Chapter 4　Outline of Diagnosis

The four examinations for gynecological diseases are the examination of menstrual symptoms, pelvic and vaginal symptoms, pregnancy symptoms and symptoms occurring afer childbirth. It is important to take these points into consideration in clinic.

Visual observation of the patient’s physical characteristics and demeanor is an important aspect of diagnosis and should be actively carried out from the beginning of the consultation.

Additionally observations can be made of the external reproductive organs, the nature and quantity of the menstrual blood or vaginal discharge can be observed or described as can the quantity and quality of breast milk in the breastfeeding mother. The tongue should also be observed.

Inspection of the Spirit

The spirit is the master of the body, and the body is the house of the spirit. They are closely inter-related to each other and are both important in diagnosis. The spirit is the refection of life. Assessment of the spirit, from the brightness of the eyes, and the general demeanor can enable one to determine whether the essence is exuberant or deficient, and the extent of any disease and its prognosis. This applies to all diseases including gynecological ones.

Inspection of the Complexion

The complexion refects whether internal organ function is healthy or not and whether qi and blood are sufcient. Through inspection of the complexion, doctors of gynecology can diagnose the states of the viscera, qi and blood, and pathological states.

Inspection of the Body

This inspection of the body focuses on constitutional body type and growth and whether there is obesity or emaciation.

Inspection of the Tongue

Through the inspection of the color, coating and texture of the tongue, the doctor can determine the physical function of internal organs and any pathological changes.

Inspection of Menstrual Paterns

Frequent periods indicate blood heat or qi deficiency. Infrequent periods indicate deficiency of blood, kidney deficiency, or blood stagnation due to congealing cold. Sometimes, menstrual blood fow is alternately heavy or light. This indicates qi constraint or a kidney defciency. A purple or bright red menstrual fow is due to blood heat. A pale red menstrual flow indicates deficiency of qi or blood. A darkish-purple menstrual flow indicates blood stasis and qi stagnation. Thick and sticky menstrual blood is usually caused by stagnation and heat. Thin menstrual blood is always indicative of defciency and cold. A purplish menstrual blood fow with clots is caused by blood stasis.

Inspection of Leukorrhea

Profuse vaginal discharge is a morbid condition, usually caused by severe damp-heat, or a spleen or kidney defciency. It is necessary to clearly diferentiate these clinically. A whitish discharge is usually due to defciency of the spleen or kidney. A yellow colored discharge is due to damp-heat, or dampness toxin. A reddish colored discharge, or one mingled with blood, is ofen caused by blood heat or pathogenic toxin. A thin discharge usually indicates spleen or kidney defciency. A sticky discharge is indicative of damp-heat accumulation.

Lochia Inspection

An excessive amount of lochia that is pale and thin is a sign of qi defciency. A bright purple red and thick lochia indicates exuberant heat in the blood. Darkish purplish lochia with clots is caused by blood stasis.

Listening and smelling include listening to the speaking voice of the patient and smelling the odor of any secretions.

Listening to the Voice

A low, weak voice indicates a defciency of center qi. A disjointed voice with gloomy tone and frequent sighing indicates binding constraint of liver qi. A loud sonorous voice, talking a lot and a restless nature indicate excess and heat patterns. Frequent belching, nausea and vomiting are caused by spleen-stomach disharmony and counterflow of stomach qi. A cough and rapid respiration are due to fuid retention in the heart, as well as failure of lung qi to difuse.

Smelling the Odor

The odor of the patient’s body and any secretions can help to diagnose imbalance of yin and yang, cold and heat. In gynecology, it is mostly the odor of menstrual blood, leukorrhea and lochia that we are interested in. An unpleasant odor indicates cold-damp; an ofensive odor indicates blood heat or accumulation of damp-heat. A putrid or roten odor suggests exuberance of pathogens or ulceration, a dangerous condition.

