Premenstrual+Dysphoric+Disorder+(Xue+Ku)

Premenstrual dysphoric disorder (PMDD) or severe PMS is a biologically based medical condition that causes impaired social and occupational functioning and affects interpersonal relationships. Relevant Western Diseases: Premenstrual dysphoric disorder, cyclic psychosis, premenstrual psychosis, hormonal psychosis, other menstrual disorders with obvious emotional components, and psychoneurosis, affective disorder, schizophrenia and highly stress reactive types with premenstrual complaints

Diagnosis: A. Moody, frequent emotional changes before or around menstruation B. Symptoms appear to follow the menstrual cycle C. Feel relief after onset, after a few days of flow, or after finish of menstruation D. History of Shen or emotional disharmony E. Evidence from western medical examination Should have A, then refer others

Research criteria for PMDD lists 11 symptoms: (1) Marked depressed mood, (2) Persistant anger and irritability, (3) Marked anxiety or tension, (4) sudden sadness or depression, (5) Difficulty concentrating, (6) Lack of interest in activities once enjoyed, (7) Noticable lack of energy, (8) Marked change in appetite, (9) Insomnia or hypersomnia, (10) Feeling overwhelmed or out of control, (11) other physical symptoms such as joint pain or breast tenderness and/or distention. At least five must be present.

Prognosis: The menstrual Shen and emotional disharmony can be a life-long pathology, every period. Some suffer only during certain periods and get better automatically. In general, every female experiences a varying degree of symptoms, these symptoms largely depend on the individual situation, but most will have good results with proper treatment.

Differential Diagnosis: Medical Disorders: A. Thyroid Disease B. Other endocrinological disorders C. Endometriosis D. Systemic Lupus Erythematosus (SLE) E. Seizure Disorders Effects of Substances: A. Alcohol or illicit substance intoxication or withdrawal B. Side effects of medications Psychiatric Disorders: A. Major Depressive Episode B. Bipolar Affective Disorder (BAD) C. Somatoform disorders, including Conversion Disorder and others D.<span style="font-family: "Times New Roman"; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> Eating disorders

TCM Etiology and Pathogenesis: “Many parts of the body assist the menses, the meridians involved are the Chong and Ren, the Zang Fu involved are the liver, spleen ad kidney, and the extraordinary organ is the uterus. These organs and channels are the key to identifying the etiological and pathological situation. Emotional disorder is the most common cause of the disease; these disharmonies not only affect the liver, kidney and spleen but also other organs and the Chong and Ren channels directly. Poor diet and overexertion are other factors leading to Zang Fu disharmony which then causes Shen and Chong, Ren disharmony. Pathogens such as Qi and blood stagnation or evil Qi invasion can cause organ and channel disharmony and disturb the Shen and emotions simultaneously.”2

“During the second half of a woman’s cycle, the blood is sent down from the heart to the uterus. If a woman’s blood tends to be scanty, this may leave the heart malnourished above. Thus the spirit becomes disquieted. In addition, there may also be insufficient blood to nourish the liver. In that case, the liver may fail to do its duty of controlling coursing and discharge. Therefore, the liver becomes depressed and the Qi becomes stagnant. Because of the interrealtionships between the heart and spleen, heart and liver, and liver and kidneys, heart blood vacuity may lead to spleen Qi vacuity, liver depression transforming into heatmay give rise to heart fire effulgence and liver blood vacuity may evolve into kidney Yin vacuity with ascendant Yang hyperactivity. Because of the relationship of Qi to blood and static blood to the engenderment of new blood, blood stasis may be engendered or worsened premenstrually.”1

