Qiological Community

Shortened menstrual cycle

Hello All

I could use some help with this case! Any thoughts and ideas would be very welcome
Here it is:

Sarah - 48 years old teacher and social worker

Chief complaint : very short menstrual cycle

Appearance demeanor : Dresses in a clean but very frumpy way +7. She is bitter and judgmental of others +8. She has recently been asked to leave her job which was no surprise to me but is something she definitely did not see coming +8. She is very organized and is a natural academic +9.

Lifestyle : Sarah is very sedentary. She claims that she exercises daily, but there is no evidence of that in her body morphology. She has a sweet tooth +7 and blames her husband for baking. She spends a lot of time reading and studying (Just finished her PhD) +9

Body morphology : Sarah has gained a considerable amount of weight in the last year. She is puffy +8 and her joints tend to swell +9.

Menses : Sarah has been vacillating between skipping her period for many months and then falling into a zone where her periods come every 3 weeks. When she is not having her period, she has extreme hot flashes +9. Now she is bleeding every 2 weeks. There is some mild clotting & pain +4 with her period. She bleeds for 3-5 days.

Temp : normal and then very hot when the night sweats are in play

Fluids : heavy sweats when there are night sweats. Lots of swelling. Not particularly thirsty

GI : Sarah can be constipated as well as have loose stool. She can feel blocked and stuck in her abdomen. At the moment, her digestion is OK. But she is feels very distended with the onset of her period +8

Skin & Skin : Her hair is thin and dry +8, skin is normal

Resp : history of asthma which when triggered can be severe +8 and chronic sinus infections. She is usually aware of some sort of pressure and blockage in her sinuses that varies in severity. Sinuses are at a +6 now

Sleep : poor when there are night sweats. She is sleeping well now

Emotions : pent up/frustrated +8

Excess presentations:

Ht: hot flash and heat +9

UB: judgmental and not a lot of warmth towards others +8

GB: pent up/frustrated +8, asthma/trouble breathing

P: academic, librarian energy +9

SJ: 0

Liv: not self aware/did not see her job loss coming +8

Lu: Sinus congestion +6, asthma can be +8

St: 0

LI: 0

Sp: weight gain & puffy +8 lots of swelling +9, sweet tooth

SI: frumpy +7

Kid: mild clotting and cramping with period +4

Treatment = LI +

Sarah felt great during treatment. She fell into a deep sleep on the table. BUT, she emailed the next day saying that she had felt exhausted after the session and had needed to sleep for two hours. She woke up feeling puffy and distended in her abdomen and started bleeding again the next day. Yikes! What did I miss? She is returning for another visit on Fri and I am loath to tonify Spleen with all of the water signs (weight gain, swollen joints etc), sedentary nature, and the sweet tooth, but feel like I must given the negative reaction to tonifying LI.

Moving forward I am considering K+ to consolidate the bleeding. She exhibits some SI exc – not a lot of care in how she dresses and perhaps if there was more love for herself, there would be more love and acceptance of others. But I am a little hesitant because she has some mild clotting and pain with her period. Another thought I had was +St to try and redistribute the water from the inside to the outside, but I am not seeing how this would help her bleeding. SJ+ has also come to mind, but I am worried about the fact that that treatment is a little warming and she so easily moves in to hot flashes and feeling hot. But perhaps since she is not in that zone now the mild warming quality of SJ+ might not push her in that direction and would instead open her up and bit and brighten her glum and taciturn nature. But again, would this treatment slow the amount of bleeding that she is experiencing.

Any insight into this case would be very much appreciated!

what’s her skin like?
:heart: :orange_heart: :yellow_heart: :green_heart: :sweat_drops: :dizzy: :boom:

Hi Amy
Here skin is unremarkable. Not especially dry or oily.
Thanks!
Marintha

What is the grossest thing in the room?

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Hi Kristin
There are two gross things in the room. Her obvious weight gain is one. Every time that she comes in for a visit (I see her about 1x/mo), she seems to have gained more weight & look more puffy. The second is her glum and bitter disappointment with those around her (husband, co-workers, & students). Together they make for a very heavy and sullen quality.
Thanks for the question!
Marintha

She sounds less GB aggressive and reactive and more some combo of Liver and UB excess emotionally dark and cold.

Does she typically get tired and bloated just before her period? Was the timing of the bleed consistent with her recent pattern? If so, I wouldn’t consider this an adverse reaction. I would keep it on the radar and look out for dryness.

Is her flesh dense?
Is she symmetrical? Any blood stasis signs besides some cramping/clots? The direction of the K/SI imbalance isn’t so clear to me.

My vote from the info so far is to treat the heavy sullen, dark, grim nature with SJ+. Along with her P excess tendencies, her general energetic is so down and in. This could be seen as a hypofunctioning or species of stasis that might lead to bleeding. I admit that this is a reach :slight_smile: but it is the clearest path forward to my eyes. I wouldn’t worry about the hot flashes because she isn’t in that phase right now.

This is an interesting case. Thanks for sharing.

