Author: Yuxiang Wang
This paper is a study on the theory of menstrual physiology in Chinese medicine. The author advances the theory that menstrual physiology relies on the Qihua (Qi activity for the transformation of material) of Kidney which is based on the interaction between Kidney-Qi, Tiangui, and the Tai-Chong meridian (the leg branch of the Chong meridian). In brief, Tiangui is one component of primordial Qi in the Life Gate, and it goes to the uterus through the Chong and Kidney meridians. Both the Chong meridian (Tai-Chong vessel) and Kidney meridian share the same pathway, so when the Chong Qi in the Tai-Chong vessel (supplied by Tiangui) goes downwards through the Kidney meridian, the Qi in Kidney meridian moves upwards. This opposing movement of Qi creates the force for the Blood and Qi to penetrate into the muscles and collaterals. Also, the Kidney coordinates with the Heart, Liver, Spleen and Lung, so Blood and Qi in the Chong meridian nourish the viscera interiorly and muscles and joints exteriorly. The upward, downward, inward and outward circulation of Blood and Qi are what results in the regular period bleeding and the storing and eliminating function of Kidney. Clinically, it is important to regulate Qi movement when treating gynecological diseases. When there is a deficiency of Chong-Qi, Kidney Qi should also be strengthened and the Liver should be regulated, especially when there is abnormal Qi movement in cases of Chong –Qi excess syndromes.
Huang Di Nei Jing is the earliest text in Chinese medicine that describes human sexual development. It points out that at age seven, girls start to develop permanent teeth and their Kidney Qi starts to mature. Menstruation occurs at age of 14 with the appearance of Tiangui and the flourishing flow of Qi and Blood in the Ren and Chong meridians. In later texts, many medical men have advanced the theory about the Kidney, Tiangui, and Chong and Ren meridians, but much information is still lacking on their interactions.
This theory is very important for the study and clinical treatment of gynecology and menstrual physiology in Chinese medicine. It is imperative to explore this interaction between the Kidney, Tiangui and Chong meridian.
Qihua (Qi activity) of Kidney and Menstrual Physiology
As stated earlier, there are three key factors in menstrual formation: the growing of Kidney Qi, the arrival of Tiangui, and the flourishing flow of Qi-Blood in Chong and Ren meridians. The prerequisite is the maturation of Kidney Qi which therefore plays the most important role on the formation of the menstruation.
Zhang Jing Yue, who wrote the Complete Works of Jing Yue, states: “menses are the extra part of blood,” ultimately implying that menses originate from the blood. All kinds of material transformations that happen through life rely on the function of Qihua of the Kidney. Transformation from blood into menses occurs under the power of Qihua upon maturation of the Kidney Qi which initiates the production of Tiangui. Tiangui is the component of Kidney Qi which mainly focuses on sexual function.
The Nature of Tiangui and its role on the Qihua of Kidney
In Chinese, Tiangui or Tiangui Zhi has two meanings. Firstly, Tiangui is the growing from feebleness to prosperity (“Zhi” meaning ‘strength’ or ‘prosperity’). Secondly, it denotes the transportation of Tiangui to the uterus after being produced by the Kidney (“Zhi” also means ‘arriving’). These two meanings are complementary for the reason that only prosperous Tiangui is able to be transported to the uterus.
The nature of Tiangui has been a topic of dispute from ancient times to present times. During the Ming dynasty, Ma Shi stated that Tiangui is innate Kidney Yin-essence (Yuan Yin); Zhang Jing Yue held that Tiangui is one component of primordial Qi (Yuan Qi); while the author of the book Yi Zong Jin Jian (Golden Mirror of Medicine) described Tiangui as the active Qi between both Kidneys.
Although these views of Tiangui differ, they have the same basic perspective about the nature of Tiangui. Yuan Yin and Yuan Qi are the same concept within two aspects. Yuan Yin is the substance for Yuan Qi; Yuan Qi is the manifestation of Yuan Yin. Yuan Qi is stored in the Life Gate (Ming Men), which is located between both Kidneys. This has led to the wide belief that Tiangui is the active Qi between both Kidneys.
With regards to the relationship between Tiangui and Yuan Qi of the Life Gate, predecessors recognized that Yuan Qi of the Life Gate plays some role in reproductive function; the book Classic on Medical Problems (Nan Jing) says: “Ming Men (Life Gate) has the function of storing sperm for men and being in charge of the pregnancy process for women.” But no predecessors have clarified the relationship between Tiangui and Yuan Qi. After studying the function of Tiangui and Yuan Qi of the Life Gate, it has been deduced that they are same substance: Yuan Qi contains Tiangui and is encompassing concept; Tiangui is only a part of Yuan Qi which is transported to the uterus and has its function with menstrual formation and pregnancy.
