Modern Gynecology of Traditional Chinese & Western Medicine.  Chief Editor:  Niu Jian Zhao.  China Science and Technology Press.   Selection from Pages 137-140

Dao Jing, upside down menses, is cyclical, but the blood flow is reversed and goes up.  Other than the uterus, blood can come out of the nose, stomach, intestine, lung, bladder, retina, etc.  Most of the time blood comes out of the nose.

From a TCM perspective, the occurrence of this condition is related to the menstrual cycle.  The menstrual flow is usually reduced and in extreme cases there is no flow.  It’s like the menstrual flow changes direction and goes up.  The Lei Zheng Zhi Cai calls this Dao Jing.  The Ben Cao Gang Mu calls this Ni Xing (counterflow movement).  “When the menstrual flow happens as coughing blood, a nose bleed, or blood coming out of the eyes or ears, this is called Ni Xing.  Ye Tian Tu Nu Ke calls this condition Ni Jing. “When the menses is not flowing down and blood is coming out of the mouth or nose, this is called Ni Jing”.  It is also called by a variety of other names.

Disease Cause and Dynamic

II. – Chinese Medicine Disease Cause and Dynamic

Su Wen – Zhi Zhen Yao Da Lun says “All counterflow that moves vigorously upward, belongs to fire.”  The condition primary occurs when hot, chong channel qi counterflows upward causing the blood to move recklessly.  Premenstrual, or during the menstrual cycle, the chong channel qi is vigorous and the sea of blood is full.   If there is heat, then the chong channel qi will counterflow upward, the blood will move recklessly following the qi upward and resulting in the external eruption of blood.  The primary causes of this counterflow of hot blood and qi are: 1) liver channel depressed heat, 2) stomach fire blazing, 3) stasis and heat binding together, and 4) the vacuity of lung and kidney yin.

A.     Liver Channel Depressed Heat

Liver stores the blood, controls coursing and discharge and also governs the Chong channel.  When the liver qi is moving in an orderly manner, the Chong channel is calm.  If ongoing worry, depression, repressed feelings, or sudden outburst of anger, the coursing and discharge of liver qi becomes abnormal so that the liver qi becomes depressed and stuck.  If this happens for a long period of time, the qi turns to fire which flames upward and carries the qi in the Chong channel upwards with it so that it counterflows.  If the coursing and discharging is greatly excess, then the qi dynamic becomes chaotic.  In this case, when the Chong channel is full premenstrually, the chong qi leads to fire which counterflows upwards causing reckless movement of blood and the external eruption of blood.  Lei Zheng Zhi Cai says “Dao Jing is when blood come out of the nose and mouth which is caused by liver fire forcing itself upwards and not following it’s ordinary path.”

B.      Stomach Fire Blazing

The Stomach channel has lots of qi and blood and the Chong channel is subordinate to it.  Addiction to eating hot & spicy or warm & dry foods can result in heat building up in the stomach.  This fire within the stomach stirs up the qi.  During menses when the Chong qi tends towards excess, this latent fire in the stomach harasses the Chong channel. “With exuberance there is heat and blood moves recklessly.”  Qi in the Chong channel follows the upward counterflow of stomach fire, damaging the blood collaterals and resulting in the external eruption of blood.  Ye Tian Tu Nu Ke says “Excessive eating of spicy, hot, ginger type things will damage the blood so that the blood becomes chaotic and moves upward.”

C.     Stasis and Heat Binding Together

As blood stasis build up internally, over a long time it may generate heat which will bind together with the stasis.  Alternatively the stasis may bind together with an externally contracted heat evil.  During the menses, when the chong channel qi is more vigorous, the stasis follows it, counterflowing upwards resulting in the external eruption of blood.

