The term ‘late menstrual period’ refers to menstrual cycles that are longer than 35 days for at least 3 consecutive cycles. In extreme cases, periods may be overdue by three to five months. The medical term is oligomenorrhea.

Long menstrual cycles that are less than 35 days are not considered to be “late menstrual period” neither are those which are delayed occasionally. The first year after the puberty or during the perimenopausal period, late or irregular cycles are considered normal.

Late menstrual period is usually caused by deficiency or stasis （or a complex of both）. The disease is located in the chong and ren mai, and the uterus and involves either an insufficiency or an obstruction such that the blood sea （ chong mai） cannot be filled on time.

Late menstrual period may be accompanied by scanty period flow, but one that lasts the normal duration of a few days.

This condition pertains to the TCM category of menstrual diseases. Western medicine considers late menstrual period to reflect delayed ovulation and it is sometimes present in conditions of dysfunctional uterine bleeding.

This condition involves deficiency or excess. The former is mainly concerned with an insufficiency of essence-blood as a result of kidney deficiency, blood deficiency, or deficiency cold which leads to emptiness of the chong and ren mai. In such conditions the sea of blood cannot be filled on time and menstruation is delayed.

The latter is mostly due to blood-cold and qi stagnation which result in obstructed blood circulation and blockage of the chong and ren mai. Such obstruction also prevents the sea of blood being filled on time, causing late menstrual period.

Constitutional weakness of kidney qi, or a lot of sexual activity or many pregnancies （which impair kidney qi） can all cause insufficiency of the chong and ren mai, and the sea of blood not being filled on time with late menstrual period as a result.

Repeated damage to the blood, many pregnancies or breast feeding many infants, constitutional weakness after a prolonged illness, and inadequate nourishment, can all cause ying-blood deficiency, further leading to insufficiency of the chong and ren mai, so that the sea of blood cannot be filled on time, causing late menstrual period.

Constitutional yang deficiency or yang damaged by prolonged illness can give rise to internal cold, depriving the viscera of warmth. This impairs generation and transformation of qi and blood, leading to qi and blood deficiency, thus bringing about insufficiency of the chong and ren mai so that sea of blood cannot be filled on time, causing late menstrual period.

Invasion of external pathogenic cold or overconsumption of cold drinks and food can cause pathogenic cold to lodge in the chong and ren mai, coagulating blood, blocking the uterine vessels, and obstructing blood circulation. The sea of blood cannot be filled on time, causing late menstrual period.

Depression or emotional distress fails to disperse qi, leading to stagnation of blood which blocks the chong and ren mai, causing stagnant qi and blood circulation. This leads to the sea of blood not being filled on time, causing late menstrual period.

The diagnosis and patterns can be determined based on general condition of the patient and the history of menstruation in combination with the presenting symptoms and signs, including the tongue and pulse.

There may be a history of constitutional weakness, many pregnancies, or recent invasion of external pathogenic cold, overconsumption of cold drinks, or emotional distress.

Menstruation is delayed for more than seven days, or in severe cases, up to three to five months. The menstrual flow may be abnormal in amount and duration, and the condition lasts for more than two consecutive cycles.

（1） Gynecological Examination （GYN）: Normal uterine size or slightly small.

（2） Auxiliary Examinations: Pelvic ultrasound may be performed to assess the state of the uterus and its lining and the ovaries. Blood tests to check hormone levels can also be performed to assess ovary function.

Bi-monthly menses refers to a woman free from illness with her menstruation coming once every two months; tri-monthly menstruation is the menstruation occurring every three months. Both of these cycles are rare, but they are a physiological phenomenon with a fixed cycle and an absence of other symptoms.

A sexually active woman of childbearing age whose menstruation is overdue should first exclude pregnancy. A urine or blood test will be positive for HCG. Early pregnancy may also be suspected if there is breast swelling or nausea. A gynecological examination will reveal uterine enlargement and softness and changes in the cervix. Ultrasound examination will show a gestational sac in the uterine cavity.

If the previous menstrual cycle was normal, but the current period is delayed and the volume or quality of blood is different from normal, one should once again exclude pregnancy since this may be a threatened miscarriage, or an ectopic pregnancy, particularly if there is lower abdominal pain.