How does Tiangui get to uterus? The answer can be found in the Qing dynasty book: Essence of Medical Classic in the Confluence of Chinese and Western Medicine, written by Tang Zong Hai, who stated: “Tiangui travels to uterus through the Kidney meridian.”
As stated earlier, the transformation of blood into menses relies on the Qihua of Kidney; Tiangui in the uterus responds to this transformation of blood to menses. Tang Zong Hai wrote: “Blood from meridians of Chong and Ren arrive in the uterus, interact with Tiangui and are transformed to menses.”
The role of the Chong Meridian in Menstrual Formation and how the Tai-Chong Meridian is Impacted by Kidney Qi and Tiangui
From meridian theory we know that the Chong meridian originates from the uterus and it has three major branches. One branch travels upwards along the spine, another branch goes up the foot-Yang Ming Stomach meridian, and the third goes inside of Foot-Shao Yin Kidney meridian. It is the Sea of Blood and its functions are to nourish the viscera and muscles and send its extra blood down to the uterus to transform into menses. The term ‘Tai-Chong’ is mentioned in the Nei Jing, but there are very few other doctors that discuss what exactly this meridian is. According to Wang Bing, the first scholar to study the Nei Jing, the Tai-Chong meridian travels down the Kidney meridian – opposite in direction to the flow of Kidney Qi, which flows up from the foot to the chest. Therefore, Tai-Chong is regarded as the most prosperous branch of the Chong meridian because it is supplemented by both Tiangui and Kidney Qi.
Since the Chong meridian originates from uterus, uterine Tiangui not only transforms blood to menses through the Qihua function of the Kidney, but also warms and nourishes the muscles and joints to keep them strong and flexible. This is achieved through the opposing movements of the Chong Qi traveling down to the feet and the Kidney Qi going upwards to the uterus and beyond which powerfully forces the Qi and Blood to go to the collaterals. This explains why patients with menstruation problems often manifest with signs and symptoms such as cold feet and swollen ankles: the Chong Qi is unable to go downward to warm and nourish the muscles and joints. There is also strong evidence that shows the connection between Tiangui, Chong Qi and the lower leg muscle in the menopause stage. After menopause, Tiangui starts to disappear, and with declining Chong Qi, menses will cease and the leg and foot muscles can start to atrophy and the joints can become stiff.
Interaction of the Kidney with other Viscera in Menstrual Physiology
The Nei Jing said: “Kidneys regulate water and menses through their function of both storing and eliminating. Menses are the manifestation of the eliminating function of Kidney, and after menses, the Kidneys store the Blood-Essences until next menses.
Menstruation demands that the Qihua function of the Kidney coordinate with the other viscera: the Heart, Liver, Lung, and Spleen must coordinate in a dynamic synergy. The interaction of the Kidney and Heart: the Heart connects to the Uterus through collaterals and the Kidney connects to the uterus through the Chong channel. The Qihua function of the Kidney relies on the upward movement of Kidney Qi in conjunction with the downward movement of Heart Qi. This harmony of movement is a prerequisite for maintaining normal menstrual physiology. If the Heart Qi is unable to travel to Uterus, the Kidney Qi will be unable to eliminate and amenorrhea will occur. If excessive fire of the Heart disturbs the Uterus, the Kidney will eliminate excessively and heavy menstruation will occur.
Interaction of Kidney and Liver: Liver has the function of maintaining the free flow of Qi. Therefore, movement of Kidney Qi and Heart Qi relies heavily on the Liver’s function of free flow. Liver Qi goes down to the Uterus via the Chong channel where it distributes the Blood for transformation into menses Blood. Liver Qi stagnation or overacting Liver Qi will affect the harmony of Qi movement and cause a dysfunction with how the Kidney stores and eliminates, either resulting in amenorrhea or dysfunctional uterine bleeding.
The interaction of Kidney and Spleen: Spleen Qi is ascending in nature and Stomach Qi is descending in nature, thus this action is known as the pivot of Qi movement. A Spleen deficiency will cause dampness to accumulate, which will ultimately affect the movement of Kidney Qi, Heart Qi and Liver Qi, causing menstrual problems.
