CLASSICAL CHINESE MEDICINE: PART III; Reproductive System Energetics; Ob/Gyn & Fertility Disorders

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CLASSICAL CHINESE MEDICINE: PART III; Reproductive System Energetics; Ob/Gyn & Fertility Disorders

In an attempt to provide a comprehensive view of this subject and to open communication in the medical field at large, the aspects under consideration here shall be both the reproductive energetics common to classical Chinese medicine (particularly the contemporary European refinement and its methods of diagnosis, description, and treatment) and wherever possible, a comparison to Western gynecological methods of diagnosis, description, and treatment.

A general knowledge of some Western medical terminology (ACTH, FSH, LH, etc.), Western physiology, and a complete background in Traditional Chinese Medicine are presupposed. A preliminary discussion, from both Eastern and Western points of view, of the basic physiology involved in normal cyclic menstrual function is essential to understanding the mechanism at work when abnormal function occurs and symptoms appear. The principal types of functional menstrual disorders will be discussed in some detail, with particular emphasis on the specific features of energetics, diagnostic approaches, principles of management, and the types of therapy proved most successful in each.

Energetic Properties and Circulatory Mechanisms

Throughout the active period of reproductive years functional disturbances in normal energetics and the related symptomatic manifestations of normal cyclic function constitute the single most common type of clinical problem associated with the delivery of health care to women. These disorders are often transient and self-limiting. When persistent, however, they frequently lead to excessive blood loss and secondary anemia; and may cause serious disability that results in work absenteeism and may also produce infertility. Also ever present is the need to establish definitive diagnoses of energetic disturbances and to exclude or avoid overlooking the concomitant presence of more serious organic disease such as local uterovaginal or adnexal lesions or more generalized, fundamental endocrine related disorders with ovarian, thyroid, ad renal, or pituitary involvement. These conditions, if not already present, may also be generated by protracted energetic disturbances.

Primary Energies

As with any system in the human body, the reproductive system employs three types of energy in order to function. Namely Ancestral Energy, Nutritive energy, and Defensive energy. It's quite interesting to note that, expressed in a different manner, the same concept is commonly accepted in Western medicine.

ANCESTRAL ENERGY (yuan qi), also called hereditary energy, whose description is closely linked with genetic organization, corresponds to the regulatory programming of the organism. It flows primarily in the Ancestral Vessels and is tied, on the most part, to lunation for its cyclical properties. It is the basis of cellular differentiation and specialization, the constitutional elements of the individual and a great number of "archaic" characteristics of the species. It presides over the formation and functioning of the nervous, endocrine and in particular, the reproductive systems of the female and the male.

As its name indicates, it is transmitted patronymically. Its essential character lies in the fact that it is quantitatively fixed at birth and, therefore, not renewable. This manifests on a physical level, for example, as the inability to regenerate nervous tissue or the predetermined number of ovules in the female.

It should be strongly emphasized that the prime role of Ancestral Energy is one of regulation. Throughout the course of life, this regulatory influence over the organism shifts its focus onto three distinct stages of development. Each stage constitutes roughly one third of the life-span: from birth through puberty Ancestral Energy stimulates and guides the usage of Nutritive energy facilitating the growth phase of the individual; from puberty throughout the next third it exercises its influence over the changes in the secondary sexual characteristics and the reproductive career of the individual; in the final phase the regulatory role of Ancestral Energy is then involved with directing the maintenance of the organism until its remaining quanta are ultimately spent. According to the theories of the Yellow Emperor's time, these periods are made up of still smaller increments -- of seven years in the female and eight years in the male. These periods are discussed at length in chapter one of the Su Wen.

This is a rather eloquent expression of Five-Phase Energetics (Wu-xiang). The interface occurring between each third, guided by the transformational influence of the Earth phase, presents a vivid and dynamic representation of the philosophical principles of birth, growth, transformation, decline and death. Regarding the more proximate concerns of this paper, it is that second phase (the middle third) of this pattern, from menarche to menopause, which is of interest and shall be examined in this study.

NUTRITIVE ENERGY (ying qi), fulfills, as its name indicates, an essentially nutritive and supportive role. It circulates in relationship to the circadian rhythms with concentrations in the Principal Channels occurring in two hour intervals. It is renewable and is regularly produced in the organism by means of two external sources: alimentation and respiration (metabolic alterations of Ge qi and Da qi are detailed in separate article entitled "Sanjiao Energetics" in a previous issue of this journal).

Its contribution to the organism, following these metabolic refinements, is to affect trophicity and bring nutrition to the tissues via the Principle Energetic pathways and the circulation of blood which, in traditional Chinese medicine, rightly represents no more than a materialized form of circulating energy.

