Acupuncture in the Treatment of Premenstrual Syndrome

The occurrence of premenstrual physical and psychological changes was first mentioned in the writings of Hippocrates1, whilst premenstrual syndrome itself was first identified in the 1930's by Frank2,3. Premenstrual syndrome (PMS) is defined as "a collection of differing signs and symptoms which occur only in the premenstruum, i.e. after ovulation, and is relieved by menstruation4". Symptoms may therefore occur any time between 1 and 14 days (usually 7-10) before menstruation begins, and remit after the onset of bleeding5. The combination of symptoms seen in PMS occurs regularly, either every month or most months, although their severity may vary considerably from one cycle to the next. It is generally accepted that PMS gets worse with age (worst between the ages of 30-40)6, and usually does not improve after childbirth. Symptoms Although as many as 150 individual premenstrual symptoms have been noted, the most common symptoms can be put into four main groups:

¥ Anxiety, irritability, mood swings and nervous tension.
¥ Depression, insomnia, lethargy and confusion.
¥ Bloating, weight gain, headaches and breast tenderness.
¥ Increase in appetite, cravings for sugar and/or salt and

fatigue. Other often-reported symptoms include unease, insomnia, sleepiness, aggressiveness, crying spells, clumsiness, poor co-ordination, difficulty in concentrating, decrease or increase in libido, swelling, puffiness of the abdomen, face or fingers, weight gain, constipation, diarrhoea, acne and skin rashes, muscle aches and pains, and exacerbation of epilepsy, migraine, asthma, rhinitis or urticaria. Incidence Depending on how it is assessed, between 5% and 97% of women have been reported as suffering from PMS. More accurate estimates point to around 35% of women having moderate to severe symptoms which disrupt social life, work and family life and may cause a woman to seek treatment, whilst 5-10% will experience severely debilitat-
ing symptoms causing major disruption in all aspects of life7. As a result of these figures, PMS has been described as the world's commonest disease. PMS has variously been reported to result in increased psychiatric admissions, suicides, alcohol abuse, child abuse, accidents, accidents to children, examination failure, varicose veins, glaucoma, cardiac failure and hospital admissions in general. It has even served as a defence in murder cases. PMS is not usually seen in the absence of other menstrual symptoms. One study showed that while 15% of women suffered premenstrual distress only, and 9% distress during the menstrual flow only, 58% reported distress during both phases8. Aetiology The cause of PMS has resulted in much debate, contradiction and confusion. This is in part because both physical and psychological factors have been found to be both precipitating factors and symptoms. As a result, there is dispute over whether PMS has a biological or a psychological cause. Reported precipitating causes of PMS include a past history or family history of depression, mental illness or alcoholism, past history of sexual abuse, discontinuation of the oral contraceptive pill, bilateral tubal ligation and hysterectomy. An extraordinary number of possible aetiologies has been advanced for PMS. These include progesterone deficiency, a fault in progesterone receptors, oestrogen-progesterone imbalance, fluid retention due to raised aldosterone levels in the luteal phase, deficiency of vitamin B6, hypoglycaemia, and psychosocial and personality factors. None of these theories is generally accepted as having been substantiated. Cultural factors One part of the discussion around PMS centres on the way it is frequently defined not by women, but by men, and how because of difficulty accepting female assertiveness and anger, premenstrual changes are generally defined as a medical problem requiring treatment: "The symptoms of PMT which the doctors show most concern over - depression, anxiety and so on - are mental states which do not 'fit' with women's culturally-created notions of ourselves as nice, kind, gentle etc. 'Mood change' as such, is often listed as a symptom - demonstrating that change as such is not culturally acceptable. Why are women's moods seen as such a problem? Men have moods too, after all"9. "A double standard exists. Everyone is aware that men's moods change, but a man does not need to explain his temper tantrums, and male violence is an accepted part of their nature ... PMS is now cited as the cause, and female frustration can continue to be ignored or invalidated; drugs are given to soothe the women and ensure they are not disruptive"10. "Both the negative evaluation and the medicalisation of premenstrual and menstrual change function to preserve the asymmetrical roles of men and women in the family and society"11. "Might we (i.e. women) not dive deeper into menstrual pain and irritability to see what it is and use it in some positive way? In presenting this possibility, there is no intent to belittle menstrual pain or suggest it would all go away with a better attitude. Yet, some of us can benefit by looking at the upsets, rage and sense of 'worthlessness' that often accompany PMS. We can ask ourselves what these worthless feelings have to say about women's position in society. If we are more sensitive and responsible in the premenstrual phase, then perhaps we realise, even unconsciously, that what bothers us is very important to us. We can't just brush it off as we usually do the rest of the month; it erupts in the classic PMS symptoms because, premenstrually, feelings we've repressed all month characteristically surface12". In fact according to a 1984 study, around 12% of women feel better before menstruation, reporting increased energy, sensitivity and creativity, heightened arousal and desire for sex and general well-being13. It has been pointed out that most questionnaires produced to evaluate PMS do not include a section to report positive experiences. In considering cultural factors, it should be noted that incidence of PMS appears to be similar throughout a range of races and nationalities, including Apache Indian, Greek, Turkish, Japanese, Nigerian and American women. Treatment Treatment is 'largely empirical and is frequently no better than the average placebo response rate of 40%'14. As with the proposed aetiology of PMS, a considerable number of treatments are advocated by different authorities, including hormonal (progestagens, progesterone, oral contraception, testosterone, danazol etc.), non-hormonal (tranquillisers, antidepressants, lithium, diuretics, vitamins, aldosterone antagonists, essential fatty acids etc.), and other (psychotherapy, diet, hypnosis, yoga, acupuncture, masturbation, hysterectomy, low salt/high protein diet, reduction in alcohol, caffeine and tobacco etc.).

