WOMEN’S SYMPTOMS

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Chapter 46

imageWOMEN’S SYMPTOMS

HOW WE ASK

When asking about a woman’s gynaecological history, we should always start from the beginning by enquiring about the conditions of her cycle 2 years after menarche (because it is common for the cycle to be irregular for the first 2 years before it settles down).

We should ask systematically first about the actual menstrual cycle and, secondly, about all other events in a woman’s gynaecological history.

Regarding the menstrual cycle, we should ask about: the age of menarche, the cycle, the amount of bleeding, the colour of menstrual blood, and whether there are clots, pain, and any premenstrual symptoms.

With regard to other gynaecological events, we should ask specifically about: childbirth, abortion, miscarriage, use of contraceptives (the Pill, uterine coil), or of hormone replacement therapy, the presence of pelvic inflammatory disease, whether there have been any gynaecological surgical interventions (such as dilatation and curettage, laser treatment, hysteroscopy, colposcopy, laparoscopy, etc.).

THE GYNAECOLOGICAL HISTORY

Women’s gynaecological history may sometimes be complicated; for example, a woman may have used the contraceptive pill or the coil for some years, or she may have had two children with possibly one or more miscarriages or terminations in between. In such cases, it is useful to draw a diagram illustrating clearly the ages at which such events occurred. As an illustration, Figure 46.1 shows the gynaecological history of a woman whose menarche occurred at 14 and who had an abortion at 18, a child at 24 and 28, an ovarian cyst at 36 and the menopause at 52.

If the woman’s cycle is irregular and characterized by discharges or mid-cycle pain or discharge, it is also useful to draw a diagram illustrating clearly at what part of the cycle such events take place. As a way of illustration, Figure 46.2 shows the menstrual cycle of a woman whose period lasts 7 days and who experiences mid-cycle pain and premenstrual tension with breast distension.

Some women may complain of prolonged menstrual bleeding whereas, in fact, they may suffer from mid-cycle bleeding. Case history 46.1 illustrates this.

Case history 46.1

A 42-year-old woman complained of ‘almost constant menstrual bleeding’. She said that her period would last for 3 weeks and she would then have a week without bleeding before the next period began. However, on closer interrogation it emerged that what she described as ‘bleeding’ was in fact a dark vaginal discharge. The diagnostic interpretation and treatment were therefore obviously different from what would be suggested by prolonged bleeding.

BREAST SYMPTOMS

The breasts in women are influenced primarily by the Stomach channel, which controls the main tissues of the breast and the lactiferous ducts; the Liver channel influences the nipple but also, together with the Gall-Bladder channel, the lateral side of the breast. The Penetrating Vessel also influences the lactiferous ducts and the connective tissues of the breast, which, in Chinese medicine, would be classified as ‘Membranes’ (Huang). The Muscle channels of the Gall-Bladder, Heart and Pericardium flow over the breast. (See Fig. 46.3 and also Fig. 12.1 on p. 121 illustrating the channels coursing through the breast.)

The Penetrating Vessel originates from the Uterus and connects with the breasts and this relationship can be seen in the linkage that exists between menstrual blood and breast milk: breast milk is a transformation of menstrual blood that occurs after childbirth and the Penetrating Vessel, being the Sea of Blood, is therefore, after childbirth, the source of breast milk. Many breast pathologies, including breast lumps, especially in women over the age of 40, nearly always occur against a background of ‘disharmony’ of the Penetrating Vessel, which means either a deficiency or stasis of Blood in this vessel.

Breast lumps

Observation, Chapter 12; Palpation, Chapter 51; Symptoms and Signs, Chapter 88

A common pathology of the breasts in women is the development of lumps.

Relatively soft, movable, painless, multiple lumps with distinct edges usually indicate fibrocystic disease, which, from the Chinese point of view, is due to Phlegm.

A single, movable, relatively hard lump with distinct edges usually indicates a fibroadenoma, which, from the Chinese point of view, is due to a combination of Phlegm and Blood stasis.

A single, painless, immovable lump with indistinct edges may indicate carcinoma of the breast which, from the Chinese point of view, is usually due to a combination of Phlegm, Qi stagnation and Blood stasis.

The age of the patient may give a rough indication of which is the most likely of these three pathologies because fibroadenomas are more common between the ages of 20 and 30, cysts between 30 and 50 and carcinoma from 50 onwards; of course, these are only general statistical indications which always have exceptions in practice.

Box 46.1 summarizes patterns underlying breast lumps.

BOX 46.1   BREAST LUMPS

Premenstrual breast distension

Observation, Chapter 12; Symptoms and Signs, Chapter 88

One of the most common presenting breast symptoms is premenstrual breast distension, which is a very typical sign of Liver-Qi stagnation. Although Liver-Qi stagnation affecting the breasts is a very common condition, stagnation of Lung-Qi also has an important influence on the breasts in women. Emotional problems such as sadness, grief and worry affect the Lungs and may impair the circulation of Qi in the chest and therefore in the breasts as well. For this reason, many breast pathologies in women, including breast lumps, may be due to stagnation of Lung-Qi rather than Liver-Qi and to the above-mentioned emotions rather than anger or repressed anger. In particular, some modern Chinese doctors relate breast pathologies to the emotional stress deriving from separation such as widowhood, breaking up of relationships, divorce, death of one’s children or bereavement at a young age from the death of one’s spouse. Liver-Qi stagnation is accompanied by irritability and a Wiry pulse, whereas in Lung-Qi stagnation there is sadness and a Weak pulse.

If the breasts become also swollen, uncomfortable and noticeably larger before the period, this also indicates also Liver-Qi stagnation but combined with Phlegm, in which case the tongue is swollen. If the breasts are distended and noticeably painful before the periods, with a Purple tongue, this indicates Liver-Blood stasis. A slight feeling of distension of the breasts after the periods, with a Choppy pulse, is usually due to Liver-Blood deficiency.

Case history 46.2 illustrates a pattern underlying breast distension.

Case history 46.2

A 36-year-old woman had been suffering from premenstrual swelling and pain of both breasts, but worse on the left, with a lump on the edge of the left breast which came up before the period and disappeared afterwards. She had been suffering from this problem for approximately 8 years. She suffered no other menstrual irregularity as her periods came regularly and were not too heavy or scanty and not painful.

On interrogation, it transpired that she also suffered from tiredness, floaters, weakness, dizziness, palpitations, loose stools and anxiety in the evening.

Her tongue was slightly Pale and Swollen on the sides and had a sticky coating. Her pulse was Fine and slightly Wiry.

Diagnosis:

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

MENSTRUATION

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

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.

BOX 46.3   AMOUNT OF BLEEDING

Heavy

• Qi deficiency

• Blood-Heat

• Blood Empty-Heat

• Liver- and Kidney-Yin deficiency

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