DEFENSIVE ENERGY (wei qi), is also derived from food and oxygen via the mechanisms of Sanjiao Energetics. Classical descriptions include complex patterns of interiorization and exteriorization at some 50 cycles per day and also specific movements from GV-16 (Fengfu) through the spine, to T1 and descending at a rate of one vertebra per day for 22 days, then penetrating the Chong mai where it accumulates for nine days to then reappear at the occiput on the tenth day ding Shu, Chapter 76). This processional movement of the wei qi can also carry pathogenic qi along with it, particularly those pathogens absorbed from GV-16 (Fengfu), generating complex symptom pictures as it passes the back Shu points, contaminating the associated organs. Within the framework of this study we shall keep these patterns in the back of our mind but focus our attention on the notion that it circulates, for most clinical purposes, in a diurnal fashion. That is, exteriorizing during the day and interiorizing at night.

Furthermore, we should be cognizant that wei qi, the most yang energy, flows primarily in the Tendono-muscular Channels, the longitudinal lo vessels and distinct or divergent Channels. It can be more rapidly mobilized than ying energy. By moving quickly to sites of pathogenic aggression, it fulfills primarily a defensive role against internal and external stresses, as well as presides over and manifests in immunological phenomena.

The Energetic Channels

When the Eight Curious vessels are included in this discussion, it is generally presented that only two specific groups of Ancestral Vessels are especially involved in the functioning of the reproductive system:

(1) Those originating within the "Energetic lodge" of the kidneys:

- Conception vessel (Ren mai, representing the Yin polarity of yuan qi),

- Governor vessel (Du mai, representing the Yang polarity of yuan qi),

- Penetrating vessel (Chong mai, representing the Blood).

(2) Those originating at the lower limbs:

- Yin wei mai, Yin = Progesterone effect.

- Yang wei mai, Yang = Estrogen effect.

Although these vessels regulate the primary function and are clinically employed most frequently, the remaining Ancestral Vessels cannot be ignored. The need to include them is clearly demonstrated by the concomitant symptoms often occurring in a disturbed menstrual cycle. Symptoms that are poorly explained by the above two groups can be better explained and managed by including the remaining three Vessels.

GROUP I

The three Ancestral Vessels in Group I, originating from within the Energetic Lodge of the Kidneys, follow the con, non internal channel descending to the perineum where they connect with CV-1 (Huiyin).

In males, whose genitalia are external expressing the Yang, the Conception vessel first contacts CV-1 before passing through the scrotum and penis to ascend up the mid-line. In the female, however, the internal or Yin expression creates a branch passing through the uterus and vaginal lining and then connecting to CV-1.

From CV-2 (Qugu) the external conception vessel is similar in both sexes and ascends following the anterior mid-line to the thyroidal region (where it receives energy from the terminal points of the Yin wei) and on to the mentolabial groove above the chin to terminate at CV-24 (Chengjiang). Internally at this point it bifurcates, encircles the mouth, and then joins the Stomach channel at Chengqi (St-1). This channel constitutes the yin polarity of Ancestral Energy.

The primary branch of the Governor vessel also becomes external at the perineum but ascends following the posterior midline. Supplying the yang polarity of Ancestral Energy to the pelvic area, particularly by means of GV-3 (Yaoyangguan) and GV-4 (Mingmen), it then continues to GV-16 (Fengfu) just below the occipital rid ge where a n internal branch inserts into the brain to the region of the ventricles, exercising influence over the corpus callosum, the hypothalamic-pituitary axis and the pons. The external branch continues to ascend over the vertex and then down to the nasal columella where it terminates at GV-28 (mouth Yinjiao). This channel constitutes the Yang polarity of Ancestral Energy.

The secondary branch of the Governor vessel circulation consists of both posterior and anterior branches. Originating from CV-2 (Qugu) the anterior or abdominal Secondary Governor Vessel blends with the ascending flow of the Spleen Tendino-muscular channel to the navel, internally passes through the heart to the posterior flow of the Bladder T.M.'s and then on to the face terminating at BI-1 (Jingming). The posterior branch also departs from CV-2 passing over the medial thigh in a posterior flow to also join with the Bladder T.M. to terminate at Bl-1.

The Chong mai divides into two internal channels at CV-1. One, the internal posterior branch, flows upward entering the spinal column, rises to the lumbar region and back toward the Kidneys. The other, flows to the front following the internal anterior branch and becomes external in the region of CV-4 (Guanyuan) where it ascends bilaterally and paramedially, following and joining the circulation of the principle Channel of the Kidneys, but on a more superficial route. That is to say the Chong mai circulates just below the wei energy region via points directly connected, one to each other. The actual Kidney points (11 through 21) are not directly connected to each other They are located more deeply, nearer the peritoneum but directly under the Kidney point locations. The more superficial Chong mai provides continuity to the ascending flow of the Kidneys and helps pull along the ying energy until it reaches and encircles the naso-labial region (internally). Although this channel shares the role of the yin polarity with Conception Vessel, its influence is not so much associated with Ancestral Energy distribution as it is over the circulation and distribution of the blood and the entirety of the organic liquids (Body Humours).

