Functional uterine bleeding is a common gynecological condition. It results from dysfunction of the neuroendocrine system that regulates reproduction. It is called “functional” because there is no organic abnormality in the external or internal genital organs.
Functional uterine bleeding may be ovulatory or anovulatory (associated with the absence of ovulation). Most cases are of the anovulatory type, and are characterized by irregular menstruation with variable amounts of menses. Occasionally, the bleeding may be massive.
Etiology and Pathology
The principal pathological mechanism is injury to the Chong and Ren Meridians, so that they cannot control blood in the uterine channels. The most common causes of injury are kidney insufficiency, spleen insufficiency, Heat in the blood and blood stasis.
Kidney Insufficiency. Kidney insufficiency may be the result of inadequate prenatal endowment, under-developed kidney-Qi in a young woman or decline of kidney-Qi in a mature woman. Decline of kidney-Qi may result from too early marriage and multiple pregnancies or unrestrained sexual activity. The kidney is the foundation of the Chong and Ren Meridians, and the uterine channels connect with the kidney. Deficiency of kidney-Qi results in loss of control of the Chong and Ren Meridians, hence uterine bleeding.
Deficiency of kidney-Yin may give rise to endogenous Fire. Such deficiency Fire also causes the Chong and Ren Meridians to lose control.
Spleen Insufficiency. Insufficiency of the spleen results from improper diet, excessive physical exertion or excessive brooding or anxiety. This leads to deficiency of spleen-Qi, so that the ability to control the Chong and Ren Meridians is impaired.
Heat in Blood. Heat in the blood may be of deficiency or strength type.
Deficiency Heat is endogenous Heat arising out of Yin deficiency, whether due to constitutional weakness or to serious or chronic illness. In either case, Heat disturbs the Chong and Ren Meridians, eventually leading to uterine bleeding. Uterine bleeding in turn consumes Yin and further injures the Chong and Ren Meridians. A vicious cycle develops and results in recurrent and intractable uterine bleeding.
The strength type of Heat arises if there is excessive Yang, excessive passions or excessive ingestion of spicy, acrid or drying foods or herbs. It may also be due to exogenous Heat invading the person. Like deficiency Heat, strength Heat in the blood disturbs the Chong and Ren Meridians.
Blood Stasis. Blood stasis may develop from several causes. Injury by the passions may lead to gelling of blood in the Chong and Ren Meridians. Persistent menstrual flow or post-partum bleeding, especially with superimposed exposure to Cold or Heat, may induce stasis of blood. Whether it is gelling of blood or stasis, there follow blockage of the Chong and Ren Meridians and abnormal blood flow, resulting in abnormal uterine bleeding.
Clinical Manifestation
The main characteristics of anovulatory functional uterine bleeding are uterine bleeding when not expected, irregular menstrual cycles, variable duration of menstrual flow and variable amount of menses. Occasionally, the bleeding may be massive. Several “cycles” or months of amenorrhea may precede the unexpected bleeding. The bleeding may persists for several weeks or longer, and does not stop readily. Sometimes the unexpected bleeding is the first symptom. Regardless of the etiology, if the bleeding persists or is massive insufficiency of blood may ensue.
Herbal Treatment
With anovulatory functional uterine bleeding, the external and internal genital organs are all normal and ovarian function tests show the absence of ovulation.
The basic principle of treatment is to treat the symptoms when urgent and the cause when not urgent. Within this principle the three actions are cessation, resolution and restoration – singly or in combination.
Cessation is stopping the bleeding. When bleeding is profuse the approach is to astringe and to replenish blood. It is inappropriate to apply acrid-warm mobilization of blood, as doing so can worsen bleeding and precipitate Yin exhaustion or Yang collapse. Two appropriate and commonly used formulas are Sheng Mai San (Pulse-Generating Powder) and Shen Fu Tang (Ginseng-Aconitum Decoction). If bleeding is relatively slow but persistent, the appropriate approach is to generate blood and mobilize Qi. Treatment must not apply too much astringency to avoid inducing blood stasis.
Resolution is eliminating the cause. This may require strengthening the kidney or the spleen, cooling Heat, eliminating Cold or removing blood stasis. Cessation and resolution are often applied in concert.
Restoration is returning organ functions to normality. This action is generally applied after bleeding has been stopped. Restoring normal kidney and spleen functions is important for restoring normal menstruation and reproduction, and especially so in a young female with a deficiency disorder.