In order to understand the development of premenstrual syndrome according to Chinese medicine, it is first necessary to understand the way it views the different phases of the menstrual cycle. The menstrual cycle Chinese medicine defines four stages of menstruation:

1. Post-menstruation After menstruation during which blood has been lost, there is a relative deficiency of blood and yin. Thus in the days between the end of menstruation and mid-cycle (ovulation), yin and blood grow. This is why, in the treatment of gynaecological disorders, post-menstruation treatment generally focuses on nourishing yin and blood.

2. Mid cycle "Once a certain limit is reached, a change to the opposite direction is inevitable"15 and "The fire and water of the human body is yin and yang ... without yin, yang will not be transformed"16. The middle of the cycle (ovulation) marks the transition of yin to yang, since after ovulation it is the yang qi which must grow. This proper transition from yin to yang ensures normal ovulation.

3. Pre-menstruation The period between ovulation and menstruation is characterised by growth of yang qi. In this context, yang qi refers to both Liver qi and Kidney yang. Kidney yang because the healthy transition from yin to yang through the menstrual cycle is ultimately dependent on the Kidneys, since the Kidneys are the root of yin and yang in the body, dominate sexual development, fertility and the uterus, and are the origin of the Ren and Chong Mai which are the ultimate source of menstrual blood. This growth of Kidney yang is reflected, according to modern TCM opinion, by the rise in basal body temperature from ovulation through to menstruation. The Liver qi, because it is the Liver which stores the blood that moves to fill the Ren and Chong Mai and eventually gives rise to menstruation. Therefore it is the yang aspect of the Liver - the Liver qi - which must grow in order to move the blood ("Qi is the master of blood ... when qi moves, blood moves"17). The intimate relationship between the Kidney and Liver in respect of gynaecology is reflected in the saying "The Kidney and Liver have the same source", the statement by Ye Tian Shi "the Liver is the pre-heaven qi of woman" and the important concept that ministerial (i.e. mingmen) fire is entrusted by the Kidneys to the Liver.

