Download Syndrome Differentiation and TCM Treatment of

Syndrome Differentiation and TCM Treatment of
Idiopathic Vulvodynia and Clinical Cases
LIU Dong-mei1 ZHANG Qiu-xiang2 JIANG Yi-xu1 ZHOU Guo-ma3 GAO-Jin3
(1the Fifth Hospital Affiliated to Jinhua City, Jinhua 300022, China;
2
Xianghe People’s Hospital, Langfang City, Langfang 065400, China:
3
Abstract:
the First Hospital Affiliated to Wuhan, Wuhan 430022, China)
Idiopathic vulvodynia belongs to “vulvodynia” or “vulvodynia syndrome”.
Its
symptoms are frequent, non-irritative burning pain or dull pain. At present, there are few
reports about this disease at home and abroad. Tricyclic antidepressants are usually used to
treat idiopathic vulvodynia, but these have many side effects and the compliance of patients is
poor. This article introduces the TCM diagnoses and the clinical experiences of the authors.
Key words: Idiopathic vulvodynia; syndrome differentiation and treatment of TCM; clinic cases.
Idiopathic vulvodynia is classified in dermatology as “vulvodynia” or
“vulvodynia syndrome” categories which, clinically and pathologically, do not
manifest with distinct types of vaginal pain
[1-2]
. The borders and regions [of
discomfort] may radiate to other areas [outside of the vulvar area]. Many patients
experience vulvodynia during the menstruation or following the menses. The
following points comprise the chief components of the disease: 1) Pain often
followed by brief periods of relief subsequent to a severe, sudden episode. [It]
may also take the form of a chronic, particularly persistent type, a not intensely felt
variety of vulvar burning or dull pain.
Occasionally [the pain] involves the
perianal [region from] Huiyin REN-1 to the medial thigh. 2) Pain similar to other
nerve pain syndromes such as post-herpetic neuralgia. 3) No history of vulvar
trauma or infection and lacking a cyclical characteristic. 4) No abnormality of the
vulva or occasionally observed red lesions with the possibility of normal biopsy
and lacking remarkable tenderness or pressure. [One] often observes [this
condition] in perimenopausal or postmenopausal women. 5) Use of antibiotic
treatment has no effect.
Contemporary medical treatment generally employs
tricyclic antidepressants, the first choice [being] amitriptyline.
When the results
are not favorable [one] may select doxepin, clomipramine, dosulepin, nortriptyline,
or carbamazepine but, due to severe side effects, in clinical practice patient
compliance is not very good. The authors treated 30 cases of the disease from the
perspective of Chinese medical pattern differentiation with the results obtained
being comparatively ideal. Patient compliance was relatively good, and there were
no marked adverse effects. The standard clinical pattern differentiation categories
are liver-kidney yin vacuity pattern, qi and blood insufficiency pattern, and qi
stagnation-blood stasis pattern. Our introduction of several separate examples
follows below.
Liver-Kidney Yin Vacuity Pattern
Burning external genital pain is the chief [symptom], often of an especially
persistent nature. [This is] frequently accompanied by vulvar or vaginal dryness,
dizzy head and dizzy vision, tinnitus, indistinct and blurred vision, difficult to
endure suffering from aching lumbar spine, loss of sexual desire, heart vexation
and irascibility, dry mouth, dry eyes, red urine, constipation, slightly red tongue
body with thin tongue fur or scant tongue fur, and a sunken and fine pulse.
Treatment utilizes enriching yin and clearing heat, nourishing blood, and freeing
the network vessels. The prescription uses a decoction of Liu Wei Di Huang Wan
Six-Flavor Rehmannia Teapill and Da Bu Yin Wan Great Yin-Supplementing
Teapill with additions and subtractions. There is a case of a patient, female, 45
years old, worker, with scorching pain of the external genitals for more than half a
year. Five years ago, the patient ceased menstruating. Half a year ago, with no
apparent cause there appeared the discomfort of burning external genital pain,
diagnosed and treated at many local hospitals with such topical medications as
Woman’s Health Treasure and Serta and internally with diethylstibestrol or, more
aggressively, with intravenous antibiotics [but] without effect. One day earlier,
[there was] dryness of the external genitals and unbearable scorching pain [but]
urinalysis at the Wujing Hospital was normal. There was pain of a continual
nature limited to the external genitals, with especially severe [pain of] the pubic
symphysis and the major and minor labia. Due to the pain, the patient was unable
to sit or lie down comfortably [and experienced] heart vexation, rashness, and
impatience. This was accompanied by dry mouth, dry eyes, and constipation.