Asking questions is an important part of diagnosis and through inquiry, doctors can learn about the patient’s living conditions, eating habits, and lifestyle habits. They can also learn about the symptoms of the disease, when they occur and how they have developed and any other relevant information. All of this can provide an important basis for the diagnosis and treatment of the disease. It is important that doctors should know exactly what to ask when diagnosing disease involving gynecological conditions.

Asking About Age

Women of different ages have different physical and pathological features, so their diagnosis and treatment will be different. Generally speaking, patients with menstrual disorders appearing around the time of puberty are diagnosed with kidney insufciency. Middle-aged women more often suffer from premenstrual syndrome and dysmenorrhea and those who have had babies may sufer other diseases due to blood consumption and malnutrition of the liver and kidney.

Older women more often have menopausal symptoms and in some cases malignant tumors due to defciency of the spleen and kidney.

Asking About Chief Complaint

Inquiry about the chief complaint has two aspects: the main symptoms and the time of their occurrence. Questioning must be clear, and description of the chief complaint must be recorded concisely. The chief complaint will provide clues for further inquiry and plays an important role in the examination of the patient.

Asking About Present Illness History

Recording the history of the present illness should include its cause, the time of its occurrence, the symptoms from the beginning, the course of any treatment and its efect, and the present symptom picture.

Asking About Menstrual History

Menstrual history includes time of menarche, the date of last two periods, the length of the cycle, the duration of the period, the quantity of blood fow, the color of the blood, the quality of the blood, accompanying symptoms before, during and afer the menstrual period, and any other symptoms.

Early periods mainly indicate blood heat or qi defciency, while late periods are usually caused by blood defciency or a congealing cold. Irregular periods belong to liver constraint and kidney defciency.

Continuous or heavy menstruation over seven days is referred to as menorrhagia, or prolonged menstruation. Periods that last less than 2 days are referred to as hypomenorrhea or scanty menstruation. When women of child-bearing age suffer from amenorrhea, whether they are pregnant or not should frst be determined.

Aversion to pressure on the abdomen before or during the period, indicates an excess pattern. If there is feeling of soreness in the loins and abdomen, with the preference for pressure, it indicates a deficiency pattern. If there is a feeling of abdominal distention （more than pain）, it belongs to qi deficiency. On the other hand, if the feeling of pain is more severe, it belongs to blood stasis. Abdominal pain which is alleviated with warmth and pressure is ofen due to cold defciency. If it is relieved with warmth, but there is an aversion to pressure, it indicates a cold excess patern.

Asking About Leukorrhea

Asking about the quantity, quality, color and odor of vaginal discharge must be combined with inspection and smelling in order to differentiate the various patterns. If leukorrhea is profuse, whitish, thin and unpleasant smelling, it ofen indicates a defcient cold patern. If it is yellowish or brownish in color, sticky and foul smelling, it is due to heat and excess.

It is also good to ask whether there is a bearing down feeling, a feeling of distention, any itching, or a sensation of pain in the vagina.

Asking About Marriage and Delivery History

If the patient is, or was married, ask the patient at what age she was married, methods of birth control, pregnancy history, abortion or miscarriage history and about any problems during pregnancy, such as difcult labor, still birth, hydatidiform mole, and also about the health status of her spouse and any diseases before or afer labor, etc.

Asking About Past Disease History

It is important to know a patient’s past medical history, for it may have connections with the present disease. Past chronic kidney disease may cause severe edema during pregnancy. Past hypertension may increase the possibility of vertigo and eclampsia during the late stage of pregnancy. These are severe conditions deserving special atention. Severe anemia, heart failure, drug poisoning, or serious infection can cause fetal death and miscarriage. Tuberculosis, and a history of many dilatations and curetages can cause amenorrhea from obstruction of the uterus and cervix.

Asking About Familial Disease History

It is of value to find out about any hereditary diseases or infectious diseases in the family. Tuberculosis and hepatitis are related to diseases of the blood and can be contracted by contact in daily life.