Kidney Insufficiency
Kidney-Yang Deficiency
Main Symptoms. Uterine bleeding is unexpected and is large in amount. It tends to persist and the menses are light in color and thin in texture. Additional symptoms include lumbar pain as though the back is broken, cold-intolerance, cold limbs, increased clear urine, loose feces and a dusky complexion. The tongue is pale, with thin white coating. The pulse is deep and threadlike.
Therapeutic Principle. Warm the kidney, assist Yang, make firm the Chong Meridian and stop bleeding.
Treatment. Da Bu Yuan Jian (Major Genuine Qi Restoring Decoction) augmented with buguzhi, lujiaojiao and charred aiye as clinically appropriate. The augmented composition is as follows: renshen (Panax) 10 g, shanyao (Dioscorea) 15 g, shudihuang (Rehmannia) 12 g, duzhong (Eucommia) 12 g, danggui (Angelica) 10 g, shanzhuyu (Cornus) 12 g, gouqizi (Lycium) 12 g, fried gancao (Glycyrrhiza) 6g, buguzhi (Psoralea) 12 g, lujiaojiao (Cervus nippon) 15 g, and charred aiye (Artemisia) 10 g. Note: lujiaojiao is dissolved in the finished decoction.
Kidney-Yin Deficiency
Main Symptoms. Uterine bleeding is unexpected. The amount is variable, large in some patients and small in others. In either case it tends to persist. The blood is bright red in color and viscid in quality. Additional symptoms include aching weakness in the waist and knees, dizziness, tinnitus and hotness of the five centers. The tongue is red with slight coating. The pulse is threadlike and rapid.
Therapeutic Principle. Nourish the kidney, augment Yin, make firm the Chong Meridian and stop bleeding.
Treatment. Zuo Gui Wan (kidney-Yin-Augmenting Pill) minus niuxi and combined with Er Zhi Wan. The final composition is as follows: shudihuang (Rehmannia) 15 g, shanyao (Dioscorea) 15 g, gouqizi (Lycium) 12 g, tusizi (Cuscuta) 12 g, lujiaojiao (Cervus nippon) 15 g, guiban gelatin (Chinemys) 15 g, nuzhenzi (Ligustrum) 12 g, and moliancao (Eclipta) 15 g. Note: lujiaojiao and guiban gelatin are dissolved in the finished decoction.
Spleen Insufficiency
Main Symptoms. Uterine bleeding is unexpected and is large in amount, as though a dam has broken, or persistent like a stream. The menses are light-colored and thin. Additional symptoms include lassitude, fatigue, shortness of breath, no desire to speak, anorexia and cold limbs; or, edema of the face and limbs and a sallow complexion. The tongue is pale and plump, with thin white coating. The pulse is even but feeble.
Therapeutic Principle. Strengthen the spleen, augment Qi, make firm the Chong Meridian and stop bleeding.
Treatment. Gu Chong Tang (Chong Meridian Stabilizing Decoction).
If bleeding is profuse, add renshen (Panax) 10 g and shengma (Cimicifuga) 10 g. If bleeding is not profuse but the dribbling persists, add yimucao (Leonurus) 30 g and Qiancao (Rubia) 30 g.
Heat in Blood
Main Symptoms. Uterine bleeding is unexpected and is large in amount, as though a dam has broken, or persistent like a stream. The menses are deep red in color and viscid. Additional symptoms include agitation, insomnia, thirst with desire for cold drinks, dizziness and a flushed complexion. The tongue is red with yellow coating. The pulse is slippery and rapid.
Therapeutic Principle. Purge Heat, cool the blood, make Chong firm and stop bleeding.
Treatment. Qing Re Gu Jing Tang (Heat-Coolng Meridian-Stabilizing Decoction). It has the following composition: shengdihuang (Rehmannia) 20 g, digupi (Lycium) 15 g, roast guiban (Chinemys) 10 g, powdered muli (Ostrea) 12 g, ejiao (Equus asinus) 15 g, huangqin (Scutellaria) 15 g, oujie (Nelumbo nucifera) 15 g, charred zonglu (Trachycarpus fortunei) 10 g, gancao (Glycyrrhiza) 6g, zhizi (Gardenia jasminoides) 10 g, and diyu (Sanguisorba) 15 g. Note: guiban and muli are decocted first, and ejiao is dissolved in the finished decoction.
