Gynecological problems
Tui na is an effective form of treatment for a variety of gynecological problems. It is especially useful in the treatment of menstrual disorders such as dysmenorrhea, irregular periods, amenorrhea, fibroids and premenstrual tension (PMT). It is also of great benefit in the treatment of infertility and for menopausal ailments, both of which have become increasingly common reasons for women to seek out treatment with oriental medicine.
Tui na treatment of gynecological problems has two main areas of focus:
1.Treating the presenting disharmony such as stagnation or Cold in the Uterus
2.Releasing and clearing congestion, accumulation and knotted or hypertense fascia
There are several key factors involved in creating a woman’s fertility and healthy menstrual cycle:
•An abundant supply of blood
•The smooth and harmonious movement of Qi and Blood through the Chong Mai, Ren Mai and Uterus
•A warm Uterus
•The strength and balance of Kidney-Yin and Kidney-Yang
•An abdomen free of congestion, knotting and accumulation
Depending on the underlying disharmony and upon what you find when palpating the abdomen, treatment generally involves a combination of tonifying and nourishing Qi and Blood, dispersing Qi and Blood stasis, regulating the flow of Qi and Blood through the Chong and Ren Mai, warming the Uterus, warming and strengthening Kidney-Yang, nourishing Kidney-Yin, clearing and dredging obstructing pathogenic factors, releasing the abdomen and improving the alignment of the fallopian tubes and ovaries.
Abdominal release work
It is hugely important to keep the abdomen free of congestion so that Qi and Blood can flow freely and harmoniously through the Uterus. Accumulation and stagnation of Qi, Blood and pathogenic factors can lead to problems such as ovarian cysts, endometriosis, fibroids, PMT and infertility. Stagnation is a major factor in gynecological conditions; this can be caused by a deficiency such as Qi and Blood Xu or Kidney-Yang Xu or by retention and accumulation of pathogenic factors such as Cold, Damp and Phlegm.
Abdominal release work enables Qi and Blood to move and helps to disperse accumulations, adhesions and knotting. The uterus is attached within the abdomen by tendons, which can become tight and tense. This is often due to accumulation of stagnant Qi in the intestines, commonly caused by emotional stress. This tension and stagnation in the fascia of the abdomen can cause the fallopian tubes to twist and the ovaries to become out of alignment, which can interfere with ovulation and increase the tendency to develop problems such as ovarian cysts.
Applying the abdominal release work described on pages 151–152 is, in my experience, of great benefit in the treatment of gynecological problems. In addition to this, I have found the following methods to be effective for clearing stagnation in the Uterus, helping to balance the ebb and flow of Yin and Yang throughout the monthly cycle, for aiding ovulation and encouraging the correct alignment of the fallopian tubes and ovaries:
•Kneading–grasping compound technique applied to the lower abdomen using both hands, with your fingers to one side of the uterus and your thumbs at the other. Work deeply into tight and congested areas.
•With your patient lying with her knees up, apply An fa in a rocking, wave-like motion similar to the cat’s paw technique, using the ulnar edge of your hand horizontally across Ren2 and ST30. Rock from one side to the other about 100 times.
•With your patient lying supine again, apply palm Rou fa to Ren4 for a minimum of 5 minutes.
•Apply warming palm to the abdomen with your attention at the level of the Uterus. Work with Sun Qi if there is Yang Xu or Cold, and Moon Qi if there is Blood or Yin Deficiency.
General tips for treating gynecological problems
•In the second half of the cycle, work more dynamically, focusing on moving and invigorating Qi and Blood, dispersing stasis, and clearing and dredging pathogenic factors.
•In the first half of the cycle, work more gently with a Yin approach, focusing on nourishing and tonifying Deficiency.
•In the case of menorrhagia, local abdominal work and release work should only be performed in the postmenstrual week.
•Work on the patient’s back, hips and sacrum first, stimulating relevant points, areas and channels according to your diagnosis. Stimulation of the 8 liao points from BL31 to BL34, and generally the area of the sacrum, ilium, iliopsoas and gluteus, with Rou fa, Gun fa and Ya fa is very effective for moving stagnation and warming the Uterus.
