Clinical Practicum 4
Case 1: The treatment of a 29-year-old female with recurrent
thrush by acupuncture and herbs
Case 2: The treatment of 30-year-old male with abnormal
sweating by acupuncture and herbs
Case 3: The treatment of 28-year-old female with period pain
by acupuncture and herbs
Case4: The treatment of 23 year-old female with insomnia by
acupuncture and herbs
Subject: CHM403A Clinical Practicum 4
Student Name: Ted Chung Ming Lin
Student Number: 110360
Lecturer: Nicole Andronaco / Ying Mei Hua
Word Limit: 7200 words
Word Count: 7210 words
Case 1
The treatment of a 29-year-old female with recurrent thrush by
acupuncture and herbs
Primary signs and symptoms
The 29-year-old female has been suffering from what had been diagnosed as
recurring thrush from GP about two years. The vagina is light dryness, itching
and with a burning sensation after a drinking, urination and sex action. The
vaginal discharge is yellow and without odour. She had slight dizziness and
headache on the forehead and occipital last week. She always feels tiredness
after 3 pm.
Secondary signs and symptoms
 The energy level is 5/10.
 Stress from studying and working.
 Poor appetite last week.
 Diet is irregular and no breakfast in the morning. The dinner is
eggplants, tomato, zucchini, and salmon. She also drinks one to two
bottles of wine per week.
 The urine is cloudy.
 The bowel movement is regular, but always not complete after the
toilet.
 Cold hands and foot.
 It’s blurred vision and with slight floaters when feeling tiredness.
 The tension in the neck and shoulders.
 The period cycle is always late that is 45 days per cycle.
 The period amount is scanty and the colour is fresh-red, and no period
of pain.
The patient is a gardener, and also a part-time of study as well. She does a lot
of work for her job (gardening, lifting and lots of walking), also the exercise
like running and yoga at least one or two times a week. She has taken the
oral tables of Fluconazole for her thrush from the suggestion of GP.
Tongue
The tongue shape is small, tongue body is red without coating and the tip is
red.
Pulse
Right: upper - thin, middle - thin and moderate, lower - rooted
Left: upper – floating, middle – thin, lower – rooted
Preliminary thoughts on diagnosis
The preliminary on diagnosis for this case is damp heat in the lower jiao
cause to the itching vagina, and burning sensation after drinking and
urination, and the emotional stress from studying and working caused to liver
qi stagnation. Spleen qi deficiency is from poor appetite and irregular diet.
From above information, the preliminary diagnosis is damp heat in the lower
jiao, liver qi stagnation and spleen qi deficiency.
Diagnosis post discussion with supervisor
Emotional problem ⇒ liver qi stagnation ⇒ heat in the lower jiao ⇒ vaginal
itching (thrush)
Irregular diet ⇒ spleen qi deficiency ⇒ dampness ⇒ dampness + emotional
problem ⇒ form damp-heat in the lower jiao ⇒ vaginal itching (thrush)
Overwork ⇒ deficiency of liver and kidney yin ⇒ vaginal itching (thrush)
The patient is suffering the recurrent thrush about two year that is a deficiency
type. The diagnosis of this patient is deficiency of liver and kidney yin and
spleen qi deficiency with dampness.
Aetiological factors relating to complaint
The aetiological factors for her complaint are an emotional problem, irregular
diet and overwork that all can cause to the recurrent thrush.
Clinical Intervention
Pathogenesis
Thrush is an overgrowth of fungi that normally live in the genital region, the
triggering factors include using antibiotics, birth control pills, corticosteroids,
hormonal change of body, diabetes, sexual intercourse and impaired immune
system. From a TCM holistic view, the external genitalia is regarded as part of
the female reproductive system, and their conditions are closely associated
with internal conditions. Through the small branches of meridians and the
Chong Mai, Ren Mai and Du Mai, the spleen, liver and kidney rule the
external genitalia directly or indirectly. The organs support and ensure the
external genitalia to stay in proper conditions. Persistent itchy vulva, with or
without vaginal discharges, often resulted from both internal and external
organs. Firstly, the body is in a disharmony state that makes the external
genitalia susceptible to various irritations. External factors such as germs,
parasites or injuries will take advantage of the weakness and then trigger an
itchy condition. TCM treatment for itchy vulva is based on disharmony
patterns of the individuals, and the remedies are aimed to resume the normal
functional state of organs and eliminate the local irritations as well.
Spleen qi deficiency with damp: There are several situations that lead to the
deficiency of Spleen-Qi. The most common are improper diet, physical
exhaustion and emotional stress. Injury to Spleen-Qi leads to impairment of
the spleen’s functions of transportation and transformation so that the
essences of foods and drinks cannot be extracted and made available for
generating blood. Instead, they accumulate and transform into Dampness,
which flows downward and gathers at lower jiao, then leads to the formation
of vaginal itch and burning sensation.
Kidney and liver yin deficiency: In this case, the deficiency of yin leads to
dryness and also to the development of a kind of internal wind that causes the
itching. In the deficiency type of vulvar itching, the organs involved are the
liver and the kidney. The liver channel is curved around the genitalia, and the
kidney channel controls the two lower orifices. Another, the headache is also
due to liver yin deficiency, when liver yin is a deficiency, liver yang may
ascend, and caused to the problem.
Other syndromes present
The patient also has a tension of neck and shoulders and cold hands and
foot. The can be explained as blood deficiency, and the blood can not nourish
the muscles.
Treatment principle
1. Nourish liver and kidney yin
2. Resolve dampness and tonify the spleen
Application of intervention
Acupuncture treatment

