Amenorrhea

History:
S is a 32 year old actress and writer with a 16 year history of secondary amenorrhea. She stopped menstruating at 16, when she was also suffering from anorexia nervosa. Over the past two years, she has experienced what she believed to be two menstrual periods. Both took place during visits to Italy – a place she associates with safety and comfort. She also reported eating meat and cheese during these trips, which she does not normally consume. The first period, which took place in July ’98, consisted of four days of spotting (no other details were charted). In late January ’99, she reported having one day of spotting with dark brown blood. During a recent visit to her gynecologist, the doctor explained that her hypothalamus is not functioning properly and she has been taking estrogen and progesterone for the past 4 months to regulate her hormones. Since beginning hormone therapy, the patient has been experiencing strong maternal feelings and a desire to have children, as well as an increased interest in sex.

The patient is simultaneously dealing with several emotional issues associated with repeated childhood sexual abuse and other physical and mental abuse. She reports experiencing a great deal of fear and anxiety as she becomes more social and receives more attention from men. She has also expressed some anxiety about getting her period and becoming a “whole woman”, although more recently she claims that she is ready. Furthermore, the patient has a fear of losing control that manifests itself primarily in her dietary habits. For the past several years she has belonged to a 12-step program for overeaters (“Gray Sheet”), which has put her on a very restricted diet. As part of this program she weighs and measures everything she eats. The patient fears that without these parameters, she might lose control. Recently, she has been attempting to take small steps outside these parameters by eating some of the foods that she craves that are not “on her list” (eg. soybeans, oatmeal), but this can cause acute anxiety.

Current Health Status:
Digestion: Gas and bloating after eating; trouble digesting food – some nausea/gagging
Appetite: ok; craves “mushy” food. Her diet consists largely of soymilk, wheat germ and green salads. Her dietary program permits 4oz of protein per meal (usually as tofu).
Urine: 6x/day; yellow color due to vitamins
Stool: 2x/day; well-formed
Temp: dislikes cold/dry weather
Sweat: not remarkable
Thirst: not particularly; drinks soymilk and several cups of coffee daily
Energy: good, but needs coffee to get motivated; *appears frazzled and manic.
Sleep: generally good; has been having nightmares that she wakes from gasping for air and sometimes screaming; dreams with common themes of empowerment and water.
Emotions: Anxiety related to boundary issues (people getting close, trusting); tends to dissociate and can become “spaced out”. The patient is has been fearful and manic and is inclined to worry obsessively.
Head/Eyes/Ears: Migraines (1-2x/month); throbbing, lateral headaches; better w/caffeine
Menses: amenorrhea (see above)

Past Medical History:
1969 – born jaundiced; blood transfusion after poisoning
1996 – broken ankle (steel plate inserted)
1997 – fainting/dehydration
1998 – steel plate removed
2000 – broken nose due to a fall (fainting)
Herpes (oral)
Frequent colds, nightsweats, dizziness, fainting, palpitations
Brittle bones – due to her eating disorder, the patient has osteopenia.

Family Health History:
None noted

Medications:
estrogen, progesterone

Allergic History:
n/a

Physical Exam:
a. Tongue:body: pale red, puffy, scalloped; concave in lung area
coat: thin white, becoming thicker & yellow towards root veins: normal
b. Facial complexion: yellow complexion, particularly around mouth
c. Body shape and posture: thin/slightly underdeveloped upper body; yellow hands
d. Shen: manic and animated
e. Listening and Smelling: no unusual sounds or smells observed
f. Palpation:
i. Pulse: 56 BPM
Right – slippery and forceful
Left – slippery, less forceful

ii. Abdomen/Channels: tender @ Sp 21, Ren 12, subcostal areas, Sp 4, 6, 9 & Pc 6

Diagnosis: Heart and Kidney failing to communicate; Kidney Essence Deficiency

Kidney Essence Deficiency Heart & Kidney Not Communicating
Amenorrhea for 16 years
Brittle/Broken Bones
Anorexia Thin, underdeveloped upper body
Manic behavior; restlessness
Nightsweats
Palpitations
Profuse dreaming (water themes)
Waking from nightmares gasping for air
Fear and Anxiety
history of sexual abuse




Discussion:
This patient’s pathology is rooted in emotional/physical trauma. As the victim of childhood sexual abuse, this patient suffered significant trauma at an early age, which has compromised the interaction of Heart and Kidney. Because of this, the patient’s insight is no longer rooted in her inherent nature. Without root, she cannot direct her efforts towards her own fulfillment and is constantly seeking answers and finding influences outside her own instincts.