A Theoretical Guide to Menstrual Physiology in Clinical Practice
The most important treatment method in the gynecology clinic is to Regulate Qi. It is the theoretical basis for any gynecological treatment method. My teacher, Dr. Ha LiTian, one of the most famous TCM gynecologists in China in last century, often told me his experience has been that regulating Qi when making prescriptions is the key for ideal effectiveness. In the pathology of gynecology, the abnormal movement of Qi is the leading mechanism which causes dysfunctional menstruation, leucorrhea, pregnancy problems, and postpartum diseases. Dr. Ha was very good with his use of regulating Qi herbs in his prescriptions for treating gynecological diseases. He often used herbs like XiangFu (nutgrass flatsedge rhizome) to activate Qi movement and influence the Blood, and ChuanXiong (chuanxiong rhizome) to activate the blood in order to harmonize Qi and Blood. In acupuncture treatment, Taichong (Liv3) is a very useful point to regulate Qi to treat many gynecological diseases because the point has the function of regulating Chong Qi.
Tonifying the Kidney to treat Deficiency of Chong Qi
In pathology of gynecology, impairment of Chong and Ren is the final cause of all gynecological problems. Diseases are classified into deficiency syndromes and excess syndromes. In deficiency syndromes, Chong and Ren deficiency are the most closely related with Kidney deficiency. As we have previously discussed, Chong Qi originates from Tiangui which is produced by the Kidneys; it is a part of primordial Qi (Yuan Qi), and transports to the uterus through the Kidney channel, so tonifying the Kidney is the best way to boost Chong Qi in the treatment of gynecological diseases related to deficiency of Chong Qi. In clinic, we use herbs to tonify Kidney Qi, nourish Kidney Yin and Warming Kidney Yang in order to replenish Chong Qi. The Following herbs are most often used:
TuSiZi (dodder seed), XianLingPi (epimedium), XianMao (curculigo rhizome), BaJiTian (morinda root), DuZhong (eucommia bark), LuJiaoJiao (antler fule), RongCongRong (desert-living cistanche), GouQiZi (wolfberry fruit), HeShouWu (fleece-flower root), DangGui (Chinese angelica root), ShaoYao (peony root), ShuDiHuang (prepared rehmannia root), GuiBan (tortoise plastron), SangJiSheng (loranthus mulberry mistletoe), XuDuan (dipsacus root), FuPenZi (Raspberry),etc.
Acupuncture treatment for deficient gynecological diseases, according to the principle of tonifying Kidney to replenish Chong Qi, use ShenShu (B23), QiXue (K13), Taixi (K3), SanYinJiao (Sp6), GuanYuan (R4) are often selected.
Smooth Liver Qi to treating Excess of Chong Qi due to Reversed Flow
Qihua of Kidney relies on the normal movement of Qi for menstrual formation, especially the balance between Kidney Qi move upward and Heart Qi move downward to the Uterus. The Liver has the function of maintaining free flow of Qi movement which assist in maintain the harmony between Kidney and Heart, which in turn, keeps the function of the Chong and Ren meridians normal. When Liver Qi fails to maintain free flow of Qi movement, reversed flow of Chong Qi occurs. Many gynecological diseases are pathologically related to the reversed flow of Chong Qi such as irregular menstruation, dysmenorrhea, premenstrual syndrome, morning sickness, eclampsia, leucorrhea, pruritus vulvae, infertility, invasion of the blood chamber by heat, gynecological masses, etc. In clinic, smoothing Liver Qi is the effective way to harmony Chong Qi.
There are several treatment methods for smoothing Liver Qi according to the different kinds of Liver dysfunction. The following are most common:
- Regulate Qi to smooth Liver Qi, represented by: Chai Hu Shu Gan San.
- Lower upward adverse Qi to smooth Liver Qi, represented by: Wen Dan Tang.
- Calm down Liver Yang to smooth Liver Qi, represented by: Zhen Gan Xi Feng Tang.
- Clear away Liver to dispel fire, represented by: Long Dan Xie Gan Tang.
- Regulate Shao Yang to smooth Liver Qi, represented by: Xiao Chai Hu Tang.
- Nourish Liver Yin to smooth Liver Qi, represented by Yi Guan Jian.
- Harmonize Liver and Spleen, represented by: Xiao Yao San.
In acupuncture treatment, SanYinJiao(Sp6) is the most useful point in gynecology which has the function of smoothing Liver Qi, another two points to regulate Chong Qi are NeiGuan(P6) and GongSun(Sp4).