Acupuncture may be an effective therapy in Vulvodynia recovery

Our clinical trial protocol has been published recently in Journal of Integrative Medicine, the PDF of whole article is available based on request.

Effectiveness of two different acupuncture strategies in patients with vulvodynia: Study protocol for a pilot pragmatic controlled trial.

Fan AY, Alemi SF, Zhu YH, Rahimi S, Wei H, Tian H, He D, Gong C, Yang G, He C, Ouyang H.  J Integr Med. 2018 Oct 10. pii: S2095-4964(18)30103-1. doi: 10.1016/j.joim.2018.10.004. [Epub ahead of print]

Abstract

BACKGROUND:

Vulvodynia, or vulvar pain, is a common condition in women; however, there are few evidence-based clinical trials evaluating nonpharmacological therapies for this condition. Acupuncture is one complementary and integrative medicine therapy used by some patients with vulvodynia. This study evaluates two different acupuncture strategies for the treatment of vulvodynia and aims to evaluate whether either of the acupuncture protocols reduces vulvar pain, pain duration or pain with intercourse. The study also examines how long the effect of acupuncture lasts in women with vulvodynia.

METHODS/DESIGN:

The study is designed as a randomized controlled trial, focused on two acupuncture protocols. Fifty-one patients who have had vulvodynia for more than 3 months will be recruited. Among them, 34 patients will be randomized into Groups 1a and 1b; those who are unwilling to receive acupuncture will be recruited into the standard care group (Group 2). Patients in Group 1a will have acupuncture focused on the points in the pudendal nerve distribution area, while patients in Group 1b will receive acupuncture focused on traditional (distal) meridian points. Patients in Group 2 will receive routine conventional treatments, such as using pain medications, local injections and physical therapies or other nonsurgical procedures. Acupuncture will last 45 min per session, once or twice a week for 6 weeks. The primary outcome measurement will be objective pain intensity, using the cotton swab test. The secondary outcome measurement will be subjective patient self-reported pain intensity, which will be conducted before cotton swab test. Pain intensities will be measured by an 11-point Numeric Pain Rating Scale. Pain duration and pain score during intercourse are recorded. Local muscle tension, tenderness and trigger points (Ashi points) are also recorded. All measurements will be recorded at baseline (before the treatment), at the end of each week during treatment and at the end of the 6 weeks. Follow-up will be done 6 weeks following the last treatment.

DISCUSSION:

Results of this trial will provide preliminary data on whether acupuncture provides better outcomes than nonacupuncture treatments, i.e., standard care, and whether acupuncture focused on the points in pudendal nerve distribution, near the pain area, has better results than traditional acupuncture focused on distal meridian points for vulvodynia.

TRIAL REGISTRATION:

Clinicaltrials.gov: NCT03481621. Register: March 29, 2018.

Copyright © 2018 Shanghai Changhai Hospital. Published by Elsevier B.V. All rights reserved.

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Fan AY. Trial suggests both acupuncture and acupressure are effective at reducing menopausal hot flashes. Acupunct Med doi:10.1136/acupmed-2016-011119.

In their recent report in the Annals of Internal Medicine, Ee et al1 state that Chinese medical acupuncture was no better than non-insertive sham acupuncture for women with moderately severe menopausal hot flashes in a randomised controlled trial. The authors conclude that they “cannot recommend skin-penetrating acupuncture as an efficacious treatment of this indication”.1 In my opinion, the authors might have misinterpreted the results.

The ‘sham acupuncture’ used in this clinical trial was the Park sham device, which is supposed to serve as a placebo treatment. It uses a 0.35×40 mm blunt needle supported by a plastic ring and guide tube (base unit) attached to the skin with a double-sided adhesive ring. The needle telescopes into itself and shortens on manipulation, giving the visual and physical impression of insertion into the skin.1 Although the blunt needle does not insert into the skin, it does cause considerable pressure and thereby mechanical stimulation, especially given the small diameter at its tip. This Park sham device should arguably be relabelled as an acupressure device, instead of a form of sham acupuncture treatment. Indeed, this type of device and needling method is historically recognised as an active form of treatment; it is otherwise known as a Di needle (鍉针 or Di Zhen, a style of pressing needle that does not penetrate the skin), as documented in The Spiritual Pivot: Nine Needles and Twelve Source Points (Ling Shu: Jiu Zhen Shi Er Yuan) in the second part of the Yellow Emperor’s Inner Classics, which was published 2000 years ago.2 For this reason, the trial design contained an obvious weakness; it compared acupuncture with acupressure, rather than acupuncture with truly inert sham acupuncture.

According to the trial’s results, hot flash scores decreased after both interventions by about 40% between baseline and the end of treatment (10 sessions, ending after 8 weeks) and these effects were sustained for 6 months. Statistically, there is no evidence that acupuncture was better than acupressure (called ‘sham acupuncture’ in the paper) in its impact on quality of life, anxiety or depression.1 This can equally be interpreted as evidence that both acupuncture and acupressure effectively decrease hot flashes and related symptoms, as well as quality of life, if we compare the results immediately after treatment (8 weeks) and at the 3- and 6-month follow-up, with baseline in the same group (self-control) or comparator group (as a waiting list-like control).

As regards the placebo effect, evidence from the literature3 and a review of multiple trials4 shows that patients receiving placebo interventions exhibit an average decrease of 21–25% in hot flash frequency and intensity. Therefore, a 40% decrease in hot flash symptom scores with either acupuncture or acupressure treatment is notably higher than that expected with a placebo and likely to be clinically significant. Further research with a more appropriate control group is needed. Meanwhile, however, if a patient declines or cannot tolerate conventional drug treatment, then it would not be unreasonable to offer either acupuncture or acupressure as an alternative treatment for this condition.

