Author

Jennie Longbottom BSc. MCSP, SRP

Background

AS is a 40-year-old woman, with an extensive history of chronic, idiopathic, pelvic pain, severe around ovulation and subsiding to a lesser degree some ten days after. She has been investigated by a number of gynaecologists, undergone several exploratory laparotomies, all results being inconclusive as to diagnosis and prognosis. She was recently transferred to a new gynaecologist, who had had some dealing with acupuncture for the use of chronic pain management.

MRI investigations failed to reveal any spinal dysfunction or pelvic pathology; she was subsequently referred for a physiotherapy assessment to exclude mechanical low back pain. If this proved inconclusive, total hysterectomy plus bilateral salpingo - oophrectomy was discussed. The patient was reluctant to undergo surgery; it is often doomed to failure (Beard 1980), or only justifiable in older women with severe problems (Shaw 1997). She was anxious to discuss all other options before this approach.

Past Medical History

AS had a long history of menstrual dysfunction, from the age of 16 she had had no regular menstrual cycle and by 18 there was no menstruation at all, but a gradual development of non-specific pelvic pain radiating around the girdle into the low back consistent with an ovulatory pattern. Tests confirmed normal ovulation and subsequent 28-day cycle without menstrual bleeding. She was placed on the contraceptive pill aged 19, in order to reduce pain. Forbes (1998) states that oral contraception (OC) may be used diagnostically to determine the aetiology of the pain, both pelvic inflammatory disease and adhesions remaining unresponsive to contraceptive application. AS reported reduced pain whilst using OC. She has two children after normal conception and delivery; pain subsided throughout the period of pregnancy, returning when breast-feeding was completed. There is a strong ovulatory component to her pain, suggestive of blood stagnation and congested pelvic veins (Beard 1988). Ultrasound may well confirm the diagnosis of pelvic vein congestion, but much criticism is directed to poor interpretation of ultrasound results and this condition is rarely well reported (Forbes 1998). Ovarian hormones (probably oestrogen) act as vasodilators; if the levels are too high, they act directly on the veins causing stagnation of blood and the release of "P" substances which cause pain (Baldry 1995). In 1986 she was sterilised and taken off OC, after which her pain became severe. In 1997 she was placed on Medroxyprogesterone-terone acetate (MPA), 150mL three monthly, together with GnRH (gonadotropin-releasing inhibitor) to suppress ovulation as the pain had continued. GnRH is a decapeptide that is synthesised primarily in the arcuate nucleus of the anterior pituitary gland. It is primarily responsible for the synthesis and release of LH (luteinizing hormone) and TSH (thyroid-stimulating hormone) contributing to a normal ovulatory cycle (Carey, Slack 1996). Her pain has gradually increased over the last five years and she attributed this to the GnHR inhibiting drugs, but there is no clinical evidence to support this view (Slack 2001).

Presenting Factors

Over the last five years pelvic pain pattern has been consistent, but with increasing severity at the time of ovulation. It has now been associated with vomiting and inability to stand upright during the ovulatory period despite the suppressant drugs.Objective Low Back Examination

Observation

As was pale, looked tired and complained of pelvic girdle pain radiating from below the umbilicus into the lower back from L1 down to the coccyx. There was no obvious pattern of referral to indicate neurogenic or discogenic involvement. A full Maitland spinal examination was undertaken and there was no suggestion that this was referred spinal pain. She had good tone and posture.

Neurological Examination

Normal

ORGAN    SPINAL SEGMENT    NERVES
Uterine fundus. Fallopian tubes. Large bowel    T11-12 L1    Sympathetics via hypogastric plexus
Outer fallopian tubes Upper ureter    T9-10    Sympathetics via aortic and mesenteric plexus
Ovaries    T9-10    Iliohypogastric
Abdominal wall    T12-L1 T12-L1 L1-L2    Iliohypogastric Iioinguinal Genitofemoral
Myofascial trigger point examination