TCM Pattern Differentiation: Liver Qi Stagnation, Shen Irritable 1,2 Moody, upset and depressed, sensitive, easily angered, frequently cry, heart vexation, low appetite, irritable emotions and bowel movements, breast tenderness and pain, hypochondriac pain, sighing, suspiscious of small things, lower abdominal bloating and cramping, dry throat, may have lower back ache, dysmenorrhea and irregular menstruation, insomnia. Symptoms commonly start one week or a few days before menstruation and may persist during the period. -LR-2, GB-34, LI-4, PC-7, HT-7, GV-20, GV-14. Draining technique1 -LR-1, LR-3, LR-6, LR-14, LI-4, TW-6, CV-3, CV-17, Yintang2 Depressed Fire1: Use //Long Dan Xie Gan Tang Jia Jian// – [ Long Dan Cao (6-10g.), Ze Xie (10g.), Che Qian Zi (10g.), Sheng Di (12g.), Dang Gui (10g.), Shan Zhi (6-10g.), Huang Qin (10g.), Gan Cao (3-6g.), Dan Pi (6-10g.), Huang Lian (3-6g.), Gou Teng (10-12g.), Long Gu (12g.), Mu Li (12g.)] Heart-Liver Fire1: Use //Huang Lian Qing Yin Jia Jian// – [Huang Lian (3-12g.), Huang Qin (10-12g.), Long Dan Cao (6-10g.), Lian Xin (3-6g.), Sheng Di (12-15g.), Dang Gui (10g.), Suan Zao Ren (12g.), Fu Shen (10-12g.), Yuan Zhi (10g.), Gan Cao (3-10g.), Ci Shi (15-25g.)] Depressive Heat w/ Spleen Vacuity1: Use //Dan Zhi Xiao Yao San Jia Wei// – [Dan Pi (6-10g.), Shan Zhi (6-10g.), Chai Hu (10g.), Dang Gui (10g.), Bai Shao (10-18g.), Bai Zhu (10g.), Fu Ling (10-12g.), Gan Cao (6-10g.), Bo He (6g.), Ye Jiao Teng (15g.), He Huan Pi (15g.)] Depressive Heat w/ Spleen Vacuity and Phlegm Dampness1: Use //Chai Hu Jia Long Gu Mu Li Tang Jia Wei// – [Chai Hu (10g.), Dang Shen (6g.), Ban Xia (10g.), Fu Ling (10-12g.), Huang Qin (10g.), Long Gu (12g.), Mu Li (12g.), Dang Gui (6-10g.), Bai Shao (10-15g.) ,Gui Zhi (6g.), Da Huang (3-6g.), Sheng Jiang (2 slices), Da Zao (3 pieces) Depressive Heat in Liver, Lungs, and Stomach1; Possible Phlegm: Use //Xiao Chai Hu Tang Jia Wei// – [Chai Hu (10g.), Dang Shen (10-12g.), Ban Xia (10g.), Huang Qin (10g.), Dang Gui (6-10g.), Bai Shao (10g.), Gan Cao (6-10g.), Sheng Jiang (2-3 slices), Da Zao (3-5 pieces)
 * Tongue:** pink or red tongue, white coat
 * Pulse:** wiry, tense, rapid
 * Acupuncture Treatment:**
 * Herbal Treatment:**
 * -**[Chai Hu, Yu Jin, Huang Qin, Bai Shao, Chi Shao, Chuan Xiong, Xiang Fu, Chen Pi, Dan Shen, Zhen Zhu Mu, Fu Ling, Shi Jue Ming]2
 * Modifications:**