References 1. Ee C, Xue C, Chondros P, et al. Acupuncture for menopausal hot flashes: a randomized trial. Ann Intern Med 2016;164:146–54. doi:10.7326/M15-1380 [Medline] 2. Wu JN (translator). Ling Shu or The Spiritual Pivot. University of Hawaii Press, 2002. 3. Loprinzi CL, Michalak JC, Quella SK, et al. Megestrol acetate for the prevention of hot flashes. N Engl J Med 1994;331:347–52. doi:10.1056/NEJM199408113310602 [CrossRef][Medline][Web of Science] 4. Sloan JA, Loprinzi CL, Novotny PJ, et al. Methodologic lessons learned from hot flash studies. J Clin Oncol 2001;19:4280–90. [Abstract/FREE Full text]

Fan AY. Trial suggests both acupuncture and acupressure are effective at reducing menopausal hot flashes. Acupunct Med doi:10.1136/acupmed-2016-011119.

http://aim.bmj.com/content/early/2016/04/19/acupmed-2016-011119.full

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Acupuncture helps inducing the labor. By Dr.Arthur Fan

Today a patient called me–She said she labored this morning and gets a baby girl after our 2 session acupuncture treatments.

Her labor was over-due at 42 weeks and 2 days pregnancy, her OB doctor suggested her using medication to induce the labor. But she liked to try acupuncture first. It was worked! She got two days’ treatments in our center for “acupuncture labor induction”.

However, another patient (with 40 weeks pregnancy) got two acupuncture treatments during this week in our center, she did not start the labor yet, only got more intermittent cramping, she did not resume our acupuncture treatment. She said she likes to wait and see what will happen.

Acupuncture does help some of the patients whose labor is over-due. Based on our experience, two to three session acupuncture is needed–once a day, each for 45 to 60 minutes. We had 7 cases for “acupuncture labor induction”– 4 were successful, 2 were not (did not have enough cramping with 36 hours after the second acupuncture treatment) , one stopped only after one acupuncture(too hurry to start the medication).

I find there are more and more needs in natural way to accelerate/ induce the labor. Some video are online:

http://www.youtube.com/results?search_query=acupuncture+baby+induction&oq=acupuncture+baby+induction&gs_l=youtube.3…1381.10887.0.11469.26.26.0.0.0.0.68.1296.26.26.0…0.0…1ac.1.11.youtube.Fe9nmJ7IzJk

For more information is at: http://www.ncbi.nlm.nih.gov/pubmed/19922252

J Altern Complement Med. 2009 Nov;15(11):1209-14. doi: 10.1089/acm.2009.0100.

Effect of acupuncture on induction of labor.

Lim CE, Wilkinson JM, Wong WS, Cheng NC.

Source

Division of Chinese Medicine, Royal Melbourne Institute of Technology University, Bundoora Campus, Victoria, Australia celim@unswalumni.com

Abstract

OBJECTIVE:

The objective of this study is to review the existing scientific evidence on the potential role of acupuncture on induction of labor during pregnancy.

DESIGN:

The Medline, EMBASE, Cochrane Central Register of Controlled Trials, AMED (Allied and Complementary Medicine), and NCCAM (The National Center for Complementary and Alternative Medicine) databases were searched to identify relevant monographs from 1970 to 2008.

INCLUSION CRITERIA:

These criteria included all available human acupuncture studies on pregnant women carrying a viable fetus due for third trimester induction of labor.

EXCLUSION CRITERIA:

These criteria included studies not meeting the inclusion criteria, in languages other than English, or animal studies.

RESULTS:

Ten (10) studies on labor induction were identified. The duration of labor as a result of acupuncture treatment ranged from 10 hours 20 minutes to 29.1 hours. All of the studies demonstrated labor induction by acupuncture treatment. However, because two randomized controlled trials reported that there was no statistically significant effect of acupuncture, these results are more suggestive than definitive. Furthermore, although the relationship between cervical ripening and interleukin-8 (IL-8), prostaglandin F(2alpha) (PGF(2alpha)), and beta-endorphin is well documented in the literature, there is no evidence to suggest that acupuncture alters these mediators. Serum levels of IL8, beta-endorphin, and PGF(2alpha) were not found to be significantly influenced by acupuncture.

CONCLUSIONS:

Although the definitive role of acupuncture in inducing labor is still yet to be established, the existing studies suggest that acupuncture may be beneficial in labor induction. Further randomized clinical trials are needed to investigate this further.

PMID:

 

19922252

 

[PubMed – indexed for MEDLINE]

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Urination difficult due to uterus prolapse: acupuncture helps

Recently, a patient came to see me for urination difficult, the former doctors’ diagnosis was “neurological bladder”(which means the patient is too nervous to urine).

After a detail inquiring and examination, the urination difficult actually is secondary to the uterus and rectum prolapse. She had three natural labors before, and had weakness of pelvic bottom. She had to use the catheter to drain the urine out of bladder in most of time, esp. before the sleep.

Dr.Fan suggested her to consult other related specialists to see if this need an operation. Patient was very hesitate to do the operation. Anyway, she still booked appointments with ob/gyn surgeon and rectum surgeon.

So, during the gap to see other doctors, we started acupuncture, twice a week. To our surprise, the result of acupuncture is very impressive–after three or four acupuncture, her urination is much much easier, and almost does not need the catheter.

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We have 76 clients got pregnant since 2007.Arthur Fan notes.

Yesterday, a 44 years old lady came and hugged me very tightly for three minutes. And then told me she got pregnant naturally after my acupuncture treatment.

She said she should be my no.76 clients got pregnant–because she had seen there was a notes on the office board-75 pregnancy since 2007.

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Acupuncture helped the mother overcome the migraine and hypertension during pregnancy. By Dr.Arthur Fan

Acupuncture helped the mother overcome the migraine and hypertension during pregnancy

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A 33 years old lady got pregnant after 8 sessions of acupuncture. By Dr.Arthur Fan

This morning, a lady reported her pregnancy test strong positive–got pregnant. This is no.65 patient got pregnant, since 2007, by our acupuncture treatments.

She is 33 years old, married for 6 years, and tried seriously to get conceive for over one years. According to her, her husband is healthy and the sperm test was good. She also has a lot acne, so she hope we could adjust her hormones for both acne and fertility.

When she first saw me, she was in day 14 of her period cycle (she had  28-days-cycles before). I gave her acupuncture according to our protocol, and herb pills. after 8 sessions acupuncture, she felt her cervical mucus is slippery and very stretchable, better than before. after another two weeks, her period didn’t come. Then her pregnancy test became positive.