Asking About Personal Life History

The patient’s personal life history includes her profession, working environment, living habits, tastes and preferences, and family situation. For example, people who spend a long time living in damp or dark environments are ofen invaded by cold and dampness. A preference for acrid and spicy foods easily induces blood heat. Inharmonious family relationships cause liver constraint. Sexual activity during the period or afer delivery can cause kidney defciency or an infection. Excessive drinking before or during pregnancy can cause poisoning of the fetus, namely fetal alcohol syndrome. Excessive smoking during pregnancy may cause low birth weight, malformations or fetal death.

Palpation includes pulse-taking and feeling the abdomen and limbs.

Cold, heat, defciency, and excess patern diagnosis in gynecological diseases is the same as for other types of disease. Here, we only talk about the pulse features of menstruation, leukorrhea and pregnancy.

（1） Menstruation Pulse

Normal Menstrual Pulse: Before or during menstruation, the pulse is mostly slippery.

Abnormal Menstrual Pulse: There are four types of abnormal menstrual pulses: deficiency and excess, and cold and heat. If the pulse feels moderate and weak, this is often qi deficiency. If the pulse is thready or weak and lacks force, this often indicates blood defciency. If the pulse is deep and thready this is indicative of kidney qi defciency. A thready, fast pulse indicates kidney yin deficiency or deficiency heat. A deep, slow, or weak pulse is a sign of kidney yang defciency. If the pulse appears to be wiry, it indicates qi stagnation and liver constraint. A strong choppy pulse is often a sign of blood stasis. A slippery, powerful pulse indicates phlegm and dampness combating and binding with the blood. If the pulse is deep and tight, this is ofen indicative of blood cold. A deep, slow pulse that lacks force suggests a cold defciency. A deep, tight or a soggy, moderate pulse mainly indicates cold and dampness coagulation and stagnation. If the pulse feels rapid and slippery or surging, it is often due to blood heat. If the pulse is thready and rapid, it is defciency heat. If the pulse feels wiry, rapid and powerful, it indicates that the liver constraint has transformed into heat.

（2） Leukorrhea Pulse

In the case of pathological vaginal discharge, a moderate, slippery pulse indicates exuberance of dampness due to spleen defciency. A deep, weak pulse is a sign of kidney qi depletion. A rapid, slippery, or a rapid, wiry pulse is ofen due to accumulation of dampheat. A deep, tight or soggy, moderate pulse is indicative of cold-damp.

（3） Pregnancy Pulse

Normal Pregnancy Pulse: Afer three months of pregnancy, the pulse in all six positions is moderate and slippery; and it does not disappear when pressed. This is more evident in the chi （cubit） position.

Abnormal Pregnancy Pulse: If during pregnancy, the pulse feels deep, thready, and choppy over the six positions, or weak at the chi （cubit） region, it is usually indicative of insufficiency of kidney qi and blood, or insufficiency of chong and ren mai; and care should be taken to prevent a miscarriage. During the last stage of pregnancy, if the pulse is wiry, vigorous, and urgent, or fast and wiry, it indicates an insufciency of liver yin and hyperactivity of liver yang. Care should be taken to prevent vertigo and pre-eclampsia.

（4） Parturient Pulse

Parturient pulse is also known as pulse of abnormal rate （ lí jīng mài, 离经脉）. There are many records of it in ancient medical classics. The Pulse Classic （ Mài Jīng, 脉经） states, “Pregnancy is a state away from the channel, and the pulse is floating.” In The CompleteCompendium of Fine Formulas for Women （ Fù Rén Dà Quán Liáng Fāng, 妇人大全良方）, it says “A deep thready and slippery pulse means the same.” In Standards for the Diagnosisand Treatment （ Zhèng Zhì Zhŭn Shéng, 证治准绳）, we can read, “When the pulse at the chi （cubit） region turns urgent and feels like beads rolling on a rope, this suggests of delivery.”Meanwhile, Xue’s Case Records （ Xuē Shì Yī Àn, 薛氏医案） says, “Hold the middle fnger of the pregnant woman, and only when the pulse at the proximal and middle knuckles beats, is it indicative of delivery.” In later ages, there were similar viewpoints. In general, lí jīngmài is a pulse of abnormal frequency of the six positions, which is floating and slippery. When delivery is imminent, the chi pulse becomes urgent and feels like beads rolling on a rope. Meanwhile, the side artery at the proximal, middle and even distal knuckles of the middle fnger throbs.