Pelvic examination demonstrated reduction in endometrial elasticity (Barral and Mercier 2001). There were areas of trigger point sensitivity in Obturator Internus which covers the anteriolateral wall of the lesser pelvis and Rectus Abdominus attaching to the crest of the pubic bone. These two muscles, when sensitised, may well produce somatovisceral effects mimicking visceral disease (Barral 1997). Conversely, visceral disease can profoundly influence somatic sensory perception and activate trigger points (Travell and Simons 1983). For central low pelvic pain, trigger points are often located in the Rectus Abdominus and Pyramidus (Slocumb 1990). Deep palpation of Obturator Internus and Rectus Abdominus produced positive trigger points, twitch response and referral of symptomatic pain (Travell and Simons 1998). Myofascial trigger points were noted on the abdominal wall at spinal segmental innovation T12, L1 and L2. There were significant jump signs at corresponding dermatomes (Travell and Simons 1998).

Explanation

Problems of pelvic stasis and poor circulation to uterine structure causes discomfort in the lower abdomen, the uterus often collapsing backwards towards the Pouch of Douglas causing inflammation and adhesions. Lower back pain is often a secondary problem to urogenital organ position (Hacker and Moore 1998). This was clearly not referred pain from the lumbar spine and a diagnosis of chronic pelvic pain due to pelvic congestion was discussed with the Consultant who felt that the only option was a total hysterectomy and oophrectomy. Of women with chronic pelvic pain who are subjected to diagnostic laparoscopy, approximately one third have no apparent pathology (Hacker and Moore 1998). Kotarinos and Carter (1996) reported that physiotherapy for myofascial pelvic pain would resolve 20-30% of cases without further intervention and this, together with TCM acupuncture, was the first optional route. Surgical procedures have not proved effective in the past (Hacker and Moore 1998) and recent studies by Reiter (1998) and Richter et al (1998) concluded that 85% of patients responded to a protocol of drug therapy, counselling, trigger point deactivation and systemic acupuncture to increase the lasting effect of spinal endorphin production.
Chronic pain with no known pathology [CPP] is suggested by Gunn (1989) to be a subtle dysfunction of the nervous system often defying treatment. Medication and surgical interventions may only give temporary relief. It is primarily reflexively maintained pain of nocioceptive origin (Lundberg 1994). It may respond well to acupuncture by the stimulation of small diameter nerves via the spinal cord. The spinal cord, mid brain and pituitary are activated to release endorphins and monoamines to block pain messages (Stux and Hammmerschlag 2001). It was suggested that acupuncture should be attempted, together with pelvic visceral mobilisation techniques (Barral 1989) and trigger point release (Travell and Simon 1989, Baldry 1995), in order to help in pain management before further consideration of surgical intervention. This was agreed by all three parties.

Biomedical explanation

CPP is defined as being longer than six months duration and is the most common presenting problem in gynaecological practice, requiring careful gynaecological evaluation in order to eliminate gastrointestinal, orthopaedic, urinogenic, neurological and psychosomatic involvement (Forbes 1998). The distribution, intensity and relationship of the pain to the menstrual cycle are essential in order to determine the primary structure involved (Surrey et al 1998). The relationship between chronic pelvic, idiopathic pain (CPIP) and the underlying gynaecological pathology is often inexplicable (Rapkin 1998). Pain impulses that originate in the skin, muscles, bones and joints travel in somatic nerve fibres, whereas those travelling in the internal organs travel in visceral nerves. Pelvic pain is visceral (autonomic), described as dragging and aching, accompanied by vagal signs (nausea, vomiting, pallor and fainting). It is usually referred to the skin supplied by the corresponding spinal cord segment.

Gynaecological history

Pain

  • This was especially severe at ovulation suggesting some degree of mechanical or blood supply involvement. Laparoscopic examination revealed normal ovaries, blood flow through the ovaries and fallopian tubes with normal ovarian tissue and no endometriosis.
  • Severe cramp radiating across the pelvis and into the coccyx.
  • During ovulation the patient was unable to stand erect and vomited. Vomiting relieved the pain for some 20 minutes.
  • Pelvic associated conditions such as endometriosis (fixed retroverted uterus); Salpingitis (bilateral pain over fallopian tubes) and uterine prolapse were all excluded.
  • Visual Analogue Scale
  • 10/10 mid cycle, 5/10 remainder of cycle. Touch and heat aggravated pain.
  • Stress
  • As reported no excess stresses either sexually or within her life. No recurrent headaches. No depression