 

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Can acupuncture help vulvodynia(sex with unbearable pain) and Vaginismus? Acupuncture Earl’s Court.

http://acupuncture.blog.co.uk/2009/11/25/can-acupuncture-help-vulvodynia-sex-with-unbearable-pain-7457496/ 

by Acupuncturist ^Pro @ 2009-11-25 – 15:34:31

vulvodynia (vulval pain) known as vulvar vestibulitis, which, although it has made perhaps two brief forays into the media in that time, seems generally unknown except to those who suffer from it. Briefly, it has no known definite cause or cure and the symptoms are simply excruciating spots of soreness just inside the entrance to the vagina,vulvodynia was a relatively common condition that affects about 15% of the UK’s female population. The latest study, published in the American Journal of Obstetrics and Gynecology, bolsters that idea.
Researchers found that of nearly 2,300 Michigan women they surveyed, just over eight percent had symptoms of vulvodynia — including pain near the opening of the vagina that had lasted for at least three months.

The prevalence of vulvodynia was similar across age groups, up to the age of 70, the study found. The decline after that age seemed to be related to a dip in women’s sexual activity.

The most common symptom of vulvodynia is pain during sexual intercourse, and the condition was first defined in 1880. It is not determined yet exactly what triggers vulvodynia, but a few theories have been tested and proven to be helpful in properly diagnosing the illness,Vulvodynia is especially difficult to diagnose because there are almost no physical signs of illness or infection and doctors have to rely on patients’ descriptions of the symptoms. vulvodynia is a common condition, but it is often undiagnosed or misdiagnosed.vulvodynia is difficult to diagnose. A diagnosis often occurs only after other conditions are excluded. “Vulvodynia is diagnosed when other causes of vulvar pain, such as yeast or bacterial infections, or skin diseases, are ruled out,” Veasley said. The tissue of the vulva region may appear swollen or inflamed, but more often than not, it looks normal.

The cause of essential vulvodynia is unknown. There is some evidence that damage to the nerves, particularly the pudendal nerve, supplying this area may play a role.

The prognosis without treatment or spontaneous remission may be for unceasing pain, leading to poor quality of life. Rarely, frequency of micturition (urination), stress incontinence, and chronic constipation may also develop.At present there is insufficient evidence to document any benefit from amitriptyline or pudendal nerve decompression for women with essential vulvodynia.

Zak acupuncture continues to push for resources and relief for women experiencing serious pain in the so-called V-spot — the vestibule where the vagina and vulva meet.An estimated 15 per cent of women have experienced the extreme sensitivity and burning related to vestibulodynia.

X, female, 55 years old, low back pain eight months, and there urgency, urethral pain, perineal pain, the clitoris pain, painful sexual intercourse. Clinical examination: straight-leg raising test, normal. Highly sensitive point in both side roots of the thigh, left was serious ,hip flexor knees at a consolidated trial, leads to the roots of the thigh pain, ulna pain, tenderness is extremely sensitive .diagnosis: the roots of bilateral thigh soft tissue damage, clitoris pain.
Treatment: zak acupuncture
Results: After a period of treatment, patient’s genital pain disappeared, the treatment of patients with satisfaction.

Vaginismus: A painful spasm and contraction of the muscles of the vagina that prevents sexual intercourse. The condition results in pain when vaginal sexual intercourse is attempted or, in some cases, during a pelvic examination by a health-care provider. Vaginismus is not common, and its cause is poorly understood. Anxiety, past sexual trauma, or other psychological conditions have been suggested as potential contributing factors. Vaginismus is considered to be a form of female sexual dysfunction. Treatment of vaginismus involves education, counseling, and the use of vaginal dilation exercises and acupuncture.

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Acupuncture for vulvodynia. By Powell J, Wojnarowska F.

J R Soc Med. 1999 Nov;92(11):579-81.

Acupuncture for vulvodynia.

Powell J, Wojnarowska F.

Abstract

Vulvodynia is the sensation of burning and/or pain of the vulva in the absence of abnormal clinical findings. We offered acupuncture to twelve patients with this syndrome. All had experienced severe distress and impairment of sexual function and usual treatments had failed. The patients attended weekly for acupuncture and progress was monitored at each visit by enquiry, a questionnaire and a visual analogue scale for pain. Half had treatment for the first five weeks only, the other half for the second five weeks only. Side-effects were negligible. Two patients felt so much improved that they declared themselves ‘cured’; three believed their symptoms had improved and wished to continue acupuncture; four felt slightly better and judgedacupuncture more effective than any other treatment; and three noted no effect at all. Acupuncture is time-consuming and a large part of its beneficial effect in this study may have come from the regular specialist contact. However, in view of the patients’ lack of response to other measures their satisfaction with the acupuncture was surprisingly high.

PMID:10703496 [PubMed – indexed for MEDLINE] PMCID: PMC1297434   Free PMC Article

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The ACTIV study: acupuncture treatment is effective in provoked vestibulodynia.Posted by Dr.Arthur Fan

J Sex Med. 2010 Feb;7(2 Pt 2):981-95. Epub 2009 Nov 12.

The ACTIV study: acupuncture treatment in provoked vestibulodynia.

Curran S, Brotto LA, Fisher H, Knudson G, Cohen T.

Source

Elements of Health Centre, Victoria, Canada.

Abstract

INTRODUCTION:

Provoked vestibulodynia (PVD) is a distressing genital pain condition affecting 12% of women. Treatment modalities vary and although vestibulectomy has the highest efficacy rates, it is usually not a first-line option. Acupuncture has a long history in the traditional Chinese medicine (TCM) system and operates on the premise that pain results from the blockage or imbalance of important channels. The main principle of treatment is to move Qi and blood to cease genital pain.

AIM:

To explore effect sizes and feasibility in a pilot study of acupuncture for women with PVD.