The pattern differentiation of late menstrual period must distinguish between deficiency and excess based on the amount, color and quality of the menstrual flow and other signs and symptoms, including the tongue and pulse. Deficiency patterns include blood deficiency, kidney deficiency, and deficiency cold; excess patterns include cold coagulation and qi stagnation.

Generally speaking, if menses is scanty, light red in color, thin in volume, and accompanied by sallow or pale complexion, dizziness, insomnia, dull pain in the lower abdomen, a pale tongue with a thin white coating, and a thready weak pulse, the disease falls in the category of a blood deficiency pattern.

If late menstrual period with a scant flow of darkish thin blood, is accompanied by lower back ache and sore knees, copious clear urine, a pale tongue with a thin white coating, and a deep slow pulse, this is a kidney deficiency pattern. Women with this pattern may have a late puberty.

If the menses is light red, thin and clear with dull pain in the lower abdomen and preference for warmth and pressure, or cold pain in the back, loose stools, a pale tongue with a white coating, and a deep and slow forceless pulse, deficiency cold is indicated.

If menses is scanty, darkish red with clots, and accompanied by cold pain in lower abdomen with aversion to pressure, fear of cold, cold limbs, and a tight deep pulse, this is an excess cold pattern.

If the menses is slight with normal or darkish-red with clots that are difficult to discharge, and accompanied by mental depression, or lower abdominal pain and distention, or breast distention, a normal or darkish tongue and a wiry pulse, this is classified as a qi stagnation pattern.

Treatment should focus on regulating the menstrual cycle in light of the principle “treating deficiency with supplementation and treating excess with drainage”.

A deficiency pattern should be treated by supplementing the kidney and nourishing blood, or warming the channels and nourishing blood.

However, care must be taken when administering cold, sour astringing medicinals such as shēng dì huáng and bái sháo.

Excess patterns should be treated by regulating qi, relieving stagnation and dissipating cold.

For deficiency-excess complex, one should identify whether deficiency or excess is predominant and treat deficiency and excess accordingly. Most cases of this disease pertain to deficiency and cold patterns. Therefore, the excessive use of pungent dry and bloodbreaking medicinals is inappropriate because they can damage yin-fluids and qi and blood.

[Main Manifestations]

Late menstrual period, scanty, darkish, clear and thin menses, and clear discharge.

[Other Signs and Symptoms]

Aching lower back and knees, dizziness and tinnitus, dull or dark complexion, or dark macules on the face.

[Tongue and Pulse]

Pale tongue with thin white coating, and a deep, thready pulse.

[Pattern Differentiation]

Kidney deficiency （with its attendant essence and blood insufficiency） and deficiency of the chong and ren mai means the sea of blood will not fill in time and the period therefore arrives late and the flow is scanty. When kidney qi is deficient there is a lack of fire to warm the blood, resulting in the menses being darkish, thin and clear.

If kidney deficiency leads to a loss of warming and transformation in the lower jiao and the ren and dai mai are not secured, turbid dampness will appear as clear thin vaginal discharge.

[Treatment Principles]

Supplement the kidney, nourish blood, and regulate menstrual period.

[Formula]

Dāng Guī Dì Huáng Yĭn （Chinese Angelicae and Rehmannia Beverage, 当归地黄饮）.

[Formula Analysis]

Dāng guī, shú dì huáng, and shān zhū yú nourish blood and replenish essence.

Shān yào and dù zhòng supplement the kidney qi to secure the life gate.

Niú xī strengthens the lower back and the bones and activates the menses through supplementation and promoting circulation.

Gān căo harmonizes the ingredients.

The entire formula acts to supplement kidney qi and replenish essence-blood.

[Modifications]

With scant menses, add zĭ hé chē （Placenta Hominis） （decocted separately） 10 g, ròu cōng róng （Herba Cistanches） 10 g, and dān shēn （Radix et Rhizoma Salviae Miltiorrhizae） 10 g.