Depression and Disability questionnaire 2/30
Sleep disturbance, memory loss and attitudes towards pain by patient and significant others are essential. A history of physical, sexual and emotional abuse in the past or present is necessary (Grace 1998) in order to exclude any deep psychological trauma. These were initially excluded.
Traditional Chinese Examination (TCM)

Tongue

This was remarkable. During mid cycle when her pain was at its maximum, there were two large superficial, raw, red triangles over the Liver and Gall bladder region, indicating blood staisis and internal heat (Maciocia 1995). The tip was sore and red often indicating Heart Yin deficiency caused by deep emotional problems or Kidney Yin deficiency failing to supply Qi to the Heart. This was further reinforced in the pulse, night sweats, dryness of the mouth and throat and confused the general picture as she reported no undue stress or anxiety in her life. When ovulation had ceased the tongue returned to lighter shade of red but the tip remained red without soreness. This suggested obstruction of blood in the Liver Channel at the time of ovulation with some Zang Fu involvement of the Heart (Maciocia 1995).

Pulses

Si/Ht - Unsure. This fluctuated from weak to bounding    
Li/Lu
GB/Liv - Deep, wiry and bounding at mid cycle    
St/Sp - Empty / weak Mid Cycle
UB/Ki - Thready/Thin
SJ/Pe

The wiry, bounding pulse indicated stagnation of Blood and Qi and the bounding Heart pulse indicated Yin deficiency. The Stomach and Spleen pulses were weak when pain was severe which would account for rebellious Qi and vomiting.

Nutrition

Diet is a major contributing factor in many Western women’s menstrual pathology. Overeating damp, chilled uncooked, fatty or sweet foods, damages the Spleen and leads to Spleen Xu. This will prevent transformation and transportation of Qi and Blood and stagnation may accumulate (Flaws 1997). AS was healthy, of good weight and felt she maintained a balanced die, but ate a lot of cold foods. When her tongue was raw she developed a large thirst, not quenched by water with a sour taste. This would indicate involvement of Liver and Heart heat, Liver invading the Stomach (Dunbar et al 1986).

Lifestyle

She owned a small sandwich business, which kept her busy for the mornings, but she was careful to restrict her work. She did no formal exercise but was busy all day. She did not admit to any underlying stress, disharmony or anxiety, however, I sensed an underlying suggestion of anxiety, reinforced by the tongue and pulse but she was not ready to discuss this and will be referred to later in the course of treatment.

Sleep

She slept well until mid cycle when she was plagued by violent dreams and night sweats. Again, there may be some suggestion of Liver Qi, Blood disharmony and Heart involvement, which can give rise to violent dreaming and night sweats (Maciocia 1989).

TCM Explanation of Presenting Symptoms and History

According to the Nei Jing the female reproductive system is known as the Extraordinary Fu organs (Bao Luo Gong) in charge of menstruation and gestation. It neither pertains to nor shares an interior/exterior relationship with any internal organ as is demonstrated in the paired organs of the Zang Fu. The reproductive system, however, is closely related to the Qi, Blood and Zang Fu, channels and collaterals of the entire body (Flaws 1987).

Women’s physiology is characterised by menstruation, the Essence of Consummate Yin (the Kidneys) and the Qi of Consummate Yang (the Heart). Menstruation and the ability to conceive are dependent on the abundance of blood sent down via the Chong Mai, which connects the Heart and Kidneys to the uterus. Disorders in these Zang Fu may give rise to gynaecological disorders. Normal menstruation will arrive between the ages of 11 and 14 years when the Kidney Qi is exuberant. The digestion and Spleen-Stomach function is not mature until approximately 6 years when surplus Qi and Blood is then stored and adds to the Kidney Qi (Flaws 1997). Menstruation will not arrive if the pre-natal kidney essence is Xu, if the Spleen fails to transform and transport, or if the Heart fails to transform the Essence into Blood. The Liver is accorded a special role in menstruation, storing the blood; if the Liver Qi is depressed or stagnant there will be no free flow of menstruation through the uterus. Amenorrhea, or absence of menstruation as with this case, is referred to as Jing Bi (Flaws 1997) in Chinese Medicine, Bi meaning blocked and Jing referring to the menses.