METHODS:

Eight women with PVD (mean age 30 years) underwent 10 1-hour acupuncture sessions. Specific placement of the needles depended on the woman’s individual TCM diagnosis. TCM practitioners made qualitative notes on participants’ feedback after each session. Main Outcome Measures. Self-reported pain (investigator-developed), pain-associated cognitions (Pain Catastrophizing Scale [PCS], Pain Vigilance and Awareness Questionnaire), and sexual response (Female Sexual Function Index) were measured before and after treatment sessions 5 and 10. Qualitative analyses of TCM practitioner notes were performed along with one in-depth case report on the experience of a participant.

RESULTS:

A repeated measures analysis of variance revealed significant decreases in pain with manual genital stimulation and helplessness on the PCS. An examination of effect sizes also revealed strong (though nonsignificant) effects for improved ability to have intercourse and sexual desire. Qualitative analyses were overall more positive and revealed an improvement in perceived sexual health, reduced pain, and improved mental well-being in the majority of participants.

CONCLUSIONS:

Effect sizes and qualitative analyses of practitioner-initiated interviews showed overall positive effects of acupuncture, but there were statistically significant improvements only in pain with manual genital stimulation and helplessness. These findings require replication in a larger, controlled trial before any definitive conclusions on the efficacy of acupuncture for PVD can be made.

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What is the difference between IVF and Acupuncture in infertility treatments? By Dr. Arthur Fan in Washington DC Area

My patients and many others sometime want to know what is the difference between IVF and acupuncture in infertility treatments.

Actually, the difference is significant.

1. IVF, using artificial procedure to help the infertility couple to get baby(s). It is a procedure with the external help(doctors) and get “pregnancy”, like a game.  And, sometime, using donor’s egg or sperm. The result could know in one month. If you see the patient has bleeding after some days post the procedure(embryo transferring), the IVF is failed.

2. Acupuncture, adjusts the hormones and improving the function, which makes patient become a normal people. And then she could get pregnancy in any cycle.

Yesterday, one patient told me she got pregnancy after our acupuncture treatments.

 

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Effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization: a systematic review and meta-analysis.

Fertil Steril. 2012 Mar;97(3):599-611. Epub 2012 Jan 11.

Zheng CH, Huang GY, Zhang MM, Wang W.

Source

Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People’s Republic of China.

Abstract

OBJECTIVE:

To evaluate the effect of acupuncture on in vitro fertilization (IVF) outcomes.

DESIGN:

Systematic review and meta-analysis.

PATIENT(S):

Women undergoing IVF in randomized controlled trials (RCTs) who were evaluated for the effects ofacupuncture on IVF outcomes.

SETTING:

Not applicable.

INTERVENTION(S):

The intervention groups used manual, electrical, and laser acupuncture techniques. The control groups consisted of no, sham, and placebo acupuncture.

MAIN OUTCOME MEASURE(S):

The major outcomes were clinical pregnancy rate (CPR) and live birth rate (LBR). Heterogeneity of the therapeutic effect was evaluated with a forest plot analysis. Publication bias was assessed by a funnel plot analysis.

RESULT(S):

Twenty-four trials (a total of 5,807 participants) were included in this review. There were no significant publication biases for most of the comparisons among these studies. The pooled CPR (23 studies) from all of the acupuncture groups was significantly greater than that from all of the control groups, whereas the LBR (6 studies) was not significantly different between the two groups. The results were different when the type of control was examined in a sensitivity analysis. The CPR and LBR differences between the acupuncture and control groups were more obvious when the studies using the Streitberger control were ignored. Similarly, if the underlying effects of the Streitberger control were excluded, the LBR results tended to be significant when the acupuncture was performed around the time of oocyte aspiration or controlled ovarian hyperstimulation.

CONCLUSION(S):

Acupuncture improves CPR and LBR among women undergoing IVF based on the results of studies that do not include the Streitberger control. The Streitberger control may not be an inactive control. More positive effects from using acupuncture in IVF can be expected if an appropriate control and more reasonable acupuncture programs are used.

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No.56 “Acupuncture baby” saw me today,by Dr.Arthur Fan in Washington Dc & N.Virginia

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“Opening Through” the menstruation Tong Jing 通经，by Dr.Xia Guicheng

“Opening Through” the menstruation Tong Jing 通经

from http://chinesemedicinetopics.wordpress.com/2010/05/11/%E2%80%9Copening-through%E2%80%9D-the-menstruation-tong-jing-%E9%80%9A%E7%BB%8F/

May 11, 2010 by sharon weizenbaum

I’ve been away in Taiwan for the last month and have unfortunately neglected this blog while I was away!  I hope I didn’t lose your attention!  If you are interested in our travels in Taiwan you can click here for the little blog of our trip.   Well I’m back and have some interesting material to post that I hope you’ll enjoy!  I am going to do a series now, relying heavily on the work of Dr. Xia Guisheng.  I’ll start here with a brief introduction to Dr. Xia and and follow this with a discussion of learning some of the subtleties in treatment and the term that I am translating as “opening through”.  I’ll follow this with some entries that include the writings of Dr. Xia together with some of my own clinical experience utilizing his insights.

Dr. Xia is the director of the Gynecology Department at the Affiliated Hospital in Nanjing and professor of Gynecology at the Nanjing University of Tradition Chinese Medicine.  Bringing  over 50 years of experience and insight to his writings, he is not only a highly effective practitioner, he is also a clear teacher/writer.  His material is written in a way that guides the student/practitioner through the necessary steps to gain understanding.

 

He has pioneered the articulation of the theories that direct us to work with the ebb and flow or Yin and Yang in relation to the menstrual cycle.  He applies this understanding to all areas of gynecology in great detail.  It is no surprise, after reading his books, to discover that he has become know as a manifestation of Guan Yin, the Chinese goddess who come to the aide of women and children.  Though he is perhaps best known in the West for his work with modifying formulas according the the timing of the menstrual cycle, Dr. Xia pays such close attention to the details of patho-physiology in combination with the function of formulas and the individual herbs within them that his books are really a treasure trove of useful gems.  In this particular series, I will be paying attention to his work with blood stasis and the idea of “opening through” in relation to women’s physiology, patho-physiology and menstruation.  These ideas have many implications in the treatment of women including but going beyond the treatment of dysmenorrhea and infertility.