•Work distally on appropriate channels and points.
•Work on the chest and ribs if the patient has signs of Qi stagnating in the chest or has emotional symptoms such as depression and irritability or insomnia.
•Apply local abdominal work after you have worked on the back, distally and on the chest.
•Use the abdominal release work if there are areas of knotting, congestion and adhesion or stagnation and accumulation of pathogenic factors.
•Work on the face and head to finish if the patient has emotional symptoms, headaches or insomnia.
To help you plan a Tui na treatment for gynecological problems, see Table 13.1 for some suggestions of techniques to consider including in the treatment of common patterns of disharmony. In all cases the foundation area routine for the abdomen can be used as an outline for the local work, with the addition of any abdominal release work and techniques and methods relevant to the presenting disharmony.
To help illustrate the treatment of gynecological problems, three cases of patients I have treated follow.
Dysmenorrhea
Main complaint
Karen, aged 30, came for treatment to help with her period pains and premenstrual tension. She had suffered with intense period pains for the previous 4 years and often had to take time off work because she felt so awful. She had pain every month on the first day of her period and every few months it was particularly intense. On these occasions the pain was often accompanied by nausea, sometimes with vomiting and diarrhea; she felt light-headed, and very drained but also restless. She applied a hot water bottle to her abdomen and after an hour or so she was able to lie down and rub her abdomen and would eventually fall asleep. When she woke the pain was much better but she felt very tired and could not do much for the rest of the day. The flow started hesitantly with pinkish blood, which turned dark by the end of the first day; there were substantial dark red clots. She had a regular 29–30 day cycle. The bleed lasted for 7 days; the last 2 days the flow was very light and brown. She now always took painkillers on the first day of her period, which she thought helped to take the edge off the pain.
Premenstrually, Karen felt irritable or depressed and weepy, her breasts were sore and distended and her abdomen felt uncomfortable and bloated.
Secondary complaint
Karen also had frequent headaches around her eyes and temples that were worse in the premenstrual week. She felt very stiff in her neck and the tops of her shoulders.
Palpation and observation
When I saw Karen, it was day 21 of her cycle. Her abdomen looked and felt generally distended. There were several areas of knotting and congestion in the small intestine below her navel and the area under her ribs was very tight and tender on pressure, especially on the right.
Tongue
Her tongue had a purple hue and was red at the tip, with some scallops at the sides, and distended and purple sublingual veins.
Pulse
Her pulse was Deep and Wiry.
Diagnosis
The diagnosis was stagnation of Qi and Blood, accumulation and congestion in the abdomen, rebellious Liver-Qi, underlying Qi and Blood Xu.
Treatment principle
In the second half of her cycle, treatment was to move Qi and Blood, eliminate stasis, disperse accumulation and congestion in the abdomen and soothe and regulate the Liver. In the first half of her cycle, it was to invigorate Qi, nourish Blood, soothe the Liver and strengthen the Spleen.
Treatment
Second half of cycle treatment
With the patient lying prone
•Tui fa on the back down the Bladder channel
•Kneading–grasping GB21 on one side and heel of palm Rou fa down the Bladder channel on the other side; repeat on the other side
•Tan bo fa along the paraspinal muscles focusing on BL17, BL18, BL23 and the 8 liao (BL31–BL34)
•Gun fa over the lower back, sacrum and buttocks accompanied by Rou fa, Na fa and An fa down the back of the legs
•Gun fa down the back of the legs plus forearm Rou fa over the lower back, sacrum and buttocks
•Pushing–pressing BL40
•Ya fa to BL53, BL36 and GB30
•Heel of palm Rou fa to the sacrum
•Ca fa over the lower back and sacrum with woodlock oil
With the patient supine
•Yi zhi chan tui fa to stimulate SP4 on the right, PC6 on the left, Liv3 on the left and LI4 on the right
•Palm Ya fa to SP12
•Kneading–grasping and kneading–pinching down the Spleen and Liver channels stimulating SP10 and SP8 on the way
•The basis of the chest and ribs routine with an emphasis on Tui fa, Ji dian fa, Zhen fa and pushing–pressing
Local abdominal work I used the abdominal foundation routine as the basis for the local work, integrating the abdominal release work to break up the congested areas in her lower abdomen and under her ribs, as follows:
•An fa and Rou fa to stimulate ST25, ST29 and Ren4
•Kneading–grasping the lower abdomen with both hands
•Palm Rou fa and Zhen fa over Ren4
Finally I did 5 minutes’ work on her face using Tui fa, Ma fa, Rou fa and warming palm.