Women are particularly susceptible to injury to the source of blood. The generation, circulation and control of Blood depends upon the regulatory mechanism of the Qi, conversely the Qi is nourished by the blood. If the Qi is weak it will not engender and transform the blood, it may become sluggish and stagnant, the blood becoming static and stuck (Flaws 1992)

"Qi is the commander of the Blood and Blood is the Mother of the Qi"
Nei Jing

Menstrual harmony thus depends upon the regulation and homeostasis of Qi and Blood. However, Qi and Blood originate from the Zang Fu: -

  • The Heart controls the Blood
  • The Liver stores the Blood
  • The Spleen restrains Blood within the vessels
  • The Kidney stores the Essence for the generation of Blood.
  • The Lungs control the circulation of Qi acting as a commander of the Blood
  • The Spleen and Stomach are the source of Qi and Blood.

When the Zang Fu is in harmony the Qi and Blood will circulate freely and normal menstruation will occur. On maturity the Kidney water is said to be full (Wang Bing Yang Dynasty) allowing the Ren Channel to flow unobstructedly and menstruation will occur.

Qi and Blood are circulated in the reproductive system via the Extraordinary Vessels and synergistic action of the Zang Fu. The Extraordinary Channels are closely related to female physiology and menstruation; the Chong Mai (Penetrating Vessel) is linked with the Yin Linking Vessel and Ren Mai (Directing Vessel) linked with the Yin Heel Vessel. The Chong Mai is known as the Sea of Blood (Yin) and is important for moving Qi and Blood in the Lower abdomen; the Ren Mai is responsible for tonification of Blood and Yin, regulating the Qi in the reproductive system. The Channels and network vessels are responsible for the circulation and disbursement of Qi and Blood to the rest of the body via the following vessels

  • The Chong Mai nourishes all the channels and may be Bu Gu (unsecured), Bu Tiao (unregulated) or Sun Shang (damaged)
  • Ren Mai (Directing Vessel) Opening Point: Lu 7, Coupled Point: Ki 6
  • Flows from the Kidneys through the uterus and is of paramount importance in the reproductive system of men and women. (Maciocia 1998).
  • Du Mai (Governing Vessel) Opening Point: SI 3, Coupled Point: Bl 62
  • Dai Mai (Girdle Vessel) Opening Point: GB 41, Coupled point: TE 5

(Yang Ji Zhou 1601)

The use of the Directing Vessel is particularly useful in the treatment of such symptoms as night sweats, violent dreams and dry, sore mouth. It regulates the uterus and Blood and is thus responsible for menstruation, conception, pregnancy, childbirth and menopause (Maciocia 1989). Both are dependent on the abundance of Kidney Qi. In healthy females normal 28 menstrual cycle will arrive when the Ren Mai is patent and free from obstruction and the Chong Mai is full and abundant allowing blood to flow in cyclical pattern.

Pathophysiology or injury to these Extraordinary Vessels is thought to be the main cause of gynaecological complaints. Direct causes of imbalance of the Chong Mai include repeated infections and injury during excessive sexual indulgence, abuse or very early pregnancy. Indirect causes include internal injury due to invasion of pathogens (especially damp, cold and heat causing obstruction), inappropriate diet (disharmony to Qi and Blood) and dysfunction of Zang Fu from emotional disturbances (stagnation of Liver Qi and Heart Yin). Anxiety may damage the Heart and Spleen and fright may injure the Kidneys.

The Kidneys and Liver are the foundation of the Chong and Ren Mai and are responsible for normal functioning of the Lower Jiao, stimulating the Lung descending action and Kidney reception of Qi.