Most entry level Chinese herbalists have a very limited idea of gynecological blood stasis, it’s diagnosis and treatment.  This becomes very apparent as the practitioner works with women in the clinic and finds that so much of what was learned in school simply doesn’t work or works in a way that is far from ideal.  Poor clinical results can be frustrating but they can also push us to learn more and can help our diagnosis and treatments become more nuanced. For me, less than excellent results have pushed me to research many topics, including the topic of “opening through” in relation to gynecology.  This topic also brings up the concept of a more nuanced use of individual herbs.  In relation to blood stasis – many of my own students don’t come in with much more of an understanding of blood stasis herbs other than that they all move the blood and that they should therefore not be used when there is heavy bleeding or during pregnancy.  And yet, through experience we learn that sometimes we must strongly move the blood in order to stop heavy bleeding and that sometimes moving the blood can help prevent a miscarriage.  We also learn that all blood vitalizing herbs are not equal to each other nor the same as each other.  They range from strong to weak and from cold to hot.  Some are especially good at stopping pain, others are especially good improving the quality of the blood itself.  Here is a bit of a preliminary list just some of the various functions of some individual blood vitalizing herbs:

Stopping pain

Softening hardness

Cracking stasis

Warming the blood

Regulating the Qi within the blood

Stopping bleeding

Harmonizing the blood

Nourishing the blood

Supplement the Kidneys

Descend the Heart blood to the uterus

Cool the blood

Relieve constipation

Open up the chest and breast area

And finally blood vitalizing herbs that function to “open through” the menstruation…..

I first noticed that there was something going on with this idea of “opening through” when I was working beside my teacher Dr. Sheng Yufeng, in Hang Zhou, PRC.  I was constantly trying to figure out why she would use particular herbs in particular situations.  I noticed that there were times she would give a formula for blood stasis and include herbs like Huai Niu Xi or Chuan Niu Xi along with herbs such as Su Mu, Chong Wei Zi and Shan Zha.  I wanted to know when and why she used these herbs.  It was not until I found the writings of Dr. Xia Guicheng that these ideas were fulling articulated for me.  Since studying these writings, the diagnosis and appropriate treatment methods for of some patients in my clinic has become clearer and the treatment results improved.

So, what is this “opening through”?  I am translating the character 通, tong1. as “opening through”.  The Eastland Press glossary translates this as “unblocks, promotes, pervades”.  Wiseman and Ye’s Practical Dictionary of Chinese Medicine, Second Edition translates this term variously as “free, open, restore flow, unstop and connecting.  Thinking of this as “opening through” just what gets opened through?  This term is used when the Luo vessels, the channels, the Qi, the lactation, the bowels, the nasal passages, the blood vessels, the urination, the Ren vessel and finally, the menstruation are blocked. What I want to point out in relation to all of these functions is that what is being “freed” or “opened” or “connected” all relates to structures in the body that are tubular.  This is why the idea of “opening through” is useful.  It gives us the image, not only of blockage, but of a tube that is blocked up and needs to be opened.  Though the term “unblocking” may suffice, it does not convey the image of a tube that should be open end to end the way that “opening through” does.  I have to admit “opening through” is a rather bulky term though, but at least for now, I’d like to use it to effectively illustrate the physiology, patho-physiology, treatment principles and function of herbs.

A bit more about the character tong1 通. It is made up of two parts. The first is this: 甬 yong3 which carries the meaning of path or corridor.  The second is 辶 chou4, which carries the meaning of walking or going.  So altogether we have the meaning of movement through a corridor or path.   When we take the 甬 yong3 corridor or path part of the character and combine it with the disease radical getting 痛 tong4, meaning pain.  In other words, when the corridor is pathologically effected, there is pain.  The characters 通 and 痛 are the one’s that are in the famous saying 通则不痛，不通则痛,  or when there is opening through there is no pain and when there is no opening through there is pain.

So what is this tube that is related to “opening through” the menstruation?  This tube is related both to the Ren Vessel and to the Bao Tai, which connects the upper body, especially the Heart and chest, to the uterus.  This tube can get blocked up and when it does, it needs to get opened through from end to end.  Various symptoms can arise when this tube gets blocked up including amenorrhea, scanty menstruation, lack of free flow of menstruation, painful menstruation, heavy menstruation and infertility.  Upper Jiao symptoms can involve the breasts, the head, the emotions or even cause bleeding in the upper warmer as the menstrual blood fails to descend.  The blockage can effect the middle Jiao as well.  Recently I successfully treated a woman with Achalasia, which involved difficulty swallowing and esophageal spasming that was worse premenstrually, integrating the method of opening through the menstruation.  In general, when the menstruation is not open through, a failure of the downward movement of the Qi mechanism can lead to a whole variety of upward rebelling symptomatology in addition to the lower warmer issues.

Before moving on to the entries that include the Dr. Xia’s writings on this topic, I want to include a bit about how he organizes his discussions in his book, Gynecology Formluas and Herbs from Clinical Experience and Study in Fifteen Chapters. In this text, Dr. Xia has a whole chapter devoted to the idea of “opening through”.  He divides this chapter into 8 parts, each part being represented by one of his “opening through” experiential formulas.  He begins with a basic formula Jia Yu Tong Yu Jian (modified Opening Through Stasis decoction) which is based on Zhang Jingyue’s formula Tong Yu Jian (Opening Through Stasis decoction). He uses this formula as a jumping off place for the deeper, more detailed discussion of the topic.  The formulas that follow morph off of the original idea in the variety of ways that Dr. Xia sees most often in his clinical work.  By carefully going through each chapter, the practitioner learns, not only about these particular formulas but so much more.  We learn how to modify a formula to suit a variety of clinical realities but more importantly, we learn about women’s physiology and patho-physiology in great depth.  Finally, we learn about the individual herbs and their nuanced and careful use.  It is like looking at an issue through a variety of lenses until we feel we have quite a complete understanding.  I’ve not previously seen texts organized in this manner and have found it to be an excellent way to transmit his valuable information.

So, stay tuned!  Dr. Xia’s writings will soon be posted here!

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Opening Through [Two]. Original by Dr.Xia Guicheng, a Chinese Gynecologist (Nanjing, China).