D.     Lung and Kidney Yin Vacuity

The lung opens the orifices in the nose.  The Chong Vessel has one branch of it’s collaterals coming out at the palate just behind the nose.  The kidney governs the storage of essence.  In cases of constitutional yin vacuity, or kidney yin becoming depleted and vacuous, or long term disease which damages essence and blood, or chronic loss of blood, the yin and blood become insufficient so that internal vacuity fire is generated.  After the menses when blood has drained from the lower jiao, the yin becomes even more vacuous. Shen Shi Nu Ke Ji Yao Jian Zheng says “When there is yin vacuity in the lower jiao, the yang flows upwards vigorously.  When the yin cannot contain the yang, the qi in the Chong channel becomes excessive.  As the qi in the Chong channel becomes vacuous, fire flames in the upper jiao damaging the lung collaterals so that blood overflows the Chong vessel and there is external eruption of blood.

Treatment

II. – Chinese Medicine Treatment Methods

Treatment by Pattern Differentiation

The differentiating characteristics of this disease dynamic are suffering from fire heat and counterflow of qi in the upper jiao.  In order to clear heat and downbear counterflow, the treatment should be consistent with the primary treatment principles of, “when there is heat, clear it”, “when there is counterflow, calm it”.

Because this condition happens premenstrually and during the menses, bitter cold herbs cannot be excessively used to clear the heat in order to avoid congealing the blood and causing stasis.  Strongly downbearing herbs cannot be excessively used in order to avoid damaging yin and blood.  Sheng Ma, Chai Hu and other upbearing herbs should not be used to avoid raising the yang and helping fire.

A.     Liver Channel Depressed Heat

1)      Signs and Symptoms:  Premenstrual, or during menses, there is vomiting of blood or nosebleed, with a significant amount of fresh red blood.  May be accompanied by early menstruation, premenstrual chest, ribside and breast distention pain, vexation and easy to anger, bitter taste in mouth and dry throat, headache and dizziness, thin yellow tongue coat and a wiry, rapid pulse.

2)      Analysis of Disease Condition:  Worry, depression or great anger damages the liver, so that it’s ability to outthrust is lost and the qi dynamic becomes depressed and stagnant and, after a while, transforms into fire.  During the menses, when the Chong qi is flourishing, the fire follows the Chong qi which counterflows upward damaging the blood collaterals and leading to vomiting of blood and nosebleeds.  Heat breaks the blood, causing it to move frenetically in great amounts and gives it a red color.  Heat also harasses the sea of blood so that the Chong and Ren vessels are no longer secure and menses can arrive early.  When the liver qi becomes depressed and bound, the regular coursing and discharging is lost, leading to chest, rib side and breast distention pain.  Depressed fire builds up internally leading to vexation, agitation and easy to anger, bitter taste in the mouth and dry throat.  Liver fire harasses the clear orifices leading to headache and dizziness.  A thin yellow coat and a rapid wiry pulse is the pattern for liver channel depressed heat.

3)      Treatment principles:  Smooth the liver, clear heat and guide blood downward.

4)      Formula: Qing Gan Yin Jing Tang

Sheng Di 10g, Dan Pi 10g, Huang Qin 6g, Chao Zhi Zi 6g, Dang Gui 6g, Bai Shao 10g, Chuan Lian Zi 10g, Chuan Niu Xi 10g, Bai Mao Gen 15g, Qian Cao 10g, Gan Cao 6g.

5)      Analysis of Formula: Sheng Di and Dan Pi clear heat and cool blood.  Huang Qin and Chao Zhi Zi clear heat from the liver and drain fire.  Dang Gui nourishes the blood and harmonizes the blood in order to regulate the menses.  Bai Shao constrains the liver yin, relaxes the tenseness of the liver,  and nourishes blood in order to calm the liver.  Chaun Lian Zi courses the liver and unbinds depression, regulates and smooths the qi dynamic.  Bai Mao Gen and Qian Cao cool the blood.  Chuan Niu Xi guides the blood downward.  Gan Cao regulates and harmonizes the other herbs.

6)      Modifications: 

·        If there is obvious lower abdominal distention pain, add Dan Shen 15g and Yi Mu Cao 20g in order to invigorate blood, transform stasis and free the menses.

·        If there is dizziness and an extreme headache, add Hang Bai Ju 10g and Sheng Shi Jue Ming 30g (previously decocted) in order to calm the liver and subdue the yang.

