Premenstrual Syndrome (PMS) is defined as physiological and mental changes before menstruation, such as irritability, susceptibility to rage, nervousness, edema, diarrhea, headache, and distending pain in the breasts without obvious organic finding. This syndrome usually occurs 2-14 days before menstruation and typically disappears after menstruation. Depending on the methodology used to gather the data, many women – perhaps a majority, experience mood and behavioral changes associated with the menstrual cycle, and many women seek care for self-diagnosed PMS. Perhaps 3% to 5% of menstrual women suffer from symptoms so marked that they qualify for a diagnosis of premenstrual dysphoric disorder (PMDD).
PLEASE NOTE: this is a long – but complete article. It can be used for reference, but for patients and students alike it shows how all-encompassing TCMis and how detailed it can be. For patients, see the end of the article for prevention and home treatment for PMS.
Causes
According to Western Medicine, the underlying causes of PMS are obscure. There may be an imbalance between estrogen and progesterone, excess ADH or aldosterone, conditions such as hypoglycemia, or it may be due to psychogenic factors. More recently disturbances in the interaction between central opioids and catecholamines, have been suggested as possible contributing factors. But by checking PMS patients, no specific hormone levels or markers are associated with premenstrual symptoms.
According to Chinese Medicine, emotional strain or stress causing Liver Qi stagnation is the most important factor, that along with excessive consumption of dairy products or greasy foods leading to phlegm accumulations. Otherwise, overwork can lead to deficiency of Liver and Kidney Yin resulting in stagnation. Basically, PMS is due to stagnation.
Diagnosis & Treatment in Western Medicine
One or two weeks prior to menstruation, patients suffer from a series of symptoms which subside or diminish abruptly at the onset of the menses. Symptoms differ among women but are fairly constant from one cycle to the next for the same individual. PMS Symptoms include mood changes such as nervousness, agitation, irritability, or depression; neurological changes such as headache, vertigo, or aggravation of epilepsy; respiratory symptoms such as colds, hoarseness of the voice, aggravation of asthma; or internal disturbance such as abdominal bloating, edema, breast tenderness, palpitations, and a feeling of bearing down in the pelvis.
Treatment for this includes lifestyle changes such as eliminating caffeine from the diet, smoking cessation, regular exercise, adequate sleep, stress reduction, serotonin reuptake inhibitors, fluoxetine, or other antidepressants. Other treatments include diuretics, progesterone, oral contraceptives, bromocriptine or prostaglandin synthetase inhibitors.
Diagnosis & Treatment in Chinese Medicine
Depending on the expert, there are two ways to study PMS according to Chinese Medicine. One way is through PMS as a whole, while the other is examined based on main complaint. Maciocia divides these based on ‘PMS’ and ‘Problems at Period Time.’ PMS is an accumulation of symptoms, while Problems at Period Time is broken down by main complaint for those not fully affected by PMS in all its aspects.
Basically, PMS is mainly caused by emotional factors that lead to pathological changes and dysfunctions in the Liver which generally affects the function of the Spleen and Kidney. Liver Qi stagnation is responsible for the symptoms of distention around the breast and chest. Liver Qi stagnation and Liver fire or Yin deficiency usually causes emotional and neurological symptoms such as irritability, depression, or headache. When the Spleen is overacted on by the Liver or there is Spleen and Kidney deficiency, the result is water accumulation that transforms into phlegm, which then rises to the head and causes vertigo, and dizziness, and also diarrhea or edema.