If stagnant liver-Qi have given rise to Fire, with tightness and pain in the chest and breasts, agitation, irascibility, frequent sighing and a taut and rapid pulse, use the formula Dan Zhi Xiao Yao San (Tree Peony-Gardenia Carefree Powder).
Blood Stasis
Main Symptoms. Uterine bleeding is unexpected, in large or small amount but persistent. The menses are dark purple and contain clots. In addition, there is pain in the lower abdomen, with guarding. The tongue is cyanotic or speckled with purpuric spots. The pulse is impeded.
Therapeutic Principle. Mobilize blood, eliminate stasis, firm Chong and stop bleeding.
Treatment. Zhu Yu Zhi Ben Tang (Stasis-Eliminating Bleeding-Stopping Decoction). It has the following composition: danggui (Angelica) 12 g, chuanx-iong (Ligusticum) 10 g, sanqi (Panax pseudoginseng) 10 g, moyao (Commiphora) 8 g, wulingzhi (Pleropuspselaphon) 10 g, mudanpi (Paeonia suffruticosa) 10 g, danshen (Salvia) 12 g, aiye (Artemisia) 10 g, ejiao (Equus asinus) 15 g, puhuang (Typha angustifolia) 15 g, longgu (fossil bone) 20 g, muli (Ostrea) 30 g, and wuzeigu (Sepia esculenta) 15 g. Note: longgu and muli are decocted first.
Acupuncture Treatment
For anovulatory functional uterine bleeding in general, select the acupoints Guanyuan (RN-4), Sanyinjiao (SP-6) and Yinbai (SP-1).
If it is due to strength Heat, add the acupoints Xuehai (SP-10) and Shuiquan (KI-5).
If it is due to deficiency Heat, add the acupoints Neiguan (PC-6) and Taixi (KI-3). If it is due to Qi deficiency, add the acupoints Pishu (BL-20) and Zusanli (ST-36). If there is syncope as well, add the acupoint Baihui (DU-20).
Case Study
The patient was a 32-year married woman who had irregular vaginal bleeding for over a year. The amount of bleeding varied. There were also lower abdominal distention and pain with guarding, distending pain in the breasts, aching in the waist and anorexia. Previous gynecological examination showed secretory hyperplasia of the breasts. Uterine curettage showed hypertrophy of the endometrium with some localized adenoma-like changes.
At the time of consultation she had been bleeding for 2 months, sometimes more and sometimes less. The menses were dark purple and contained clots. Her tongue was dusky red and was covered with a thin layer of pale yellow coating. Her pulse was deep and threadlike. In the guan position it was also somewhat impeded.
Diagnosis. Anovulatory uterine bleeding, functional, due to blood stasis causing blockage of the Chong and Ren Meridians.
Therapeutic Principle. Mobilize Qi and blood, regulate menstruation and stop bleeding.
Treatment and Course. The prescribed formula had the following composition: liujinu (Artemisia anomala) 12 g, Qiancao (Rubia) 9g, chishaoyao (Paeonia) 9 g, xiangfu (Cyperus) 9 g, chuanxiong (Ligusticum) 9 g, chaihu (Bupleurum) 9 g, danshen (Salvia) 15 g, biejia (Amyda) 18 g, yanhusuo (Corydalis) 6g, danggui (Angelica) 12 g, and gancao (Glycyrrhiza) 6g.
She returned for follow-up in 5 days. Her lower abdominal pain was alleviated and the bleeding stopped. The aching in the waist and anorexia persisted. Urination and defecation were normal. The pulse was threadlike. With the partial response, a different therapeutic principle became appropriate – strengthen the kidney and the liver, nourish blood and regulate menstruation. The new prescription had the following composition: liujinu (Artemisia) 12 g, sangjisheng (Loranthus) 12 g, duzhong (Eucommia) 12 g, shanzhuyu (Cornus) 12 g, xuduan (Dipsacus) 9g, baishaoyao (Paeonia) 9g, wangbuliuxing (Vaccaria segetalis) 12 g, chaihu (Bupleurum) 12 g, chuanxiong (Ligusticum) 9 g, gegen (Pueraria) 12 g, and gancao (Glycyrrhiza) 6 g. The patient was instructed to take this formula for 15 daily doses.
She returned for a third visit 5 weeks later. At the end of her 15 days of treatment she began to menstruate. The flow lasted for 6 days. The menses were somewhat increased and were bright red. There were occasional clots. She had some aching in her waist, but no abdominal pain. At follow-up 3 months later, she reported normal menstrual cycles during the interval.