SP3 and ST36: Tonify the spleen and resolves dampness

ST40: Transforms phlegm and dampness from the body

LV5: Regulates the liver Connecting channel which flows to the
genitalia

KD2: Clear deficiency heat and regulates the lower jiao

LV8: Nourish liver and kidney

LU7 and KI6 Regulate the Directing Vessel and nourish liver and
kidney yin
The size of needles is 0.18mm x 30mm to use in this treatment.
Herbal prescription
Sho Di 9g
Shan Yao 15g
Shan Zhu Yu 9g
Fu Ling 15g
Mu Dan Pi 6g
Ze Xie 6g
Huang Bai 6g
Zhi Mu 6g
Yi Yi Ren 15g
Cang Zhu 8g
Sha Ren 3g
This formula is a modification from Zhi Bai Di Huang Wan. The action of Zhi
Bai Di Huang Wan is enriched yin, nourishes the essence of the liver and
kidney and reduces deficiency fire. In this modification of formula, Zhi Mu is
for clear heat, drains fire, enriches yin, moistens dryness and generates fluids.
Huang Bai is for Drains damp-heat, removes kidney fire and resolves toxicity.
Shu Di Huang is for nourishes yin and blood and tonifies the kidney. Shan
Zhu Yu is for nourishes kidney yin and yang, astringes yin and stops excess
perspiration. Shan Yao is for strengthens the spleen, stabilises the kidneys
and nourishes jing. Fu Ling is for strengthens the spleen and drains
dampness. Mu Da Pi is for clears heat, cools and invigorates the blood, clear
deficiency fire and dispels blood stasis. Ze Xie is for promotes urination and
prevents kidney fire as a result of tonification. Sha Ren is to strengthen the
spleen and transform dampness, promotes the movement qi and stop
vomiting. Cang Zhu is for dries dampness and tonifies the spleen and clear
dampness from lower jiao.
Dietary and lifestyle advice
Like itching in other regions, good personal habits are essential, which can
protect the genital area, promote healing as well as avoid unnecessary
irritations to cause further damages. For whatever the causes avoid
scratching and rubbing, stay dry and cool, proper cleaning, proper rest and
healthy diet, all are beneficial to alleviate the discomfort. The healthy food has
a positive impact on the skin since many skin problems are a reflection of
internal changing of the body. Thus, recommended the patient to abstain from
smoking, alcohol, tea, coffee, seafood and spicy food, because they do not
favour the healing processes of the skin and membrane.
Contraindications
There is not any contraindication for this treatment.
Reflection
This case is my first experience in gynaecology in the school clinic. It is a
good internship experience for me, and especially a male practitioner faces a
female patient. So there may have some questions are shortages for this
patient. She is a new patient for me. Thus I spent the time in the consultation
is too long. I think that I still need some improvement in time management. I
believe that it will be more confident in seeing the patient in the next time.
Also in the future treatment, the condition of menstruation must ask more
about the cycle, the amount of bleeding, and the colour of blood, quality and
pain. The leucorrhoea must be distinguished according to colour, consistency
and smell.
Both acupuncture and herbal medicine will give good results for vulvar and
vaginal itching but it may take a long time to eradicate the problem
completely. In the next treatment, maybe the external herbal remedies for
itchy vulva is another option for the patient. It's important for itchy vulva in
TCM and is usually applied in wash, compression, power or cream forms. The
active ingredients can direct action on the private part, to clean, deodorise,
eliminate harmful irritations, arrest discharges, stop itching, antiseptic, antifungal, and promote tissue repair. In the prognosis and prevention, I told my
patient not to consume too many dairy foods or greasy foods that create
dampness.
Research
Vaginal yeast infections are due to excessive growth of Candida. These yeast
are normally present in the vagina in small numbers. It is not classified as a
sexually transmitted infection; however, it may occur more often in those who
are frequently sexually active. Risk factors include taking antibiotics,
pregnancy, diabetes, and HIV/AIDS. Eating a diet high in simple sugar may
also play a role. Tight clothing, type of underwear, and personal hygiene do
not appear to be factors. Diagnosis is by testing a sample of vaginal
discharge. As symptoms are similar to that of the sexually transmitted
infections, chlamydia and gonorrhoea, testing may be recommended (Sobel,
2007). Treatment is with an antifungal medication. This may be either as a
cream such as clotrimazole or with oral medications such as fluconazole.
Based on TCM theory of syndrome differentiation, genital infection is divided
into several TCM syndrome types, and then different traditional Chinese
medicines are composed together to treat different syndrome types. Two
approaches can be used in treatment: oral and external approaches, which
can be applied independently or in combination. According to the theory of
TCM, the pathogen of genital infection can be summarized as follows: heat,
toxin, damp, stasis, and cold. The accumulation of these factors in the
genitals leads to pathological changes, causing the symptoms of genital
infection.
A clinical research has shown that Chinese medicinal compounds have
certain satisfactory effects on genital infection including vulvitis, vaginitis,
cervicitis, and PID. External therapy of TCM is a form of traditional medicine
therapy, preventing and curing diseases by stimulating the meridians,
acupuncture points, skin, mucous membranes, muscles, and bones (Liu et al.,
2014).
Reference
Liu, C., Zhang, Y., Kong, S., Tsui, I., Yu, Y., & Han, F. (2014). Applications
and therapeutic actions of complementary and alternative medicine for
women with genital infection. Evidence-Based Complementary and
Alternative
Medicine :
ECAM
TA
-
http://doi.org/10.1155/2014/658624
TT
-,
2014,
LK
658624.
-
https://lesa.on.worldcat.org/oclc/5595931368
Sobel, J. D. P. (2007). Vulvovaginal candidosis. The Lancet TA
- TT -,
369(9577), 1961–1971. http://doi.org/10.1016/S0140-6736(07)60917-9
LK - https://lesa.on.worldcat.org/oclc/5899402339
Case 2
The treatment of 30-year-old male with abnormal sweating by
acupuncture and herbs
Primary signs and symptoms
The 30-year-old male has been suffering from the abnormal sweating on the
chest about two year. This condition is from after radiation therapy of cancer.
The sweating is happened at daytime, and not sweating at night. It’s easy to
spontaneous sweating when exercise, walking or normal movement. He had
been removed tonsils and adenoids tissue when he was a child due to the
recurrent tonsillitis.
Secondary signs and symptoms

Energy level is 6/10.