Original Article from http://chinesemedicinetopics.wordpress.com/2010/05/11/opening-through-two/(May 11, 2010 by sharon weizenbaum)

 

[This re-post was got kind permission from Ms.Weizenbaum.]

加减通瘀煎 Jia Jian Tong Yu Jian Modified Opening Through Stasis Decoction

“it is very important that the lack of free flow is paired with fullness, pain or up-bearing symptoms”

By way of introduction to this first chapter, I’d like to write a bit about women’s physiology and the tubular quality of the Ren vessel and the Bao Tai.  Though I have not heard of these pathways written or spoken of as “tubular” per se, thinking of them in this way has helped me to visualize and understand women’s physiology, patho-physiology and the use of herbs in formulas.  So, please bear with me…If we think of the Ren vessel/Bao Tai as a tubular pathway extending from the upper body (Heart and chest) to the womb, physiologically, this tube provides the route for the Heart fire to descend to warm the womb and for the Kidney water to ascend to control, moisten and cool the Heart.  This pathway allows the communication and interaction of fire and water between the upper Jiao and womb.  We can also see that what travels within this tube is the interaction of fire and water which is the red blood.  The scenario that requires the use of formulas like Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction), is characterized by blood in this tube becoming congealed and blocking the tube.  If we think about the Qi mechanism and the necessity for there to be a constant free flow of Qi up and down, we can see that a plug in this tube could cause a disruption in this free flow.  The Heart Qi and fire may be unable to move down to the womb.  This can cause a myriad of upward rebellion symptoms along with the primary pathology of the uterine contents, whether blood, lochia or fetus, failing to move out freely.

Dr. Xia’s Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is his foundational formula to, for lack of a better analogy, sort of blow the plug out like a spit ball out of a straw.

What we want to know how to do in the clinic is to recognize when there is this kind of plug in the tube – i.e. how to diagnose this.  Additionally we want to know which herbs discharge this manifestation of blood stasis and how to modify a formula for the various presentations we will see clinically.  The presentation may vary in terms of aspects such as excess/deficiency or heat/cold and it can also vary in terms of presenting symptoms such as headaches, insomnia or, as I mentioned in the last post, difficulty swallowing.  Main complaints can vary from PMS, dysmenorrhea, PCOS, endometriosis and infertility to amenorrhea.  We also want to know how to administer the purgative therapy safely – this has to do with careful diagnosis and timing of the treatment.

The main signs I use clinically to diagnose the presence of this “plug” is the combination of lack of free flow of the uterine contents with lower abdominal discomfort and fullness.  Lack of free flow by itself can be due to pathologies such deficiency of blood or Yin fluids or cold etc. in which case blowing out the plug would be unsuitable if not detrimental.  Lower abdominal fullness and discomfort could also be due to many pathologies such as uterine infection, simple blood stasis that does not block the menstrual flow or other stasis in the lower abdomen.

Lack of free flow of the uterine contents manifests as amenorrhea, scanty menstruation, menstruation the stops and starts, failure of the lochia to discharge or non progression of labor.  All of these pathologies can come form other disease factors besides this one and so it is very important that the lack of free flow is paired with fullness, pain or up-bearing symptoms.

The primary herbs that Dr. Xia uses for opening through menstruation here are:

Shan Zha

Qing Pi

Chuan Niu Xi

Ze Lan

Hong Hua

Tao Ren

We will see others in future posts.  It is important to notice that these herbs do have this kind of special indication.

Below is Dr. Xia’s writing on the 1st formula in the 7th chapter of his text.

Translated by Sharon Weizenbaum

Jia Jian Tong Yu Jian 加减通瘀煎 Modified Opening Through Stasis Decoction

Formula Name:

Tong 通 means to open the flow and Yu 瘀 is stasis and refers to blood stasis.  Jian refers to the method of cooking which is to boil.  Opening stasis refers to a strong method of transforming stasis.  One should use stronger vitalizing blood herbs when the intention is to open the passageways, free the flow of blood stasis, scatter and transform blood stasis.  Based on the pathological condition of the patients, I have modified Zhang Jing-yue’s Tong Yu Jian (Open Through Stasis Decoction) into my own experiential formula.

Formula Constituents:

Chao Dang Gui Wei     12 gm

Shan Zha                      10 gm

Xiang Fu                       9 gm

Hong Hua                    6-9 gm

Wu Yao                        6 gm

Qing Pi                        5 gm

Chuan Mu Xiang          9 gm

Ze Lan Ye                    10 gm

Chi Shao                      10 gm

Chuan Niu Xi               10 gm

Tao Ren                        6-10 gm

Method of Application

One package is for one day, divided into two doses.

Formula Function:

Regulates Qi and vitalizes the blood, opens through stasis and synchronizes the menstruation.

Formula Application

This formula treats blood stasis type late menstruation, scanty menstruation, prolonged menstruation and dysmenorrhea.

Formula explanation:

This formula treats blood stasis type irregular menstrual pathology.  This includes blood stasis type dysmenorrhea and amenorrhea presentations.  It places Dang Gui Wei in an important position for vitalizing blood and transforming stasis.  However, these days pharmacies do not discriminate between Dang Gui Wei, Dang Gui Tou and Dang Gui Shen.  Consequently we assist the function of Dang Gui to open stasis with Tao Ren and Hong Hua making this a stronger blood vitalizing formula. Zhang Jing-yue’s original formula contains Hong Hua but is without Tao Ren.  Tao Ren must be added.  Generally, because of the demands of opening through stasis, I base my formula on Tong Yu Jian (Open Through Stasis Decoction), though, according to the clinical presentation I also add Ze Lan Ye and Chuan Niu Xi to open the pathways of the menstruation.  The goal is to vitalize the blood while guiding its flow and opening through the menses. Therefore, in addition to using herbs to vitalize blood and transform stasis, one should also assist with herbs to synchronize and regulate Qi and move stasis.  The point is to first give herbs to move the menstrual Qi.  It is said that “When menstrual blood does not move, first move the Qi because when the Qi moves, the blood will move.  When there is Qi stasis, there is blood stasis and when there is blood stasis, the blood obstructs the Qi movement”.  Because of this, I add Xiang Fu, Wu Yao and Mu Xiang.  These 3 herb flavors regulate the Qi and synchronize the Qi of the Liver, Kidney and Spleen Zang.  When regulating Qi and moving stasis it helps to vitalize blood and open the menstruation and so you can add Qing Pi.  This herb helps promote easy flow and discharge and strengthens the regulating and synchronizing of the Liver Qi.  Because the Liver stores the blood and governs free flow and discharge, when you want to help the flow and discharge of the menstrual blood and this will regulate Qi and synchronize the menstruation.  Therefore when regulating the Qi and synchronizing the menstruation, one should lay stress on the Liver.  One can add Shan Zha.  Master Zhang uses this not only to vitalize blood and open the menstruation, but also to synchronize and regulate the Qi mechanism.  Because of all this, Jia Jian Tong Yu Tang (Modified Open Through Stasis Decoction) is frequently used in the clinic.