It is the growth of yang prior to menstruation, and especially the growth of Liver qi, that most commonly causes premenstrual symptoms. When the Liver is harmonious it is characterised by softness, openness and free flow. If there is overt or hidden stagnation, however, this will become more pronounced as the Liver qi grows prior to menstruation. Liver qi stagnation is thus the primary pattern seen in PMS.
4. Menstruation During menstruation the emphasis is on the harmony and free flow of blood. PMS is frequently accompanied by menstrual disturbance since stagnation of Liver qi may easily result in blood stasis, whilst heat due to transformation of Liver qi may easily enter the blood and give rise to reckless bleeding. Overview of PMS patterns Liver qi stagnation Liver qi stagnation is the primary pattern seen in PMS. The Spiritual Axis stated "The Liver stores blood, the blood is the residence of the hun; when Liver qi is xu there is fear, when shi there is anger"18, and "with anger the qi rebels upwards and accumulates in the chest"19. When Liver qi is bound and constrained, there will be depression and weepiness (tears are the fluid of the Liver), outbursts of irritation and anger, distention and pain in the chest and breasts and sighing. "The Liver governs uprising"20, and Liver qi stagnation may rise to the neck, back and shoulders causing tension, knotting and pain. "The Liver dominates physical movement"21 and Liver stagnation may bind up the available qi leading to feelings of lethargy, or burst out from constraint into hyperactivity. At the same time vigorous movement (physical exercise) will help to unblock the dammed-up qi. Binding Liver qi stagnation may extend to the intestines and give rise to sluggishness of the stools or constipation. Such is the importance of Liver qi stagnation in PMS that it is a perfect example of Zhu Danxi's statement "When the qi and blood course harmoniously, the myriad diseases will not arise. Once there is constraint, all diseases may come into being. Disease in humans therefore usually arises from constraint"22. Chinese medicine stresses the idea that the unwelcome emotional changes that occur as Liver qi waxes premenstrually reflect a state of qi stagnation that is in fact present through the whole month. These changes, however, can seem so alien to those women who prefer not to own their 'dark' side that they may report the feeling that they have been taken over by a completely different person. Chinese medicine has long recognised that the principal cause of Liver qi stagnation is emotional. When the Liver qi is flowing freely and harmoniously, we are likely to be aware of (i.e. feel), as well as express, our constantly changing emotions. At the same time this emotional spontaneity is a precondition for a freeflowing Liver function. Fei Bo Xiong said "Joy, anger, melancholy, anxiety, grief, fear and terror are common to everyone. Giving vent to joy, anger and melancholy as occasion requires is what is meant by venting emotions properly". Failure to vent emotions, especially anger, results in Liver qi stagnation and subsequent depression, resentment, weepiness, irritability etc. Many people are afraid of their own and others' anger, whether through childhood experience of anger as violence, or because their original family frowned on its expression, especially by girls. Repression of anger, however, can lead to various kinds of depression. One way out of this impasse is to learn assertiveness, which can help us to recognise and express our feelings at an early stage and is an important middle way between excessive passivity and its transformation into aggressiveness, but in real life some anger is probably unavoidable. As well as early childhood, puberty is an important time in the development of emotional patterns. It is said that at puberty, the Liver is entrusted with ministerial (Kidney) fire; in other words mingmen fire passes to the Liver to facilitate the decisiveness and assertiveness required to establish our adult identity. As this Liver fire struggles to find its proper expression there can be periods of great emotional lability and unpredictable moods, especially rage23. It is possible that active suppression of such emotional expression within the family at this time especially, teaches a lifelong pattern of potentially harmful restraint. Any discussion of anger should also emphasise that Chinese medicine believes unbridled anger to be harmful. Cao Tong, of the Qing dynasty for example, recommended in Common Sayings on Gerontology "When faced with something exasperating, one should calmly consider which is more important, anger or health. This comparison will enable one to gradually eliminate one's anger24". From a pattern perspective, we can say that developing greater assertiveness, combined with appropriate venting of anger, can promote the healthy freegoing of Liver qi whilst the problem is still at the level of Liver qi stagnation. If Liver qi transforms to fire (see below), however, it becomes like a blazing fire with an unlimited supply of fuel, and giving vent to rage and anger will not only fail to dispel the fire but will continually stoke and encourage it. At the same time, the anger itself will injure the body, and at this stage assistance is needed to help a person moderate excessive emotion. One final important aspect of the premenstrual waxing of Liver qi needs to be mentioned. For some women, in whom there is relatively little constraint, the days preceding menstruation occasion a welcome feeling of greater assertiveness, decisiveness, clarity and creativity. Even when there is stagnation that bursts out premenstrually, it may mean that what needs to be said is said, and what needs to be done is done. Liver blood and yin xu "The Liver is yin in its substance and yang in its function25". Whilst this statement may be said to apply to all the zangfu, it is especially important in relation to the Liver. The Liver is known as the 'indomitable zang' and corresponds to the energies of Spring, growth and forcefulness. Although the Liver's free-going function assists the ascent and descent of the qi of all the zangfu, its own qi direction is upwards, hence the saying "The Liver governs uprising". Since its growing, spreading and rising yang activity is by nature exuberant, the Liver yin and blood must be equally strong to restrain and lubricate the potential harshness of the Liver qi. Blood and yin deficiency can therefore lead both to a failure of the freegoing function of the Liver and to excessive uprising of Liver yang. Because of menstruation, women are prone to blood deficiency, and PMS as well as many other gynaecological disorders, is often characterised by the combination of Liver qi stagnation and blood xu. In just the same way, the decline of Kidney yin as women approach menopause, may result in malnourishment of Liver yin and a greater tendency to Liver stagnation and/or uprising of Liver-yang. As far as treatment is concerned we can generalise to the extent of saying that in cases of Liver qi stagnation in women, the Liver blood or yin must almost always be nourished. Spleen disharmony The nature of the Liver is to spread and extend, and this assertive and outgoing quality can easily become aggressive when the Liver is shi. At the same time, the Spleen, ceaselessly expending its qi in transportation and transformation, easily becomes weakened and exhausted and thus unable to resist encroachment by the Liver. The pattern known as Liver-Spleen disharmony which is almost invariably present to some extent in PMS, may spring primarily from an aggressive Liver which suppresses the Spleen, or from a deficient Spleen which is unable to withstand even the normal spreading and extending of the Liver. This important clinical relationship is recognised in the statement by Zhang Zhong Jing "When encountering Liver disharmony, it should be remembered that the Liver often invades the Spleen, therefore strengthen the Spleen first". According to the Essential Questions "When the spleen is diseased, damp is generated"26, and "Damp, swelling and fullness all pertain to the Spleen"27. When Liver wood overacts on Spleen earth in this way, therefore, the Spleen is unable to transform liquid and solid food resulting in such symptoms as heaviness, swelling, oppressive sensations, loose stools and oedema28. When Spleen deficiency is further complicated by Kidney yang deficiency, the swelling and oedema will be even more pronounced. Since "When qi flows water also flows"29, Liver qi stagnation can also play a part in this oedema. When the body is heavy with dampness, the mind clouded, and body movement weighted and lethargic, the consequent uncoordinated movements may result in