With excessive vaginal discharge, add lù jiăo shuāng （Cornu Cervi Degelatinatum） 20 g, jīn yīng zĭ （Fructus Rosae Laevigatae） 10 g, and qiàn shí （Semen Euryales） 10 g.

With late menstrual period that lasts for many cycles, add ròu guì （Cortex Cinnamomi） 6 g.

With dull pain in the lower abdomen, add bái sháo （Radix Paeoniae Alba） 10 g, ē jiāo （Colla Corii Asini） （melted） 10 g, and xiāng fù （Rhizoma Cyperi） 10 g.

[Main Manifestations]

Late menstrual period with scanty, clear thin, light red menses.

[Other Signs and Symptoms]

Sallow complexion or pallor, dizziness and blurred vision, palpitation and insomnia, or persistent dull lower abdominal pain which responds well to pressure.

[Tongue and Pulse]

Pale lips and tongue with a thin white coating; a thready and weak pulse.

[Pattern Differentiation]

Ying-blood depletion results in the inability to supplement the chong and ren mai, and the sea of blood fails to be filled on time, resulting in late menstrual period and scanty flow.

The menses are light red and thin due to blood and essence deficiency, and the dull lower abdominal pain is caused by blood deficiency failing to nourish the uterine vessels.

Blood deficiency means that inadequate blood reaches the head and eyes resulting in dizziness and blurred vision, and the facial skin will be pale.

As the heart fails to be nourished, there is vexation and insomnia. The tongue is pale. Moreover, blood fails to fill the channels, so there is a weak and thready pulse.

[Treatment Principles]

Replenish qi, supplement blood, regulate menstruation

[Formula]

Dà Bŭ Yuán Jiān （Major Origin-Supplementing Brew, 大补元煎）

[Formula Analysis]

Rén shēn, as the sovereign medicinal, strongly supplements original qi. When qi is generated, blood is increased.

Shān yào and gān căo assist rén shēn to supplement spleen qi and nourish the source of generation and transformation.

Dāng guī nourishes and activates blood and regulates menstruation.

Shú dì huáng, gŏu qĭ zĭ, shān zhū yú, and dù zhòng nourish the liver and kidney, replenish essence and blood, thus achieving the purpose of supplementing blood by enriching yin.

The whole formula functions to supplement original qi, replenish essence, and nourish blood.

[Modifications]

For spleen deficiency failing to transform and transport, poor appetite and loose stools, remove dāng guī and add bái zhú （Rhizoma Atractylodis Macrocephalae） 10 g, biăn dòu （Semen Lablab Album） 10 g and shā rén （Fructus Amomi） 6 g （decocted at the end）.

For palpitations and insomnia, add yuăn zhì （Radix Polygalae） 10 g and wŭ wèi zĭ （Fructus Schisandrae Chinensis） 10 g.

For blood deficiency and yin depletion with tidal fever, night sweats and vexation, add nǚ zhēn zĭ （Fructus Ligustri Lucidi） 10 g, hàn lián căo （Herba Ecliptae） 10 g, hé shŏu wū （Radix Polygoni Multiflori） 10 g and dì gŭ pí （Cortex Lycii） 10 g.

[Main Manifestations]

Late menstrual period, scanty dark red flow with clots.

[Other Signs and Symptoms]

Pain in the lower abdomen which is averse to pressure and is alleviated by warmth, pale bluish complexion, aversion to cold, and cold limbs.

[Tongue and Pulse]

A dark tongue with a white coating; a deep, wiry or tight pulse.

[Pattern Differentiation]

Invasion of external cold or overeating cold-natured foods can lead to blood coagulation. Blood circulation in the chong and ren mai may be obstructed and the sea of blood will not fill or empty on time. Thus, menstruation is delayed and the flow is scanty.

Coagulation of the blood in the chong and ren mai manifests as a dark clotty flow.

Internal cold that lodges in the uterus will disrupt smooth circulation of qi and blood causing lower abdomen pain （“obstruction causes pain”）.

Such pain is able to be alleviated by warmth because heat can disperse the obstructed qi and blood.

As cold coagulates on the inside of the body, yang is unable to circulate in the exterior parts of the body, thus limbs become cold and there is aversion to cold.