The patient’s will (zhi) focuses externally on trying to control her body and her eating habits. She struggles on a regular basis with what she craves or is instinctually drawn to, choosing instead to direct her will towards adhering to strict dietary regimen that was designed to address an eating disorder that she believes she has. She exercises control by weighing and measuring all of her food, literally depleting her innate potential of jing to satisfy habitual desires of the mind. Over time, her prior anorexia and present diet, which consists primarily of cold and raw foods in very limited quantities, has deprived her of the gu qi/food qi she requires to produce post-heaven qi. Without sufficient gu qi produced by the Spleen, her body tapped into its reserves, using yuan qi or essence from the Kidneys. Deficient Kidney essence has led to brittle bones and the patient is prone to fractures. Her overall constitution has been compromised and she has muscle atrophy and weakness in her upper body. Deficient Spleen qi hinders the Spleen’s functions of properly transforming and transporting food and water, and dampness has accumulated in the patient’s middle jiao, producing gas, bloating and nausea after meals . And since the middle jiao serves as a pivot between the upper and lower jiao, the relationship between the heart and kidney is further compromised. The patient’s slippery pulse is indicative of the excess damp that is accumulating. Her puffy and scalloped tongue body also points to the inability of Spleen to properly nourish muscles and send water downward through the water passageways.

The Chong is the “Sea of Blood” and is strongly related to gynecological and reproductive function. This channel relies on blood produced by the Heart and Spleen and essence from the Kidneys in order to warm and nourish the womb. Overthinking, emotional trauma and lack of nutrients have damaged both Heart and Spleen Qi, preventing them from producing blood. Without sufficient blood and essence, the Chong can no longer nourish the womb and promote reproductive function and the patient cannot get her period.

Heart fire normally descends to warm the kidneys as Kidney water rises to meet with the heart, maintaining a balance of water and fire. When heart fire no longer descends to meet the kidneys, fire flares upward to cause mania and restlessness and frequently manifests as fever blisters around the patient’s mouth. Without its connection to the kidneys, the Heart spirit (shen) wanders and the patient experiences profuse dreams. Frequent dreams of water may be evidence of the heart shen (fire) seeking its link to the kidney (water). The patient wakes from nightmares gasping for air since the Kidneys are also responsible for grasping the Qi. Furthermore, the heart governs intimacy. Without the connection between heart and kidney, the patient appears to long for intimacy in every interaction while simultaneously mistrusting and fearing truly intimate relationships. The kidneys, which are strongly associated with sexuality and reproductive functions, no longer have the guidance of the heart and the patient is threatened by her sexuality. She becomes easily “disconnected” when social interactions overwhelm her.


Treatment Plan:
Secure Kidney Essence; Tonify Heart & Kidney Yin

Prescription:
a. Acupuncture:
Sp 4 Confluent of the Chong - Harmonizes the Chong, Regulates Menses, Rectifies the Qi Dynamic, Supplements the Spleen & Stomach
Pc 6 Confluent of the YinWei –Eliminates Vexation; Calms the Mind; Regulates Heart Qi and blood
Lu 8 Jing River (Metal/horary)
Ki 7 Jing River (Metal/mother) – Tonifies the Kidneys and resolves damp; Tonifies Yin
Du 20 Intersects Yang Channels & Ren – Clears the Spirit & Returns inversion; Tonifies Yang; Calms the Spirit; Raises Yang Qi and brings Clear Qi to the head; Strengthens Ascending Fx of the Spleen
Ren 4 Front Mu of SI; Intersects with SP/LV/KI; Banks the Kidneys & Secures the Root; Supplements Qi and Returns Yang; Warms and Regulates the Blood Chamber and Palace of Essence; Eliminates Cold in the Genitals; Nourishes Blood and Yin; Roots the Ethereal Soul.
Ht 5 Luo – Quiets the Spirit and Regulates Heart Qi; Clears Heart Fire (through urine/UB)