·        If there is constipation, add Lu Hui 3g in order to clear heat from the liver, drain fire and free the stool.

B.      Stomach Fire Blazing

1)      Signs and Symptoms:  During menses, or premenstrually, there is vomiting of blood or nosebleed, with a significant amount of fresh red blood.  May be accompanied by advanced menstruation, a dry mouth with desire for cold drinks, bad breath, a dry and bound stool, maybe vexation heat in the chest, red tongue with yellow coat, and the pulse is rapid or slippery and rapid.

2)      Analysis of Disease Condition: The Chong vessel is subordinate to the Stomach channel and during the menses the Chong qi tends to be vigorous.  So when there is excessive eating of hot spicy or warm dry foods, or when fire-heat evil hidden in the stomach and the menses occurs, the Chong qi and Stomach fire counterflow upwards, damaging the blood collaterals and causing the blood to overflow as external eruption of a large amount of fresh red blood.  The abundance of stomach fire consumes and damages the yin and jin fluids so that there is a dry mouth with a desire for cold drinks and a dry and bound stool.  The stomach fire blazing upwards causes the bad breath.  Heat harassing the heart and chest causes the vexation heat in the chest.  A red tongue with a yellow coat and a rapid pulse or a slippery rapid pulse are all patterns of stomach fire internally blazing.

3)      Treatment principles:  Clear and drain stomach fire and guide blood downward.

4)      Formula: Xie Xin Tang

Da Huang 6g, Huang Lian 3g, Huang Qin 3g, Dan Pi 10g, Chi Shao 10g, Ou Ji 10g, Bai Mao Gen 10g, Hua Fen 10g, Chuan Niu Xi 10g.

5)      Analysis of Formula: Da Huang clears heat from the blood and drains fire, guides out stagnation, frees the stool and guides heat out of the large intestine.  Huang Lian and Huang Qin clears the heat evil that is scorching the upper and middle jiaos in order to expel the heat the vexation heat from the heart and chest. Dan Pi and Chi Shao clears the fire that is in the blood.  Ou Ji and Bai Mao Gen clear heat and cool blood.  Hua Fen nourishes yin, clears heat, generates jin fluids and stops thirst.  Chuan Niu Xi guides blood heat downward.

6)      Modifications: 

·        If the dry mouth and thirst are extreme, add Shi Hu 10g and Lu Gen 20g in order to nourish yin, clear heat and generate fluids.

·        If the stool is dry and bound and not resolved for a number of days, increase Da Huang to 10g (add late in the cooking) and add Mang Xiao 10g, in order to strengthen the functions of clearing heat, draining stomach fire and freeing the stool.

·        If there is nausea and vomiting add Qing Zhu Ru 10g and Chen Pi 10g in order to calm the exuberance, downbear counterflow and stop  the vomiting.

C.     Stasis and Heat Binding Together

1)      Signs and Symptoms:  Premenstrually, or during menses, there is vomiting of blood or nosebleed, with a light or heavy amount of dull red blood and the menses has clots.  May be accompanied by with an unsmooth menstrual flow, lower abdominal aches and pains, low grade fever, dry mouth, dull red tongue body, and the pulse is either normal or wiry and rapid.

2)      Analysis of Disease Condition: When stasis and heat are bound internally, premenstrual Chong channel qi tends to be excessive.  Since the blood moves where the qi moves, the blood overflows when the qi counterflows.  Chong qi counterflows upwards and heat causes the blood to move recklessly.  When the blood stasis moves and follows it, then there is an external eruption of blood.  When there is blood statis, the color of the blood is dull and the menses has clots.  When the blood stasis causes an internal blockage, the qi mechanism becomes obstructed so that the menses does not flow smoothly and there is lower abdominal pain.  With internal stasis heat there is a low grade fever and dry mouth. A dull red tongue with a wiry rapid pulse are all patterns of blood heat with stasis.

3)      Treatment principles:  Clear heat, transform stasis, downbear counterflow and stop bleeding.