First half of cycle treatment
With the patient lying prone
•Tui fa and Rou fa on the back along the Bladder channel
•Forearm Rou fa over BL17, BL18, BL20, BL23 and the 8 liao
•Gun fa over the lower back, sacrum and buttocks coordinated with Tui fa, Rou fa and An fa down the backs of the legs along the Bladder channel
•Ca fa either side of the spine and across the sacrum
With the patient supine
•Tui fa, Mo fa and Rou fa along the Spleen and Liver channels
•Holding and connecting with my middle fingers SP6 and SP12
•Mo fa over Ren12 coordinated with Tui fa down the leg along the Stomach channel
•Holding and connecting ST36 and ST30
•Tai chi Mo fa on the lower abdomen
•Zhen fa and palm Rou fa to Ren4
•Warming palm over the Uterus and Spleen and Liver
Finally I applied the foundation routine for the head and face.
Advice to the patient
Karen worked at a computer all day so I advised her to increase her exercise and to do more exercise in the second half of her cycle to encourage Qi and Blood to move. I encouraged her to join a yoga class, showed her how to massage her abdomen and suggested she do this every day.
Progress and subsequent treatments
Karen came for treatment once a week for the next 3 months. We continued with treatment as described above and made steady progress; the pain became less intense, the blood flow less hesitant and scanty at the start and her premenstrual symptoms were diminishing. When she came for treatment after the third period, she reported a marked difference. She said it took her a bit by surprise because she did not have any mood changes or sore breasts. She described the pain as more of a background, dragging sensation without any of the previous intensity and the blood was generally less dark and clotty. She had not experienced any of the rebellious Qi symptoms and had noticed that she had not been having her usual headaches.
I continued to treat Karen on a fortnightly basis for another three cycles, timing the treatments to coincide with her pre- and postmenstrual weeks. I continue to see her on a monthly basis in her premenstrual week for maintenance treatments. She no longer has anything more than a mild ache on the first day of her period and she has had no further problems with PMT.
Fertility
Main complaint
Danielle, aged 42, worked in the media world and had a very lively and exciting lifestyle involving long hours, both working and socializing. She did not have any children and it was only over the previous few years that she realized that she would like to have a child. She had become pregnant 3 years before but had miscarried at 10 weeks. Since then she had tried two cycles of in vitro fertilization (IVF) which had proved unsuccessful at the stage of implantation. An ultrasound scan had revealed a small cyst on her left ovary; her hormone levels were within the normal range. She was planning to start another IVF cycle in a month’s time.
In the past her periods had always been regular and painless but over the previous few years her cycle had become longer, around 31 days, and she was experiencing intense pains in her abdomen and sacral area on the first 2 days of her period. The blood was bright red with a lot of purplish clots; the flow was light and lasted for 5 days. She used a hot water bottle to ease the pain which she described as intense. She felt cold easily.
Secondary complaints
Danielle had lower backache, which she felt around her sacrum and iliac crest. She urinated frequently and always had to get up once at night. Other than that she said she felt very well and her energy levels were good.
Palpation and observation
Danielle’s abdomen was distinctly cold to the touch; she was aware of this herself and told me she often tried to warm it up with a hot water bottle. On palpation there was discomfort around the area of ST30 on the left-hand side; the area around Ren4 was noticeably hollow to look at and very empty on pressure. There were several areas of congestion in her lower abdomen. Her navel was being pulled slightly diagonally in the direction of her left hip.
Tongue
Her tongue was pale.
Pulse
Her pulse was Deep, Slow and Weak.
Diagnosis
The diagnosis was Kidney-Yang Xu, and stagnation of Cold obstructing the Uterus.