clumsiness. As far as the stools are concerned, when Liver and Spleen suffer dual disharmony, the symptom of alternating constipation and loose stools is frequently seen, with constipation for several days as Liver stagnation builds, and diarrhoea or loose stools usually one or two days before the period when Spleen deficiency predominates. Spleen deficiency is traditionally associated with diminished appetite in Chinese medicine, although clinical practice shows that it is often more complicated than that, since Spleen deficiency often co-exists with some degree of overt or hidden Stomach fire (and hence excessive appetite). Also, when the Spleen is very deficient, there may be a craving for food in general and sweet foods in particular which rapidly, even if temporarily, boost it. Such cravings are commonly encountered premenstrually30. "Blood is the essence of water and grain ...generated and transformed in the Spleen"31. When the Spleen is oppressed and weakened by Liver encroachment, it may be unable to perform its function of generating qi and blood, and thus there may be tiredness and exhaustion as well as blood deficiency which may fail to nourish the Liver and complicate its qi stagnation. Liver fire As emphasised above, the free and unobstructed spreading of the Liver qi is closely related to the harmonious interplay of the seven emotions. Repression of any of the emotions will cause the Liver qi to stagnate, and after time to transform to fire. The pattern of Liver fire is characterised by outbursts of anger and fury as well as many signs of the qi stagnation from which it transforms. If fire rises from the Liver to the Heart there will be restlessness and insomnia, often with vivid dreams, in which feelings of internal aggression are projected into violent characters or events. When the fire rushes upwards to the head, there may be dizziness, tinnitus, headaches, neck pain etc. If heat consumes yin fluid there will be thirst, and if it enters the blood (the Liver stores the blood) there will be signs of reckless bleeding such as early, heavy or prolonged menstruation. Phlegm In a small percentage of cases of PMS, the emotional disturbance may extend beyond the more normal range of depression, weepiness and outbursts of anger. In these cases there may be more severely disturbed emotional behaviour including violence to the self and others, severe depression, disturbance of consciousness, exacerbation of psychiatric disorders etc. These symptoms reflect stagnant fire of the Liver and Heart with phlegm-heat obscuring the Heart orifices. Stagnant fire (transformed from Liver qi stagnation) both affects the Liver and rises to the Heart. Phlegm is produced by the combination of qi stagnation and heat. The relationship of qi stagnation to phlegm is an important one. Li Yong-Cui said "Shock, fury, sadness and worry: phlegm stems therefrom"32, whilst Zhu Danxi said "Those who treat phlegm effectively do not treat the phlegm, but first treat the qi. When the circulation of the qi is smooth and ordered, this will lead the body fluids in a smooth and ordered circulation as well"33. As far as Liver and Heart fire is concerned, the heat will distil and condense body fluids into phlegm. Finally, the disturbance of Spleen function which commonly accompanies Liver qi stagnation, will contribute to the formation of phlegm. Breast pain, distention and lumps According to Zhu Danxi "The breasts are where the yangming passes, and the nipples are ascribed to the jueyin." Breast disorders, therefore, are mainly ascribed to disharmony of the Liver and Stomach, although as far as acupuncture treatment is concerned it is important to remember that the Pericardium primary channel and the Gall Bladder muscle channel traverse the breast. Premenstrual breast distention, swelling, pain and lumpiness involves three main patterns, in order of increasing severity: i. Liver qi stagnation (breast distention, hypersensitivity, pain and lumpiness), ii. Liver stagnant fire which further transmits to the Stomach channel (more severe pain, hypersensitivity and heat sensation), and iii. Liver qi stagnation complicated by phlegm and/or phlegm-fire (more pronounced lumps). Diarrhoea Pre-menstrual diarrhoea is commonly encountered in clinical practice. The most frequently seen pattern is Spleen deficiency, which may be complicated by dampness. If Liver qi stagnation transforms to heat, however, the heat and dampness may combine to form damp-heat which sinks to the lower jiao causing diarrhoea, often accompanied by leucorrhoea. The qi stagnation that results from obstruction by damp-heat may also give rise to pain, especially exacerbation of existing pain, in the lower back and hips. Headache Pre-menstrual headache is commonly encountered clinically. Once again the most likely pattern is some form of Liver disharmony, whether qi stagnation, qi stagnation transforming to heat, or Liver yang rising. This last pattern is due to the gathering of yin blood in the Ren and Chong Mai prior to menstruation which leaves a state of relative deficiency elsewhere and results in separation of yin and yang. Sometimes, the Spleen deficiency aspect of Liver-Spleen disharmony may result in phlegm which obstructs the clear yang rising to the head, resulting in dizziness and headache with a heavy and bound sensation in the skull. In rare cases headache may result from regular periodic attack of exterior wind prior to menstruation, due to deficiency in the upper body as the available blood, yin and qi gather below. In such cases, there will be signs of exterior invasion such as chills and fever, body aches etc. Hot or cold sensations Many women will experience changes in body temperature as part of the premenstrual pattern. The possible mechanisms for these changes can be complicated, but the most commonly encountered clinically are: i. heat sensations due to transformation of Liver qi to fire, ii. cold sensations due to stagnant qi or stagnant fire failing to warm the extremities (this is an example of 'true heat, false cold' and in some cases therefore, despite the coldness, the tongue will be red), iii. cold sensations due to qi and blood xu, iv. heat sensations resulting from uprising of yang and empty heat due to blood and yin xu, v. more rarely, hot or cold sensa tions may be due to the kind of attack of exterior pathogens discussed under headache. Acne If Liver fire transmits to the Stomach and/or Lung it can manifest as outbreaks of premenstrual facial acne. Two other pathological mechanisms may be involved. One is the tendency of heat to separate off and rise (to the face) when yin accumulates below, and the second is the resonance between blood stasis in the lower jiao and in the acne lesions themselves. Non Liver patterns Although Liver qi stagnation is the primary pattern seen in PMS, there is another important mechanism for disharmony at this time. As menstruation approaches, blood gathers in the Ren and Chong Mai and if there is an overall body pattern of blood xu, it is likely to become more pronounced at this time. Since the most common precondition for blood xu is Spleen qi deficiency, the combined pattern of qi and blood xu may be encountered. The blood xu fails to nourish the Heart (anxiety, palpitations, insomnia etc.) and Liver (dull lingering headaches, body aches etc.), whilst the qi xu gives rise to general fatigue, lassitude and possibly oedema. In women approaching menopause, as well as younger women who are constitutionally Kidney xu, a similar mechanism (gathering of blood and yin prior to menstruation) may give rise to exacerbation of symptoms of yin xu and empty heat. In such cases there may be little sign of Liver stagnation. Patterns of Premenstrual Syndrome Liver qi stagnation ¥ Depression, weepiness ¥ Irritability, frustration ¥ Experienced positively as greater assertiveness, creativity and clarity, less passivity ¥ Distention, swelling or pain in the breasts and/or nipples, with dislike of touch and pressure; in severe cases may begin around ovulation or even persist through most of the menstrual cycle ¥ Breast distention may be accompanied by lumps or nodules which disappear soon after onset of menstruation or enlarge and reduce according to the menstrual cycle; the more pronounced the swelling and lumps, the more likely Liver qi stagnation is to be accompanied by phlegm due to poor fluid circulation ¥ Suffocated, oppressive feeling in the chest with difficulty in taking a satisfactory breath, undue consciousness of breathing, sighing ¥ Headache, neckache, tightness and pain in the region of Jianjing GB-21 ¥ Desire to stretch the body or yawn excessively ¥ Lower abdominal distention or pain prior to menstruation, which is relieved at onset of bleeding