The function of the Ancestral Vessels of this group, simply stated, is the distribution of Ancestral Energy into the entire body. Not only into the areas supplied by the pathways described above, but into all the tissues by means of sub-Channel ramifications and other crossing points.

The physiologic effects of these channels as well as their topographical distribution reminds one of the regulatory influence the sympathetic/parasympathetic nervous system has over the vascular system, that is to say the vaso-constriction/dilation, local blood volumes, and central and peripheral perfusion characteristics.

GROUP II

The second group have a vastly different purpose and is made up of a functional network represented by the two Ancestral Vessels known as the Yin wei mai and the Yang wei mai.

Remarkable characteristics of these two Ancestral Eessels are as follows:

1. They do not "originate" at the Kidneys as is the case for the former ones, but on principle channels of the lower limbs. The Yin wei originates on the Kidney Channel at the point Ki-9 (Zhubin). The Yang wei originates on the Bladder Channel at the point B1-63 (Jinmen).
2. They are bilateral.
3. They circulate exclusively in areas corresponding to their polarity, viz.: Yin wei circulates medially and on the anterior plane; Yang wei circulates laterally and on the posterior plane.
4. They consist of several segments, linked to each other: (The segmental concepts presented herein may represent a new idea to certain schools of thought. However, reflection upon the associated principle Channel points will justify the relationship to each energetic layer).
5. Their fundamental role is to connect and harmonize the interior and the exterior as we shall see in detail, later From a Western point of view, they can be considered as governing the neuro-endocrinal processes. The Yang wei is in direct contact with cerebral zone and the various cortices, whereas the Yin wei is topological in contact with the thyroidal region and the various genital effectors.

The Yin wei includes the Spleen segment, corresponding to the Tai yin layer with two points situated on its course Sp-15 (Daheng) and Sp-16 (Fuai); the Spleen/Liver segment, corresponding to the Jue yin layer also having two points of influence at Sp-13 (Fushe) and Li-14 (Qimen).

The Kidney/Conception vessel segment, corresponding to the Shao yin layer which is directly connected to the two terminal points of the Tin wei vessel, CV-22 (Tiantu) and CV-23 (Lianquan). The Yang wei includes the Yang ming segment/layer, point LI-14 (Pijiao).

The Shao yang, the most important segment because of the number of points it includes:

GB-35 (Yangjiao), GB-29 (Juliao),

SJ-15 (Tianliao), GB-21 (Jianjiing),

GB-20 (Fengchi), GB-19 (Naokong),

GB-17 (Zhengying), GB-15 (Linqi),

GB-14 (Yangbai), GB-13 (Benshen);

The Tai yang segment includes B1-63 (Jinmen) and SI-10 (Naoshu); and creates a direct connection with GV by means of the GV vessel points at GV-15 (Yamen) and GV-14 (Dazhui).

The Principle Channels

All of the principle channels are involved, to some degree, in the functioning of the reproductive system. The point should be made, however, that their role is in supplying nutritive (ying and "blood") energy whereas the Ancestral Vessels provide the cyclical regulatory influence.

The Channels that are of therapeutic import are clearly those which traverse the pelvic region and thus the lower limbs.

- The Spleen Channel (Foot Tai yin) whose pathway is ascending (as are all yin channels) and concerns particularly the ovarian region.

- The Liver Channel (Foot Jue yin) which is connected to the tuboovarian region in the female and the testicles, epididymus and the deferens canals in the male.

- The Kidney Channel (Foot Shao yin) and the area it irrigates, the uterus in the female, and the ejaculatory canal in the male.

These three channels cover the yin-polarity irrigation and maintenance of the pelvic region. Further, the Spleen Channel rules more particularly the Blood supply (similar to the Ancestral Chong mai); the Liver Channel, the yin energetic supply dike the Ancestral Conception vessel); and finally, the Kidney Channel, supplying the reserves of Nutritive energy to what some acupuncture text books call the Yin bao -- "Yin Envelope" or the "Energetic Envelope of the Uterus".

The concept of energetic envelopes is pervasive in the classical texts and to facilitate broader understanding a small digression into that area seems in order.

At the thoracic level, in the region of CV-17 (Shanzhong), an extremely dense network of luo or secondary channels form the xin bao luo (literally "channels enveloping the heart") and constitute, such as it is, the Pericardium "organ." The role of this network is to provide protection to the heart.

At the pelvic level, in the region of CV-3 (Zhonggi) and CV-4 (Guanyuan) an extremely dense network of luo or secondary channels form the Yin bao or bao luo gong (literally "channels enveloping the uterus" or "the envelope of the menstrual blood and the sperm"). The role of this network is to provide protection and integrity to the uterus/fallopia/ovaries or the testicles/epididymus/vas deferens.

