Chief Complaint: dark scanty menstrual blood
Medical History: Patient is a 35 year old pilates instructor.
- very active lifestyle with a 4 year old daughter
- eats irregularly and often on the run
- healthy pregnancy and no surgeries or major illness
Questioning exam: – blood dark in colour, brownish purple and scanty with some clots.
-energy levels very low lately
-some lower abdominal cramping first day of menstruation
-fatigue worse during and just after menstrual cycle
-complexion pale
Pulse exam: thin, choppy, wiry
Tongue exam: pale purple tongue more pale on the sides
OM Diagnosis: Liver blood deficiency and blood stasis
Treatment Principle: Tonify liver blood, dispel blood stagnation
Point Prescription: Sp4, P6, St 36 Liv 3 Li4 Liv 8 Sp10
R4, K3
Herbal Formula: Ba Zhen Tang for the first 2 weeks of cycle and then Tao hong si wu tang for last 2 weeks of cycle
Lifestyle Prescription: Ask patient to follow a spleen qi diet, eating more cooked foods, less dairy and wheat.
- eat on a regular basis and stop eating on the run, sit down to eat, chew food well
-to listen to her body and if she is feeling tires to try to get some rest and miss a day of exercise
Results: After 2 months cycle has improved,abdominal pain is gone, menstrual blood is a much brighter colour and the blood flow is becoming heavier
-overall energy has increased and feeling less stress
Synopsis: Overall patient has learned how to listen to her body, to take the time to slow down when tired and also has stopped eating on the run. These have made a large difference in her health and overall well-being.
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