Sophie, 25, has suffered from menstrual pain for several years. Like most of her friends, she always thought it was okay to spend the first day of her period in bed frequently, with a hot water bottle to soothe her cramps. Didn’t his mother tell him that it would stop after a first pregnancy?

Recently arrived on the job market, Sophie realizes that it is now more difficult for her to be absent for an entire day almost every month. A colleague, who herself had used acupuncture to calm her menopausal hot flashes, suggested that she see an acupuncturist.

50 to 75% of women experience difficult and painful periods, also known as dysmenorrhea. Sometimes they appear as soon as you have your first period, but more often during the first two years of menstruation. The intensity of the pain, the period and the frequency of onset are different for each woman and may vary from cycle to cycle. Generally perceived as part of the lot of suffering attributable to the condition of women, dysmenorrhea is rather, according to Traditional Chinese Medicine (TCM), the sign of an energy imbalance.

1- Question

The first questions obviously relate to all the information relating to the menstrual cycle. It appears that Sophie’s cycle is 26 to 28 days, and the flow lasts about four days. The flow is dark with soft, dark clots the size of peas; it is a little hesitant the first day, and never becomes excessively abundant thereafter.

Asked to describe her pain, Sophie explains that it appears about 30 minutes after the start of her period. She has made a habit of taking pain medication as soon as her period starts. However, these seem to be less effective over the past two years. First dull, the pain then comes in spurts that she feels in the lower abdomen. Her legs are heavy and she perceives a tightening that descends from the lower back to the heels. Occasionally, the pain rises to the upper back. The hot water bottle remains her best companion in these difficult times, and she uses it alternately on her stomach and on her lower back.

Although she is rather tired on the day one of her period, Sophie however noticed that a small walk was doing her good. On the other hand, she is too cautious to walk in winter. A small glass of cognac – maternal remedy – does her good then… The pains are practically absent on day two, and she can function normally. During the premenstrual period, Sophie experiences a slight distension in the breasts and can easily have tears in the eye, or even get carried away if she is upset. Her gynecological history does not reveal any pregnancy or sexually transmitted diseases. She has lived in a relationship with the same man for two years and finds her sex life normal and satisfactory.

The second part of the questioning focuses first on the digestive sphere. Sophie eats normally, but admits having occasional chocolate cravings. A distinctive feature, she loves fruit salad for breakfast, with a full glass of milk, just like when she was little. We also learn that she doesn’t experience any particular stress, and that she loves her new job. She swims three times a week to keep fit, even though it sometimes takes a lot of willpower to face the cold water in the municipal swimming pool.

2- Auscultate

Auscultation is not used in this case.

3- Palpate

The pulse is deep and stringy. Palpation of the four quadrants and abdominal percussion (see Auscultation) ensure that there is no pain that would have revealed a pathology of the reproductive system or the intestines.

4- Observer

The tongue is slightly bluish and the coating normal.

The causes of menstrual pain listed by TCM fall into four main categories:

• Emotional tensions.
• Cold and Humidity.
• Overwork or chronic illness.
• Excessive sexual activity, including starting sex too young, or multiple and closely spaced pregnancies.

In Sophie’s case, neither emotions, overwork, or excessive sexual activity seem to be the root of the problem. Only the Cold or the Humidity remains. But where would they come from? Food is probably partly to blame. Sophie’s breakfast is in fact the ideal recipe to keep the cold going. Fruit salad and milk are cold in nature, and are very Yin (see Food). Heating up all that Yin requires a lot of Qi from the Spleen / Pancreas, resulting in a deficit in the uterus; it is then invaded by the cold. The Spleen / Pancreas is also unduly requested in the morning at a time when it should, on the contrary, receive Yang. The practice of swimming is a second factor that brings cold. Sport is beneficial in a case like this, but unfortunately frequent exposure to cool water tires out the Yang of the body, especially in winter (see Cold).

The energetic physiology of menstruation mainly involves three Organs: the Liver, Spleen / Pancreas and Kidneys.