¥ Irregular menstruation (either early or late) ¥ Dream-disturbed sleep ¥ Erratic energy - lethargy or hyperactivity ¥ Constipation Tongue: normal colour, or purplish all over, or purple spots along the sides Pulse: wiry

Liver qi stagnation transforms to fire Many of the qi stagnation symptoms will be the same with the addition of: ¥ Restlessness, thirst ¥ Outbursts of real anger and fury maybe alternating with crying and depression ¥ Headaches, dizziness, tinnitus ¥ Insomnia, dream-disturbed sleep (often violent or fearful dreams) ¥ Early menstruation, or profuse menstruation Tongue: red sides and tip Pulse: wiry and rapid

Liver qi stagnation complicated by Kidney yin xu Symptoms of Liver qi stagnation and heat are seen, with the addition of: ¥ Soreness of the back and knees before, during or after menstruation ¥ Dizziness ¥ Frequent urination ¥ Hot flushes, night sweats, vaginal dryness ¥ Insomnia, anxiety Tongue: red and dry with scanty coating Pulse: rapid, thin, wiry

Liver and Stomach stagnant fire Symptoms of Liver qi stagnation and heat are seen, with the addition of: ¥ Severe breast pain, maybe sharp ¥ Itchiness or hypersensitivity of the nipples ¥ Heat sensation in the breasts ¥ Irritability, restlessness, anger ¥ Dry mouth and thirst ¥ Possibly excessive leucorrhoea Tongue: red with a yellow dry coating Pulse: wiry and rapid

Liver-Qi stagnation accompanied by blood xu Many of the qi stagnation symptoms will be the same with the addition of: ¥ Scanty or delayed menstruation ¥ Pallor, dizziness, insomnia ¥ Fatigue, cold limbs and body ¥ Pain of the neck, shoulders and upper back with tightness,

hardness or knotting of the muscles Tongue: pale, especially on the sides Pulse: thin and wiry Heart and Liver fire stagnation, phlegm obscures the clear orifices ¥ Extreme emotional disturbance (e.g. hopelessness, confusion, suicidal depression, murderous rage etc.) ¥ Thirst ¥ Constipation Tongue: red sides and tip, yellow or white dry or greasy coating Pulse: wiry, slippery, rapid

Spleen dampness due to Spleen xu and Liver suppression Many of the qi stagnation symptoms will be the same with the addition of: ¥ Oedema of the face, eyelids, feet, ankles or even swelling of the whole body ¥ Abdominal bloating and distention ¥ Heavy oppression of the chest and epigastrium ¥ Clumsiness ¥ Poor appetite, loose stools/diarrhoea, nausea ¥ Craving for sweet foods ¥ Cold extremities ¥ Pallor, tiredness, listlessness, sighing ¥ If complicated by Kidney yang xu, then cold limbs and

body, weakness or aching of the lower back etc. Tongue: swollen and pale with teethmarks, maybe pale purple or with purple spots along the sides, white sticky coating Pulse: wiry and slippery or soggy Liver (channel) damp-heat ¥ Premenstrual diarrhoea with strong and unpleasant smell ¥ Burning sensation in the anus ¥ Lower abdominal pain and/or heaviness ¥ Dark urine ¥ Dark menstrual blood ¥ Irritability, easily angered ¥ Excessive white or yellow leucorrhoea, with unpleasant smell and irritation ¥ Bitter taste in the mouth, red face ¥ Pain of the lower back or hips Tongue: red with yellow dry or greasy coating, especially at the rear Pulse: wiry, slippery and rapid

Liver Fire transmits to the Lung and Stomach In addition to symptoms of Liver fire there may be: ¥ Facial acne Tongue: darkish red Pulse: wiry ¥ Key factors that determine Stomach rather than Lung involvement include constipation, more thirst, excessive appetite, digestive symptoms and a thicker tongue coating. ¥ Key factors that determine Lung rather than Stomach involvement include premenstrual facial swelling, swelling of the hands and feet and oppressive sensation in the chest.

Blood Xu (Heart and Spleen) ¥ Dull, lingering, nagging headache ¥ Dizziness ¥ General aching before, during or after menstruation ¥ Poor sleep, insomnia, dream-disturbed sleep ¥ Anxiety, palpitations, depression, poor memory ¥ Fatigue, breathlessness, poor appetite ¥ Pale puffy face ¥ Profuse or scanty menstruation without clots (depending

on whether qi or blood xu is more predominant) Tongue: pale (with thin white coating) Pulse: thready, weak or sodden, small General treatment principles It should be noted that although PMS is discussed as a discrete disharmony, it is commonly seen clinically in combination with other gynaecological disorders, for example early, delayed or irregular menstruation, scanty or excessive bleeding, blood clotting, or abdominal distention and/or pain, before or during menstruation. The treatment principle may therefore be quite complicated, indeed gynaecological disorders have the potential to be among the most complex disorders to treat as not only must the different interwoven patterns be identified, but the treatment principle must be adapted to the changing phases of the cycle. As always, it is important to listen carefully to establish what the main presenting problem is, and whilst taking account of other symptomatology, focus treatment on this key disorder. Generally speaking, acupuncture treatment for premenstrual syndrome begins after ovulation, a few days before the expected onset of symptoms. Treatment may then be quite concentrated, for example every other day. Where there is significant deficiency of blood or yin, this should be treated between the end of menstruation and ovulation. Where there is disorder of menstruation itself, treatment should be continued throughout the bleeding phase. Significant Spleen deficiency can be treated throughout the month. It is widely accepted that treatment needs to be given over at least three menstrual cycles to stand a chance of long-term effect. Point selection The points listed below are only suggestions. There are many other acupuncture points that can be used effectively. Liver qi stagnation • Taichong LIV-3: The name of this point, 'Great Thoroughfare' refers to its function as the great passageway for the flow of qi in the channel. It is a primary point for promoting the free-flow of Liver qi, and can resolve Liver qi stagnation giving rise to pain and distention in any part of the body, whether the head, eyes, throat, chest, Heart, breasts, epigastrium, abdomen, flanks, hypochondrium, uterus or genitals. In modern clinical practice, Taichong LIV-3 is also much used for emotional and psychological manifestations of qi stagnation such as depression, frustration, pent-up feelings, irritability etc. It is striking however, that these indications are almost entirely absent from classical sources. ¥ Neiguan P-6: Since this point belongs to the hand jueyin channel which meets with its paired foot jueyin Liver channel at Qimen LIV-14, it is especially suited to regulate and unbind stagnation of qi of the upper jiao, manifesting as oppression and tightness of the chest. Due to the pathway of the Pericardium channel through the three jiao, it is also effective in the treatment of disorders of the middle and lower jiao, and was classically indicated for deficiency and cold of the Spleen and Stomach, nausea and vomiting, abdominal pain and diarrhoea. The Pericardium is the 'wrapping' of the Heart which stores the shen, and the Pericardium longditudinal luo-connecting channel links Neiguan P-6 directly with the Heart. Neiguan P-6 is therefore able to regulate the Heart zang and calm the shen and is indicated for insomnia, mania, poor memory, sadness, fear, panic and apprehension. ¥ Ganshu BL-18: the back-shu point of the Liver zang is able to regulate most Liver functions. In the context of PMS, it is able to spread and deobstruct the Liver qi, calm anger and manic feelings, nourish Liver blood and yin, and soften and relax the tendons in the neck, shoulders and whole body. ¥ Sanyinjiao SP-6: this point is able to harmonise the Spleen (both tonifying its qi deficiency and resolving dampness), soften the Liver (both spreading the Liver qi and nourishing Liver blood), benefit the Kidneys, and treat insomnia. It is of course additionally one of the foremost acupuncture points to regulate menstruation itself. ¥ Zulinqi GB-41: Zulinqi GB-41 is one of the main acupuncture points to spread the Liver qi, especially when qi stagnation manifests along the course of the Gall Bladder channel giving rise to distention, pressure and pain in the chest, head, eyes, breast and flanks. It is specifically indicated for such symptoms as fullness of the chest, inability to take a satisfactory breath, headache, dizziness, distention, menstrual irregularity, and pain, lumps and phlegm nodules in the breast.