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Super interesting. I feel like I would go SJ+ too. It makes me think of how blood pathology can lead to water swelling. Maybe not blood stasis like KD XS but that cold and dense gloominess.
Do her heels offer any insight into the KID/SI dynamic?

Thank you Kristin and Shannon!

She does get bloated and tired before her period. This seemed in the extreme, but maybe not necessarily out of the ordinary for her. I was not absolutely clear where she was in her cycling, but will double check. It would be far less confusing if her reaction to the treatment was not due to LI+ being completely wrong & more that tonifying LI did not have a huge impact on the bleeding that she is having.

Sarah has no other blood stasis signs aside from the mild cramping and clotting with her period. She is not symmetrical and her medial heel does not offer anything significant. I agree that the Kid/SI axis is murky.

I would say her flesh is dense, but the squishy/puffiness of the weight gain really stood out to me at the time of treatment.

Thank you for the SJ+ encouragement! That feels right.

Kristin, could you say more about this? What aspect is hypofunctioning and what is static that might be the cause of the bleeding?

This is an interesting new twist on how to think of stasis and water swelling. It does feel like it is her static nature that is causing the bleeding, I am just having a hard to fully understanding it.

Thank you so much for helping me work through this!

I have recently been curious about GB+ instances of what we might call depression. Is the frustration about the lack of movement, lack of fresh new energy (spring), and does it feel weighted like a manhole cover on your head so you can’t stand up and get going. With Toby’s teachings, I have been cautious to use it, but have had some real breakthroughs when I can justify it. In the way that we get our “favorites”, I feel like GB+ has the opposite, like an ‘un-favorite’. I have been looking for reasons to use it and have been happy with the results. In your case, I would agree that SJ+ would be helpful first. Just a thought… As an aside, I have been interested using it for woman who say they have “poor Boundaries” to give them more uprightness…that which is just and exact.

Toby’s famous case of the freezing cold young woman with severely heavy bleeding treated by H+ and Liv+ is part of the inspiration for the hypofunctioing idea. T used it to explain how H+ could be used to stop bleeding. In that case lack of warm yang fails to hold.

In this case, there is loss of rhythm with her flow, alternating not flowing and then flowing too often. Her body is like a tree that is mostly trunk and roots. In places, the capacity to be open to light and the metabolic and physiological processes that light mediates has been lost. I imagine her womb is a dark gloomy place that doesn’t know what season it is or whether it is day or night. So it bleeds and then when it doesn’t the yang that isn’t able to be held by the too dense yin flies up as hot flashes- each phase expressing a loss of connection with rhythm.
The tissues that have lost the light are starting to support the grow of mushrooms. Their fruiting bodies are manifesting as extra weight in her body.

Dampness or water being a by product of blood stasis is part of this dynamic, as mentioned by Shannon. Liver excess isn’t blood stasis per de, but it is blood and structure that has become too dense to receive and circulate light and warmth.

How do these musings sit with you all?

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Hi Amy, There are a number of threads to your point. Maybe you have already seen them.

I wouldn’t want to give this patient GB assertiveness until she has more light and warmth but maybe way down the road it would be a good idea.

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Adding to ideas why SJ + might help bleeding/ weight gain, I was thinking how she is sooo Wood XS. With GBxs & LiV xs. So thinking about through what we learned with Sharon her pivot isn’t working so the SJ fire can’t get into position. She’s not bleeding from a kidney deficiency but from the SJ fire not getting into position. We don’t need to stoke the fire But instead pivot it… and if SJ fire isn’t in position it can’t transform fluids hence the water accumulation.
But these are pontifications. As Sharon says the proof is in the pudding! Let us know how it goes. Theory is great but clinic reality is sobering! LOL!

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Shannon and Kristen
Thank you for these insights!
Thinking of the dark, dense quality of Sarah’s Liver excess obscuring her ability to connect to the cycling of Yang brightness and light is a beautiful way to understand how out of rhythm her body is. Tying in Sharon’s idea of the blocked pivot unable to root the fire in the Shao Yin so that waters can be warmed and transformed could explain the hot flashes as well as the pooling water retention.
I will be seeing Sarah on Friday and let you know how SJ+ works out!

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Hello again
I am circling back with this case.
When I saw Sarah next, I was relieved to hear that, as Kristen suggested, it was not LI+ that had caused the exhaustion and bleeding, but rather that she was continuing in the two week cycling that she has been in. So it was not an adverse reaction to LI+, but instead LI+ just did not have much effect. I treated with SJ+ and she rested deeply.
I saw her again in 3 weeks. She reported that following the +SJ treatment, she continued to bleed in a two week cycle, but the bleeding has been less. I noted that her hands were very swollen. She felt that the swelling was occurring from the waist up. She mentioned that a recent routine colonoscopy revealed intestinal polyps and that in the past she had had uterine polyps. She had scheduled an ultrasound to investigated. Taking the masses into account, I treated SI+.
Sadly, I just received an email from her stating that she has been bleeding lightly now for 8 days. The ultrasound revealed a fundal myoma (likely not causing the bleeding) and a thickened uterine lining.
What next?!
SJ+ seemed to help a little.
SI+ did not have much effect, although the ultrasound seems to have supported the idea of blood stasis…
I am scheduled to see her this Wednesday and have been thinking of draining Liv for her. But 11/25 will put me 6 days shy of the full moon. I don’t yet have a sense of how close to the full moon we need to be to safely drain a patient.
Also, I am not sure how to interpret swelling in the upper part of the body? I have in my notes that coolness in the upper body is a sign of Liver excess, but is all pathology that manifests in the upper body considered Liver excess? Some how that does not feel right.
Any insight or suggestions would be greatly appreciated, as always.