Clinical Application

According to Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns), Tong Yu Jian (Open Through Stasis Decoction) treats Qi stasis, congealed blood, inhibited menstruation and vessels and extreme abdominal pain.  In addition to treating late menstruation, lack of smooth flow of menses and painful menstruation, Jia Jian Tong Yu Jian (Modified Open Through Stasis Decoction) can also treat post partum congealed blood excess pain as well as blood reversal or blood rebellion.

1.Late Menstruation, scanty menstruation and painful menstruation:
This formula can be used when there is scanty menstruate that does not flow smoothly.  This presents with abdominal pain that resists pressure, purple blood with dark with clots, pain and distention in the abdomen, chest oppression and vexation.  The pulse is thin and wiry and the tongue is purple and dark.  In this circumstance you can add herbs such as Rou Gui and Ze Lan Ye.

2.Post partum blood stasis abdominal pain:
During the post partum time, if the lochia stops too soon or does not flow out smoothly and this is accompanied by purple dark blood with clots, lower abdominal distention and pain, low back soreness and weakness with chest oppression, abdominal distention, purple dark tongue and a thin rough pulse, one should add Ze Lan Ye, Yi Mu Cao and Yan Hu Suo to this formula.

3.Blood stasis blood fainting: 
This presentation can be due to trauma from an accident, or it can simply manifest when there is scanty menstruation with abdominal pain.  The patient suffers from dizziness, fainting, cold limbs, nausea and vomiting, abdominal distention, a thin pulse and a purple dark tongue.  In this circumstance you can add herbs such as Shi Chang Pu, Guang Yu Jin, Zhi Mo Yao or Zhi Ru Xiang.

Modifications:

This formula is from the Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns and it can be modified as below:

1.If there is cold stasis add Rou Gui and Wu Zhu Yu

2.If there is full fire with inner heat with blood that does not move due to dry blood add Chao Shan Zhi, Dan Pi.

3.With slight heat and blood deficiency add Bai Shao and Gui Shen.

4.With blood stasis with very scanty blood add Su Mu and Chong Wei Zi

5.With dry knotted stool add Da Huang and E Zhu or add Mang Xiao and Tao Ren.

Clinical Experience

Tong Yu Jian(Open Through the Menses Decoction) is really 3 formulas. 

1.Tong Yu Jian (Open Through the Menses Decoction) comes from the (Jing Yue Quan Shu: Fu Ren Gui (The Complete Works of Jing Yue: Women’s patterns).  MyJia Jian Tong Yu Tang (Modified Open through the Menses Decoction) was developed based on this formula and my own clinical experience.

2.The second formula is from the Xian Nian Ji (Immortal Collections): Vol. 4. This formula uses Gui Wei, Da Huang, Hong Hua, Su Mu.  These are strong herbs for dispelling stasis but in this formula the dosages are light.  It is for moving evil blood and is used primarily for dispelling when there is post partum congealed blood and stasis leading to poor flow of the menstruation.  This is considered evil blood.

3.The third formula is from Guang Lue Liu Shu: chapter 25. It uses Pu Huang, Wu Ling Zhi, Chuan Yu Jin, Xiao Zhi Shi, Bai Zhu Tang, Jian Ze Xie, Xi Chi Shao, Tao Ren Ni, Ming Hu Bo.  This formula is used to treat blood stasis in which the abdomen becomes filled with fluid.  The pulse is rough and not smooth.  In theFang Lun Xuan Lu (Selected Writings on Formula Theory) it is written: “When blood stasis is not dispersed, the Spleen and Stomach loose their ability to be fortified and to transform and transport the minute essences.  The turbid Yin gets stopped up and this leads to abdominal distention and fullness.  This is called Blood Tympanites (Gu 臌).  Pu Huang cracks congealed blood, it opens the channels and collaterals.  Wu Ling Zhi cracks congealed blood and also descends the turbid Yin.  Tao Ren cracks the congealed and also moistens dryness.  Chi Shao cracks the congealed and also discharges fire.  Zhi Shi disperses distention and fullness. [Bai] Zhu Tan fortifies the Spleen Qi.  Yu Jin synchronizes the Qi and opens depressive knotting.  Ze Xie separates the clear Yang.  Hu Bo disperses congealed blood and allows open permeability, allowing the congealed to be transformed and for the Qi to be synchronized.  The result is that the Chong vessel is clear and harmonized, the Spleen and Liver Qi transform and the blockage is immediately opened.  How could abdominal distention not recede”?

What these formulas treat is not the same.  However, the meaning of the formulas is identical.  They can be used together in the clinic and adjusted according to the presentation.  When I use Tong Yu Jian (Open Through Stasis Decoction) in the clinic, I often add Shi Xiao San (Powder for Loss of Smile), Tao Ren, Ze Lan and Chuan Niu Xi.  This strengthens the force of transforming stasis and opening the menstruation.  This is because, when the menstruation is blocked and not flowing smoothly, this is usually related to congealed blood and Qi stasis.  So we can say that if we want to open the menstruation we must transform stasis.  If we want to transform stasis we must assist this by moving the Qi.  Qi and blood movement complement each other.  Therefore, in relation to illnesses of menstruation, the meaning of opening through stasis is to open through the menses and transform stasis.