Physical exam:
the vulva was generally normal, with no remarkable skin
pathology. The tongue was red with thin, white fur, and the pulse was fine and
rapid. Vaginal discharge tested normal, and Mycoplasma hominis and Chlamydia
trachomatis testing were not seen to be abnormal.
Diagnosis: idiopathic
vulvodynia. Chinese medical diagnosis: external genital pain. Pattern identified
[as] liver-kidney yin vacuity. Treatment employed enriching yin and clearing heat,
nourishing blood and freeing the network vessels. Formula used: shu cooked and
sheng uncooked rehmannia, 24g each, shan yao dioscorea 15g, bai shao yao white
peony root 10g, gou qi zi lycium berry 20g, sha shen adenophora/glehnia root 10g,
shi hu dendrobium 10g, tai zi shen pseudostellaria 12g, dang gui tangkuei 15g,
chuan xiong ligusticum 10g, ji xue teng millettia root 15g, sheng yi yi ren
uncooked coix 30g, bai mao gen imperata root 30g, lian zi xin lotus embryo 6g,
and gan cao licorice 6g. 7 packets of water-based decoctions were prescribed, and
she was advised to take the first two doses as oral decoction and use the third dose
as a topical wash. Follow-up diagnosis after seven days: the external genital pain
was already relieved. [She was] aware of intermittent vulvar dampness, heart
vexation, marked alleviation of hot rashness, no reduction in dry mouth and dry
eyes, and stools still dry and bound. [There was a] pale-red tongue with thin fur
and a sunken and fine pulse.
To the subsequent prescription huang bai
phellodendron, nu zhen zi ligustrum, and han lian cao eclipta were added and shi
hu dendrobium and yi yi ren coix removed. The previous method was continued
for another 14 packets. At the patient’s third follow-up exam, with the exception
of occasional dry mouth and dry eyes, there was already cessation of any
remarkable discomfort. It was advised that the patient use one packet of the
previous formula every other day. After continuing 14 packets, a three-month
prescription of Liu Wei Di Huang Wan Six-Flavor Rehmannia Teapill followed to
consolidate effects.
Commentary: A 45-year-old patient experiences menopause and exhaustion of
the tian gui heavenly tenth, withering and emptying of the sea of blood, and lack of
moistening and nourishment of the external genitals and vulva. Lack of luxuriating
results in pain. Yin vacuity effulgent fire gives rise to heart vexation and hot
rashness. Liver and kidney share the same source. [There is] insufficiency of the
kidney channel in filling and nourishing the liver blood, and liver blood
insufficiency results in dry eyes. In Liu Wei Di Huang Wan Six-Flavor Rehmannia
Teapill with mu dan pi moutan, ze xie alisma tuber, and fu ling poria removed and
sheng di huang uncooked rehmannia, gou qi zi lycium berry, lian zi xin lotus
embryo, sha shen adenophora/glehnia, and shi hu dendrobium added, the root
treatment is enriching yin and clearing heat. Combining [this formula] with Si Wu
[Tang] Four Materials [Decoction], ji xue teng millettia nourishes blood and frees
the network vessels to relieve pain. After [the primary course of treatment] Liu
Wei Di Huang Wan Six-Flavor Rehmannia Teapill is used to support yin and
consolidate the root, seeking to “invigorate the governor of water to restrain the
brilliance of yang.”