• The Liver, by its function of storing Blood, provides the blood necessary for the uterus on a monthly basis to prepare the implantation of the ovum. By its function of circulating Qi, it also allows the onset of menstruation.
• The Spleen / Pancreas manufactures the Blood which will be stored by the Liver. By its function of supporting Qi, it maintains the Blood within the uterus.
• The Kidneys, guardians of the Essences, provide the basic material for the elaboration of menstrual blood.

The graph opposite compares the phases of the menstrual cycle with the energetic movements of Organs and Substances.

It is difficult to isolate a single characteristic in the establishment of the energy balance of dysmenorrhea, since three organs are strongly involved in the menstrual cycle, but it seems all the same that the cold has a predominant influence here:

• The clots and dark flow can come from the Cold which tends to condense the Blood.
• Dull ache, akin to tightness, can also be attributed to the Cold, which creates constriction. It is also not surprising that a hot hot water bottle – which drives cold from the uterus – brings comfort.
• The hesitant onset of menstruation and dull ache are both signs of Stagnation and Cold.
• The bursting pain felt in the lower abdomen, sometimes radiating to the upper back, the legs which are heavy, and the tightness which descends from the lower back towards the heels all signal an attack by the Cold of the tendon-muscular meridians ( see Meridians) of the Bladder and Kidneys.
• The fact that Sophie is cautious confirms the problem. The kidneys are too stressed when the body has to compensate for the cold water in the swimming pool. Over time, the Lower Heater (see Viscera) becomes depleted and can no longer effectively combat External Cold in general. Of course, a small glass of cognac is comforting; alcohol being Yang, it circulates Qi and heats up, which decreases Qi Stagnation and reduces Cold.

Another cause of the problem appears to be Qi stagnation.

• The fatigue felt on day one is explained by a Qi Void resulting from the onset of the rules. Indeed, this process requires a good amount of Qi from the already vulnerable Spleen / Pancreas.
• Light physical exercise is comforting, which indicates that it fights a certain Stagnation of Qi. This is because light exercise promotes the circulation of Qi, while intensive exercise exhausts it.
• The fact that Sophie feels a slight distension in the breasts and has tears easily in the premenstrual period are also signs of Stagnation. During this period, the Qi of the Liver increases and rises naturally. If this movement, which is Yang, is too strong and stagnates, emotions become on edge, and areas dependent on the Liver Meridian, such as the breasts, become congested.
• Deep pulse signals internal stagnation, and rope pulse reflects tension from both liver and pain.

The primary objective of the treatments will be to warm the uterus, to expel the cold and to circulate the blood. They will be applied throughout the menstrual cycle, because the cold is not only present during the rules. It has intruded into the inner part of the body over the years. The treatments will vary over the weeks, however, because the acupuncturist must take into account the energy state of the patient. The week preceding the rules will be the one where we will act most intensively on the circulation of Qi, because it is then in full expansion. On the contrary, gentleness will be the order of the day on the days of menstruation, as the Blood moves externally, which weakens the body. The choice of acupuncture points will be made accordingly. It is usually necessary to carry out treatments for three consecutive menstrual cycles to achieve lasting results.

In the second place, it will be important to treat the conditions of the ground (see Questioning) in which the diagnosis takes place, that is to say the Void of Qi of the Spleen / Pancreas. In addition to the acupuncture sessions which will aim to tone up the Qi of this organ, the patient must follow the diet and lifestyle advice given by her acupuncturist.

Sophie should avoid the cold in her diet, especially at lunch which should instead consist of warm or lukewarm Nature Foods such as oatmeal and hot fruit compotes (see Diet). She should also reduce her consumption of sugar and alcohol (Yang elements) in the premenstrual phase, because during this period the Yang is already strongly stimulated. It will be beneficial for him to adopt a soft and balanced diet and to continue to exercise. However, swimming should be avoided during menstruation and the week preceding them, because the uterus is then very vulnerable to cold. It would also be preferable to completely avoid the swimming pool during the winter, a period already very demanding for the Yang of the Kidneys.