In my own clinical practice I see patients who have serious endometritis.  This may develop after dilation and curettage surgery and it can give rise to adhesions of the uterine cavity.  The degree of adhesions can vary as can the extent to which it influences the menstruation.  It may give rise to scanty menstruation or even amenorrhea.  In general though, this is due to stasis and obstruction in the uterus with lack of free movement of the blood. Tong Yu Jian (Open Through Stasis Decoction) can treat this but the effect is only good in relatively light cases.  For more serious cases surgery must be used to sever the adhesions and this formula can be used after that.

Detailed analysis of the principle herbs in this formula: Hong Hua and Shan Zha.

There are three principle herbs in this formula: Dang Gui Wei, Hong Hua and Shan Zha.  Dang Gui Wei is represented by Dang Gui and has been discussed in previous chapters so here I will discuss Hong Hua and Shan Zha.

Hong Hua

Hong Hua is also called Hong Lan Hua.  It is pungent and its nature is warm.  It enters the Heart and Liver.  Its function is to vitalize blood and open through menses.  It dispels stasis and stops pain and can be used for congealed blood type amenorrhea and post partum congealed static blood abdominal pain.   TheBen Cao Guang Mu (The Grand Compendium of Materia Medica) considers Hong Hua an herb to “vitalize blood, moisten dryness, stop pain, disperse swelling and open through the menses”.  It also says “Blood is generated in the heart wrapper, stored in the Liver and belongs to the Chong and Ren vessels.  Hong Hua is the likeness of blood and therefore, in men it is able to move the blood vessels and in women it opens through the menstrual water.  In large amounts it moves the blood and in small amounts it nourishes the blood.  The Ben Cao Hui Yan (Treasury of Words on the Materia Medica) says “Hong Hua cracks the blood, moves the blood, vitalizes the blood and synchronizes the blood.  Primarily it is used to treat the 100 diseases of pregnancy and birth in which the blood is damaged.  It is also used to treat blood vexation, blood dizziness, unconsciousness with an inability to speak, the lochia striking the Heart, gripping pain around the umbilicus, difficult birth, uterine lining failing to discharge or expired fetus in the abdomen.  All of these are presentations of birthing which Hong Hua can treat.  If there is post partum blood dizziness, lock jaw with clenched fists or an evil enters the blood chamber with incessant talking to the point of craziness or blood oppression with interior distention and the patient falls over stiffly as if dead.  These are all post partum presentations for which Hong Hua cannot help but calm.  If there is amenorrhea with no opening through with cold and heat mixed together or late menstruation with abdominal pain and dark purple dripping or traumatic injury with Qi and blood congealed and accumulating – these are all due to a lack of harmony of Qi and blood.  How can Hong Hua fail to synchronize”?

Shan Zha

Shan Zha is sweet and sour and its nature is slightly warm.  It enters the Spleen, Stomach and Liver channels.  Its function is to disperse food and fortify the Stomach.  When we analyze the pharmo-dynamics of Shan Zha we see that it increases the secretion of the digestive enzymes and is also able to promote the digestion of fats.  This is accompanied by an ability to strengthen Heart function and lower the blood fat. This can be used for presentations that include indigestion, post partum congealed obstructed abdominal pain, hernia and chest obstruction heart pain. The Shen Nong Ben Cao Jing Shu (Commentary on ‘Shen Nong’s Classic of the Materia Medica) says “Shan Zha enters the foot Yang Ming and Tai Yin channels.  The Ben Jing Classic of Materia Medica says that the flavor is sour and the Qi is cold.  That this is able to disperse the digestion and move congealed blood indicates that it is not cold.  Shan Zha is able to enter the Spleen and Stomach, scatter abiding accumulated stasis and water dysentery with post partum blocked pain in the abdomen. Generally Shan Zha is thought to transform food and fluids, fortify the Spleen and Stomach, move knotted Qi and disperse congealed blood.  Because of this it is a suitable food for children and birthing women.  The Ben Jing Classic of Materia Medicaalso says that this is cold and so it has a function as a wash for scabies.  We can see that fundamentally Shan Zha fortifies the Spleen and disperses food stasis.  It also functions to vitalize the blood, transform stasis and disperse accumulated stasis.

Practical Experience

Tong Yu Jian (Open Through the Menses Decoction) is a formula I use frequently in the clinic for lack of free flow of the menstruation.  I often use it with Yue Ju Wanor Wu Wei Tiao Jing San (Tang).  The results are quite good.  For acute abdominal pain use Hong Hua Jiu and the pain will stop.  The Jin Gui (Essentials From The Golden Cabinet) discussed early on that the single flavor Dang Gui in Dang Gui Wan (San) is used for painful menstruation.  The Xian Dai Zhong Yao Xue Da Ci Dian (The Modern Great Dictionary of Chinese Herbs) says that as a principle herb, Shan Zha treats functional dysmenorrhea.  Use 30 gm without the pit, Sunflower seed with the husk 15 gm.  After roasting, grind these into a powder and add 60 gm of brown sugar.  Take one package a day divided into 2 doses or decoct.  Every time before the menses take two packages and do this for 2 cycles.  I treated 105 patients: 30 had a cure, 50 improved and 25 were without effect.  The effect was good for those with blood stasis and deficiency cold.

I treated one case of long cycle.  Ms. Zhang was 35 and her menstruation was scanty and did not flow smoothly.  The color was purple red with small clots and there was lower abdominal acute pain.  When she bled this pain lasted for 12-15 days.  She had an IUD.  Her gynecology and bi-manual check-up revealed no abnormalities and the position of the IUD was normal.  It had been there for 5 years.  Her menstruation had lengthened for the last 5 months.  Her pulse was thin and wiry and her tongue body was dark red with a yellow sticky moss.  On the first day of her menstruation, I gave her 7 packages of Jia Jian Tong Yu Jian(Modified Open Through the Menses Decoction). She stopped bleeding after 8 days.  At the next menstruation I again gave her 7 packages of Jia Jian Tong Yu Jian (Modified Open Through the Menses Decoction).  She bled for 7 days and on day 2 and 3 the amount of blood increased.  She then resumed a normal menstrual cycle.

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