Amenorrhea may be primary or secondary. Primary amenorrhea is the failure of menstruation to appear at all in a female aged 14 or over who has not developed secondary sex characteristics, or in a female aged 16 or over who has developed secondary sex characteristics. Secondary amenorrhea is the absence of menstruation for either 6 months or three cycles in a woman who has had regular menstruation. During pregnancy and breast-feeding amenorrhea is normal.
During adolescence the diagnosis of amenorrhea requires care. Adolescence is a state of transition between childhood and adulthood. It is not uncommon for menstruation to be irregular, sometimes even skipping for as long as 6 months.
Etiology and Pathology
The etiology and pathology of amenorrhea are relatively complex. Amenorrhea may be of the deficiency or strength type.
The deficiency type of amenorrhea is mostly due to insufficiency of the liver and the kidney, deficiency of Qi and blood, or deficiency of Yin leading to depletion of blood. These conditions lead to deficiency of essence and blood in the Chong and Ren Meridians, so that the sea of blood cannot be filled and is empty. There is simply no blood available to become menses.
Liver and Kidney Insufficiency. In some patients prenatal development of the kidney is inadequate, so that kidney-Qi does not reach ampleness and flourish. Since kidney essence and Qi are insufficient Liver-Blood is also insufficient and the Chong and Ren Meridians are not adequately nourished and cannot supply blood for menstruation. In other patients, deficiency of kidney-essence and Liver-Blood results from multiple pregnancies, miscarriage, excessive sexual activity or chronic illnesses affecting the kidney. The result is again failure of the Chong and Ren Meridians to provide blood for menstruation.
Deficiency of Qi and Blood. Chronic weakness of the spleen and the stomach, improper diet, fatigue or excessive brooding, grief or anxiety may injure the heart.
Any one of these may induce deficiency of Qi and blood, resulting in inadequate function of the Chong and Ren Meridians.
Blood Depletion due to Yin Deficiency. Constitutionally inadequate Yin or Yin deficiency resulting from excessive blood loss and overindulgence in spicy and drying foods may all lead to emptying of the sea of blood, hence amenorrhea. In severe chronic illnesses essence and Yin may become depleted; this may also lead to deficiency amenorrhea.
The strength type of amenorrhea is mostly due to Qi stagnation with blood stasis, obstruction by Phlegm-Dampness, or blood stasis due to Cold in the blood. These conditions lead to blockage of the Chong and Ren Meridians.
Qi Stagnation and Blood Stasis. Internal injury by the passions, especially long-lasting depression or rage, may induce stagnation of Qi and stasis of blood. As the movement of Qi and blood in the Chong and Ren Meridians becomes blocked the sea of blood cannot fill, resulting in amenorrhea.
Accumulation of Phlegm-Dampness. Phlegm and Dampness tend to be abundant in obese persons. Phlegm and Dampness can also form when the spleen functions are impaired. Fats, Phlegm and Dampness readily obstruct the Chong and Ren Meridians. Closure of the channels of the uterus leads to amenorrhea.
Blood Stasis due to Cold in Blood. Blood may become insufficient during and following the time of menstrual flow or following childbirth. Overindulgence in cold and raw foods or exposure to cold and water in such conditions permits the Cold evil to invade and lodge in the Chong and Ren Meridians. Lodged Cold then congeals blood and induces stasis, so that the sea of blood cannot fill.
Clinical Manifestation
In some patients amenorrhea may be associated with poor physical development, deformities, menopause, obesity, hirsutism, infertility, galactorrhea or tuberculosis. In these patients these associated conditions have their own symptoms.
Herbal Treatment
The past medical history is critically important. Look for retarded physical development, congenital defects and other disorders in the patient and in family members. Ask also about delayed menarche, pattern of menstruation, repeated endometrial curettage, postpartum uterine bleeding, tuberculosis and use of contraceptives.
The physical examination should assess the general condition, physical development, nutritional status and development of secondary sex characteristics. Look for evidence of the associated conditions mentioned in the previous subsection, and for abnormalities or deformities of the internal genital organs.