This uterine envelope communicates with the Ren mai at the above mentioned abdominal points CV-3 and 4. Clearly, the bao luo gong is linked to the Kidney and perhaps not so clearly to the Liver and Spleen via the insertion points. It is also linked to the Chong mai and Du mai through the common internal channel (descending to the perineum).

The link of the Yin bao with the Chong mai supports the relationship to the Liver and the Blood. Additionally, the bao luo gong appears to correspond anatomically to the sacral and pudendal plexi as demonstrated at the point B1-48 (New-53) or Bao huang the "envelope of vitals" located on the horizontal line of the second sacral foramen. The point Li-9 is, in Chinese, Yin-bao or Yin Envelope, and likely represents the Liver Channel's "loop" around the reproductive organs.

Through these internal connections, all the "envelopes" are intimately related. These relationships operate through the Jueyin energetic layer: The foot Jue yin is directly connected to the bao luo gong (uterus) and the hand Jueyin is directly connected to the xin bao luo (heart-envelope). This also explains many of the genital and sexual indications of the Pericardium Channel, the functional thoracic symptomatology related to gynecological disorders, associated vascular pathologies, the vagal reflex triggered by certain gynecological maneuvers and finally why some of the earliest European authors translated the Shou Jue yin as the Circulation-Sex Channel.

Yang energy is supplied to the pelvic region by means of the Stomach Channel via St-28 (Shuidao), St-29 (Guilai), and St-30 (qichong). These points provide a shunt of Yang energy to the pelvis (the only true anterior Yang) and represent the Yang ming. The Gall Bladder Channel and its points GB-26, (Daimai), GB-27 (Wushu), GB-28 (weidao), represent Shao yang and the Dai mai relationship (see below). The Bladder Channel via Bl-30 (Baihuanshu), Bl-31 (Shangliao), Bl-32 (Ciliao), Bl-33 (Zhongliao), Bl-34 (Xialiao), represents the Tai yang.

The Dai mai or Belt Channel regulates the connection between the upper and lower aspects. This makes it particularly useful in cases of passive blood congestion of the small pelvis. It is always implicated in cases of leukorrhea and is, therefore, frequently employed according to these Energetics. This Channel is primarily ruled, not only by Ancestral Energy (being one of the Eight Curious Vessels) but also by tile proper functioning of (because of its fundamental relationship to) the principle channels, Gall Bladder and Stomach.

The Dai mai connects the "vital essence of the middle of the body" function of the Gall Bladder to the Kidneys at GV-4 (Mingmen), the pelvic region and the bao luo gong. This involvement of the Gall Bladder must necessarily involve the other side of the Shao yang Layer, namely the Sanjiao, which also descends to the small pelvis. The numerous Gall bladder and San jiao points of the Yang wei mai bears out a relationship to and clearly implicates the Yang wei in relation to the Dai mai function. Thus the Yang wei, albeit somewhat indirectly, plays a significant role in Dai mai pelvic irrigation.

There are of course other Channels and Energetic networks supplying the pelvic area but lack specificity in terms of reproductive system energetics and therapeutics.

Energetics of the Normal Menstrual Cycle

Before discussing the etiologies common to menstrual dysfunction we must understand the normal energetic processes of the organism that occur throughout the menstrual cycle.

Two energetic circulatory systems operate simultaneously. These are of course the Ancestral and Nutritive systems. As stated, the Ancestral Energy represents the regulatory influence over the organism as a whole and the Nutritive represents the alimentary supplies as indicated by its name.

With respect to the regulatory Energies, another unique characteristic, probably due to its non-renewability, is that fact that portions unused at the end of its circulatory journey are recuperated and recirculated.

Two main currents are involved in the total dynamics of menstruation. The first is essentially a constant distribution whereas the second one is tidal or cyclical through the various segments of the Ancestral Vessels of the lower limbs.

Constant Circulation

The first consists, quite independently of the menstrual cycle itself, of the regular flow of Ancestral Energy from the kidney reserves down the common internal branch to CV-1 (Huiyin). At that point the distribution takes three separate courses: toward the Yang area (Governor Vessel), toward the yin area (Conception Vessel or yin energy) and to the Chong mai or "Blood energy".

Within this circulation we find not only a direct link between the CV & GV vessels at their source but there is also an anastomotic link between CV22 and GV-9, as well as CV-23 and GV-16. Furthermore a link exists between CV-24 and the first point of the Stomach Channel. Additional distribution of Ancestral Energy also occurs in all the intercostal spaces at the upper branches of the Chong mai as this channel disperses into those regions in a reticular or network-like fashion.