（5） Postpartum Pulse

Normal Postpartum Pulse: After delivery, qi and blood in chong and ren mai are insufcient; thus, the pulse is ofen weak, moderate and relaxed.

Abnormal Postpartum Pulse: During the puerperal period, the pulse might be foating, slippery, and rapid due to sudden defciency of yin blood and the relative exuberance of yang or the external contraction of an excess pathogen. If the pulse is deep, thready, choppy, and weak, it is ofen an indication of various paterns of blood depletion.

Palpation of gynecological patients includes feeling the abdomen and the four limbs to check for pathological changes.

Palpation of the lower abdomen aids the diagnosis of patients with dysmenorrhea, amenorrhea, or zhēng jiă （abdominal mass, 癥瘕）. This method enables the doctor to tell a defciency patern from an excess one, and pregnancy from a gynecological disease. During the menstrual period, if there is lower abdominal pain, which is worse for pressure, this is an excess condition; if the pain is dull and alleviated by pressure, this is a deficiency condition. Cold limbs and lower abdominal pain relieved by heat and pressure often indicate defciency cold. Feeling a lump in the lower abdomen indicates the condition of abdominal mass （ Zhēng Jiă, 癥瘕）. If the mass is hard, doesn’t move when pushed, and feels tender when pressed, it is caused by blood stasis. If the mass is not hard, movable when pushed, and scaters when pressed, it is the result of qi stagnation.

Cold limbs indicate yang defciency or qi defciency; and heat in the palms and soles indicate yin defciency with internal heat.

Palpation of the lower limbs in pregnant women with edema will help to diagnose the cause. If pressure with a finger leaves an obvious dent in the skin which may even hide the finger, this is often due to excessive water. If there is no remarkable dent left and the skin rebounds back immediately afer the fnger is removed, the swelling is due to excessive qi.

Gynecological and auxiliary examinations are sometimes needed to make a definite diagnosis. For pregnant women, pressing and observing the abdomen are necessary.

In summary, clinical diagnosis should use the four examination methods in combination, paying close atention to the main symptoms, and analyzing the pathological changes.

The essentials of pattern differentiation for gynecological disease are based on the clinical features of menstruation, leukorrhea, pregnancy, and delivery in combination with general symptoms and tongue and pulse conditions. Diagnosis must abide by the eight principles of yin, yang, exterior, interior, cold, heat, defciency, and excess. A comprehensive examination of specifc signs or symptoms, together with the general patient condition, will lead to a clear identifcation of zang-fu, qi, or blood pathology.

The methods of pattern differentiation in gynecology are generally zang-fu pattern diferentiation and qi-blood patern diferentiation.

In a few cases, wei-qi- ying-blood pattern differentiation is also used. For example postpartum fever, due to contraction of pathogenic toxin, develops like a warm febrile disease and it is suitable for the method of wei-qi- ying-blood pattern differentiation. No matter what method is used, it is applied under the guidance of the eight principles of patern diferentiation.

Zang-fu patern diferentiation is the diferential analysis based on the physiology and pathology of the viscera.

（1） Kidney Qi Defciency

Clinical Gynecological Diseases: Irregular menstrual cycles, late periods with variable menstrual blood fow, scanty period fow that is light red in color, fooding and spoting, amenorrhea, threatened or recurrent miscarriage, infertility, prolapse of uterus, and difcult delivery.

Signs and Symptoms: Aching lower back and weak lower limbs, vertigo, tinnitus, frequent urination, listlessness, sallow complexion, light-red tongue with thin white coating, and a deep, thready, weak pulse.

（2） Kidney Yin Defciency

Clinical Gynecological Diseases: Early or late periods, scanty in amount and bright red in color, amenorrhea, flooding and spotting, perimenopausal syndrome, threatened miscarriage and infertility.