According to symptoms ¥ Depression and weeping: Tongli HE-5, Shenmen HE-7, Xinshu BL-15, Tianfu LU-3 ¥ Breast pain: Shanzhong REN-17, Rugen ST-18, Qimen LIV-14, Liangqiu ST-34, Jianjing GB-21 ¥ Headache: according to location, probably shaoyang channel hence Taiyang (Extra), Shuaigu GB-8, Waiguan SJ-5, Yangfu GB-38 ¥ Stiff neck: Fengchi GB-20, Jianjing GB-21, Xuanzhong GB-39 ¥ Lower abdominal distention: Qihai REN-6 ¥ Irregular menstruation: Daimai GB-26, Xuehai SP-10, Ligou LIV-5 ¥ Dream-disturbed sleep, insomnia: Shenmen HE-7, Danshu

BL-19, Wangu GB-12, Zuqiaoyin GB-44 • Constipation: Zhigou SJ-6, Daheng SP-15 Liver qi stagnation transforms to fire In addition to the points listed for Liver qi stagnation: ¥ Xingjian LIV-2: the Great Compendium of Acupuncture and Moxibustion says "When the Liver is shi, drain Xingjian LIV2" whilst according to the Classic of Difficulties34 ying-spring points are indicated for "heat in the body". Xingjian LIV-2, the ying-spring and fire point of the Liver channel, is therefore the principal acupuncture point to clear Liver fire and descend Liver yang. ¥ Laogong P-8: the ying-spring and fire point of the Pericardium channel is a powerful point to clear heat from the Heart. Due to the close relationship of the Pericardium and Liver jueyin channels, Laogong P-8 is particularly indicated when stagnant Liver fire transmits to the Heart giving rise to various manifestations such as susceptibility to anger, sadness, apprehension, restless zang disorder35, mania-depression disorder, and burning sensation and pain in the region of the Heart in women. ¥ Tianfu LU-3: this point, which is rarely used nowadays, was traditionally indicated for Liver fire which attacks the Lungs ("sudden and severe thirst, internal rebellion, Liver and Lung struggle against each other"36) as well as for a variety of psycho-emotional disorders such as somnolence, insomnia, sadness, weeping, disorientation and forgetfulness. ¥ Yongquan KID-1: this is an important point to root excessive yang and fire which rushes upwards giving rise to such symptoms as dizziness, vertex headache, agitation, insomnia, poor memory, rage with desire to kill people, depression with disordered speech, and constipation. ¥ Xiaxi GB-43: as the ying-spring and water point of the Gall Bladder channel which is externally-internally paired with the Liver channel, this point is indicated for Liver and Gall Bladder heat which ascends along the channel to the head and gives rise to such symptoms as headache, dizziness, deafness and tinnitus.

Liver qi stagnation complicated by Kidney yin xu In addition to the points listed for Liver qi stagnation: ¥ Taixi KID-3 and Shenshu BL-23: as the shu-stream and back-shu points of the Kidneys respectively, these are the two principal points to tonify all deficiency patterns of the Kidneys. ¥ Guanyuan REN-4: as a meeting point of the three leg yin channels with the Ren Mai, this is one of the principle acupuncture points to benefit jing-essence and nourish Kidney yin. ¥ In case of hot flushes and night sweats, add Rangu KID2, Fuliu KID-7 and Yinxi HE-6.

Liver and Stomach stagnant fire In addition to the general points listed for Liver qi stagnation, the points given above for breast distention and pain should be used. Especially important are: ¥ Liangqiu ST-34: as the xi-cleft point of the Stomach channel which passes through the breast, this point is indicated for all acute and severe breast disorders. ¥ Daling P-7: as stated above, the Pericardium jueyin channel has a close relationship with both the Liver jueyin and Stomach channels (the Pericardium primary channel passes through the middle jiao). In addition to treating breast pain and abscess, this heat-clearing point is indicated for insomnia, restlessness, anxiety with a hungry sensation, weeping, fullness of the chest, chest and flank pain, sighing and foul breath.

Liver qi stagnation accompanied by blood xu In addition to the points listed for Liver qi stagnation: ¥ Geshu BL-17: as the hui-meeting point for blood, this is an important point to treat all blood disharmony, including blood deficiency. ¥ Zusanli ST-36: "The Stomach is the sea of qi and blood " and "He-sea points treat the internal fu37". As the he-sea point of the Stomach channel, this is the most important point on the channel to tonify both blood and qi. ¥ Pishu BL-20: As the back-shu point of the Spleen zang, where the qi of the Spleen emanates from the interior to the body surface, this point has a strong action on regulating and tonifying the Spleen, and thus promoting blood formation.