Recuperation (drainage vs. supply) of Ancestral Energy which has been carried beyond its channels of origin occurs at certain special points on the principle channels, among which we cite the Antique points, ling (well) and Yu-yuan points. Further, the lower branch of the Chong mai drains surplus Ancestral Energy from the internal lining of the lower limbs at Sp-4 (Kungsun). And as well, certain principle channels recoup and recirculate Ancestral chi directly back toward the Ancestral Vessels such as the Kidney Channel from point Ki-9 (Zhubin), the origin of the Yin wei mai.

It must also be remembered that, even beyond the extra vessels, a circulatory movement of Ancestral Energy occurs constantly in the Pelvis between the posterior and anterior branches of the Chong mai, and the Conception vessel (which is also anterior). Following the same pattern, the three segments of the Yin wei, on the anterior lining of the stomach, also function as a drainage system. This system primarily recoups Ancestral Energy at the level of the Channel points where they pass. But as always the Ancestral Energy is not alone. The ying energy, in circulating outside its channel, lows the same route. It is pulled along with the Ancestral Energy and thereby experiences the same permanent movement.

It is this constant circulation/recuperation that ensures the distribution of Ancestral Energy into the Eight Extra Vessels and thus into the entire body. This erects the energetic background upon which the generatory function of the menstrual cycle is superimposed.

Cyclic Circulation

This second circulatory system (of the menstrual cycle proper) occurs in the two Ancestral Vessels Yin wei and Yang wei. You will remember, the Yin wei consists of three branches making up the segments whose common point of origin is Ki-9 (Zhubin). These three branches are representative the three Energetic layers: Tai yin, Jue yin, and Shao yin. As stated previously, the Tai yin segment exercises influence over the ovarian region, the Jue yin over the tuboovarian region and the Shao yin over the uterine region.

One last, important point is that a cyclic evolution corresponding to the chronology of the four phases of the menstrual cycle also occurs in the three segments of the Yin wei. The intensity of circulation (in each segment) and the anterior drainage which results, develops in the course of a 28-day period, in four successive seven-day phases.

- The first primarily in the Spleen segment (Tai yin).

- The second primarily in the Spleen/Liver segment (Jue yin).

- The third primarily in the Kidney/Conception segment

- The fourth in the Du mai-Conception Vessel axis.

In summary, during the first phase, the energy drained at Sp-15 (Daheng) and Sp-16 (Fuai) is carried up to the reunion points of yin and toward the Conception Vessel at CV-22 (Tiantu) and CV-23 (Lianquan).

During the second phase, the energy drained at Sp-13 (Fushe) and Li-14 (qimen) is in turn brought to CV-22 (Tiantu) and CV-23 (Lianquan).

During the third phase, the entirety of the couple, Kidney and Conception vessel, circulate upward connecting to the ascending flow of the Chong mai (whose course follows that of the Kidney Channel), "lifting" the energy of the Kidney at the interior region of the pelvic cavity.

Finally, this energy mass emerges at CV-22 (Tiantu) and CV-23 (Lianquan) and by means of anastomoses to GV-9 (Zhiyang) and GV-16 (Fengfu), it circulates into the Governor vessel. As well, these Energies also flow to CV-24 (Chengjiang) to merge with the Yang of the upper part at St-1 (Chengqi) and from there to BI-1 (Jingming), in other words, into the entire yang region.

The Yang wei is also made up of several segments:

- Tai yang segment;

- Shao yang segment;

- Yang ming segment; and

- Governor Vessel segment.

The energy in the various Yang Channels is mobilized at the points of each segment. As in tile case of the Yin wei, a similar yet antithetical, rhythmic pattern presides over the activity of each Yang wei segment. The intensity of circulation follows thusly:

First the Yang ming segment, and then successively, Shao yang segment, Tai yang segment and finally the Governor Vessel segment.

Therefore, in considering the distribution through the depths of the Energetic layers within the upper and lower and internal and external aspects of the body, it is possible to say that a movement of exteriorization occurs at the level of the Yang Channels and the upper region, and a movement of interiorization, complimentary and simultaneous to the proceeding one, occurs at the level of the yin Channels and the lower region.

The same time as the evolution of the energetic distribution of yin and yang according to the exterior-interior connection, there occurs another evolution according to the upper-lower levels as well as one according to empty-full relationships.

A cyclic succession of the predominance of the various energies takes place in the abdominal pelvic region, with an alteration of yin-yang, the yin nutritive being mobilized by the arrival of the yang nutritive for whom it makes room, and the Yang is then mobilized by the Yang wei just as the yin has been by the Yin wei. This is how the succession takes place in connection with the dominant energy:

1. Conception Vessel and Governing Vessel,
2. Spleen (Tai yin) and Stomach (Yang ming)
3. Liver (Jue yin) and Gall Bladder (Shao yang),
4. Kidney (Shao yin) and Bladder (Tai yang).