Working and standing 7 hours per day.

Slight bloating after meal.

Most of the vegetables in the diet, three meals a day, and a little bit of
fish.

Mouth is dryness and thirsty, and drink a lot of water every day.

Urination is frequency and clear, about 10 times per day. The bowel
movement is regular.

Body temperature is felt warm.

Emotional sadness from the illness and worry abut the job.

Sleep quality is not good, sleep hour is 6 hours per day.
The patient is a baker. He has to wake up at 4 am and prepare to work per
day. He does jogging and exercises at the gym, and easy sweating a lot even
just normal movement. It’s especially profuse sweating at the portion of the
chest.
Tongue
The tongue body is slight red, thicker yellow coating in the back (the patient
had a coffee before treatment), and red in the tip.
Pulse
Right: upper – slippery, middle – thin, lower – thread
Left: upper – deficiency, middle – deficiency, lower – thin
Preliminary thoughts on diagnosis
The preliminary on the diagnosis of this patient is the weakness of the
constitution lead to the lung qi deficiency, and the lung is controlled skin and
hair, thus cause to spontaneous profuse sweating at daytime. The diet of
imbalance cause to the spleen qi deficiency, because the spleen and lungs
are involved in the production of qi and they influence each other that reason
to the function of the lung is the weakness, and lead to the abnormal sweating.
The heart also controls the sweating, and maybe the patient is disturbed the
mind from emotion, this can lead to heart qi or heart yang deficiency. Another
the weakness constitution due to the illness in childhood, as a cause of the
kidney deficiency, may lead to weak interstice and outward leakage of body
fluids. Thus, the preliminary diagnosis is lung qi deficiency, spleen qi
deficiency, heart qi or heart yang deficiency and kidney deficiency.
Diagnosis post discussion with supervisor
Weakness constitution ⇒ kidney yang deficiency ⇒ fail to transform the fluids
⇒ resulting in frequency and clear ruination.
Overwork ⇒ wake up at 4 pm every day to work ⇒ the time is belong the lung
channel, thus lead to the imbalance the lung ⇒ lung function deficiency ⇒
abnormal spontaneous sweating.
Radiotherapy ⇒ toxic heat ⇒ exhausts qi and body fluids ⇒ damage the
function of spleen and stomach ⇒ spleen and stomach qi deficiency ⇒ also
may lead to the heart qi or yang deficiency ⇒ abnormal spontaneous
sweating.
Emotional stress ⇒ disturb the mind ⇒ depress the heart function ⇒ heart
governs blood ⇒ heart blood deficiency.
The diagnosis for this patient is spleen and lung qi deficiency, heart blood
deficiency and kidney yang deficiency.
Aetiological factors relating to complaint
The aetiological factors for his complaints are weakness constitution,
overwork, radiotherapy and emotional issue that all can cause to the
spontaneous sweating.
Clinical intervention
Pathogenesis
Spontaneous sweating is a type of persistent sweating free from the external
environment at any time of the day and becomes worse upon physical
exertion. The pathology of abnormal spontaneous sweating caused by yingyang imbalance of human body, disharmony between ying-nutrient and weidefense and weak interstice, and the superficial is not solid. Due to the
deficiency of wei-defense qi, it is improper to manage the function of open and
close of pores, resulting in leakage of body fluids. Spontaneous sweating is
more common in yang deficiency or qi deficiency and often accompanied by
symptoms such as palpitation, fatigue and shortness of breath.
Spleen and lung qi deficiency: It’s can result from constitution lung deficiency
or chronic cough consuming lung qi. Deficiency lung qi fails to diffuse
protective qi to the surface and interstitial layer between the skin and muscle.
The pores are in the unconsolidated protective layer open and abnormal
sweating occurs.
Heart blood deficiency: As we know the blood and body fluids mutually
interchange each other. The heart governs blood and this has a relation of
mutual interchange with body to sweat. Therefore the profuse and continuous
sweating can lead to the heart blood deficiency.
Kidney yang deficiency: Excessive physical work or exercise may weaken
kidney yang, when kidney yang is deficiency it fails to transform the fluids,
which therefore accumulate, resulting in profuse and clear urination.
Other syndromes present
That only the tongue coating is thick yellow in the back, but the patient have a
coffee before treatment, so it’s not necessary to consider in the stage.
Treatment principle
1. Tonify the spleen and lung qi
2. Nourish the heart blood
3. Tonify the kidney yang
Application of intervention
Acupuncture treatment

SP6: Tonifies the spleen and stomach, and resolves dampness.

SP9: Regulate the spleen.

ST36: Fortifies the spleen and foster original qi

KD3: Tonify kidney yin and essence.

HT7: Regulate and tonify the heart, and calm the spirit.

LU7: Tonify the lung qi.