4)      Formula: Xue Fu Zhu Yu Tang

Sheng Di 10g, Chi Shao 10g, Dang Gui 10g, Tao Ren 10g, Hong Hua 10g,  Zhi Qiao 10g, Da Ji and Xiao Ji each 10g, Hua Rui Shi 10g, Chuan Niu Xi 10g, Gan Cao 10g.

5)      Analysis of Formula: Sheng Di and Chi Shao clear heat and cool the blood.  Dang Gui nourishes and harmonizes the blood.  Tao Ren and Hong Hua invigorate the blood and transform stasis. Zhi Qiao regulates and smooths the qi dynamic in order to reinforce blood movement.  Da Ji and Xiao Ji cool the blood and stop bleeding.  Hua Rui Shi transforms stasis and stops bleeding    Chuan Niu Xi guides blood downward.  Gan Cao regulates and harmonizes the other herbs.

6)      Modifications: 

·        If there is an obvious low grade fever, add Dan Pi 10g and Bai Wei 10g in order to reinforce clearing heat and cooling blood.

·        If the condition is long term or stubborn with lots of bleeding and clots and the blood color is dull purple, add San Leng 10g and E Zhu 10g in order to transform stasis and disperse entrenched stasis.

D.     Lung & Kidney Yin Vacuity

1)      Signs and Symptoms:  During menses, there is vomiting of blood or nosebleed, with a scanty amount of dull red blood.  May be accompanied with scanty menstrual flow, 5 palm vexation heat, tidal fever with sweating, dizziness, tinnitus, dry throat and mouth, coughing up a scanty amount of phlegm, tongue red with a light coat, and the pulse is thin and rapid.

2)      Analysis of Disease Condition:  With constitutional yin deficiency or after a long term disease has damaged yin, the yin and fluids are not sufficient so that vacuity heat is generated internally.  During menses, the menstrual blood drains and the yin and blood aren’t able to recover.  With the Chong qi tending to be vigorous, vacuity fire flames in the upper jiao damaging the blood collaterals leading to external eruption of blood.  Since yin and blood are deficient, the blood amount is scanty and the color is dull red.  Yin vacuity internal heat causes 5 palm vexation heat, tidal fever and sweating.  Since the Kidney essence is not sufficient, the clear orifices lose their nourishment resulting in dizziness and tinnitus.  Vacuity heat scorches the lungs and damages the jin fluids causing the dry mouth and throat and coughing up a scanty amount of phlegm.  A red tongue with a light coat and a thin and rapid pulse is the pattern for yin vacuity with heat.

3)      Treatment principles:  Enrich kidney, moisten lung and guide blood downward.

4)      Formula: Shun Jing Tang

Dang Gui 10g, Bai Shao 15g, Sheng & Shu Di Huang each 15g, Sha Shen 15g, Dan Pi 10g, Nu Zhen Zi 15g, Han Lian Cao 15g, Hei Jing Jie 6g, Chuan Niu Xi 10g.

5)      Analysis of Formula: Dang Gui and Bai Shao nourish blood and harmonize blood.  Shu Di Huang enriches and supplements the liver and kidney, boosts the yin and replenishes the essence.  Sheng Di and Dan Pi enrich the yin, clear heat and cool the blood.  Sha Shen nourishes the yin and generates the jin fluids in order to moisten the lung and stop the coughing.  Nu Zhen Zi and Han Lian Cao supplement the liver and kidney, boosts the essence and blood, and cools the blood and stops the bleeding.  Hei Jing Jie guides blood back into the channels.  Chaun Niu Xi guides the blood down in order to downbear the upward flaming fire.

6)      Modifications: 

·        If the coughing is extreme, add Bai He 10g, Bei Mu 10g, Pi Pa Ye 10g in order to nourish yin, moisten lungs and stop the coughing.

·        If there is obvious tidal fever, add Qing Hao 10g, Bie Jia 10g,  Mu Dan Pi 10 g in order to enrich yin and abate the vacuity heat.

·        If the stool is dry, add Yuan Shen 10g and Mang Xiao 10g, in order to moisten dryness and free the stool.