b. Acupuncture Analysis:
This formula focuses primarily on tonifying the Kidneys, calming the heart and restoring blood and yin in the Chong to bring about menstruation. Sp 4 and Pc 6 are used together to open the Chong and have particular functions to regulate the patient’s menses and calm her restless spirit. These points will also tonify her Spleen and redirect rebellious qi, enabling her to digest food better to produce qi and blood. Lu 8, the mother (metal) point on the Kidney’s mother channel, is used with Ki 7, the mother (metal) point on the Kidney channel, to tonify the Kidneys . In addition to tonifying kidney yin, Ki 7 has a special function to regulate waterways and prevent damp accumulation, which is useful since this patient is having digestive difficulties that tend to encourage dampness. Du 20 works with both Pc 6 and Ht 5 towards calming her spirit to address her mania and alleviate her “spaced out” feeling. These points can also help with her dream disturbed sleep. Once the qi has been distributed and tonified, Ren 4 is used to bring her back to center, tonifying her Kidneys, securing essence and supplementing blood in her reproductive organs and warming and calming this patient.

c. Herbs: Tian Wang Bu Xin Dan + Bai Zhu, Xiang Fu, Yi Mu Cao

Herbal Analysis:
The patient’s formula, a moderated version of Tian Wang Bu Xin Dan, is intended to tonify yin and blood of the Heart and Kidneys to soothe the patient’s anxiety and provide nourishment to the Chong to promote menstruation. The formula also addresses and underlying Spleen Qi vacuity and prevents dampness and stagnation with moving and mildly draining herbs.

Tian Wang Bu Xin Dan is a formula designed to tonify Heart and Kidney Yin and reestablish the relationship between the two organs. It’s chief herb, Sheng Di Huang, nourishes both blood and Kidney yin, enabling Kidney (water) to control the heart fire that disturbs the patient’s spirit. Zhu Sha aids in anchoring the spirit, along with Bai Zi Ren and Yuan Zhi, which help soothe the patient and prevent her manic tendencies, palpitations and nightmares. Mai Men Dong, Tian Men Dong and Xuan Shen help to tonify yin and clear deficient heat while Suan Zao Ren and Wu Wei Zi prevent leakage of Heart Qi and work with the yin tonifiers to prevent night sweats and help the patient sleep more soundly. Dan Shen and Dang Gui work together to nourish and move blood to promote menstruation. Ren Shen and Fu Ling also nourish and protect heart qi, but can also tonify Yuan Qi and strengthen the spleen, providing her with both pre-natal and post-natal qi. Fu Ling can also drain some of the dampness that has accumulated due to her spleen deficiency.

Bai Zhu has been added to further tonify Spleen Qi and address dampness. Xiang Fu and Yi Mu Cao work together to move both Qi and blood, particularly in the lower jiao and uterus, to bring about her period.


Subsequent Visits
S reports feeling good following treatment and feeling very “grounded”. She has gradually gained self-confidence and begun to trust her own instincts. She has stopped measuring her food and is attempting to develop healthy eating habits for herself, although she still has a great deal of fear and struggles with a tendency to binge under stress. She began gaining weight as soon as she began to make dietary changes (she was initially slightly underweight), and recently gained significant weight very rapidly due to erratic eating during an exceptionally stressful period. The patient’s complexion is significantly less jaundiced and she is generally less fragmented, although still prone to very manic behavior, particularly when issues related to her childhood abuse surface.