Yin tang: Calm the spirit.
The size of needles is 0.18mm x 30mm to use in the treatment.
Herbal prescription
Ren Shen 9g
Bai Zhu 9g
Fu Ling 9g
Zhi Gan Cao 6g
Chen Pi 9g
Sha Ren 5g
Mu Xiang 6g
Wu Wei Zi 12g
Lian Zi 12g
Dang Gui 9g
Shao Yao 9g
Huang Qi 12g
Mu Li 12g
This formula is modified from Si Jun Zi Tang. Ren Shen is to tonify qi and
strengthen the spleen and stomach. Bai Zhu is to strengthen the spleen,
augment qi and dry dampness. Fu Ling is to dry dampness; strengthen the
spleen and moderate the drying nature of Zhi Gan Cao. Zhi Gan Cao is for
harmonizing, warm and strengthen the middle jiao and moderate the drain
properties of Fu Ling. Chen Pi is to regulate qi and adjusts the middle. Sha
Ren is to promote the movement of qi, strengthen the spleen and transform
dampness. Mu Xiang is to promote the movement of qi and strengthen the
spleen and prevent stagnation. Wu Wei Zi is to astringe the sweat and
generates the fluids, and quiets the spirit and calm and contains heart qi. Lian
Zi is to nourish the heart and calms the mind. Dang Gui with Bai Shao is to
regulate and harmonise the qi and blood and treat the blood deficiency heat.
Huang Qi is for tonify qi and blood, and generate body fluids. Mu LI is to
heavy settle and calm the spirit, and prevent leakage of fluids.
Dietary and lifestyle advice
1. Keep physical exercise, balance work and rest, avoid too much mental
stress and take less hot, spice food and greasy food.
2. Avoid wind-cold during sweating to prevent common cold and dry up
sweats with a dry towel after perspiration.
3. Change underwear on time after sweating and keep clothes or bedding dry
and clean.
Contraindication
There is no any contraindication in this treatment.
Reflection
From this case, I learn the sweating is the body fluids that have been pushed
out by yang qi, any organ related to the formation of body fluids, such as the
lung, spleen, stomach, or kidney, there are play an important position in the
sweating. Especially the heart has an intimate relationship with sweat. This
patient is sweating at daytime that is belonging the spontaneous sweating,
maybe consider that is connected to the heart yang qi deficiency. Also, heart
yang deficiency may indirectly be caused by any of kidney yang deficiency. In
the next treatment, I may be to consider the moxa at the points of KD3 and
DU4 to tonify the yang qi, and also I expected to have a good result after ten
treatments.
From the perspective of Western medicine, hyperhidrosis is unexplained
excessive sweating, probably because the sweat glands are too developed, or
the sympathetic line that regulates sweat secretion is too sensitive. The
treatment of Western medicine for hyperhidrosis is included the use of topical
antiperspirants, tap water iontophoresis, Botox injection, etc., but these may
not cure the disease. Surgery rules include sweat gland resection,
sympathectomy, etc., but there are possible certain risks and side effects to
my patient. Thus, it’s not to suggest the patient have surgery or referral to GP.
Research
Sweating is an essential function of the body; it helps cool the body, moisten
the skin and excrete metabolic wastes. How much you sweat depends on how
many sweat glands you have and how active they are. The mood, diet,
hormone level, some drugs and medical conditions influence sweating.
Generally, women have more sweat glands than men, but men's glands are
more active. Either excessive or too little sweating is abnormal (R.P., 2012).
Excessive focal sweating such as on the face, hands, feet or underarms
usually has no apparent cause; the condition seems to run in families.
However, excessive sweating over a large area of the body may indicate an
underlying cause. It can be a side effect of medication or a sign of health
problems commonly seen in menopause, low blood sugar, hyperthyroidism,
anxiety, cancer and infections (Schlereth, Dieterich, & Birklein, 2009).
According to Traditional Chinese medicine (TCM) theory, sweat is
transformed by yang qi evaporating body fluids especially the blood, which
then it emerges out of the body through the sweat pores. Normal sweating
helps regulate and harmonize the internal and external body, and is also
responsible for nourishing the skin. Sweating has a dual nature when
occurring in disease; the first is to eliminate pathogens, a normal reaction of
the body's defence system. Secondly, as sweat is transformed from body
fluids, excessive sweating depletes body fluids and blood causing further
internal disturbance.
Hyperhidrosis is sweating in an amount that is more than the physiological
needs of an individual and which disturbs his/her quality of life. It generally
starts at the age of 25 and is seen most commonly in the axillae, the palms of
the hands and the soles of the feet. Hyperhidrosis is thought to affect men
and women equally and occurs in approximately 3% of the population.
Treatments are available, but none is without limitations or associated
complications, and side effects and compensatory sweating are still common
potentially severe problems. Acupuncture has been reported to provide
improvement in this disorder without any side effects (Cayir & Engin, 2013).
Reference
Cayir, Y., & Engin, Y. (2013). Acupuncture for primary hyperhidrosis: case
series LK - https://lesa.on.worldcat.org/oclc/5521269005. Acupuncture in
Medicine TA - TT -, 31(3), 325–326.
R.P.,
B.
(2012).
Hyperhidrosis
LK
https://lesa.on.worldcat.org/oclc/824770134. Consultant TA
- TT
-,
52(11).
Schlereth, T., Dieterich, M., & Birklein, F. (2009). Hyperhidrosis--causes and
treatment of enhanced sweating. Deutsches Arzteblatt International TA TT
-, 106(3), 32–37. http://doi.org/10.3238/arztebl.2009.0032 LK
https://lesa.on.worldcat.org/oclc/422687492
-
Case 3
The treatment of 28-year-old female with period pain by acupuncture
and herbs
Primary signs and symptoms
The 28-year old female has been suffering from the period pain about four
years. The pain comes from both side of abdomen radiate to the centre and
the lower back, breast distention and the body is shacking causes by the pain.
The worst of the pain is on the first day of the period and feel the energy is a
weakness. The colour of the period is cherry red with small clotting. Before
period, always has a bit of the spotting of bleeding. She takes the pain killer
when the pain is severe. She had an ultrasound test from the suggestion of
GP, but it showed no syndrome from the result.
Secondary signs and symptoms

Energy level is 6/10, and tiredness always.

Stress from the study and job.