[Heart] Qi and Blood Deficiency, Shen Irritable 1,2 Feels weak and exhausted quickly, feels sad and lonely, desire to cry, sudden spirit essence abstraction, inability to control oneself, insomnia, restless sleep and not awake rested, waking up frequently, palpitations, fearful throbbing, taciturnity, scanty speech, excessive worry and anxiety,mild soreness in lower abdomen and lower back, pale complexion, low appetite Symptoms generally start with menstruation and persist several days afterward; can also occur before menstruation with delayed scanty menstrual cycle. -Tonify: ST-36, HT-7, BL-15, BL-17, BL-20; Drain: GV-20, Yintang 1 -ST-36, HT-7, PC-6, SP-3, SP-4, SP-8, GB-13, CV-6, GV-20 2 -//Gan Mai Da Zao Tang Jia Bai He Di Huang Tang// – [ Huai Xiao Mai (25-60g.), Gan Cao (10-15g.), Da Zao (5-10 pieces), Bai He (15-60g.), Sheng Di (15g.), Suan Zao Ren (12g.), Yuan Zhi (10g.)] 1 Severe Qi Vacuity: Use //Gui Pi Tang Jia Wei// – [Huang Qi (10-18g.), Dang Shen (10g.), Fu Shen (12g.), Bai Zhu (10g.), Gan Cao (10g.), Yuan Zhi (10g.), Shi Chang Pu (10g.), Dang Gui (10g.), Suan Zao Ren (12g.), Long Yan Rou (10g.), Mu Xiag (6-10g.)] 1
 * Tongue:** pale tongue, thin white coat
 * Pulse:** deep, thin
 * Acupuncture Treatment:**
 * Herbal Treatment:**
 * -**[Huang Qi, Bai Zhu, Dang Shen, Fu Ling, Dang Gui, Shu Di Huang, Bai Shao, Ye Jiao Teng, He Huan Pi, Bai He] 2
 * Modifications:**

Spleen and Kidney Yang Deficiency, Shen Disharmony 1,2 Premenstrual feeblemindedness, essence spirit abstraction, no thought for food or drink, cold feet and hands, sensitive to the cold, lower abdomen and back are cold and ache, lack of strength, low appetite, irregular and painful menstruation, loose stools and diarrhea, nocturia, feeling puffiness or swollen on the body especially the eyelids and extremities. In general symptoms occur before, during and several days after the menstrual cycle. -CV-4, CV-8, CV-12, BL-20, BL-21, BL-23, GV-41 -KI-3, KI-7, KI-9, SP-3, SP-5, SP-9, CV-4, CV-7, ST-36, GV-202 - //Jian Gu Tang Jia Jian// – [Dang Shen (10g.), Bai Zhu (10g.), Fu Ling (10-12g.), Yi Yi Ren (21g.), Bai Ji Tian (10g.), Gan Jiang (6-10g.), Mu Xiang (6-10g.] 1 Diarrhea1: + Bai Bian Dou, Ge Gen, Bu Gu Zhi Marked bodily cold and chills1: + Fu Zi, Rou Gui, Xu Duan Shortness of breath & falling/sagging abdominal feeling1: + Huang Qi, Sheng Ma Chest oppression1: + Xiang Fu, Zhi Ke with blood stasis1: Use //Si Ni Tang Jia Wei// – [Fu Zi (6-10g.), Dang Gui (10g.), Shan Yao (10g.), Fu Ling (10-12g.), Shu Di (15g.), Xian Ling Pi (10g.), E Zhu (10g.), San Leng (10g.), Chi Shao (10g.), Chuan Xiong (10g.), Gan Jiang (6-10g.)]
 * Tongue:** pale tongue, white watery coat and teeth marks
 * Pulse:** deep, slow, weak
 * Treatment Principles:** Warm and supplement the spleen and kidneys
 * Acupuncture Treatment:**
 * Herbal Treatment:**
 * -**[Zhi Fu Zi, Shan Yao, Du Zhong, Shu Di Huang, Tu Su Zi, Huai Niu Xi, Qian Shi, Hai Piao Xiao, Sang Shen Zi]2
 * Modifications:**

Kidney Yin and Liver Blood Deficiency, Shen Irritable 2 Scanty and delayed menstruation, 5-palm heat, frequently angry, depressed, irritable, tinnitus, malar flush, feels heat burning up and cold on the feet, sensitive and moody, emaciation and low energy, insomnia, dry mouth and thirst, skin and eye dryness, night sweats, constipation, scanty urine
 * Tongue:** red tongue, thin or no coat
 * Pulse:** thready, deep, rapid
 * Acupuncture Treatment:** KI-2, KI-3, KI-6, KI-9, KI-27, LR-3, LR-8, SP-6, Yintang
 * Herbal Treatment:** [Shu Di Huang, Shan Yao, Shan Zhu Yu, Mu Dan Pi, Fu Shen, Ze Xie, Ji Xue Teng, Dan Shen, Dang Gui, Bai Shao, Chi Shao]