Laboratory examination may include tests for formulas, ultrasonic B scanning, pituitary function tests, ovarian hormone levels, thyroid hormone levels and adrenal gland function tests. Specific tests of uterine and ovarian functions may be appropriate, including diagnostic curettage, special x-ray studies, cervical smear cytology and crystal test, and ovarian stimulation test.
In general, if the patient has exceeded the normal age of menarche or the menstrual flow has progressively diminished, then stops, and there are other symptoms of deficiency, then the amenorrhea is of the deficiency type. If the patient has established and regular menstruation and menstruation suddenly ceases, and there are other symptoms of strength illness, then the amenorrhea is of the strength type.
The key to effective treatment of amenorrhea is the determination whether it is of the strength type or the deficiency type. It is also important to assess whether it is due to some other illness. In general, the basic therapeutic principle is the following. If it is of the deficiency type, restore what is deficient. If it is of the strength type, purge what is strong.
However, it is inappropriate to apply purgation indiscriminately or to restore too vigorously. The physician must avoid making the deficiency worse or aggravate the strong. Also, if the amenorrhea is due to some other illness then that illness must be treated first.
The deficiency type of amenorrhea is more common than the strength type.
Liver and Kidney Insufficiency
Main Symptoms. Either menarche is delayed or the menses show progressive reduction in amount, eventually ending with amenorrhea. In addition, the body constitution tends to be weak, with aching weakness in the waist and knees, dizziness and tinnitus. The tongue is pale red, with slight coating, and the pulse is deep and feeble or threadlike and impeded.
Therapeutic Principle. Strengthen the kidney and nourish the liver to regulate menstruation.
Treatment. Gui Shen Wan (Kidney-Restoring Pill) augmented with jixueteng (Spatholobus suberectus) and heshouwu (Polygonum).
Deficiency of Qi and Blood
Main Symptoms. The menstrual cycle becomes progressively longer and the menses decreased in amount, light-colored and thin. Eventually amenorrhea ensues. There may be dizziness with blurred vision, or palpitations of the heart with shortness of breath, lassitude and tired limbs, or anorexia with lusterless hair and skin. The tongue is pale with slight or thin white coating, and the pulse is deep and even.
Therapeutic Principle. Nourish Qi and blood and regulate menstruation.
Treatment. Renshen Yang Rong Tang (Ginseng Qi-and-Blood-Nourishing Decoction). It has the following composition: renshen (Panax) 10 g, huangqi (Astragalus) 20 g, baizhu (Atractylodes) 12 g, fuling (Poria) 20 g, yuanzhi (Polygala) 10 g, chenpi (Citrus tangerina) 6g, wuweizi (Schisandra) 10 g, danggui (Angelica) 10 g, baishaoyao (Paeonia) 15 g, shudihuang (Rehmannia) 12 g, rougui (Cinnamomum) 8 g, and fried gancao (Glycyrrhiza) 6 g.
In occasional patients, amenorrhea is due to severe postpartum hemorrhage and is accompanied by lack of interest, vaginal dryness, vulvar and axillary hair loss, reduced libido and genital atrophy in addition to symptoms of Qi and blood insufficiency. This is due to depletion of essence and blood, deficiency of kidney-Qi and emptiness of the Chong and Ren Meridians. For treatment, use Renshen Yang Rong Tang with added lurong (Cervus nippon) 10 g, lujiaoshuang (Cervus nippon) 10 g, ziheche (human placenta) 10 g or other restorative herbs. The formula should be taken over a long period of time.
Blood Depletion due to Yin Deficiency
Main Symptoms. The menses progressively become less until menstruation ceases all together. In addition, there may be such symptoms as hotness in the five centers, fever with exhaustion, and recurrent fever with night sweats or hemoptysis. The tongue is red with slight coating. The pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin, cool Heat and regulate menstruation.