Appetite and digestion is normal

Diet is 3 meals per day, and has vegetable, chicken and red meat.

No thirst, drinks about 1.5L water per day.

Urination is normal, Bowel movement once a day, but the stool
sometimes soft and sometimes hard.

General feels of cold, prefer warm water, but feels hot and sweating
at night before period about 4-5 days ago.

Slight blurry vision after study in computer.

Slight tinnitus with low pitch on both sides.

Sometimes feel dizziness.

Phlegm in the throat and difficult expectorate about 2 months ago,
and the phlegm is sticky and light yellow.

Sleep is fine, and about 8 hours per day.

Pimples breakout on the face, the color is pale-red.

Always feels lower back pain, but not radiate to the legs.
This patient is a full time student, and part time job on Saturday and Sunday
that working about 9 hours per day. She still has a lot of cycling and walking.
Tongue
The tongue body is large and swollen with tooth mark on both sides, and
slight thicker white coating in the middle.
Pulse
Right: upper-deep deficiency, middle-deep deficiency, lower-deep deficiency
Left: upper-deep deficiency, middle-deep thin, lower-deep deficiency
Preliminary thoughts on diagnosis
The emotional stress from the study and job all may lead to liver qi stagnation,
then cause to blood to stagnate in the uterus leading to period pain. The
patient is full time study on weekly and working on weekend and standing
about nine hours at the site. The physical overwork leads to deficiency of qi
and blood, especially of spleen and stomach. Deficiency of blood leads to
malnourishment of the Penetrating and Directing vessels that causing
stagnation and pain. Another the lower back pain can explain the kidney
deficiency. From above the information to diagnosis the patient is liver qi and
blood stagnation, spleen and stomach deficiency and kidney deficiency.
Diagnosis post discussion with supervisor
Emotional strain ⇒ stress ⇒ liver qi stagnation ⇒ blood stasis in the uterus ⇒
period pain
Overwork ⇒ spleen and stomach qi and blood deficiency ⇒ blood not nourish
the penetrating and directing vessels ⇒ period pain
The diagnosis after discussion with supervisor is liver qi and blood stagnation
and spleen and stomach qi and blood deficiency.
Aetiological factors relating to complaint
The aetiological factors for this patient are emotional stress and overwork to
cause the period pain.
Clinical Intervention
Pathogenesis
Stagnation of qi and stasis of blood are the main patterns occurring in painful
periods for this patient. Also, they are often accompanying other patterns. For
example, the deficiency of qi and blood may occur in combination with some
stagnation of qi and blood. Similarly, cold obstructing the uterus leads to
stasis of blood. In TCM, stagnation of qi and blood always related to the liver
and the penetrating vessel. A free flowing liver qi is essential to move blood
before and during the period, if liver qi stagnation, blood does not move
properly and pain results. The penetrating vessel is also usually involved in
painful periods from stagnation as it is the sea of blood and it flows through
the uterus. It’s the most important one in the pathology of painful periods.
The spleen makes blood that is then stored in the liver. Therefore the blood of
liver is both the gynecological blood expression of Tian Gui of the kidneys and
the post-natal blood deriving from the post-natal qi of spleen and stomach. If
the spleen not holding the blood and spleen blood deficiency, and cannot
nourish the uterus that will leads to the period pain. The spleen qi deficiency
from this patient, no doubts because of the excessive use of the mind in
studying and working, and is frequent consequence leads to the formation of
dampness. As the spleen is responsible for transporting food qi to the four
limbs, so the patient feels weakness and tiredness that is the spleen qi
deficiency, and the limbs will be deprived of nourishment.
Other syndromes present
The patient has the pimples on the face. The stomach meridian and lung
meridian are main to effective this symptom. When heat is excess in the body
it raises up to the face. Maybe the patient eats too much spice, greasy or fired
foods then dampness or undigested metabolites are created and transform
into heat and caused to pimples breakout on the face.
Treatment Principle
1. Move qi and blood, eliminate stagnation and stop the period pain.
2. Tonify the spleen qi and resolve the dampness.
Application of Intervention
Acupuncture treatment

SP6 and ST36 are help to invigorate blood and stop pain.

LV3 is to move qi and blood and stop pain.

Ren4 with lamp heat to warm the uterus.

SP4 (on the right side) and PC6 (on the left side) are to regulate the
penetrating vessel and regulate blood in the uterus.
The size of needles is 0.18mm x 30mm, and used reducing or even method in
this treatment.
Herbal prescription
Wu Zhu Yu 1.5g
Gui Zhi 12g
Dang Gui 12g
Bai Shao 12g
E Jiao 6g
Mai Men Dong 9g
Mu Dan Pi 9g
Dang Shen 12g
Gan Jiang 6g
Bai Zhu 12g
Fu Ling 12g
Ban Xia 6g
Yan Hu Suo 12g
Wu Ling Zhi 12g
Hong Hua 6g
This formula is modified from Wen Jing Tang. Wu Zhu Yu is to warm the
middle jiao, disperse cold, expel damp-cold, promote the movement of qi,
spread the liver and alleviate pain. Gui Zhi is to warm the channels and
collaterals, disperse cold, and facilitate the flow of yang qi in the chest and
warm the flow blood through the vessel. Dang Gui is to tonify the blood,
regulate menstruation, and invigorate and harmonize the blood. Bai Shao is to
nourish the blood, soften the liver and regulate menstruation. E Jiao is to
tonify blood and stop bleeding. Mai Men Dong is to nourish stomach ying. Mu
Dan Pi is to cleat heat, cool and harmonize the blood, activate the blood and
dispel blood stasis. Dang Shen is to tonify the spleen qi, moderate spasms
and alleviate pain. Gan Jiang is to warm the middle, expel cold, and rescue
devastate yang and expel internal cold. Bai Zhu is to tonify the spleen,
augment qi, and dry the dampness and promote water metabolism. Fu Ling is
to strengthen the spleen and leach out the dampness. Ban Xia is to dry
dampness, transform phlegm and harmonize the stomach. Yan Hu Suo is to
invigorate the blood, circulate qi, stop pain and disperse extravasation. Wu
Ling Zhi is to dispel blood stasis, stop bleeding and alleviate pain. Hong Hua
is to invigorate the blood, dispel blood stasis, unblock menstruation and stop
pain.
Dietary and life advice

Eat warm, nourishing foods, and avoid inflammatory foods.