A pale bluish complexion, a dark tongue with a white coating, and a deep tight pulse are all signs of excess cold.

[Treatment Principles]

Warm the channels to dissipate cold and regulate menstruation.

[Formula]

Wēn Jīng Tāng （Channel-Warming Decoction, 温经汤）

[Formula Analysis]

Ròu guì warms the channels, activates yang to dissipate cold, dredges the channels, and regulates menstruation.

Dāng guī and chuān xiōng nourish and activate blood to regulate menstruation.

Warm and sweet rén shēn supplements qi.

É zhú, mŭ dān pí and niú xī activate blood and expel stasis, also assisting dāng guī and chuān xiōng to relieve blood stagnation.

Bái sháo and gān căo relax tension and relieve pain.

On the whole, the formula acts to warm the channels, dissipate cold, activate blood, and regulate menstruation.

[Modifications]

For scanty menses, add juăn băi （raw Herba Selaginellae） 10 g and jī xuè téng （Caulis Spatholobi） 12 g.

If the menstrual flow is not so scanty or becomes heavy, remove é zhú and niú xī during menstruation, and add páo jiāng （Rhizoma Zingiberis Praeparatum） 10 g, ài yè （Folium Artemisiae Argyi Carbonisatus） 10g and qiàn căo （Radix et Rhizoma Rubiae）10 g.

For abdominal pain, add wŭ líng zhī （Faeces Trogopterori） 10 g and pú huáng （Pollen Typhae） 10 g （wrapped）.

For lumbar pain, add sāng jì shēng （Herba Taxilli） 10 g, xù duàn （Radix Dipsaci） 10 g and gŏu jĭ （Rhizoma Cibotii） 10 g.

For loose stools, add bái zhú （Rhizoma Atractylodis Macrocephalae） 10 g, shān yào （Rhizoma Dioscoreae） 10 g and shén qū （Massa Medicata Fermentata） 10 g.

For qi stagnation and abdominal distension, add xiāng fù （Rhizoma Cyperi） 10 g and wūyào （Radix Linderae） 10 g.

[Main Manifestations]

Late menstrual period with a scanty flow, light red in color, thin flow with no clots.

[Other Signs and Symptoms]

Dull pain in the lower abdomen with a preference for warmth and pressure, lumbar aching and weakness, copious clear urine and loose stools.

[Tongue and Pulse]

A pale tongue with a white coating; a deep and slow, or thready and weak pulse.

[Pattern Differentiation]

Since yang qi is deficient in this pattern, internal cold develops and the internal organs cannot function. A lack of yang means fundamental processes in the creation and transformation of qi and blood will fail.

Deficiency of qi and blood means the filling of the chong and ren mai is impaired, the outflow of the sea of blood is delayed, manifesting as the late arrival of the period.

Deficiency of yang and warmth in the blood and the uterus, means the blood is scanty thin and light red and there is dull pain in the lower abdomen.

Yang deficiency of the kidney manifests as lower back pain.

Copious clear urine, loose stools, a pale tongue with a white coating, and a deep and slow or thready and weak pulse are all further signs of yang deficiency.

[Treatment Principles]

Warm the channels, reinforce yang, nourish blood, regulate menstruation

[Formula]

Wēn Jīng Tāng （Channel-Warming Decoction,温经汤）

[Formula Analysis]

In this formula, wú zhū yú and guì zhī function to warm the channels and the uterus, dissipate cold, and dredge the blood vessels.

Dāng guī, chuān xiōng, bái sháo and ē jiāo nourish and activate blood and regulate menstruation, and mŭ dān pí dispels stasis.

Mài dōng, bàn xià and shēng jiāng harmonize the stomach, and descend adverse qi.

Rén shēn and gān căo supplement qi and harmonize the middle.

The entire formula aims at rectifying the complex condition of cold and heat and excess and deficiency, warming cold deficiency in the chong and ren mai and resolving blood stasis. The action of the herbs includes warming, clearing, supplementing and resolving in general, with specific focus on warming the channels and dissipating the cold, nourishing the blood and dispelling stasis.