Hi Marintha,

Thanks for continuing to share this case.

One SJ+ treatment making some mild improvement is definitely not an invitation to drain the Liver. Since many students on this forum do not have permission to drain because they haven’t taken the advanced class, I will private message Marintha to review the necessary elements for draining.

Liver excess being cool in the upper is correct but all upper body pathology is not Liver excess.

Findings on scan have low clinical weight in Saam. Mild clotting and cramping are weak K excess signs while frumpy 7+ gives much more weight to SI excess. Even though the bleeding after SI+ wasn’t heavy, 8 days is longer than usual for her. This isn’t clearly an adverse reaction but could be. Consider K+.

Damp, possibly on the exterior. Previously you reported that her skin is normal.

The sinus congestion and asthma could just as well be part of St excess. What do her thenar eminences look like? How much qi does she have in the interior? She gets bloated before her period but is she internally puffed up. Exhausted swollen ladies in the 3rd trimester are one of my models for Stomach excess- damp exterior and dry/qi xu in the interior. Could her swelling and weight gain (damp exterior) and bleeding (too much down) be explained by Stomach excess?

K+ and Lung+ are the ideas that make the most sense to me from here. What do others see?

Thank you for this, Kristen!

You are correct, I jumped at the polyps and fibroids as an easy way to explain the bleeding and ignored her clear SI excess presentation. Ugh, these diagnostic habits die hard.

Good to know there was nothing specific that I was missing about swelling in the upper body and that I can simply say that it is just Dampness

I am having a hard time seeing her as clearly St excess. Yes, the asthma and congestion along with all of the swelling could definitely support wet on the outside/St excess, but I don’t see any signs of dryness on the inside. Also, her thenar eminences are plump. She has low energy, but I don’t see it as depleted as I have in patients who were more clearly St excess. I will do some more digging and see if there are more interior signs of dryness that I have missed.
In the mean time, I leaning toward treating with Kid+ when I see her next. You are right that 8 days of bleeding is longer than usual for her and if that is due to mistreating with SI+, then I would like to rectify that and perhaps it will help consolidate her situation. I think I leaned away from Kid+ in the past because it felt wrong to consolidate someone who is already so dense.
I will let you know how it all unfolds!

Is there any correlation to her cycles coming too frequently and her job loss? Is she concerned about her resources after the job loss?

Part of me is with you on not wanting to consolidate someone who is dense even Liver density is different than Kidney consolidated self. I tend to want to conflate some excess presentations too. Patients are here to cure us of these misconceptions and show us the amazing ways these channel qualities combine to create individuals. :slight_smile:
Looking back at the details, you mentioned lack of symmetry which also adds more juice to SI excess.

Please let us know what happens.

This is one of those “where does the interior end and the exterior begin” conundrums for me. What are the interior dry signs you tend to see that may suggest supplementing LU? Dry hard constipation? Dry tongue? Weak pulse low volume? Excess thirst? I’m curious as to what you see for this Kristin.

The knowing of when to view swelling as the exterior seems to have some artful elegance to it. I certainly have had experience where the same type of swelling could be either…(and yes we’ve talked about it before but since you brought up an example I thought it may be worth a revisit for others.)

(and sorry to hijack your thread Marintha)

My take on the tradition approaches the Lung/Stomach teeter-tooter 2 ways. First is the damp/dry exterior/interior, including morphology. For the swollen pregnant ladies, I often look more to morphology instead of frank dry signs like dry constipation. What is the lady’s body like underneath the belly/breasts and swelling? If I can see a thin, skinny body under the products of pregnancy and there is swelling I have had good results using Lung+ if it fits her chief complaint.

The second approach more relates to resources outside of fluids. If the patient seems deflated and could use an injection of qi to blow up her balloon, and it fits her chief complaint, I will consider Lung+. The resource demands of the baby seem to pushed some systems into a Stomach excess pattern. I’ve seen Lung+ work for normal moisture constipation, glomus, and incontinence among other problems in pregnancy when this picture presents.

Thank you for your always thorough and thoughtful reply Kristin.

Even if not pregnant I still find this tricky as I think back to Toby palpating someone’s arm that I considered thin and saying “fog”. That “fog” idea can trip me up.

Thanks - i have been concerned about using a supplementation of LU+ in these cases, but you’ve provided a new lens for me that I will dial in this week.