Rest on days of pain. Avoid strenuous exercise or demanding days but
do go for a gentle walk that can help relieve pain.

Stay warm. Cold constricts the blood vessels and constricted blood
vessels don’t let the blood flow properly.
Contraindication
This formula is contraindicated when the patient is during pregnancy.
Reflection
From this case to understand more about the period of pain that can last for
just the first day of a woman’s menstruation or can go on for days. Many
young women experience this at menarche, and it can often go on for many
years. Many associated symptoms can develop as well such as acne due to
the changes in hormones. The primary form of treatment in Western Medicine
is to artificially regulate the cycle by use of the Oral Contraceptive Pill or
painkiller to stop the pain.
The severity of this pain can vary greatly; many patients complaining of being
bedridden for almost a week. Some can experience pain around ovulation
also. Other symptoms can occur around the commencement of menstruation
like back pain, headaches and changes to their bowel movements. Those
symptoms have also happened in my patient.
The ‘ideal’ menstrual cycle should occur every 28 days, and the bleed should
last 3-5 days. There will often be some discomfort, but the pain should not be
debilitating. Likewise, the bleed should not be overly heavy, only a small
amount of clotting should occur, and the blood should be red. If the bleed is
extremely painful, large clots passed and the blood is a dark red or purple,
then Chinese Medicine describes this as ‘blood stagnation’.
Pain is a result of Qi and Blood not moving, depending on how impeded their
flow is, dictates the severity of the pain. Aching pains are described as Qi
stagnation, whereas sharp/fixed pains are Blood stagnation. Often you can
have pain that alternates. So what impedes their flow? Environmental
elements such as cold, pathogens such as damp (which can come from
humidity or poor diet) can impede their flow. Another, stress and a lack of
sleep are two very common internal causes of disruption.
Research
Dysmenorrhea, defined, as painful, spasmodic cramping in the lower
abdomen, just before and/or during menstruation, in the absence of any
discernable macroscopic pelvic pathology, is the most common gynecological
condition among women of reproductive age. Dysmenorrheic pain is most
severe during the first or second day of menstruation and typically lasts for 8–
72 hours. The pain may radiate to the back and thighs and is frequently
accompanied by systemic symptoms including nausea, vomiting, diarrhea,
fatigue, and insomnia (Proctor & Farquhar, 2006).
Dysmenorrhea is believed to result from excessive Prostaglandin release,
which causes vasoconstriction of uterine blood vessels (uterine ischemia) and
increased uterine smooth muscle contraction. The contraction of the ischemic
uterus is the likely cause of dysmenorrheic pain (Iacovides, Avidon, Bentley, &
FC, 2009). Nonsteroidal anti-inflammatory drugs (NSAIDs) are principal
pharmacological therapies for dysmenorrhea. Oral contraceptives also can be
used in the management of dysmenorrhea in clinical practice. NSAIDs have
many side effects on human body, including digestive tract, liver, and kidney.
Oral contraceptives have potential side effects of water retention, nausea and
endometriosis.
TCM is well-accepted in countries such as China, Japan, and Korea. The
commonly used herbal formulas for the treatment of primary dysmenorrhea
include Danggui Shaoyao San, Shaofu Zhuyu decoction, and Wenjing
decoction. Different herbal formulas are prescribed by physicians for different
patients according to a patient’s symptoms. For example, if blood clots are
observed during menstruation, physicians prefer to use Shaofu Zhuyu
decoction to treat primary dysmenorrhea. If cold is felt in the lower abdomen,
Wenjing decoction is preferred. When primary dysmenorrhea is accompanied
by gastrointestinal discomfort, Danggui Shaoyao San is prescribed. Several
systematic reviews of TCM for the treatment of primary dysmenorrhea have
been conducted. The article conducted a systematic review to evaluate the
efficacy of Danggui Shaoyao San for the treatment of primary dysmenorrhea
and concluded on the superiority of Danggui Shaoyao San over analgesics or
placebo (HW et al., 2016). Another article conducted a systematic review to
evaluate the TCM Shaofu Zhuyu decoction for the treatment of primary
dysmenorrhea, and the meta-analysis results showed the superiority of
Shaofu Zhuyu decoction compared with NSAIDs (Lee, TY, CS, JA, & MS,
2016). However, no relevant systematic reviews have assessed the clinical
effectiveness or the risk of Wenjing decoction in the treatment of primary
dysmenorrhea.
Reference
HW, L., JH, J., KJ, K., BS, K., CH, L., & MS, L. (2016). Herbal medicine
(Danggui Shaoyao San) for treating primary dysmenorrhea: A systematic
review and meta-analysis of randomized controlled trials. Maturitas TA TT
-, 85, 19–26. http://doi.org/10.1016/j.maturitas.2015.11.013 LK
-
https://lesa.on.worldcat.org/oclc/5995523768
Iacovides, S., Avidon, I., Bentley, A., & FC, B. (2009). Diclofenac potassium
restores objective and subjective measures of sleep quality in women
with
primary
dysmenorrhea.
LK
-
https://lesa.on.worldcat.org/oclc/435828043. Sleep TA
- TT
-, 32(8),
1019–1026.
Lee, H., TY, C., CS, M., JA, L., & MS, L. (2016). Herbal medicine (Shaofu
Zhuyu decoction) for treating primary dysmenorrhea: A systematic review
of randomized clinical trials. Maturitas TA
- TT
http://doi.org/10.1016/j.maturitas.2016.01.012
-, 86, 64–73.
LK
-
https://lesa.on.worldcat.org/oclc/6002999598
Proctor, M., & Farquhar, C. (2006). Clinical review - Diagnosis and
management
of
dysmenorrhoea
https://lesa.on.worldcat.org/oclc/102302298.
Journal / TA - TT -, 332(7550), 1134.
LK
BMJ :
British
Medical
Case 4
The treatment of 23 year-old female with insomnia by acupuncture and
herbs
Primary signs and symptoms
The 23-year-old female has been suffering from the sleep problem for over
four years. She found it difficult to fall asleep and the mind still racing and
active between 8pm-12pm. She woke up frequently during the night and can’t
fall asleep again. Occasionally, she sweated a lot when gradual fever at night.
She has a medication for the insomnia from GP, but still not too many help the
problem.
Secondary signs and symptoms