Signs and Symptoms: Aching lower back and weak lower limbs, vertigo, tinnitus, dry mouth and throat, malar fush, feverish feeling in palms and soles, insomnia, night sweats, red and dry tongue, scanty or no tongue coating, thready, fast pulse, weak pulse at chi （cubit） region.

（3） Kidney Yang Defciency

Clinical Gynecological Diseases: Menstrual diarrhea, vaginal discharge that is clear and thin in texture, gestational edema, infertility, flooding and spotting, and threatened miscarriage.

Signs and Symptoms: Aching lower back and weak lower limbs, severe lumbar pain, tinnitus, fear of cold, cold limbs, clear copious urine, nocturia, low libido, listlessness, diarrhea, edema, a pale tongue with thin, white, and moist tongue coating, a deep, thready or a slow, deep, and weak pulse.

（1） Binding Constraint of Liver Qi

Clinical Gynecological Diseases: Irregular menstrual cycle with varying amount of blood, dark red in color, inhibited flow of menstrual blood, dysmenorrhea, amenorrhea, premenstrual syndrome, infertility, and difculties with breast feeding.

Signs and Symptoms: Distending pain in the hypochondrium and the breasts, chest tightness and discomfort, lower abdominal distending pain, frequent sighing, belching, poor appetite, normal tongue with thin, white tongue coating, and a wiry pulse.

（2） Liver Constraint Transforming Into Fire

Clinical Gynecological Diseases: Early periods profuse in amount and purple-red in color, fooding and spoting, menstrual hematemesis and epistaxis, morning sickness.

Signs and Symptoms: Headache, vertigo, tinnitus, red and swelling eyes, bitter taste in mouth with thirst, fdgeting and irascibility, hypochondriac pain, red tongue with thin, yellowish tongue coating, and a wiry, fast pulse.

（3） Damp-heat in the Liver Channel

Clinical Gynecological Diseases: Yellow or red leukorrhea with a foul smell, vulvar itching, and vulvar erosion.

Signs and Symptoms: Chest tightness, hypochondriac pain, vexation, irascibility, dry stool, dark urine, biter taste in the mouth, dry throat, a red tongue with a yellow, slimy coating, and a wiry, slippery, fast pulse.

（4） Ascendant Hyperactivity of Liver Yang

Clinical Gynecological Diseases: Perimenopausal syndromes, vertigo during pregnancy.

Signs and Symptoms: Vertigo, headache, fuzzy vision, deafness, tinnitus, limb numbness, trembling, litle sleep, dreaming a lot, a feverish feeling in palms and soles, a red tongue with a scanty tongue coating, and a wiry, thready or a wiry, vigorous pulse.

（5） Internal Stirring of Liver Wind

Clinical Diseases of Gynecology: Pregnancy eclampsia, postpartum convulsion.

General Signs and Symptoms: Headache, vertigo, fuzzy vision, sudden syncope, unconsciousness, limb convulsions, opisthotonus, a red or crimson tongue that is exfoliated or has no coating, and a wiry, thready, fast pulse.

（1） Spleen Qi Defciency

Clinical Gynecological Diseases: Early periods, menorrhagia with blood of light color, fooding and spoting, amenorrhea, leukorrhea and uterine prolapse.

Signs and Symptoms: Yellowish complexion, limb lassitude, a bland taste in mouth, no appetite, abdominal distention, a pale tongue with a thin, white tongue coating, and a moderate and weak pulse.

（2） Spleen Yang Defciency

Clinical Gynecological Diseases: Menstrual diarrhea, leukorrhea, gestational edema, infertility, late periods, amenorrhea, and morning sickness.

Signs and Symptoms: Bright white complexion, lassitude, fear of cold, cold or swollen limbs, poor appetite, abdominal distention and fullness, loose stools, obesity, palpitation, shortness of breath, an enlarged pale, tender tongue with a white, slimy tongue coating, and a slippery, moderate or slippery, forceless pulse.