Treatment principle
This was to warm Kidney-Yang, disperse Cold and accumulated congestion, warm the Uterus, and encourage Qi and Blood to move harmoniously through the Uterus.
Treatment
With the patient lying prone
•Tui fa and palm Rou fa along the Bladder channel from the nape to the sacrum and along the Governing Vessel from Du2 to Du14
•Double-handed Gun fa along the Bladder channel from the shoulders to the waist
•Coordinated Gun fa and Tui fa. Gun fa in the lower back especially around BL23 and Tui fa from the buttocks down the legs along the Bladder channel
•Coordinated Gun fa and forearm Rou fa. Forearm Rou fa over BL23, the sacrum and 8 liao (BL31– BL34) and the ileum and Gun fa down the legs along the Bladder channel
•Clockwise thumb Rou fa to stimulate Du4, Du14 and Du20
•Yi zhi chan tui fa to stimulate BL23 and BL31
•Rou fa either side of the sacrum with fingers interlaced, using the heels of the palms
•Elbow Ya fa plus Rou fa to GB30 and BL54
•Lifting–grasping along the Governing Vessel from Du2 to Du14
•Ca fa across Du4, BL23 and BL52, across the sacrum and either side of the spine along the Bladder channel using red flower oil
•Tui fa, Rou fa and kneading–grasping along the Yin channels of the legs, following the flow of the primary meridians
•Clockwise thumb Rou fa to stimulate KD3 and KD7
•Ca fa along the medial thigh over the three Yin channels
•Ca fa on the thigh along the Stomach channel
•Single-finger Ji dian fa to stimulate ST36
•Palm Ya fa and Ca fa to the inguinal area over SP12
Local abdominal work
•Palm Tui fa from Ren2 to Ren15 and along the Stomach channel from ST21 to ST30
•Tai chi Mo fa focusing on Ren6 and Ren4
•Abdominal release work to break up areas of congestion
•Kneading–grasping the lower abdomen with both hands, working deeply into tight and congested areas
•With her knees up, I applied An fa in a rocking, wave-like motion across Ren2 and ST30 with the ulnar edge of my hand
•Palm Rou fa and Zhen fa to Ren4 for several minutes
•Warming palm to the Uterus and Kidneys using breath and intention to project Sun Qi
Ancillary therapies
I applied three small moxa cones directly to Du4, Du14, BL23 and BL31 after applying the work on her back. I applied three large moxa cones on salt to Ren8 and three large cones directly to Ren4, blowing the smoke as they burned to help disperse the Cold before I applied the local abdominal work.
Advice to the patient
I showed Danielle how to apply moxa with a moxa stick to her abdomen and to KD3 and advised her to apply this every day for 10 minutes on her abdomen and for 3 minutes on each of the Kidney points. I also advised her to eat warm foods and to stay off the salads and icy drinks that she was fond of.
Progress and subsequent treatments
As Danielle wanted to start IVF within a month, she came for treatment three times a week for the next 3 weeks so that we could concentrate on clearing the congestion and warming her Uterus and Kidney-Yang. She continued to use moxa between treatments. I also showed her how to apply some self-massage to her abdomen, lower back and thighs. By the time she started her IVF cycle, her abdomen was feeling quite warm and the areas of congestion and tenderness had dispersed; she also had no more discomfort in her lower back.
During the IVF cycle I continued to treat Danielle once a week up to the point of egg collection. I no longer applied abdominal release work but instead focused on warming the Uterus and stimulating the ovaries. The work on the back and the distal work remained the same as that described above. The local work consisted of Tui fa, tai chi Mo fa, palm Rou fa and Zhen fa plus wave-like An fa over Ren2 and ST30 and Zhen fa to stimulate the extra point Zi gong. The application of moxa remained the same.
Egg collection was successful. I treated her twice more before implantation and once immediately after implantation. This treatment simply consisted of moxa on BL23 and Du4 followed by gentle holding An fa applied to the points with my middle fingers for several minutes and warming palm over the kidneys and sacrum. I applied three small moxa cones to SP6 followed by holding An fa and finally warming palm to the Uterus for 10 minutes.
I am happy to say that at the time of writing this book, Danielle was 19 weeks pregnant.