Energy lever is about 6/10.

High intensity of exercise 4-5 days per week.

She is vegetarian, no breakfast and until to 11am to have the first
meal.

Urine is feeling urgent and frequent.

Bowels are soft and once a day.

Hot flush at the evening and gradually get worst from last year.

Dizziness, memory loss and poor concentration when the sleep is not
good.

Palpitation and shortness of breathe in the morning when sleep is not
well.

Knee pain on the both side, it’s a click and constantly pain when walk
down or up the steps.

Pins and needles feeling on the foot.

The length of cycle is 30 days, bright red in the first 2 days, slight
darker in the end. The amount of period is heavy in the first two days.
She had been has the contraceptive pills for the acne about six
months four years ago.

She was diagnosed acute anxiety from psychologist when in 20172018. There is lymph nodule for 2 month when she was 12 years old.
Tongue
The tongue body is long and red with a thin white costing, and red tip and red
spot on the lung region.
Pulse
Right: upper – slippery, middle – soft, lower – deficiency
Left: upper – soft, middle – wiry, lower – deficiency
Preliminary thoughts on diagnosis
My diagnosis for this patient is liver qi stagnation, spleen qi deficiency and
heart blood deficiency. The liver qi stagnation is due to the emotional stress of
study and relationship of family, and showed on the pulse is wiry on the
middle position of left side. The spleen qi deficiency is due to her poor
appetite, imbalance diet that showed the energy level is low and loose stool
and the pulse is deficiency on the middle of spleen position. The heart blood
deficiency is due to physical overwork that lead to the qi and blood deficiency.
Diagnosis post discussion with supervisor
Emotional problem (study and relationship) ⇒ liver qi stagnation ⇒ maybe
cause to the fire and disturbed the mild of heart ⇒ insomnia.
Diet (imbalance nutrition, irregular diet) ⇒ damage function of spleen and
stomach ⇒ spleen qi deficiency or disharmony the stomach qi ⇒ cause to the
damp heat ⇒ disturbed mild of shen ⇒ lead to insomnia.
Weakness constitution ⇒ kidney yin deficiency ⇒ imbalance the heart and
kidney (fire and water) ⇒ maybe heart fire upward to disturb the mild ⇒ lead
to difficult fall asleep.
Prolong illness ⇒ cause to heart blood and yin deficiency ⇒ heart loss the
nourishment ⇒ uneasy the mild ⇒ cause to insomnia.
The diagnosis is heart and kidney yin deficiency with empty heat, heart blood
deficiency, liver qi stagnation, and spleen qi deficiency with dampness.
Aetiological factors relating to complaint
The aetiological factors are emotional problem, diet, weakness of constitution
and prolong illness.
Clinical Intervention
Pathogenesis
1. Impairment of the heart and spleen due to mental stress: Impairment of the
heart may cause heart blood consumption and the heart failing to govern the
heart mind, and impairment of the spleen may cause a poor appetite and
insufficient generation of qi and blood to be delivered to the heart, which may
in turn disturb the heart mind and result in sleep problem.
2. Hyperactivity of fire due to yin deficiency and disturbance of the heart mind:
emotional injury may affect the function of the liver in governing the free flow
of qi and cause liver qi stagnation, which may in turn transform into fire that
rises up and disturbs the heart mind, which may in turn disturb the heart mind
and result in sleeplessness.
3. Congenital deficiency or chronic disease consume too much kidney
essence and affect the function of the kidney and hyperactive heart fire
disturb the heart fire disturbing the heart mind and subsequently
sleeplessness.
4. Impairment of spleen and stomach due to improper diet: Irregular diet or
food retention and affect the normal flow of stomach qi, leading to
sleeplessness or food retention may transform into phlegm heat and disturb
the heart mind, leading to sleep problem.
Other syndromes present
The acne about six months, and had the contraceptive pills to treat it. There
is lymph nodule for 2 months at 12 years old.
Treatment principle
1. Nourish heart and kidney yin, clear empty heat.
2. Remove the liver qi
3. Tonify the qi and blood.
4. Resolve the dampness.
Application of intervention
Acupuncture treatment

SP3: Tonify the spleen and resolves dampness

ST40: Transforms phlegm and dampness from the body

KD6: Nourish kidney yin

LV3: Move qi stagnation

HT3: Calm the mind and clear heat.