[Modifications]

For lower abdominal pain during menstruation, add bā jĭ tiān （Radix Morindae Officinalis） 10 g, xiăo huí xiāng （Fructus Foeniculi） 6g and xiāng fù （Rhizoma Cyperi） 10 g.

For sloppy diarrhea that occurs two or three times a day, add chăo bái zhú （dry-fried Rhizoma Atractylodis Macrocephalae） 10 g, shén qū （Massa Medicata Fermentata） 10 g and páo jiāng （Rhizoma Zingiberis Praeparatum） 10 g.

For copious clear urine, add shén qū （Massa Medicata Fermentata） 10 g and yì zhì rén （Fructus Alpiniae Oxyphyllae） 15 g.

[Main Manifestations]

Late menstrual period with slightly reduced or normal amount of flow that is sluggish, dark red in color with clotting.

[Other Signs and Symptoms]

Mental depression, lower abdominal distention and pain, breast swelling and pain.

[Tongue and Pulse]

A normal or red tongue possibly with a thin yellow coating; a wiry or choppy pulse.

[Pattern Differentiation]

Liver injury due to depression impairs the free flow of qi, and affects blood circulation. As a result the sea of blood does not fill on time and menstruation is delayed. The flow is not smooth, and may be clotty. If there is no excess cold or heat in the body, the color, amount, and quality will be normal.

Constraint of qi flow in the liver channel leads to distention and pain in the breasts, the ribs and the lower abdomen.

A wiry pulse is a sign of qi stagnation; if liver constraint transforms into heat, there will be a red tongue with a thin yellow coating, and pulse will become wiry and rapid.

[Treatment Principles]

Regulate qi, move stagnation, activate blood, regulate menstruation

[Formula]

Wū Yào Tāng （Lindera Decoction, 乌药汤）.

[Formula Analysis]

Wū yào regulates qi and moves stagnation.

Xiāng fù regulates qi and menstruation, while mù xiāng moves qi and relieves pain.

Dāng guī activates blood, moves stagnation and regulates menstruation.

Gān căo acts to harmonize all the formula ingredients.

Overall, this formula functions to promote qi flow and activate blood circulation to regulate menstruation.

[Modifications]

For period pain, add é zhú （Rhizoma Curcumae） 10 g and yán hú suŏ （Rhizoma Corydalis） 10 g to regulate qi, move stagnation and check pain,

For qi constraint transforming into fire, add dān pí （Cortex Moutan） 10 g and zhī zĭ （Fructus Gardeniae） 10 g.

For severe distention and pain in the breasts, rib-sides and lower abdomen, add chái hú （Radix Bupleuri） 10 g, yù jīn （Radix Curcumae） 10 g, chuān liàn zĭ （Fructus Toosendan） 10 g and wáng bù liú xíng （Semen Vaccariae） 10 g

For scanty menses, add jī xuè téng （Caulis Spatholobi） 15g and dān shēn （Radix et Rhizoma Salviae Miltiorrhizae） 15g.

For cold lower abdomen, add ài yè （Folium Artemisiae Argyi） 10 g and ròu guì （Cortex Cinnamomi） 6g.

[Treatment Principles]

Warm the channels and dissipate cold, regulate the chong and ren mai

[Main Points]

RN 6 （ qì hăi）, SP 6（ sān yīn jiāo）, KI 13 （ qì xué）

[Modifications]

For excess cold, add ST 25 （ tiān shū） and ST 29 （ guī lái）.

For deficiency cold, add DU 4 （ mìng mén） and RN 4 （ guān yuán）

[Manipulations]

Needle RN 6 （ qì hăi）, KI 13 （ qì xué） and SP 6 （ sān yīn jiāo） with supplementation.

For ST 25 （ tiān shù）, ST 29 （ guī lái）, DU 4 （ mìng mén） and RN 4 （ guān yuán）, use moxa （cone, direct, stick, suspended or warming needle）.

[Analysis]

When the chong and ren mai are healthy and vigorous, the tai chong mai is flourishing and kidney qi is sufficient, only then can menstruation arrive on time.