（1） Defciency of Both the Heart and Spleen

Clinical Gynecological Diseases: Late periods, scanty in amount, amenorrhea, threatened abortion, early periods, fooding and spoting, and visceral agitation （hysteria）.

Signs and Symptoms: Sallow complexion, vertigo, palpitations, severe palpitations, amnesia, litle sleep and excess dreaming, mental fatigue, limb lassitude, light red tongue with a thin, white tongue coating, and a thready, weak pulse.

（2） Non-Interaction Between the Heart and the Kidney

Clinical Gynecological Diseases: Perimenopausal syndrome, and visceral agitation （hysteria）.

Signs and Symptoms: Severe palpitations, amnesia, deficiency and vexation, excess dreaming, vertigo, tinnitus, aching lower back and weak lower limbs, red tongue with no or thin tongue coating, and a thready, fast pulse, weak in the chi （cubit） region.

（3） Liver-Kidney Yin Defciency

Clinical Gynecological Diseases: Flooding and spotting, vertigo during pregnancy, visceral agitation （hysteria）, and pruritus vulvae.

Signs and Symptoms: Presence of symptoms and signs of both “kidney yin defciency”and “ascendant hyperactivity of liver yang”, a red and dry tongue, and a wiry, thready, and fast pulse.

（4） Spleen-Kidney Yang Defciency

Clinical Gynecological Diseases: Menstrual diarrhea, leukorrhea, and gestational edema.

Signs and Symptoms: Presence of signs and symptoms of both “kidney yang defciency”and “spleen yang defciency”, pale tongue with a white moistened or slimy tongue coating, and a deep, slow or deep, weak pulse.

Women’s physiology is blood-based. Qi and blood are the foundations of physiological activities.

Qi-blood patern diferentiation is a method based on clinical symptoms which leads to the diagnoses, qi defciency, blood defciency or both qi and blood defciency. This method also determines whether there is any obstruction to the fow of qi and blood manifesting as qi stagnation, blood stasis or blood stasis due to qi stagnation. And fnally it determines whether there is qi counterflow, qi sinking, blood heat, blood cold or other related pathological changes.

（1） Qi Defciency

Clinical Gynecological Diseases: Early periods, profuse in amount, pale in color and thin in texture, fooding and spoting, excess lochia, prolapse of the uterus and retention of the placenta.

Signs and Symptoms: Bright pale complexion, shortness of breath and a reluctance to speak, listlessness, lack of strength, vertigo, blurred vision, an empty and dropping sensation in the lower abdomen, pale tongue with a thin, white tongue coating, and a moderate, weak pulse.

（2） Qi Stagnation

Clinical Gynecological Diseases: Late periods, spoting or unsmooth fow, dysmenorrhea, amenorrhea, abdominal mass, and difculty breast feeding.

Signs and Symptoms: Chest tightness and discomfort, lower abdominal and hypochondrial distending pain on both sides, migratory pain; abdominal mass, movable and scattering when pressed; normal tongue with a thin, white coating, and a wiry pulse.

（1） Blood Defciency

Clinical Gynecological Diseases: Late periods, scanty in amount, pale in color and thin in texture, amenorrhea, dull abdominal pain after menstruation, threatened miscarriage, infertility and insufcient breast milk.

Signs and Symptoms: Sallow complexion, pale fnger nails, pale lips, dry skin, vertigo, blurry vision, palpitations, lack of sleep, fatigue and lassitude, numbness of feet and hands, pale tongue with a scanty tongue coating, and a thready, forceless pulse.

（2） Blood Stasis

Clinical Gynecological Diseases: Irregular menstrual cycles with purplish blood and clots, inhibited fow of menstrual blood, dysmenorrhea, amenorrhea, fooding and spoting, abdominal mass, postpartum abdominal pain, difcult discharge of lochia or leukorrhea, retention of the placenta.

Signs and Symptoms: Lower abdominal pain or mass, sharp stabbing pain of fixed location, worse with pressure and beter with discharge of clots, dry scaly skin, thirst with no desire to drink, dark purple tongue with petechiae at the tongue edge, and a deep, choppy pulse with force.