Qi and Blood Insufficiency Pattern
Clinically [presenting with] external genital pain of a persistent nature, the main
[symptom] is continual, deep pain frequently accompanied by fatigued spirit and
lack of strength, shortness of breath and laziness to speak, withered-yellow facial
complexion, heart palpitations and insomnia, dizzy head and dizzy vision, and
scant menstrual flow with pale color or moderate amenorrhea. The tongue is pale
with thin fur, and the pulse is sunken and fine or fine, weak, and forceless.
Treatment involves boosting qi and nourishing blood, freeing the network vessels
and relieving pain. The formula chosen is Ba Zhen Tang Eight-Gem Decoction
and Shi Quan Da Bu Tang Perfect Major Supplementation with additions and
subtractions. There is a case of a woman, 35 years old, examined on September 3 rd,
2004. Primary review: insidious vulvodynia for 8 years. Eight years ago, six
months after having had a C-section delivery, without obvious cause, there was
persistent, insidious vulvar pain despite no increase in sexual intercourse. On the
contrary, [there was] a decrease in libido.
[The patient] previously sought
treatment around the country without seeing results. The patient’s menstrual cycle
was normal except for the scant flow and pale color [of the menses]. Physical
exam: facial complexion withered-yellow, fatigued spirit and lack of strength,
laziness to speak, melancholia and low spirits, and pale lips. The vulva was
normal, and the mucosae of the inner margins of the labia majora and minora were
pale and without red lesions, erosion, ulcerations or other characteristic
dermatological abberations. The tongue was a pale red with thin fur, and the pulse
was sunken, fine, and forceless. Vaginal discharge tested normal.
Tests for
Mycoplasma hominis, Chlamydia trachomatis, and syphilis were negative. No
abnormal gynecological exam or B-type ultrasound exam findings. Diagnosis:
idiopathic vulvodynia. Chinese medical diagnosis: external genital pain. The
patterns identified [were] qi and blood insufficiency and vessel and network loss of
construction. Treatment utilized boosting qi and nourishing blood, freeing the
network vessels and relieving pain. Prescription used: huang qi astragalus 30g,
dang gui tangkuei 15g, dang shen codonopsis 30g, bai zhu ovate atractylodes 12g,
chuan xiong ligusticum 15g, shu di huang cooked rehmannia 18g, bai shao yao
white peony root 30g, e jiao ass-hide glue 10g (melted into the decoction), fu shen
root poria 12g, huai niu xi achyranthes 15g, da zao jujube date 5 pieces, and zhi
gan cao mix-fried licorice 10g. 14 packets [prescribed] as a water-based decoction,
one batch daily.
On September 18th during a follow-up exam [there was] alleviation of pain and,
during the interim, a marked improvement in mood. The tongue and pulse [were]
as before. Accordingly, [there was] no change in the prescription, and it was
advised to continue the medication for one month.
On October 20th, during the follow-up examination, it was reported that the pain
had disappeared, and [the patient] herself felt that, compared to before, vigor and
physical strength were much improved. The tongue was pale-red with thin fur, and
the pulse was sunken, fine, and forceful. It was advised to continue 1 packet of the
original formula, every other day, for three months.
Commentary: The case of this patient involves a history of blood loss. Over
time, blood vacuity gives rise to qi vacuity, and qi-blood vacuity weakness [leads
to] the vessels and networks losing construction, with loss of luxuriance resulting
in pain. The Penetrating Vessel is the sea of blood, and the Directing [Vessel]
governs the uterus and the fetus. The Governing Vessel is the sea of the yang
vessels. The three Penetrating, Directing, and Governing vessels all arise from
within the uterus. Blood vacuity, depletion vacuity of the Penetrating Vessel, and
Directing Vessel loss of moistening and nourishment result in scant menstrual flow,
pale [menstrual] color, and decreased libido. The Governing Vessel is unable [to
obtain] fullness and surplus leading to fear of cold, fatigued spirit, and somnolence.