RN 6 （ qì hăi） is a channel point of the ren mai; KI 13 （ qì xué） is the crossing point of the chong mai and the kidney channel; SP 6 （ sān yīn jiāo） is the intersection of the three yin channels of the foot. The combined use of the three achieves the effect of regulating and supplementing the chong and ren mai, nourishing yin, and harmonizing the blood.

ST 25 （ tiān shū） and ST 29 （ guī lái）, as foot yangming channel main points, act to warm and dredge the uterine vessels, activate blood, and dredge the collaterals.

Moxibustion on DU 4 （ mìng mén） and RN 4 （ guān yuán） functions to warm the kidney, strengthen yang, and dissipate cold. Cold coagulation will only be eliminated when yang qi is invigorated; then blood circulation will recover naturally.

[Treatment Principles]

Supplement the spleen, nourish blood, regulate the chong and ren mai

[Main Points]

RN 6 （ qì hăi）, SP 10 （ xuè hăi）, ST 29 （ guī lái）, BL 17 （ gé shù）, ST 36 （ zú sān lĭ）, SP 6 （ sān yīn jiāo）

[Manipulations]

Needle with supplementation, or use warming needle moxibustion.

[Analysis]

RN 6 （ qì hăi） is the channel point of the ren mai, and SP 6 （ sān yīn jiāo） is the junction of the three yin channels of the foot. Their combined use acts to regulate the chong and ren mai, nourish yin, and harmonizes blood.

ST 29 （ guī lái） and ST 36 （ zú sān lĭ） are channel main points of foot yangming which act to harmonize blood and supplement qi.

BL 17 （ gé shù） is the meeting point of the blood, so it is indicated for all blood deficiency, blood heat, and various hemorrhagic conditions.

[Therapeutic Principles]

Soothe the liver and regulate qi, harmonize blood and regulate menstruation

[Main Points]

KI 13 （ qì xué）, LV 5 （ lí gōu）, LV 2 （ xíng jiān）, SP 6（ sān yīn jiāo）

[Manipulations]

Needle all points with reducing technique.

[Analysis]

KI 13 （ qì xué） is the crossing point of the chong mai and the kidney channel, and SP 6 （ sānyīn jiāo） is the intersection of the three yin channels of the foot. Their combined use achieves the effect of regulating and supplementing the chong and ren mai, nourishing yin, and harmonizing the blood.

LV 2 （ xíng jiān） and LV 5 （ lí gōu）, respectively as the ying-spring point and luo-connecting point of the liver channel, together act to soothe the liver and regulate qi.

[Ingredients]

Functions: Acts to supplement qi, harmonize the nutrient aspect, nourish blood, and regulate menstruation. Indicated for qi and blood insufficiency caused by irregular menstruation presenting with late periods, cold pain in the lower abdomen during menstruation, or empty pain in the lower abdomen after menstruation.

Administration: Taken orally with warm water or yellow wine, 1 pill twice a day.

[Ingredients]

Functions: Acts to resolve depression, normalize qi, regulate menstruation, and nourish blood. Indicated for late periods due to blood stagnation characterized by chest tightness and qi constraint, bilateral rib-side distention and fullness, reduced food intake, lack of strength in the limbs, or abdominal blood masses with pain that scurries, or vaginal discharge due to cold dampness.

Administration: Taken orally, 6 g once a day.

Lengthy menstrual cycles and scanty flow can often be resolved in a timely manner with proper treatment. Delay or lack of treatment may lead to amenorrhea or infertility.

1. Caution should be taken to avoid exposure to cold and damp before and during the period so as to prevent blood stagnation due to cold dampness, and the development of menstrual disease. A woman’s constitutional defenses are weaker during menstruation.

2. Similarly it is wise to avoid consuming cold foods and drinks during menstruation to prevent blood stagnation in the channels and the vessels.

3. It is important at this time to try to maintain stable emotions and a calm mind and avoid excesses of the seven emotions.

Attention to appropriate contraception is important if pregnancy is not desired.

Ms. Wang, age 24, unmarried

Initial Visit: October 26, 1975

Chief Complaint: Delayed menstruation for more than one year.