Yin Deficieny with Ascendant Liver Yang Hyperactivity 1 Premenstrual irascibility, easy anger, dizziness, vertigo, tinnitus, head distention and/or pain, profuse dreams, insomnia, red face and eyes, low back pain [Tian Ma (10g.), Gou Teng (12-15g.), Shi Jue Ming (18-24g.), Zhi Zi (10g.), Huang Qin (10g.), Yi Mu Cao (10-12g.), Chuan Niu Xi (12g.), Du Zhong (10-12g.), Sang Ji Sheng (10-24g.), Ye Jiao Teng (10-30g.), Fu Shen (10-15g.)] Yin vacuity with fire effulgence: Use Huang //Lian E Jiao Ji Zi Huang Tang Jia Wei//1 - [Huang Lian (3-12g.), Huang Qin (10-12g.), Bai Shao (10-18g.), E Jiao (12g.), Bai He (15-30g.), Sheng Di (12-15g.), Fu Shen (12-15g.), Ji Zi Huang (2-3g.)]
 * Tongue:** red tongue
 * Pulse:** bowstring, fine, rapid or surging, rapid
 * Treatment Principles:** Clear the Liver and subdue Yang, nourish the blood ad enrich the Kidneys
 * Acupuncture Treatment:** GV-20, GB-20, Yintang, PC-7, LR-3, SP-6, KI-3
 * Herbal Treatment:** //Tian Ma Gou Teng Yin//1
 * Modifications:**

Liver-Spleen Disharmony 1 Premenstrual irritability, emotional lability, fatigue, lack of strength, constipation, loose stools, or alternating constipation and diarrhea, cold hands, chest oppression, tendency to sig, craving for sweets, tendency to water swelling, breast distention and pain, abdominal distention and pain and/or menstrual pain [Chai Hu (6-10g.), Bai Shao (10-12g.), Dang Gui (6-10g.), Bai Zhu (10g.), Fu Ling (10-12g.), Gan Cao (6-12g.), Bo He (6g.), Sheng Jiang (2 pieces)] Marked premenstrual breast distention and pain: + Xiang Fu, Chen Pi, Ju Ye, Ju He, and or Qing Pi; +CV-17, ST-18, ST-34 Abdominal distention or pain: + CV-6, ST-25, ST-29 Loose stools or diarrhea: + Mu Xiang, Sha Ren Spleen vacuity is pronounced w/ fatigue, weakness: + Huang Qi, Dang Shen; + BL-20, BL-21 Spleen vacuity complicated by kidney yang vacuity: + Xian Ling Pi, Xian Mao or Gan Jiang and Fu Zi Spleen dampness: + SP-5, CV-12
 * Tongue:** pale but dark, swollen or enlarged tongue, thin white possibly slightly slimy coat
 * Pulse:** bowstring, fine
 * Treatment Principles:** Course the liver and rectify the Qi, fortify the spleen and bost the Qi
 * Acupuncture Treatment:** LR-3, LI-4, ST-36, SP-6, PC-6
 * Herbal Treatment:** //Xiao Yao San//
 * Modifications:**

Liver and Stomach Heat, Shen Disharmony 2 Feel irritable and angry before menstruation, frequently cry, hypochondriac pain and feel hot or burning, breast and lower abdominal tenderness, nausea and vomiting, feeling heat and foul smell in the mouth, talkative and overactive, prefers cold drinks and food, constipation and yellow scanty urine
 * Tongue:** red tongue, yellow coat
 * Pulse:** wiry, slippery, rapid
 * Acupuncture Treatment:** LR-2, LR-4, LR-6, ST-25, ST-30, ST-40, ST-45, LI-4, LI-11, HT-7, Yintang
 * Herbal Treatment:** [Sheng Di Huang, Huang Lian, Mu Xiang, Dan Shen, Zhi Zi, Shi Hu, Sheng Shi Gao, Yu Zhu, Dan Zhu Ye, Lu Hui, Qing Pi]