2/22 The patient is experiencing increasing sexual awareness with slightly less anxiety. Feeling empowered
Points: LU 7, KI 6, UB 44,52,47,20, DU 20, KI 1

3/11 Patient has anxiety about weight and body image; lots of creative and sexual energy
Points: DU 20, KI 1 & 7, HT 7, Ren 4 & 6, ST 30

3/21 Patient is scattered and unfocused, reporting breast tenderness for the first time ever with slight spotting. She continues to expand her diet with some anxiety. Patient’s complexion is becoming significantly less yellow and sallow.
Points: SP 4, PC 6, HT 3, KI 7, 6 (open pt), ST 30, GB 41 (ashi), Yin Tang
Ear: Endocrine, Liver

3/25 Period began on Thursday. Flow was initially dark brown and continuous, eventually turning bright red. This is the longest period she has had with a continuous flow. Reports knee aching/pain which extends down to her ankle.
Points: HT 7, KI 7, Zi Gong Xue, LV 8, GB 34, 40, 41, Yin Tang

3/28 Finished period (4 day flow). The patient returned to Gray Sheet for a few days; binged after an argument with her mother regarding critical comments about her weight. Feeling colder; reports some dizziness
Points: DU 20, UB 43, 44, 20, 52, 62 (open pt), SP 6

4/1 Binging issues; abuse issues surfacing. Patient wants to stop taking prozac
Points: HT 1, SP 21, SP 6, KI 7 & 22, Ren 6, SJ 4, Yin Tang

4/7 Increasing self-confidence – spoke out at a Gray Sheet meeting; stopped binging; frontal HA
Points: DU 4, KI 7, DU 20, UB 15,44, 23, 52, 20
Herbs: Modified Tian Wang Bu Xin Dan and Gui Pi Tang
(Sheng Di Huang, Dan Shen, Dang Gui, Ren Shen, Fu Ling, Yuan Zhi, Suan Zao Ren, Long Yan Rou, Mu Xiang, Da Zao, Bai Zhu, Shan Yao, He Huan Hua, Mei Gui Hua)

5/4 The patient gained significant weight over the break, particularly in her lower body, and has been having difficulty with controlling binging urges as more of her abuse issues surface.
Points: UB 44 & 52, DU 4, UB 20 & 21, SP 4

5/12 Period began 5/10, preceded by cramping, irritability and breast tenderness. Brown with clots at onset, turning pink and then red-red; light bleeding, but continuous flow; frontal HA.
Points: HT 3, KI 6, 7, UB 67, Yin Tang
Ear Seeds: Mouth, Stomach, Exciting Pt.

6/4 Peroid began 6/4

* Patient has received her period every month, regularly, since.


TCM Patterns of Amenorrhea
• Liver & Kidney Vacuity – absence of initial menstruation by 18 years old, or late menstruation where the menstrual discharge gradually decreases to the point where menstruation no longer occurs; accompanying symptoms include weak physical condition, low backache, leg weakness, dizziness and vertigo.
• Depletion of Yin & Blood Dryness: gradual decrease in menstrual discharge until menstruation no longer occurs, vexing heat in the five hearts, flushed cheeks, dry mouth and throat, night sweats, steaming bone with a red tongue with little coating and a rapid, thready pulse.
• Qi and Blood Vacuity: gradual lengthening of menstrual cycle, light menstrual discharge of pale color and thin consistency, with the menses eventually ceasing. The patient will have a pale tongue with thin white coat and a weak, thready pulse.
• Qi Stagnation and Blood Stasis: cessation of menstruation, psychological depression, irritability, distension and fullness in the chest and costal region, lower abdominal distension with pain that is aggravated by external pressure. The pulse is deep, wiry and rough and the tongue will be dark purple
• Obstruction by Phlegm Dampness: cessation of menstruation, obesity, fullness and oppression in the chest and costal regions, nausea and vomiting, excessive phlegm, tiredness, fatigue, excessive white vaginal discharge, edema of the face and feet.

Non TCM Pattern
• Heart & Kidney Not Communicating: nightsweats, mouth sores, red tongue with little coating, irritability, restlessness and insomnia the prevents the patient from not getting enough sleep