The following can be deduced:

- 1st phase: Conception Vessel/Governing Vessel, corresponds to the duration of menstruation.

- 2nd phase: Tai yin/Yang ming in the vicinity of the 14th day corresponding to ovulation.

- 3rd phase: Jue yin/Shao yang, corresponding to the tubal migration of the ovum. At the point in time when fertilization may occur.

- 4th phase: Shao yin/Tai yang, corresponding to the premenstrual period and the preparation of the uterine mucosa (decidua), at the point in time when implantation may occur.

Therefore the aforementioned energetic movements establish a directive pattern which determines the menstrual cycle in the female and reveals the possible etiologies of a number of symptoms directly connected to the energetic alterations and the actual flow of menstrual blood.

However, although the female is more yin and the male more yang, the energetic structures are similar. One may very well believe that the male also has the equivalent of a menstrual cycle. The only difference is that in women, being more yin, the manifestations occur essentially at the level of the blood, whereas in the male, Yang, they predominate at the energetic level. This would explain, inasmuch as one wants to take the trouble to look for them, the various groups of syndromes of cyclical evolution found in the male, clinically observed, and which result from none other than the evolution of the Energetic movements equivalent to menstruation.

But what are the factors lying at the origin of this cyclical evolution, these biorhythms? An examination of them would be too lengthy for this paper But their mechanisms can be explained by comparing the cyclical movements (and the interrelationship to Humankind) of what the Chinese call the Celestial Stems and Terrestrial Branches, which are the laws governing the evolution of the whole of the cosmic phenomena that influence man.

RECAPITULATIVE TABLE OF PHASES Days Phase Interior/Exterior Manifestation 1-7 1st Phase Conception/Governing Menstruation 7-14 2nd Phase Tai yin/Yang ming Ovulation 14-21 3rd Phase Jue yin/Shao yang Tubal Migration 21-28 4th Phase Shao yin/Tai yang Proliferation

Thus, in the yin layers the dominant energy works toward the deep regions and in the Yang layers toward the superficial, simultaneously.

Physiology of the Normal Menstrual Cycle

Inductive Mechanisms of the Hypothalamic-Pituitary-Ovarian Axis via the yin energetic zones of Conception Vessel, ventral Kidney points, Yin wei and Chong mai; yang energetic zones of Governor Vessel, dorsal Bladder points, Yang wei and Dai mai.

As soon as regular periodic flow has become established in a completely mature, adult pattern, the regulation of the normal cycle is under the control of the reciprocally-related energetic and neuro-hormonal mechanisms inherently present in the Eight Curious vessels and induced in the hypothalamic-pituitary-ovarian axis. The fundamental energetic features of this regulatory system and the endometrial, tubal and ovarian response patterns are discussed in the energetic section but require some additional elaboration in order to understand the concurrent physiological substratum and its activities from a more Western point of view.

Contemporary Western research has established that neurohormones produced by the hypothalamus -- the luteinizing hormone (LH) releasing factor (LH-RH) and possibly a follicle stimulating hormone (FSH) releasing factor FSH-RH (the two may, in fact, be one and the same) -- are carried to the adenohypophysis via the pituitary portal circulation. There, in a complex interaction with gonadal steroids, they are responsible for the control of the pituitary secretion of FSH and LH. In essence, these releasing factors are the energetically induced chemical messengers between the cerebral cortex and the secretory cells of the pituitary gland.

There are similar releasing factors for the thyroid- stimulating hormone (TSH), and pituitary corticotropin (adrenocorticotropin, or ACTH) -- these are respectively TSH-TH and CRF or corticotropin releasing factor. And there are releasing factors for both growth hormone secretion (somatotropin releasing factor) and growth hormone inhibition (somatostatin, growth hormone inhibiting factor).

In the first few days of each new cycle (i.e., immediately following the onset of menstruation (GV/CV/Dai mai Phase) in response to the withdrawal of the inhibiting effect of the high premenstrual levels of estrogen and progesterone (occasioned by their sudden fall to extremely low levels coincident with corpus luteum deterioration and subsequent menstrual flow), The basophilic or "beta" cells of the anterior lobe of the pituitary are once again stimulated by the hypothalamic releasing factor to secrete increasing amounts of the pituitary gonadotropin FSH. The ovary normally responds or, more correctly, the primordial ovarian follicles respond by secretory activity on the part of the follicular cells and stroma.

In the human female a single follicle ordinarily is destined to become the dominant one, and this dominant follicle is usually the only one to continue to respond and progress in maturation and function. (Occasionally more than one follicle is stimulated to the point of ovulation and corpus luteum function, thus accounting for biovular twinning.)