Heart and Liver fire stagnation, phlegm obscures the clear orifices In addition to the points listed for Liver qi stagnation and Liver fire: ¥ Fenglong ST-40: "The Spleen is the origin of phlegm"38. According to the theory of the luo-connecting points, Fenglong ST-40 is able to treat disorders of the Spleen and is the primary acupuncture point to treat phlegm disorders. It is indicated for copious phlegm, fullness, oppression and pain of the chest, plumstone throat, wind-phlegm headache, mania-depression disorder, mad laughter, likes to ascend to high places and sing, likes to undress and walk around, restlessness, sees ghosts, indolence and epilepsy. ¥ Jianshi P-5: along with Fenglong ST-40, this is the most important point to treat phlegm disorders and is indicated for such symptoms as sudden palpitations, oppression of the chest, apprehension, susceptibility to fright, epilepsy, sudden mania, manic raving, agitation and restlessness, absent mindedness, poor memory and plumstone throat. ¥ Laogong P-8: see above. ¥ Renzhong DU-26: the Du Mai both enters the brain and connects (via its anterior pathway) with the Heart. Renzhong DU-26 is one of the thirteen 'ghost' or 'devil' points of Sun Si Miao for the treatment of mania disorder and epilepsy. According to The Ode to Xihong "the ability of Renzhong DU-26 to treat mania disorder is supreme; the thirteen devil points must not be overlooked".

Spleen dampness due to Spleen xu and Liver suppression In addition to the points listed for Liver qi stagnation: ¥ Zhangmen LIV-13: as the front-mu point of the Spleen, located on the Liver channel, this is an essential point to harmonise Liver-Spleen disharmony, especially when it affects the middle and lower jiao. ¥ Yinlingquan SP-9: "Yinlingquan SP-9 opens and moves the water passages"39. Yinlingquan SP-9 is the foremost point on the Spleen channel for transforming and draining shi dampness. ¥ Zusanli ST-36: see above. ¥ Pishu BL-20: see above. ¥ Fenglong ST-40: see above. In case of complication by Kidney yang xu: ¥ Fuliu KID-7: this is an important point in the treatment of any kind of oedema, especially when due to Kidney deficiency. ¥ Jingmen GB-25: the front-mu point of the Kidneys and indicated for both chronic oedema and diarrhoea due to deficiency of the Spleen and Kidneys.

Liver channel damp heat In addition to points for Liver qi stagnation and Liver fire: ¥ Ququan LIV-8: as the he-sea and water point of the Liver channel, Ququan LIV-8 has a strong action on draining damp-heat from the lower jiao. ¥ Zhongji REN-3: as the front-mu point of the Bladder and a meeting point of the Ren Mai with the Spleen, Liver and Kidney channels, Zhongji REN-3 is able to drain damp-heat from the whole lower jiao, especially in the treatment of leucorrhoea and urinary disorders. ¥ Tianshu ST-25: the front-mu point of the Large Intestine both treats diarrhoea due to dampness or damp-heat and regulates the uterus. ¥ Daimai GB-26: this point , located on the Dai Mai girdle channel which binds the Ren, Chong, Kidney, Liver and Spleen channels, plays an important role in controlling leucorrhoea, especially when due to damp-heat.

Liver fire transmits to the Lung and Stomach In addition to points to clear Liver fire: ¥ Neiting ST-44: as the ying-spring and water point of the Stomach channel, Neiting ST-44 has a strong action on clearing heat from the upper portion of the Stomach channel in the face. ¥ Quchi L.I.-11 and Weizhong BL-40: these are two of the few acupuncture points traditionally indicated for skin disorders. ¥ Yuji LU-10: the ying-spring and fire point of the Lung channel, to clear heat from both the Lung zang and channel.

Blood xu (Heart and Spleen) ¥ Sanyinjiao SP-6: see above. ¥ Zusanli ST-36: see above. ¥ Neiguan P-6: see above. ¥ Shenmen HE-7 and Xinshu BL-15: as the shu-stream and

back-shu points of the Heart, these sre the two major points to nourish Heart blood and stabilise the shen. • Pishu BL-20: see above. Management of PMS A full discussion of the management of PMS is beyond the scope of this article. There are many PMS self-help groups which advocate dietary changes, nutritional supplements, exercise etc., and these all have their committed supporters. A brief discussion of exercise and diet, however, follows: Exercise Physical movement and exercise is one of the most effective ways to counter stagnation of Liver qi since it vigorously promotes qi circulation throughout the whole body. When stagnant qi is unavailable for use, there may be subjective sensations that mimic qi deficiency, and the resultant lethargy may mean that there is a great reluctance to exercise. If exercise is taken, however, and the qi begins to flow, there will be much greater energy afterwards, a greater feeling of well-being, and an improvement in many of the PMS symptoms40. Generally speaking, aerobic exercise is more effective than exercise such as qigong, and Chinese research has indicated that in the absence of more vigorous exercise, some kinds of qigong may fail to relieve, or even exacerbate, depression. Physical movement that combines playfulness may be even more helpful than overly serious exercise, and so dancing and sport should be considered. It is important to remember that exercise can help to manage Liver qi stagnation but will not generally resolve it. As a result, if underlying problems are not addressed, the tendency to obsessiveness that can accompany Liver stagnation may lead to an ever-increasing dependency on exercise, which has to be continually increased to deliver the same feeling of well-being that accompanies free-flow of qi. Two possible results of this are i. an even greater build-up of Liver stagnation when a person cannot exercise, and ii. consumption of qi, blood and yin through excessive exertion. Singing, shouting and breathing Singing, shouting and deep breathing can all be helpful, especially to move qi stagnation in the chest. Diet Many self-help PMS groups stress that great benefit can be obtained by reducing sugar and 'junk' foods, salt intake, tea, coffee, nicotine and alcohol, and dairy foods, and emphasising the use of green vegetables, salads, good quality vegetable oils and wholefoods. Others advocate taking small, high carbohydrate meals every three hours. As far as this latter suggestion is concerned, appropriate eating boosts the Stomach and Spleen and helps resist Liver encroachment41. Sources
1. The most thorough source on Chinese medicine patterns involved in gynaecology is My Sister the Moon by Bob Flaws, Blue Poppy Press, 1992, and I am indebted to this book in helping to disentangle the complexity of PMS patterns. Although mostly devoted to herbal medicine, there are brief lists of acupuncture points for many of the menstrual conditions discussed.
1. For a thorough discussion of PMS and Chinese medicine, see also PMS. Its Cause, Diagnosis & Treatment According to Traditional Chinese Medicine, also by Bob Flaws, Blue Poppy Press.
2. For a discussion of the dietary approach to PMS, see for example Beat PMT Through Diet, by Maryon Stewart, Ebury Press. This is the PMT Advisory Service Programme.
3. A book I found interesting and valuable is Menstrual Disorders by Annette and Graham Scambler, published by Tavistock/Routledge, 1993.
4. Personal communication with Steve Clavey and Mazin Al-Khafaji.