Treatment. Yi Guan Jian (Yin-Generating Liver-Opening Prescription), with added huangjing, danshen and zhiqiao.The expanded formula here has the following composition: shengdihuang (Rehmannia) 15 g, shudihuang (Rehmannia) 15 g, baishaoyao (Paeonia) 20 g, maimendong (Ophiopogon) 10 g, zhimu (Anemarrhena) 10 g, digupi (Lycium) 12 g, gancao (Glycyrrhiza) 6 g, huangjing (Polygonatum) 12 g, danshen (Salvia) 12 g, and zhiqiao (Poncirus trifoliata) 10 g.
For restlessness and recurrent fever, add Qinghao (Artemisia) 15 g and biejia (Amyda) 15 g. Biejia has to be decocted first.
If there are coughing and hemoptysis as well, add wuweizi (Schisandra) 10 g, baihe (Lilium) 10 g, beimu (Fritillaria) 10 g and ejiao (Equus) 15 g. Ejiao has to be dissolved in the finished decoction.
For restlessness, insomnia and palpitation of the heart, add baiziren (Biota) 12 g and yejiaoteng (Polygonum multiflorum) 15 g.
Qi Stagnation and Blood Stasis
Main Symptoms. The patient develops secondary amenorrhea, with accompanying lower abdominal pain with guarding, emotional depression, agitation, irascibility and chest and subcostal distending pain. The tongue is cyanotic or speckled with purpuric spots. The pulse is deep and taut or deep and impeded.
Therapeutic Principle. Regulate Qi, mobilize blood, eliminate stasis and unblock the channels.
Treatment. Xue Fu Zhu Yu Tang (Decoction for Releasing Blood Stasis).
If Qi stagnation is worse then blood stasis, with marked chest, subcostal and lower abdominal distention, add ezhu (Curcuma) 10 g, Qingpi (Citrus tangerina) 10 g and muxiang (Aucklandia) 15 g.
If blood stasis is worse than Qi stagnation, with lower abdominal pain with guarding, addjianghuang (Curcuma) 10 g and sanleng (Sparganium) 10 g.
Accumulation of Phlegm-Dampness
Main Symptoms. The patient has secondary amenorrhea and increased vaginal discharge that is white and viscid. In general, the patient also is obese or has generalized edema. There are also lassitude, flexed limbs, dizziness, blurred vision, heart palpitations, shortness of breath and chest and epigastric tightness. The tongue is pale and plump, with white and greasy coating. The pulse is slippery.
Therapeutic Principle. Eliminate Phlegm and Dampness, mobilize blood and regulate menstruation.
Treatment. Augmented Cang Fu Dao Tan Tang (Atratylodes-Poria Phlegm-Dissipating Decoction) – see the treatment for abnormal menstruation due to Phlegm-Dampness.
Blood Stasis due to Cold in Blood
Main Symptoms. In addition to secondary amenorrhea, the patient has cold pain in the lower abdomen, with guarding. The abdominal pain is alleviated by warmth. The body and limbs are cold, with pallid complexion. The tongue is cyanotic with white coating. The pulse is deep and tight.
Therapeutic Principle. Warm the meridians, dispel Cold, mobilize blood and regulate menstruation.
Treatment. Wen Jing Tang (Meridian-Warming Decoction) – see the treatment for abnormal menstruation due to strength Cold in the blood.
If lower abdominal cold pain is severe, add aiye (Artemisia) 10 g, xiaohuixiang (Foeniculum vulgare) 8 g and jianghuang (Curcuma) 10 g.
If the limbs are cold, add processed fuzi (Aconitum) 8 g and yinyanghuo (Epimedium) 12 g.
Acupuncture Treatment
For amenorrhea of the deficiency type, select the acupoints Pishu (BL-20), Shenshu (BL-23), Qihai (RN-6) and Zusanli (ST-36).
For amenorrhea of the strength type, select the acupoints Zhongji (RN-3), Hegu (LI-4), Xuehai (SP-10), Sanyinjiao (SP-6) and Xingjian (LR-2).