During the very earliest phases of ovarian follicle response (Tai yin/Yang ming Phase), while some growth is occurring in a number of follicles, these same anterior pituitary cells begin also to elaborate LH (identical with ICSH, or interstitial cell- stimulating hormone, in the male), and under the combined stimulation of a small amount of LH and by the now larger amounts of FSH, the follicle cells, specifically those of the granulosa and theca interna layers, begin to secrete estrogens -- a "yang effect" or activity-expansion induction.

At first, this consists of low levels of both estrone and estradiol, but by mid-cycle (Shao yang/Jue yin Phase) the levels are increasing rapidly, and the ratio of estradiol (the most yang or biologically active estrogen) to estrone is also markedly increased. As circulating estrogen levels rise, a reciprocal inhibition or braking effect on the pituitary output of FSH comes into play (initial negative feedback effect of estrogen on pituitary secretion of FSH and LH), but although FSH secretion begins to decline, the pituitary continues to produce more LH (subsequent positive feedback effect of estrogen on pituitary secretion of LH alone).

At a crucial point, approximately at or shortly before mid-cycle, as the Spleen segment of the Yin wei phases into the Liver segment, and the Stomach segment of the Yang wei phases into the Gall Bladder segment, both estrogen and LH levels are on the rise and already approaching a maximum. With FSH well on the decline but still present in a critical amount, the one dominant follicle undergoes characteristic vascular, cellular, and secretory changes and moves to a position near tile surface of the ovary.

Thereafter, ovulation is induced by the energetic phase shift or flux concentration of the yin segments moving medially -- from the ovary (Sp) to the fallopia (Li). It is assumed this change is accompanied by a sudden surge in pituitary LH production (and possibly FSH as well) initiated by the outpouring of LH releasing factor elaborated by the hypothalamus. The biochemical mechanism by which a single follicle is selected is unknown. The remaining partially stimulated follicles simply persist in a resting state or ultimately become atretic, but continue to secrete variable amounts of estrogen throughout the rest of that cycle.

Following ovulation, the pituitary continues to secrete increasing amounts of LH, but, in addition, the acidophilic cells ("alpha" cells) of the anterior lobe also appear to come into action and begin the release of a third gonadotropin, formerly referred to as the luteotropic hormone (LTH) and now referred to as the lactogenic hormone, prolactin.

prolactin (HPRL) is chemically similar to, but not identical with, human growth hormone (HGH). The mechanism by which prolactin production is triggered is again apparently based on a critical balance among the levels of the two other gonadotropins and estrogen (and possibly small amounts of progesterone as well), mediated by neuro-hormonal stimuli from the hypothalamus and regulated by the cerebral points of Yang wei mai and Du mai (particularly GV-16 as mentioned earlier).

Although HPRL is probably not absolutely essential for maintenance of the corpus luteum in the human female, the combined effects of LH and HPRL produce additional cytochemical changes in the granulosa and theca interna cells, and under this dual influence they become luteinized and elaborate increasing amounts of progesterone.

Once again, a reciprocal inhibition effect comes strongly into play toward the end of the cycle, or premenstrual Shao yin/Tai yang phase. At this point, rising progesterone levels have progressively suppressed the output of LH and HPRL, and the corpus luteum, increasingly deprived of their stimulating support, begins to decline. Simultaneously, with falling LH and HPRL levels, the return of active production of FSH is favored, and the beginning stimulation of new follicles that will take part in the succeeding menstrual cycle occurs before the current one has quite been terminated.

This should remind us that although the Extra Vessels and their associated segments undergo great shifts in concentration levels of ying, Blood, Fluids and Ancestral Qi. They are never found to be totally empty and, therefore, continue to influence the body throughout the cycle. With final corpus luteum deterioration, estrogen and progesterone levels suddenly fall dramatically under the direct influence of the invading Yang energy "evicting" the yin accumulation. This results in a rapid withdrawal of hormone support for the integrity of the endometrium and its vascular bed which leads to the desquamation and bleeding characteristic of the menstrual flow.

By now, as already noted, the early events that will result in repetition of the same sequence of balanced, reciprocally related Energetic, neuro-hormonal and cytochemical phenomena in the next and all subsequent normal cycles are well under way.

In the West, it is generally accepted that the hypothalamus exerts the controlling influence on the cyclic pituitary activity by virtue of its elaboration of the neurohormones LH-RH and also possibly FSH-RH (recall that LHRH may be responsible for the release of both FSH and LH), as well as a prolactin releasing factor, HPRL-RH, and a prolactin inhibiting factor, HPRLIE These hormone releasing factors produced in the hypothalamus are carried directly to the pituitary via the hypothalamic-pituitary portal system of blood vessels traveling along the pituitary stalk to the gland below. This better understanding of the hypothalamic-pituitary relationships has helped to clarify the underlying biochemical mechanism involved in the several clinical entities in which both amenorrhea and persistent lactation are seen (e.g., Chiari-Frommel syndrome).