When all are in harmony, abundant and overflowing as with youth, will a normal menstrual flow and cycle manifest itself.
Nei Jing

In the case of AS, absence of menstruation took place from youth with complete cessation of menses by 18 years. This indicates disharmony in Qi and Blood circulation in the Chong Mai and possibly some Zang Fu disharmony of Kidney (free flow) and Liver (Qi stagnation). There was no problem with conception, we must therefore, assume the Ren Mai is unobstructed.
Diagnosis

Interpreting these pathophysiological facts to the case of AS led me to believe that the Chong Mai was not allowed to develop at the age of 16. The pattern of disharmony does appear to be confined to the development of the Chong Mai during adolescence either from Kidney Qi insufficiency or Liver Qi and Blood stagnation and not from any disharmony to the Kidney Essence from birth as this would affect the Ren Mai and conception. The selective nature of the Chong Mai dysfunction led me to investigate the explanation of stagnation of Blood and Qi to the vessels as a possible answer to the symptoms.
Branch diagnosis (Kaptchuk 1947)
Qi and Blood stagnation directly affecting the Chong Mai. This would contribute to pelvic pain.
Root diagnosis (Kaptchuk 1947)
Kidney Qi deficiency with Liver Blood and Qi stagnation possibly with Heart Yin deficiency. It was felt that any Zang Fu disharmony could not have been very severe, as the tongue and pulse would not have calmed during the remainder of the menstrual cycle.

Discussion and Reflection

It was extremely difficult to identify any internal or external pattern to this case as the patient denied any trauma or stress associations. The prescription of oral birth control pills at the early age of 16, together with GnHR suppressants recently, would certainly contribute to the diagnosis of "latrogenesis" which in TCM terms cause stasis and wasting of the blood (Flaws 1997). According to some Chinese gynaecologists they may even damage the Kidney. Note AS reported she had been worse since being placed on these drugs).

The initial treatment plan composed of the following objectives:

  • To stimulate and open the Chong Mai and thus Qi and Blood through the uterus
  • To stimulate Qi in Liver, Kidney and Spleen
  • To stimulate Blood flow in Liver and uterus
  • To strengthen Qi during the Yang quarter of the post-ovulation cycle. (To promote the flow and supply of Qi and nourish the blood).
  • Deactivate abdominal trigger points
  • Mobilise the uterus and pelvic vessels
  • Possibly attend to the Heart Yin but this remained puzzling.

Treatment was co-ordinated to start acupuncture at the 15th- 28th day of the normal cycle. The GnHR drugs were discontinued with the agreement of the Consultant.

Treatment was initially daily to stimulate the Chong Mai. On the fifth evening after the initial treatment the patient felt very unwell with severe pelvic pain and a drawing sensation in the pelvic floor, she was hot and anxious and went to bed. During the night she had a violent dream involving pelvic demons. (This is described in detail in Yellow Emperor’s Canon Internal Medicine 1999, the opening the Chong Mai may result in the purging of demons sic). She woke in extreme pain, with severe autonomic changes, pallor, sweating and nausea. This continued throughout the night and the following morning she developed a black, tar-like discharge. By the seventh day she was bleeding quite heavily with large, black clots and severe pain. This pattern continued for four weeks and no further TCM acupuncture was given during this time. It was discussed whether menstruation should be stopped by stimulation of Spleen 1 with moxa (Simporis 2002) but further discussions resulted in suggestions that this result was primarily the unblocking of the Chong Mai and as long as the patient tolerated it the treatment plan should be pursued. Trigger point deactivation was therefore given which reduced some of the visceral pain. The case was discussed with her Consultant and a further vaginal examination was performed to eliminate any pathology. It was agreed careful monitoring of pain and menstrual flow should continue without active treatment until menstruation had ceased, which it did four weeks following treatment. The patient reported a decrease in pelvic pain during the third week of menstruation and at the cease of menstruation she reported a VAS score of 2 and felt better than she had felt for several years. Her tongue colour had subdued and she had lost the facial pallor.

Acupuncture was started again but with the express purpose of tonifying Kidney, Liver and Spleen Qi but with less attention to movement of Liver Blood and no direct stimulation of the Chong Mai. A cyclical treatment programme was undertaken as planned. The patient had now had four normal menstrual cycles with a 7-day bleeding period. The tongue signs had now changed with loss of triangular patches over the Liver areas and Liver pulse has returned to normal along with the thirst and dreams. However, the Heart tongue signs and erratic pulse had no abated and this was discussed with the patient as it continued to puzzle me. She looked well and reports VAS score of 4 during ovulation and 2 for the remainder of the cycle, rising to 4 at menstruation. She continues to have one acupuncture treatment at 14th day of cycle to reinforce Kidney, Liver and Spleen Qi.