Case Study
The patient was a 24-year old married woman with a hot temper. A year previously she had a very heated argument with her husband. Her menstruation became delayed, and her menses dark and with clots. The menses progressively decreased in amount, until her menstrual flow stopped completely 7 months previously. At that time she began to have stabbing abdominal pain with guarding. There was a vague mass on palpation. She also had subcostal pain and edema in her ankles. She was restless and irascible. She became constipated and her urine was often dark yellow. The tongue was dusky red. The tongue coating was thin and greasy, but yellow and greasy on the root of the tongue. The pulse is deep, threadlike and taut. Gynecological and endocrine examinations were normal.
Diagnosis. Amenorrhea due to Qi stagnation and blood stasis.
Therapeutic Principle. Release Qi stagnation and blood stasis, with emphasis on blood stasis.
Treatment and Course. The prescribed formula had the following composition: chishaoyao (Paeonia) 12 g, sanleng (Sparganium) 12 g, ezhu (Curcuma) 12 g, taoren (Prunus persica) 12g, liujinu (Artemisia anomala) 12 g, niuxi (Achyranthes) 12 g, danggui (Angelica) 12 g, fuling (Poria) 9 g, houpo (Magnolia) 9 g, xiangfu (Cyperus) 9 g, chuanxiong (Ligusticum) 6 g, and nuzhenzi (Ligustrum) 12 g.
After three daily doses, she returned for follow-up. She had passed much flatus but defecation was not yet smooth. The lower abdominal pain was less intense. She still had edema in the ankles, and her tongue and pulse were unchanged. This was due to persistent blood stasis. Though the prescribed formula was correct, it was not sufficiently potent. The same therapeutic principle was continued, but using a more potent one. The new formula had the following composition: danggui (Angelica) 12 g, liujinu (Artemisia anomala) 12 g, niuxi (Achyranthes) 12 g, chishaoyao (Paeonia) 12 g, danshen (Salvia) 15 g, wulingzhi (Pleropus pselaphon) 12 g, puhuang (Typha angustifolia) 9 g, zelan (Lycopus lucidus) 9g, honghua (Carthamus) 9g, Qiancao (Rubia) 9g, sanleng (Sparganium) 9g, ezhu (Curcuma) 9g, dahuang (Rheum palmatum) 9g, xiangfu (Cyperus) 9g, and walengzi (Arca inflate) 24 g. Note: dahuang was wrapped separately and added after the other herbs; and as soon as defecation was smooth, it was to be discontinued or its amount cut in half.
She took this formula for three daily doses, and returned for a third visit in 2 weeks. Defecation was now normal, and subcostal and abdominal pain further improved. Menstruation returned, but the menses were scant and dark and contained some clots. The pulse was deep and taut, but somewhat impeded in the guan position. The tongue showed more hydration, with a thin and greasy coating. Thus, the uterine blood channels had opened but not yet fully, and blood circulation improved but stasis not yet completely resolved. At this point, the therapeutic principle was to generate blood and regulate menstruation. The new formula had the following composition: danggui (Angelica) 12 g, nuzhenzi (Ligustrum) 12 g, jixueteng (Spatholobus suberectus) 12 g, moliancao (Eclipta) 9g, zelan (Lycopus lucidus) 9 g, danshen (Salvia) 15 g, puhuang (Typha) 9 g, liujinu (Artemisia) 9 g, chishaoyao (Paeonia) 9 g, chaihu (Bupleurum) 6 g, xiangfu (Cyperus) 9 g, and dahuang (Rheum palmatum) 6g. Note: dahuang was wrapped separately and added just before the finish of decocting other herbs. It was to be omitted should diarrhea develop.
The patient took this formula for five daily doses, and returned for a fourth visit in a week. Her menstrual flow was now normal, ending after 6 days. Abdominal pain was completely resolved, and both urination and defecation were now normal. She was instructed to take half a tablet of Qi Zhi Xiangfu Wan (Seven-Process Cyperus Pill) in the morning and one tablet of Tong Jing Gan Lu Wan (Menstruation-Inducing Sweet Dew Pill) in the afternoon, for a total of 20 days. Moreover, during the week prior to her next expected menstrual period she was to take four daily doses of the formula prescribed at the third visit.
She returned for follow-up in 3 months. At that time, she was completely normal.
