Chief Complaint: Chronic Pelvic Pain
Western Diagnosis: Endometriosis
Medical History: 30y.o. female presents with main complaint of chronic lower pelvic pain. Patient states she got off of Aleese (birth control pill) approximately 6 months ago and began experience pelvic pain around ovulation and menses.
Symptoms: irregular pattern of menses, occasional spotting around ovulation and pre-menses, pain during intercourse, slightly painful bowel movements, a dislike of touch around the area, large clots, thirsty, constipation. Patient has had history of dysmennorea as an adolescent and visited her family physician who began her on birth control at the age of 14. Her current reason for discontinuing is to become pregnant. Patient states that around ovulation she is irritable and frustrated. Post-ovulation and menses she becomes depressed and sad. Her pain is located left lower pelvic region–described as very sharp “as if a knife is piecing me”. This pain will last until menses subsides (usually 5-7 days). Diet: red meat, fruits/veggies, dairy, does have daily caffeine and sugar intake. Exercise habits are moderate at best and states she is too busy to have a steady exercise routine. She is seeking acupuncture/herbal treatment because her doctor simply recommends her returning on the birth control pill.
Questioning exam: Most obvious symptom was her localized chronic pelvic pain, also associated pain symptoms (painful intercourse, bowel movements, etc).
Pulse exam: Pulse: Deep, wiry/choppy, slightly rapid
Complexion is slightly red
Tongue exam: Tongue: body is bluish purple, coat is pinkish/reddish.
OM Diagnosis: Blood stasis with heat. Blood should normally be shedding during the menstrual cycle and not backing up causing the endometriosis. If the blood doesn’t shed, it becomes stagnant, and causes pain. After time, stagnant Qi turns into heat causing this patient to also exhibit heat symptoms.
Treatment Principle: Clear heat, move qi and blood
Point Prescription: Sedate LI11, Four gates, Zigong, TW6, SP6, SP10, LIV5.
Herbal Formula: The developing sequence of the follicular phase is governed by the movement of Liv qi and Blood. Liv qi triggers the transformation of yin into yang to support ovulation. The free flow of liver qi is a must so ovulation can happen. Ovulatory/menstrual pain is indicative of blood stasis and the following herbs should be continuously used for a minimum of six months to promote the free flow of qi/blood and clear heat.
Bai Shao
Yi Mu Cao
Xu Duan
Xiang Fu
Dong Chong Xia Cao
Chaun Xiong
Dang Gui
Chen Pi
Zhi Ke
Shan Zha
Gou Qi Zi
Sha Shen
Hei Zhi Ma
Dan Shen
Da Zao
Lifestyle Prescription: I recommend patient to clean up her diet. Incorporate Vit E (800iu) into her diet-this improves scar tissue caused by the internal endometrial bleeding.
Reduce yeast/sugar. Both are very inflammatory to the body–increasing her pain.
Add a high fiber, vegetarian based diet. Reduce meat/dairy–both contain hormones that may be causing hormonal/endometrial fluctuations and adding unnecessary heat.
Incorporate 30minutes of exercise 4x/week. This to increase endorphins which are our bodies natural painkillers.
Results: Great results. Patient has come to my office 2x/week for first twelve weeks, then lowered to one time a week. It is the forth month and patients symptoms have reduced by over 70%. Acupuncture/herbs are key to pain reduction, but diet and exercise factors also play a key role in gynecological conditions
Synopsis: Patient will continue with treatments. Will adjust acupuncture points and discontinue herbs one month prior to patient wanting to conceive.