After the fourth month AS was rather anxious and her Heart pulse was bounding together with red tongue tip signs. Eventually she felt she wished to discuss a problem that had been plaguing her for many years and she had not confided to any other person. At the age of thirteen years, long before she was aware of any menstruation she had conceived and had a termination under un-sterile, illegal circumstances. She had been unwell with a severe temperature for several days following this procedure and was treated with antibiotics. Artificially induced abortions constitute a traumatic attack not only to the uterus but the Shen of the Heart and are often a contributory cause to the development of static blood in the uterus, which should be eliminated following the abortion to promote normal Blood flow (Song Guang-Ji, Yu Xiao-zhen 1995). This would also account for the Heart Yin symptoms and the Qi stagnation leading to blocked menstruation. Fear and grief tend to cause a sinking and weakening of Yang Qi resulting in the Chong Mai becoming insecure and thought and worry lead to stagnation of Qi and Blood obstructing flow in the Chong Mai, hence the selective nature of this case which I found inexplicable. Sexual abuse (if this is what it was) will cause Qi stagnation and blood stasis (Flaws 1997). On reflection this would have been addressed much sooner with referral for counselling and appropriate acupuncture for the Shen.

This case history has prompted further discussion and investigation with the gynaecologists, into the use of Doppler diagnosis of the blood flow through the pelvic vessels during acupuncture treatment and conversely, any reduction of flow during the use of oral contraception or GnHR inhibitors. It would have been very interesting to look at the effect on pelvic circulation at the time that the Chong Mai was opened and not retrospectively and this is now being planned. This study supports the hypothesis that the use of acupuncture to open the Chong Mai and reduce blood stasis may offer some relief of chronic pelvic pain in selected subjects. A further more detailed randomised trial is required to determine the role of acupuncture in the treatment of these selective patients.

Point Selection

Open Penetrating Vessel (Chong Mai) and Yin Linking Vessel
Flaws (1997)
Right     Sp 4    Stagnation of Qi, Blood stasis, Obstruction
Left    P6    , Spleen and Stomach Qi deficiency

QI stagnation

Deadman et al (1998)
Sp 6 - Meeting point of 3 Yin, Spleen, Liver and Kidney
Liv 2/3 - Spreads Liv Qi/Balances Blood
Bl 24 - Treats irregular menstruation
Liv 13/Bl 18 - Spreads and regulates Qi in Lower Jiao/Back Shu of Liver

Spleen Qi deficiency

Sp 2/St 36 - Tonification point/Regulates St and Sp Qi
CV12/Bl 20
- Strengthens/ regulates Qi, Back Shu of spleen

Kidney yin deficiency

Ki 3 - Irregular menstruation, Disharmony of Kidney Qi
Bl 23 - Back Shu of Kidney
Sp 6 - Meeting point of 3 Yin, Spleen, Liver and Kidney

Heart Yin deficiency (added after 4th month)

PC6 Tonify yin, quiets heart
H7    Supports the Shen
K3 Tonify Yin of body

Treatment Protocol

Treatment 1

Daily from 15th-20th day of cycle
Points    Sp 4 P 6    Penetrating Vessel
Lu 7 Ki 6 Directing Vessel
Cyclical Treatment
Treatment one x weekly from day 15 until day 28 for 4 months
Qi deficiency Bl 24
Yin deficiency K3, Sp 6
Liver Qi stagnation Bl 17, Liv 13
Spleen Qi deficiency Bl 20
Maintenance Programme
One x monthly on 15th day of cycle
Sp 6 - Yin vessels
Bl 17 - Blood
Liv 13 - Qi

Acknowledgements

I should like to thank the following people who have supported me and listened to my wild claims during the investigation and development of this case history and who are prepared to support me further.

Dr Paddy Forbes, FRCOG, Consultant Obstetrician and Gynaecologist.
Dr Mark Slack, FRCOG, Consultant Obstetrician and Gynaecologist.
Mr Mousa Al Kurdi, Consultant Obstetrician and Gynaecologist.
Karen Simporis, MBAcC, for her support and knowledge concerning TCM

References

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