongue coating is yellow. Another pattern is that of Kidney deficiency, which is manifested by the backache, dizziness, frequent urination, nocturia, scanty periods and Weak pulse on both Rear positions.

The lack of sparkle in the eyes and the Moving and Rapid pulse suggest the presence of a Heart pattern, which is probably due to shock. This is confirmed by the insomnia and the anxiety; the tongue is slightly Pale but also Peeled in the front and we can therefore conclude that there is deficiency of both Qi and Yin of the Heart. The premenstrual tension indicates Liver-Qi stagnation but this is not a major problem in this case as it is secondary to the Kidney deficiency; this is confirmed by the fact that abdominal distension occurs after rather than before the period.

Case history 46.8

A 39-year-old woman had suffered from excessive body hair since the onset of puberty at the age of 15. She had recently been diagnosed with polycystic ovary syndrome after an ultrasound scan. Her menstrual cycle was 5 weeks long, the period lasted 5-6 days and she had a white, jelly-like vaginal discharge at mid-cycle.

She often felt tired and her sleep was not good, regularly waking up early in the morning. She had a tendency towards constipation and suffered from haemorrhoids. Her hands and feet were often cold. Her mouth tended to be dry and she had catarrh in her throat.

The tongue was Swollen with Red sides and red points on the tip and with a sticky yellow coating. The pulse was Deep-Weak and Slow (60 b.p.m.) overall, the right Front and left Rear positions being especially Weak.

Diagnosis:

Excessive body hair and polycystic ovary syndrome often go hand in hand and, in this case, are caused by Phlegm, which has developed as a result of an underlying Kidney-Yang deficiency. While in Western medicine the excessive growth of body hair is explained by an imbalance between oestrogen and testosterone (with excessive levels of the latter), in Chinese medicine it is due to a disharmony of the Penetrating Vessel: the Penetrating Vessel is the Sea of Blood and a disharmony may cause the Blood to promote the growth of body hair excessively. The Penetrating Vessel disharmony is also indicated by the onset of the problem at puberty, which is a time when the Directing and Penetrating Vessels are in a state of transition and change and are therefore susceptible to disharmonies.

The presence of Phlegm is confirmed by the Swollen tongue, the mid-cycle vaginal discharge and the ovarian cysts themselves. The symptoms of tiredness, constipation and cold extremities are due to the Kidney-Yang deficiency, which is shown by the pulse being Deep-Weak and Slow, especially in the left Rear position.

The swelling and the redness of the sides of the tongue body, the sticky-yellow tongue coating and the red points on the tip indicate Phlegm-Heat affecting probably the Lungs and Heart, but she has hardly any symptoms of this apart from the dry mouth and the phlegm in the throat.

Case history 46.9

A 41-year-old woman had been trying to conceive for over a year without success. During that year she did become pregnant once, but the pregnancy was ectopic and she had to have her right tube removed. She had already had a child two and a half years previously. She also complained of feeling tired, exhausted, with low motivation and lack of libido. Her sleep was disturbed and she occasionally experienced floaters and night sweating.

Her periods were quite normal, being regular, lasting 5 days and being not too heavy or too scanty and not painful. She had a past history of abdominal pain caused by pelvic inflammatory disease, causing dyspareunia (pain on intercourse) which had improved with acupuncture.

Her tongue was practically normal, being only very slightly Pale on the sides and with a slightly Red tip with red points. Her pulse was Wiry in general and slightly Slippery and noticeably Full at the Middle level.

Diagnosis:

This case history is presented here as an example of the importance of the pulse in diagnosis. On first analysis, it would appear that this patient suffers from a Kidney deficiency which is causing her to be infertile, tired, exhausted, lacking in motivation and libido. However, further questioning aimed at confirming or excluding the Kidney deficiency did not reveal any backache, dizziness or tinnitus. Moreover, she did conceive once resulting in an ectopic pregnancy, which normally indicates an obstruction of the Lower Burner from Dampness, Phlegm, stagnation of Qi or stasis of Blood; therefore, if she is infertile, it is probably more from a Full condition than from a Kidney deficiency. Furthermore, the pulse and the tongue do not show a deficiency of the Kidneys or any other organ.

The Wiry pulse clearly indicates severe stagnation of Qi, probably deriving from emotional problems, which is confirmed by the Red tip with red points on the tongue. Therefore we can conclude that her exhaustion, lack of motivation and lack of libido are due more to mental depression than to a Kidney deficiency. Moreover, the Full quality of the Middle level of the pulse (corresponding to Blood) confirms a condition of Blood stasis in the Uterus. Her past history of pelvic inflammatory disease and dyspareunia confirms this diagnosis.

The treatment principle in this case therefore should be to move Qi, pacify the Liver, invigorate Blood and calm the Mind.