Present History: The patient was described as having an apathetic demeanor. She frequently suffering from a gnawing pain of the flanks and abdomen. Her menstruation has been irregular for the past year, occurring once every 50 days to 2 months. The menses were scanty, dark purple and mixed with clots. There was distending pain in the lower abdomen that was averse to pressure, and during the intermenstrual period a thick turbid vaginal discharge was present. For the past two months, she felt a shivering feeling during late afternoon, with hot face, vexation, liking to hold cool objects, lassitude and mental fatigue. There was a 37.6℃ to 38℃ axillary temperature, self-taken.

She was diagnosed with “low fever of unknown origin” in Western medicine and given symptomatic treatment with no obvious effect.

Her complexion at the visit was dull and dark, her tongue dark red with a scanty coating, and her pulse thready and slightly rapid.

TCM Diagnosis: Late menstrual period due to qi stagnation with blood stasis and yingyin depletion.

Pattern Differentiation: The patient was usually depressed and quiet. Liver-wood was therefore constricted and not allowing for free activity; this caused a gnawing pain in the ribs and the abdomen. Qi stagnation failed to move blood so that the channel became stagnant, and stasis formed over time. As a result of this, menstruation occurred late, with blood clots and abdominal pain averse to pressure. Prolonged stasis obstruction consumed the ying-yin, giving rise to internal deficiency-heat manifesting with a lingering low fever.

Treatment Principles: Nourish blood, regulate menstruation, eliminate steaming heat

Formula:

Administration: 6 packs of the above medicinals, one pack taken every other day.

Prepared medicines Qī Zhì Xiāng Fù Wán （Sevenfold Processed Cyperus Pill） 6 packs and Jiā Wèi Xiāo Yáo Wán （Supplemented Free Wanderer Pill） 6 packs were prescribed, one pack of each to be taken each day, one pack in the morning and one pack in the afternoon. The pills and decoctions were taken alternately.

In addition, shé chuáng zĭ （Fructus Cnidii） 9 g, wú zhū yú （Fructus Evodiae） 3 g, and huáng băi （Cortex Phellodendri Chinensis） 6 g were wrapped in a cloth and brewed for a twice-daily hip bath.

Second Visit: November 9

After eight days, menstruation arrived 32 days after her last menstruation, the blood amount still being light with many blood clots and accompanied by flank pain and abdominal distention. Her vaginal discharge had also reduced. Her fever decreased, with an axillary temperature of 37.4℃. Treatment continued, using the previous method with some modifications.

Formula:

6 packs were prescribed along with the external medicine, to be applied simultaneously. The patient was instructed to take the pills after taking the decoction, continuing until the next menstruation.

Third Visit: December 8

After the second visit, the patient’s temperature returned to a normal 36.8℃, with no recurrence of fever before the medication was completed. Her strength and spirit were also recovered. Menstruation occurred on time the previous day, with improved color and amount, although some clots were still present. Her tongue was light red, and her pulse wiry and thready. She was been instructed to take Jiā Wèi Xiāo Yáo Wán （Supplemented Free Wanderer Powder） for another 20 days, one pack every morning and one pack in the afternoon.

[Analysis]

Resolving stasis and dredging the channels is the chief therapeutic method for the first visit, with dāng guī to nourish and harmonize blood.

Xiāng fù and sū mù regulate qi and promote blood circulation to relieve pain.

Dān shēn, liú jì nú, chì sháo, qiàn căo and niú xī activate blood and resolve stasis to dredge the channels.

Qīng hāo, biē jiă and yín chái hú nourish yin, clear heat, and eliminate steaming heat.

A small amount of zĭ sū gěng was used to regulate qi and remove stagnation in the stomach and the spleen in order to activate middle jiao. The function of middle jiao is maintained, thus transformation is possible.

Outcome: When the effects appeared the first visit, blood stasis was still hidden in the channel without being eliminated. Therefore, a slight fever lingered even though the menstruation had come on time. The second visit focused on the elimination of stasis with the application of both decoctions and pills to maintain balance between their relatively drastic and mild actions.

Source: Gynecological Case Record of Ha Li-tian （哈荔田妇科医案医话选）

What are the similarities and differences between the late menstrual period and hypomenorrhea based on the pathogenesis and treatment principles?