The prescription utilizes Ba Zhen Tang Eight-Gem Decoction, Dang Gui Yang Xue
Tang Tangkuei Blood-Nourishing Decoction, and Sheng Yu Tang Sagely Cure
Decoction with additions and subtractions to nourish blood, boost qi, and assist and
boost to moderate pain. This prescription contains huang qi astragalus, dang shen
codonopsis, bai zhu ovate atractylodes, da zao jujube date, and zhi gan cao mixfried licorice to fortify the spleen and boost qi to promote the root of engenderment
and transformation. A heavy dose of huang qi astragalus boosts qi, and qi is the
commander of blood. [This is] the idea of seeking yin within yang. Si Wu Tang
Four-Material Decoction nourishes the blood and frees the vessels.
Qi Stagnation and Blood Stasis Pattern
The pain is mostly lancinating pain, often accompanied by rib-side distention
and pain, heart vexation and irascibility, menstrual cycle irregularity, premenstrual
distention of the breasts, menstrual movement abdominal pain, presence of blood
clots [in the menses], dusky tongue body or [tongue body with] stasis macules or
stasis dots, and a rough pulse. Treatment should course the liver and rectify qi,
quicken the network vessels and relieve pain. The formula selected is Xiao Yao
San Free Wanderer Powder and Xue Fu Zhu Yu Tang House of Blood StasisExpelling Decoction with additions and subtractions. There is an example of a
patient, female, 42 years old. [She had experienced] lancinating vaginal pain for
more than two months, a pinprick, stabbing pain 10-20 times each day for 2-3
seconds per episode. [She was] previously diagnosed and treated for vulvodynia in
the gynecology department for many years [but] without effect. When first coming
to see a doctor, [she] cried bitterly while speaking and described pain that was
difficult to bear. The same day [she] felt lancinating pain of both rib-sides, with
occasional radiation [of the pain] to the shoulders and back, heart vexation and
propensity to rashness.
[The patient experienced] menstruation at irregular
intervals, menstrual abdominal pain mostly in the lesser abdomen and occasionally
radiating to the medial thighs, and counterflow cold of the hands and feet and
nausea and vomiting resulting from severe pain.
[There was] purple, dark
menstrual blood with clots, no abnormal vulvar itching, swelling and distention, or
secretions. The tongue body was dull red with a thin yellow fur, and the pulse was
stringlike and fine.
ultrasound exam:
Gynecological exam found nothing abnormal.
B-type
uterus and surrounding structures without abnormality.
Diagnosis: idiopathic vulvodynia. Chinese medical diagnosis: external genital
pain. Patterns include binding depression of liver qi, qi stagnation and blood stasis.
Treatment should course the liver and rectify qi, quicken the networks and relieve
pain. The prescription Xiao Yao San Free Wanderer Powder with additions and
subtractions: quan dang gui whole tangkuei 12g, bai shao yao white peony root
10g, bai zhu ovate atractylodes 10g, fu ling poria 10g, sheng gan cao uncooked
licorice root 4g, mu dan pi moutan 10g, zhi zi gardenia 10g, sheng di huang
uncooked rehmannia 15g, xiang fu cyperus 10g, hong hua carthamus 8g, yu jin
curcuma 10g, chuan xiong ligusticum 8g, and yan hu suo corydalis 10g. 7 packets
after beginning the medication, the rib pain had disappeared, and the frequency of
the vulvar pain was decreased. The effects justified continuing the prescription.
15g each of pu huang typha pollen and wu ling zhi flying squirrel droppings were
added to the original formula. After 14 packets, all of the symptoms had remitted.
It was recommended that she continue to use Xiao Yao Wan Free Wanderer Teapill
and Liu Wei Di Huang Wan Six-Flavor Rehmannia Teapill to be taken orally for
half a year to consolidate effects. At the follow-up visit, [there had been] no
reoccurrence for three months.
Commentary:
The liver channel issues from the perineum and wraps the
genitals, arrives at the lesser abdomen, and spreads into both rib-sides, intersecting
the Penetrating and Directing [Vessels] and entering the sea of blood. When [there
is] binding depression of liver qi, loss of coursing and discharge, and qi stagnation
and blood stasis, the result is rib-side distention and pain and lancinating pain of
the external genitals. When qi has a surplus then there is heat leading to patients
[experiencing] heart vexation, rashness, impatience, and irascibility. Xiao Yao San
Free Wanderer Powder courses the liver and resolves depression, rectifies qi and
frees the network vessels; Shi Xiao San Sudden Smile Powder and yan hu suo
corydalis move qi and relieve pain; mu dan pi moutan and zhi zi gardenia clear
liver heat and eliminate dryness-heat; sheng di huang uncooked rehmannia
enriches yin and cools the blood, thus consolidating the root. The later use of Xiao
Yao Wan Free Wanderer Teapill and Liu Wei Di Huang Wan Six-Flavor
Rehmannia Teapills also [follows] this same concept.