Phlegm Qi Depression and Binding 1 Premenstrual emotional depression, dizziness as if head were covered by a bag, profuse sticky phlegm, fatigue, somnolence, if severe, spontaneous sadness and weeping, crying out as if in pain or deep silence, an anxious heart laden with cares [Ban Xia (10g.), Hou Po (10g.), Zi Su Ye (10-12g.), Fu Ling (10-12g.), Dang Gui (6-10g.), Bai Shao (10g.), Sheng Jiang (3 slices)] Phlegm turbidity clouding the heart orifice1: Use //Ban Xia Bai Zu Tian Ma Tang Jia Wei// – [Ban Xia (10g.), Tian Ma (10g.), Bai Zhu (10g.), Fu Ling (10-12g.), Chen Pi (6-10g.), Dang Gui (6-10g.), Bai Shao (10-12g.), Gan Cao (3-10g.), Sheng Jiang (2-4 slices), Da Zao (2-4 pieces)] Phlegm heat harassing above: //Use Sheng Tie Luo Yin Jia Jian// - [Chen Pi (10g.), Fu Ling (10g.), Ban Xia (10g.), Zhi Ke (10g.), Zhu Ru (10g.), Tie Luo (15g.), Gou Teng (10-12g.), Dan Shen (10g.), Lian Qiao (10g.), Mai Dong (12g.), Zhe Bei Mu (10g.), Xuan Shen (15g.), Dan Nan Xing (10g.), Yuan Zhi (10g.), Shi Chang Pu (10g.)]; - LR-2; + PC-8 Phlegm wind: Use //Ding Xian Wan Jia Jian// - [Tian Ma (10g.), Chuan Bei Mu (10g.), Ban Xia (10-12g.), Fu Ling (10-12g.), Fu Shen (10-12g.), Dan Nan Xing (10g.), Shi Chang Pu (10g.), Quan Xie (3-6g.), Jiang Can (10g.), Hu Po (1-3g.), Deng Xin Cao (1-3g.), Chen Pi (6-10g.), Yuan Zhi (10g.), Dan She (10g.), Mai Dong (12g.)]
 * Tongue:** thin white slimy coat
 * Pulse:** soggy, fine, bowstring
 * Treatment Principles:** Rectify the Qi and resolve depression, transform phlegm and open the orifices
 * Acupuncture Treatment:** LR-3, ST-40, CV-12, HT-7, PC-6
 * Herbal Treatment:** //Ban Xia Hou Po Tang Jia We//i1
 * Modifications:**

Qi Stagnation and Blood Stasis 1 Blood stasis: Severe, fixed menstrual pain, dark blackish blood, blood clots, delayed or scanty, possibly blocked menstruation, sooty dark facial complexion, purplish dark lips, age spots, varicosities large and small, Qi stagnation: worse at night, irritablility, easy anger, chest, breast, rib-side or abdominal distention and pain [Tao Ren (12g.), Hong Hua (10g.), Dang Gui (10g.), Chuan Xiong (10g.), Chi Shao (10g.), Chuan Niu Xi (10g.), Chai Hu (3-10g.), Jie Geng (6-10g.), Zhi Ke (6-10g.), Sheng Di Huang (10-15g.), Gan Cao (3-6g.)]
 * Tongue:** blood stasis: purple tongue, staic spots/macules
 * Pulse:** blood stasis: choppy; Qi stagnation: bowstring
 * Treatment Principles:** Move the Qi and quicken the blood, dispel stasis and stop pain
 * Acupuncture Treatment:** LR-3, LI-4, SP-10, SP-6, GV-4, CV-6
 * Herbal Treatment:** //Xue Fu Zhu Yu Tang//