References and footnotes
1. Ricci, J. The Genealogy of Gynaecology, Philadelphia: Blakiston.
2. Frank, R. "The Hormonal Causes of Premenstrual Tension", Archives of Neurology and Psychology. 26:1053-7.
3. Due to a lack of source material, I am unable to give an overview of historical perspectives on premenstrual symptoms in Chinese medicine. Bob Flaws in My Sister the Moon, however, refers to the 18th century text The Golden Mirror of Medicine which gives a variety of jing xing (i.e. menstrual movement) disorders which can occur before or during menstruation.
4. Elder, M. (ed.) (1988)Reproduction, Obstetrics and Gynaecology, London: Heinemann.
5. Whilst this is usually the case and indeed some authorities insist that disappearance of symptoms immediately on onset of menstruation is a deciding factor in diagnosing PMS, in fact the symptoms may linger for a day or two, and in some cases persist through several menstrual days. All authorities, however, agree that a diagnosis of PMS requires the presence of a symptom-free week after menstruation.
6. Like many 'facts' about PMS this is not universally accepted. Some argue that the occurrence of PMS in young women may wrongly be ascribed to difficult adolescent behaviour, that PMS in women over 40 may wrongly be ascribed to the menopause, and that many women in their 20's use the contraceptive pill which diminishes the symptoms of PMS.
7. O'Brien, S. Premenstrual Syndrome, (1987), Blackwell Scientific Publications.
8. Scambler, A. and Scambler, G. (1985) "Menstrual symptoms, attitudes, and consulting behaviour', Social Science and Medicine

20: 1065-8.
1. Laws, S. (1985a) 'Male power and menstrual etiquette', in H. Thomas (ed.)The Sexual Politics of Reproduction, London: Gower.
2. Taylor, D. (1988)Red Flow: Rethinking Menstruation, Freedom, Calif.: The Crossing Press.
3. Scambler, A. and Scambler, G (1993) Menstrual Disorders, Tavistock/Routledge. 12.Taylor, D. (1988)Red Flow: Rethinking Menstruation, Freedom, Calif.: The Crossing Press.

1. Hopson, J. and Rosenfeld, A. (1984) 'PMS: puzzling monthly symptoms, Psychology Today, August: 30-5.
2. Elder, M. (ed.) (1988)Reproduction, Obstetrics and Gynaecology, London: Heinemann.


15. Saying.

16. Essential Readings in the Medical Tradition.

17. Saying.

18. Spiritual Axis (Ling Shu), Chapter 8.

19. Spiritual Axis (Ling Shu), Chapter 46.

20. Saying.

21. Saying.

22. Quoted in Formulas and Strategies, by Bensky and Barolet, Eastland Press, p. 291.

23. It sometimes seems that the ministerial fire entrusted to the Liver at puberty expresses itself primarily through emotions in young females, and through the genitals (which belong to the Liver) in boys.

24. Quoted in Health Preservation and Rehabilitation, Publishing House of Shanghai College of TCM, p. 66.

25. Saying.

26. Essential Questions (Su Wen), Chapter 74.

27. Essential Questions (Su Wen), Chapter 23.

28. As Bob Flaws points out inMy Sister the Moon, premenstrual oedema according to TCM manifests with swelling and puffiness of the eyelids and face and swelling of the hands and feet or even the body as a whole; the abdominal and breast swelling that can also occur at this time, however, is classified as distention due to qi stagnation, although in Western medicine it is considered to be due to water retention.

29. Treatise on Disorders of Blood.

30. In the context of craving sweet foods, it is worth noting the statement in the Essential Questions (Su Wen) Chapter 22 "When the Liver is in a bitter and urgent state, quickly eat sweet things to moderate it".

31. Complete Works of Zhang Jingyue.

32. Quoted in Fluid Physiology and Pathology in Traditional Chinese Medicine by Steve Clavey, pub. Churchill Livingstone,

p. 171.

33. Ibid.

34. Classic of Difficulties (Nan Jing), 68th Difficulty.

35. An episodic mental disorder most commonly occurring in women characterised by a variety of possible symptoms such as agitation, restlessness, oppression of the chest, disturbed sleep, irritability, rash and impetuous behaviour, abnormal speech, frequent yawning and stretching, disorientation, worry, grief, weeping, sighing and even convulsions without complete loss of consciousness. Generally considered to be due to emotional frustration which impairs the smooth flow of Liver qi or worry which injures Heart yin, accompanied by blood deficiency. Historically this condition was also associated specifically with blood deficiency of the uterus, drawing parallels with the original Western concept of hysteria which is how zang zao is sometimes translated.

36. Spiritual Axis (Ling Shu) Chapter 21.

37. Both Spiritual Axis (Ling Shu).

38. Essential Questions (Su Wen) Chapter 74.

39. Ode of the Essentials of Understanding.

40. By contrast, in true qi deficiency, exercise may be followed by greater exhaustion.

41. This explains why some people experience intense irritability when they are hungry. Emptiness of the Stomach means that Spleen and Stomach earth is unable to resists encroachment by Liver wood.