（3） Blood Heat

a. Excess Heat

Clinical Gynecological Diseases: Early periods, heavy flow that is purple-red in color and sticky and thick in texture, flooding and spotting, threatened miscarriage and leukorrhea.

Signs and Symptoms: Red complexion, dry mouth, and fever with a preference for cold drink, chest tightness and vexation, dark urine, constipation, red tongue with yellowish coating, and a slippery, fast or a fast, surging pulse.

b. Defciency Heat

Clinical Gynecological Diseases: Early periods, scanty in amount and bright red in color, fooding and spoting, threatened miscarriage.

Signs and Symptoms: Flushed complexion, low grade or tidal fever, vexing heat in the fve centers （chest, palms and soles）, litle sleep, excess dreams, night sweats, dry mouth and throat, red tongue with litle or no tongue coating, and a thready, fast, forceless pulse.

（4） Blood Cold

a. Excess Cold

Clinical Gynecological Diseases: Late periods, scanty in amount and red in color, fooding and spoting, threatened miscarriage.

Signs and Symptoms: Colicky pain in the lower abdomen, slightly relieved by heat, grey-white complexion, cold limbs, dark tongue with a white coating, and a deep, tight pulse.

b. Defciency Cold

Clinical Gynecological Diseases: Late periods scanty in amount and light red in color, with dysmenorrhea.

Signs and Symptoms: Continuous abdominal pain relieved by warmth and pressure, vertigo, shortness of breath, aching and weak lower back, pale tongue with a white moist coating, and a deep, slow, forceless pulse.

As for any other internal diseases, we should ask about eating and sleeping habits, bowel movements and urination etc.

But more specifically, menstrual disorder pattern differentiation will be based on information about the menstrual cycle, the quantity, color, quality, and odor of the flow, as well as the nature of any pain in the lower abdomen. We also focus on diferentiating between cold and heat, and deficiency and excess. With regard to the menstrual cycle, early periods are often due to blood heat or qi deficiency. Delayed menstruation usually results from blood defciency or blood cold. Irregular menstrual cycles are mostly caused by liver stagnation and kidney defciency. Prolonged menstruation frequently indicates qi defciency and blood heat. Shortened menstruation is ofen a sign of blood defciency and defciency-cold.

Regarding the quantity of menstrual fow, excessive menstruation is usually a result of blood heat or qi defciency. Scanty menstruation is ofen due to blood defciency and blood cold. As regards to the color, bright red or purplish blood indicates heat. A blackish color signifes cold; a pale red color indicates defciency; a light-blackish color like water mixed with smoke dust is due to deficiency-cold. Regarding the quality, thick menstrual blood is due to heat and excess, while blood that is thin is due to defciency and cold; menstrual fow containing clots is due to blood stasis. Regarding the odor, menstrual fow with a foul odor is mostly caused by heat whereas menses without any perceivable odor ofen indicates cold. Menses with a foul and offensive smell are due to putrification of static blood, indicating that the disease has reached a severe state. Regarding abdominal pain during menstruation, that which is relieved with pressure indicates a deficiency. An aversion to pressure indicates excess; pain that is alleviated by warming is due to cold, and that which is aggravated by warming is due to heat. Pain appearing before or during menstruation indicates an excess; pain appearing afer menstruation indicates defciency. Frequent pain in the lower abdomen, which is aggravated during menstruation, is most ofen due to an accumulation of damp-heat and a stagnation of qi and blood. Distention and fullness in the lower abdomen during menstruation is usually due to a stagnation of qi.

The above is the analysis and discernment of cold, heat, deficiency, and excess as applied to the menstrual cycle, the menstrual fow and the sensation in the abdomen.

However, in the clinic, a comprehensive analysis of all the available information is necessary. Take early periods as an example. If concurrently there is prolonged or heavy bleeding, red or purple blood, which is thick and foul to smell, accompanied by lower abdominal distention, this indicates qi stagnation due to blood heat. If the blood is profuse, light red and clear, and accompanied by an empty and dropping sensation in the lower abdomen, this is qi defciency. If the amount of the menstrual blood is normal or less than normal, the blood being bright red in color and thick, and there is no abdominal pain, this indicates blood heat due to yin deficiency. In summation, in the clinic a comprehensive analysis of the data collected by the four examinations is necessary to make a correct patern diferentiation.