However, if ovulation should be followed by conception and proper implantation of the fertilized ovum, a complete alteration of segmental flow occurs. The Chong mai (Blood) and Ren mai (Yin Ancestral) dominate and placental formation will insue. The early chorionic villi will attain a functional capacity adequate for the elaboration of sufficient chorionic gonadotropin as well as a placental lactogen (HPL) to continue to maintain the corpus luteum in a high state of secretory activity, even in the face of falling pituitary LH and HPRL. This in turn will prevent the onset of the menstruation and will preserve and further modify the endometrium in a manner even more favorable to the maintenance and normal development of the pregnancy. Placental gonadotropin secretion is equal to this task within the first week of implantation.

The subsequent physiological, biochemical and especially the energetic alterations throughout gestation must necessarily constitute an entirely separate study.

Adrenal, Thyroidal, and Cerebral or Psychogenic Factors

1. Cerebral: Du mai-Yangwei Terminus axis and Lateral B1.
2. Thyroidal: Ren mai-Chong mai-Yin wei Terminus axis,
3. Adrenal: Ren mai-Du mai-Chong mai Origin axis.

What has been presented thus far concerns only the basic regulatory physiology of the normal menstrual cycle and the modification introduced when pregnancy intervenes. In addition, three other influences on the otherwise "self-contained" mechahism must be acknowledged and also borne in mind as potential factors when disturbances arise.

Cerebral Cortical Centers

Psychogenic factors have never been excluded from Chinese medical theories but the exact nature of whatever may be the neural equilibrium between cortex and hypothalamus essential for normal cycle regulations is unknown. Disturbances in this equilibrium are an extremely common cause of functional menstrual disorders. Thus psychogenic influences of great variety and apparently mediated via this cortical- hypothalamic pathway often profoundly affect a previously (and subsequently) perfectly normal, regular menstrual pattern. The frequent, often prolonged, so-called hypothalamic amenorrhia of college women away from home for the first time is a familiar example, as is the delayed period in the young single woman who falsely fears she may have recently conceived. Grief reactions, acute or chronic anxiety states, too frantic a pace of living, periods of high excitements, and a multitude of mental problems or emotional difficulties are often wholly or in part responsible for the alterations in normal cyclic menstrual function that are so commonly encountered.

Thyroid Function

Normal thyroid function is an essential feature of the general background for normal cyclic female reproductive tract activity. This is not surprising, because the same anterior lobe area of the pituitary also elaborates TSH, and there may well be interrelationships between gonadotropin and TSH secretion that link TH menstrual cycle and thyroid function together a t the hypothalamic-pituitary level.

Furthermore, the general effect of thyroid hormone on tissue metabolism is obviously of importance to the proper functioning of the entire neuro-hormonal regulatory mechanism, as well as to the cellular-metabolic and cytochemical events that must take place in the ovary and subsequently in the rest of the target organs in the reproductive tract for the estrogen and progesterone produced by the properly maturing follicle.

In view of these facts, it is obvious why thyroid disorders, either thyroidism or hypothyroidism, characteristically are accompanied by functional menstrual disorders. In fact, in the case of mild degrees of hypothyroidism, menstrual dysfunction may be the sole or principal clinical manifestation prompting the patient to seek medical advice.

Adrenal Function

In the case of adrenal function, the relationship to hypothalamic-pituitary-ovarian activity is even more complex and intima re. The ACTH elaborated by the pituitary, though normally stimulating primarily the adrenal production of corticosteroids, may, particularly in excess amount, elicit the production of androgens and estrogens by the adrenal. Rising levels of these hormones, though of adrenal rather than ovarian origin, will inhibit pituitary secretion of FSH and LH and drastically interfere with normal gonadal function (as in congenital adrenal hyperplasia).

Furthermore, both LH and HPRL, in addition to their normal effects on ovarian function, also stimulate the adrenals to produce androgens and probably aldosterone as well, and these steroids of adrenal origin are also essential to the normal hormonal, metabolic, and fluid and electrolyte alterations that occur during the normal menstrual cycle. Clearly, deficient or excessive adrenal stimulation or adrenal hypofunction or hyperactivity will be accompanied by fundamental disturbances of cyclic menstrual function; this is illustrated clinically in the menstrual disorders commonly associated with Cushing's disease, Addison's disease, and the adrenogenital syndrome, whether due to adrenocortical hyperplasia or tumor.

Finally, the inherent biochemical similarities between adrenocortical cells and ovarian cortical and stromal cells in terms of the potential ability of each to synthesize a wide variety of steroids of both androgenic and estrogenic activity are sometimes reflected in the apparent production of androgens and even adrenal-like steroids by the ovary itself in certain pathologic states.

Oriental Medicine.

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By Sean Marshall

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