SP9: Regulate the spleen and resolves dampness

An Mian: Calm the spirit and pacifies the liver
The size of needles is 0.18mm x 30mm to use in the treatment.
Herbal prescription
Tian Wan Bu Xin Dan MOD
Sheng Qi Huang 12g
Dang Shen 12g
Mai Men Dong 9g
Dan Shen 12g
Fu Ling 12g
Dang Gui 9g
Xuan Shen 9g
Yuan Zhi 6g
Wu Wei Zi 9g
Suan Zao Ren 12g
Mu Li 12g
He Huang Pi 12g
Xiang Fu 12g
Bai Zhu 12g
Dietary and lifestyle advice
1. Keep mental fitness and well controlled emotions.
2. Have good sleep habits and create a peaceful and comfortable sleep
environment.
3. Keep away from cigarettes, alcohol, strong tea and coffee and avoid over
excitement.
4. Do appropriate physical labor or exercise to strengthen the body
constitution.
Contraindication
Do not take for long term and while taking this formula, avoid cilantro, garlic,
radishes seafood and alcohol.
Reflection
Western medicine treats insomnia regardless of the cause, whether young or
old that only gives sleeping pills, but it’s only suitable for short-term use and
not recommended for long-term use. Many patients are dependent or
addictive to sleeping pills and must take medication for a long time; thus, why
this patient wants to try Chinese medicine to help her insomnia. In Chinese
medicine, insomnia always caused by yin-yang imbalance and the failure of
yang to harmonise with yin resulting from emotional injuries, weakness
constitution due to chronic disease, improper diet, work rest imbalance or
congenital deficiency. Despite the location in the heart, insomnia also related
to the liver, spleen, stomach and kidney. It can find from this patient of signs
and symptoms, for example, she is a vegetarian and no breakfast in the
morning that easy to damage the spleen, the emotional stress from study and
relationship with her parents that cause to the liver issue.
Many people with poor sleep quality, maybe have anxiety, panic or worry
before going to bed. That’s why the patient was diagnosed with acute anxiety
from a psychologist before, and the symptoms have palpitation, shortness of
breast, frequent urination, etc. Prolong insomnia has to need a long time to
treat it and depend on the diagnosis of Traditional Chinese Medicine to
distinguish which type of insomnia. Through the determination, the patient is
belong to the yin deficiency of insomnia, thus used the acupuncture and herbs
to treat insomnia. I hope it can help the patient to improve her insomnia, and
expected the second treatment to understand the result from the first
treatment.
Research
Insomnia is a great challenge to the physical and mental health of individuals.
Insomnia is commonly defined as sleep difficulties that affect daytime
functioning; it does not occur in the presence of another sleep disorder,
mental disorder, or as the direct physiological effect of a substance or medical
condition (MM, 2002). Currently, the primary treatment for insomnia is
psychological treatment complemented with medications. Psychological
treatment mainly refers to cognitive behavioral therapy (CBT) for insomnia,
which has been proven to be efficient. Benzodiazepines, barbiturates and
other sedatives are the first-line pharmacological treatment for primary
insomnia (Zachariae, MS, LM, & MS, 2016). Despite their short-term efficacy
for symptomatic relief, long-term use of these medications may cause residual
symptoms such as excessive sedation, tolerance, addiction and neurological
toxicity.
Acupuncture is one of the most popular and safest therapies; it has been used
to treat primary insomnia since antiquity in China. Acupuncture balances the
body and restores its physiological function by inserting thin needles at
specific acupoints. Therefore, it does not affect the natural sleep–wake cycle.
It is found that acupuncture can increase the content of serotonin and
aminobutyric acid, and reduce glutamate levels. Thus, acupuncture treatment
can improve the function of central inhibition and help people sleep (Guo et
al., 2014).
A systematic review and meta-analysis evaluated the efficacy and safety of
TWBXD for the treatment of insomnia. In this review, analyzed treatment
effects in 1,256 patients with insomnia from 14 trials. Meta-analyses of these
RCTs over the course of 2-8 weeks show that TWBXD seems to be beneficial
for reducing the time to fall asleep. These clinical benefits are mainly
associated with TWBXD. The safety of TWBXD treatment was also examined.
There was only 1 case with minor adverse events in the TWBXD or TWBXD
combined with WM group, which is in agreement with long-term clinical
experience. However, the potential benefits of TWBXD in the treatment of
insomnia remain uncertain due to methodological deficiencies and limited
sample size for inclusion in the study. Therefore, recommendations for clinical
practice should be cautious (Yang, Liu, Ming, Fang, & Wu, 2019).
Reference
Guo, J., Wang, L.-P., Liu, C.-Z., Zhang, J., Wang, G.-L., Yi, J.-H., … Musil, R.
(2014). Efficacy of acupuncture for primary insomnia: a randomized
controlled clinical trial. Deutsche Zeitschrift Für Akupunktur TA - TT -,
57(4),
31–32.
http://doi.org/10.1016/j.dza.2014.10.009
LK
-
https://lesa.on.worldcat.org/oclc/7342531975
MM, O. (2002). Epidemiology of insomnia: what we know and what we still
need to learn. LK - https://lesa.on.worldcat.org/oclc/111474341. Sleep
Medicine Reviews TA - TT -, 6(2), 97–111.
Yang, X., Liu, L., Ming, S., Fang, J., & Wu, D. (2019). Tian Wang Bu Xin Dan
for Insomnia: A Systematic Review of Efficacy and Safety. EvidenceBased Complementary and Alternative Medicine TA - TT -, 2019, 1–7.
http://doi.org/10.1155/2019/4260801
LK
-
https://lesa.on.worldcat.org/oclc/8049553237
Zachariae, R., MS, L., LM, R., & MS, O. (2016). Efficacy of internet-delivered
cognitive-behavioral therapy for insomnia - A systematic review and
meta-analysis of randomized controlled trials. Sleep Medicine Reviews
TA
- TT -, 30, 1–10. http://doi.org/10.1016/j.smrv.2015.10.004 LK
https://lesa.on.worldcat.org/oclc/6905057217
-