Pattern differentiation of leukorrhea disorders includes the color, texture and odor of discharge. A yellowish, sticky and foul smelling discharge indicates an excess and a heat pattern. A whitish, thin and odorous discharge indicates a deficiency pattern and a cold pattern. A foul offensive odor indicates excess heat; a smell like rotten fish is due to deficiency cold. A sticky discharge with a yellow color, like the color of pus, and a foul smell, is due to the accumulation of damp-heat. A white discharge, like thin mucus accompanied by fatigue or a poor appetite, is due to the downward migration of spleen dampness. A white dripping discharge, mingled with blood, is due to internal heat from yin deficiency combined with dampness. A copious and thin leukorrhea, with aching and weakness in the waist, is due to deficiency of kidney yang. A gray, turbid, and foul leukorrhea （may include other colors）, is due to retention of lochia.

If a woman of child bearing age loses her periods, has a preference for sour foods, a tendency to vomit, and tiredness and sleepiness with a slippery pulse it is an indication of pregnancy. If she has bleeding of a thin pale nature and is constantly fatigued and has a weak pulse it indicates defciency of qi and blood. Aching and weakness in the loins and a bearing down feeling in the abdomen, together with above symptoms, are due to kidney defciency. Bleeding with deep or bright red blood, thirst and a fast, slippery pulse are due to blood heat. Morning sickness, vomiting, anorexia, and a slippery pulse are due to qi defciency of the spleen and stomach. Vomiting of biter or sour fuid, accompanied by a slippery, wiry pulse, indicates qi counterfow of the liver and stomach. Vomiting up phlegm and mucus, epigastric oppression and distension, with a soggy, slippery pulse is due to phlegm damp retention in the spleen. Edema, lassitude, epigastric distension, with a deep, weak, and slippery pulse are due to spleen deficiency. An ache in the loins, aversion to cold, and a deep, slow pulse indicate kidney yang defciency. In the later part of pregnancy, dizziness, headache, chest tightness and vomiting are the signs of pre-eclampsia. Preventative action should be taken immediately to avoid this developing into eclampsia.

The theory of the “three checks” after delivery was observed in ancient times. These are: frst, check for pain in the lower abdomen to assess the presence of lochia retention; second, check the condition of the stool to evaluate the condition of body fuid; last, check the condition of the milk secretion and diet to know about the condition of stomach qi. In addition, examine the amount, color, texture, and odor of the lochia, and check to see if there is a fever or not. If there is a profuse foul smelling lochia, pain in lower abdomen that increases when pressed, possibly accompanied by a general fever, headache, thirst with desire for cool drink, a tongue with a yellowish tongue coating, and a rapid, surging pulse, it is an indication of toxic heat directly disturbing the uterus and damaging chong and ren mai. Scanty dark purple lochia which drips continuously and contains small blood clots, also accompanied by pain in the lower abdomen, which increases when pressed, is most likely due to the retention of static blood. Scanty lochia which is pale and thin is due to a defciency of qi and blood. Lack of milk afer delivery, a distending pain in the breasts, fullness in the chest and hypochondrium, as well as anorexia indicate a stagnation of liver qi. If the patient’s breasts are sof without any distending pain and the breast milk is scanty and thin, it indicates a defciency of qi and blood.

The features of pattern differentiation described in this chapter are based on the symptoms of menstruation, leukorrhea, pregnancy, and delivery. In clinical practice, the body condition, the qi and blood, the complexion, and the pulse, as well as the other general symptoms of a patient should be taken into account when making a diagnosis. Only by comprehensive analysis using the four examinations, the eight principles, the causes of the disease, the zang-fu organs, the qi and blood and the channels, can we reach the correct diagnosis.