Conclusion
Idiopathic vulvodynia describes an abnormal feeling of external genital pain
with the primary manifestations of a painful sensation of abnormal sensitivity.
Chinese medicine does not describe idiopathic vulvodynia or vulvodynia syndrome,
but [this condition] can be included under the category of patterns and treatments
for external genital pain. We consider [the facts that the] external yin is bordered
by the jue yin reverting yin and that the kidney manages the anterior and posterior
yin. Therefore, regardless of the type of pattern, all [cases] demand inclusion of
liver and kidney. Additionally, this disease often occurs in premenopausal or
postmenopausal women.
Clinically, vacuity patterns are numerous, with the
vacuity patterns attributable to the liver, spleen, and kidney. The repletion patterns
are attributed to liver depression qi stagnation. Treatment frequently utilizes the
primary [methods of] enriching and supplementing liver and kidney, boosting qi
and nourishing blood, coursing the liver and rectifying qi, and quickening the
blood and transforming stasis. Arriving at the pattern demands [assessing] the
nature of the pain and degree [of the pain] and relating [the former] to the systemic
symptoms and the tongue and pulse to form a comprehensive analysis. [One must]
pay attention to scrupulously perceive the disease mechanisms and also support
[the chief treatment methods] by relieving pain to treat the tip. For formulas Liu
Wei Di Huang Wan Six-Flavor Rehmannia Teapill, Dang Gui Bu Xue Tang
Tangkuei Blood-Supplementing Decoction, Er Xian Tang Two Immortals
Decoction, Sheng Yu Tang Sagely Cure Decoction, Si Jun Zi Tang Four Gentleman
Decoction, Bu Zhong Yi Qi Tang Center-Supplementing, Qi-Boosting Decoction
with additions and subtractions enrich and supplement liver and kidney, boost qi
and nourish blood; use Xiao Yao San Free Wanderer Powder with additions and
subtractions to course the liver and resolve depression, free the network vessels
and relieve pain. In the clinic, [one may] frequently obtain results of optimal effect.
In addition, idiopathic vulvodynia frequently occurs during the menses or after
the menses, and patients often experience the disease before or after menopause.
Consequently, these authors consider the initial episodes of the disease to relate to
estrogen.
Thus, in clinical practice it is appropriate to add Chinese herbal
medicinals with an estrogen stimulating nature, a treatment which functions
without estrogenic side effects. There has have been reports that suggest that the
primary manifestations of idiopathic vulvodynia are thought to be allergic. An
extremely small number of people consider [the condition to be] a type of
hypochondriac phobia or a concurrent condition [combining allergy and phobia] 3.
To reiterate, idiopathic vulvodynia does not present with obvious physical signs
and is often ignored, or the patient is treated but results are difficult to obtain. The
patient experiences unusual suffering. For this reason, [it is necessary to] improve
clinical counseling and also to cure the core of this disease4.
Sources Cited
[1] Fan Li-Ming, Wu De-Hua. Vulvodynia and Vulvodynia Syndrome. Foreign
Medical Sciences: Dermatology and Venereology, 2001, (27) 6: 365—366.
[2] Tuma R., Bornsein J. Vulvar Pain Syndrome (Vulvodynia Dilemmas in
Terminology). Harefuah, 2006, 145 (3): 215—244.
[3] M. Fischer, K. M. Taube, W. Ch., et a1. Vulvodynie. Deutsche Medizin.
Dezember, 2001, 1 Band 18. Heft 6: 383—384
[4] Edwards L. New Concepts in Vulvodynia. Am Obstet Gynecol, 2003, 189:
24—30.