Menopause
Main complaint
Brenda, aged 52, was recommended by a friend to come for treatment to help her through the menopause. Her periods had become increasingly irregular over the previous 2 years and her last period was over 5 months before. She was particularly bothered by hot flushes and sweating which had become worse over the previous 6 months and which had begun to disturb her sleep. She woke several times during the night drenched in sweat with her heart racing. She frequently had palpitations when she lay down to go to sleep. She felt tired all the time and was easily stressed, irritable and anxious. She was worried about her sleep, as she had suffered with insomnia in the past.
Secondary complaints
She had lower backache, and irritable bowel syndrome (IBS) which was worse with stress and when she ate too many sweet things, which she craved all the time. She had dry skin and vaginal dryness which was also making her anxious.
Palpation and observation
Brenda had a malar flush. Her skin was dry to the touch. On palpation of her abdomen, the Ren Mai and Kidney channels felt very Empty, especially at Ren4, Ren12 and Ren14. There was marked tenderness at ST25, KD24 and KD27.
Tongue
Her tongue was red and dry, and it had lots of irregular cracks and no coating.
Pulse
Her pulse was Empty and Quick.
Diagnosis
The diagnosis was Kidney- and Heart-Yin Xu, Empty Heat in the Ren and Chong Mai.
Treatment principle
This was to nourish Yin, harmonize and tonify the Kidney and Heart, clear Empty Heat and soothe and calm the Shen.
With the patient lying prone
•Tui fa and Rou fa along the course of the Bladder channel from the nape to the toes
•Gua Fa on the back along the Governing Vessel and Bladder channel
•Nipping–grasping along the Governing Vessel from Du14 to Du4
•Mo fa over BL14 and BL23 followed by holding the points with my middle fingers and focusing my attention on tonifying the Heart- and Kidney-Yin, visualizing Moon Qi moving through the points into the organs
•Figure-of-eight Tui fa around the Heart and Kidney Back Shu points
With the patient supine
•Holding SP4 on the right, PC6 on the left, then LU7 on the right and KD6 on the left with my middle fingers, intention focused on nourishing Kidney- and Heart-Yin and harmonizing the Ren and Chong Mai
•Tui fa, Mo fa and Rou fa along the Yin channels of the legs and arms
•Tui fa KD1
•Kneading–nipping KD2 and PC8
•Thumb Rou fa to stimulate SP6, KD9 and HT6
On the face
•Tui fa from Yintang to Du24
•Ma fa across the forehead
•Rou fa Yintang and Tai Yang
•Kneading–grasping the ears
On the chest
•Tui fa across the chest and from Ren22 to Ren17
•An fa, Rou fa and Ma fa across the intercostal spaces
•Kneading and grasping the pectoral muscles, stimulating HT1 and LU1
•Gentle Ji dian fa along the kidney channel from KD27 to KD25
On the abdomen
•Tui fa and tai chi Mo fa
•Palm Rou fa on Ren14 and Ren4
•Palm Zhen fa on Ren8 and Ren4
•Holding the uterus between both palms and projecting nourishing, cooling Moon Qi
Advice to the patient
I encouraged Brenda to see a colleague of mine who is a practitioner of natural nutrition to give her some support and advice with her diet. I taught her some simple self-massage to apply every day to her chest, abdomen and lower back and to KD1 and PC8.
Progress and subsequent treatments
Initially I saw Brenda weekly for 6 months. Over this time she went through a major transformation. She made significant changes to her diet and conquered her sugar addiction, started Qigong and tai chi classes and got a place at university to study anthropology. She responded very well to Tui na which she loved. Her sleep, energy and mood improved after three treatments and the sweating and flushes diminished gradually over the months. She has very few hot flushes now and those she has do not bother her. She now sees me every fortnight for maintenance and continued support.
The menopause is a time of great potential for women, a real rite of passage. I have witnessed some incredible transformations occur, from the stages of cleansing, grief and loss of what has been to the often awe-inspiring creation and birth of a new way of life. I have been fortunate enough to treat and support many women through this extremely challenging time and have personally found Tui na an invaluable form of treatment.