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Excess Pathologies |
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| Differentiation |
Liver Qi Stagnation |
Phlegm Fire Flaring |
| PMS Signs | Abdominal and breast distention before menses, irritability, clumsiness, moodiness, depression, hypochondriac pain and distention, irregular menses. | Agitation, depression, slight manic behavior, aggressiveness, chest oppression, red face, blood-shot eyes. |
| Other Signs | Lump in the throat, slightly purple tongue or red on the sides, wiry pulse. | Cough with expectoration of phlegm, red tongue with a sticky yellow coating, overflowing-slippery-rapid pulse |
| Acupuncture | LV3, GB 34, GB 41, SP , SJ 6, PC 6 | PC 7, ST 40, ST 8, DU 24, LI 11, SP 9, SP 4, PC 6, RN 12, UB 20 |
| Herbs | Xiao Yao San, Yue Ju Wan, Chai Hu Shu Gan Tang | Sheng Tie Luo Yin, Wen Dan Tang |
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Deficient Pathologies |
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| Differentiation |
Liver Blood Deficiency |
Liver & Kidney Yin Deficiency |
Spleen & Kidney Yang Deficiency |
| PMS Signs | Depression or weepiness before period, slight abdominal and breast distention, scanty periods. | Slight breast distention and irritability before period and occasionally after. | Slight premenstrual tension with depression and weeping, slight abdominal and breast distention. |
| Other Signs | Tiredness, poor memory, poor sleep, slight dizziness, dull pale complexion, pale tongue, choppy, fine, or wiry pulse. | Sore back and knees, dizziness, blurred vision, poor memory, insomnia, dry eyes and throat, palm heat, red tongue without coating, floating empty pulse. | Tiredness, sore back, cold feeling, frequent pale urination, low sex drive, pale and swollen tongue, deep and weak pulse. |
| Acupuncture | RN 4, LU 7, KI 6, SP 6, ST 36, GB 34, PC 6, RN 6, LV 8, UB 20, UB 18 | LV8, RN 4, SP 6,LV3 | UB 23, UB 20, RN 4, ST 36, SP 6, KI 3, LU 7, KI 6 |
| Herbs | Xiao Yao San or Gui Shao Di Huang Wan | Yi Guan Jian, Qi Ju Di Huang Wan | You Gui Wan. |
According to clinical symptoms, PMS pertains to headache during menstruation, fever during menstruation, body ache during menstruation, diarrhea during menstruation, vertigo during menstruation, edema during menstruation, distension of breast during menstruation, emotional liability during menstruation, skin rash around menses, and canker sores around menses. Breaking symptoms down this way tends to help understand the pathologies surrounding PMS.
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Breast Distention before Menses |
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| Differentiation |
Liver Qi Stagnation |
Liver Blood Stasis |
Qi Stagnation with Phlegm |
Liver & Kidney Yin Deficiency |
| Breast Signs | Hypochondriac distention and oppression, distending pain in the breasts, lower abdominal bloating pain. | Pre menstrual breast distention and pain, alleviated by the onset of menses, hardness of breasts | Pre menstrual breast distention, very swollen and enlarged, may be nodules on palpation | Less severe breast distention, occasionally after periods |
| Other Signs | Depression, frequent sighing, irritability, susceptibility to rage, red tongue, thin white tongue coating, wiry pulse | Irregular periods, periods that start and stop, dark blood with clots, abdominal pain, mental restlessness, purple tongue, wiry pulse | Chest oppression, sticky taste in mouth, irritability, irregular periods, obesity, swollen tongue with sticky coating, wiry and/or slippery pulse | Malar flush, mental restlessness, insomnia, five center heat, dry throat, red tongue without coating, fine slightly wiry pulse. Mainly in older women |
| Acupuncture | LV3, LI 4, RN 17, SI 11, GB 21, ST 15, ST 18, PC 6, SP 6 | LV 3, GB 34, GB 41, LV 14, ST 18, SJ 6, GB 21, PC 6, SP 10, UB 17, SP 4 | LV 3, SJ 6, GB 41, GB 34, PC 6, RN 12, SP 9, ST 40, SP 6, ST 18, UB 20, UB 22 | LU 7, KI 6, RN 4, RN 7, SP 6, KI 3,LV3, PC 7, HT 6, KI 2 |
| Herbs | Modified Chai Hu Shu Gan San | Wu Xiang Wang + Tong Yu Jian or Shu Qi Huo Luo Tang | Jia Wei XiaoYaoSan, Jian Pi Shu Yu Tang | Yi Guan Jian, Rou Gan Zhi Tong Tang |
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Diarrhea around Menses |
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| Differentiation |
Spleen Qi Deficiency |
Liver Qi Stagnation Invades Spleen |
Kidney Yang Deficiency |
| Diarrhea Signs | Diarrhea during or after period, slight abdominal pain | Diarrhea before period | Watery diarrhea after period |
| Other Signs | Tiredness, poor digestion | Pre menstrual tension, irregular periods, tiredness, depression, abdominal distention | Feeling of cold, back ache, frequent urination |
| Acupuncture | RN 12, DU 20, RN 6, ST 37, ST 25, SP 6, UB 20, UB 21 | LV3, GB 34,LV13, RN 12, ST 36, SP 6, ST 37, UB 18, UB 20 | UB 23, UB 20, RN 4, ST 25, ST 37 |
| Herbs | Shen Ling Bai Zhu San | Tong Xie Yao Fang | Modified Si Shen Wan + Jian Gu Tang |
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Headache around Menses |
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| Differentiation |
Blood Deficiency |
Liver Fire Flaring |
Liver Yang Rising |
Blood Stasis |
| Headache Signs | Dull headache on vertex during or after period | Severe throbbing headache in temples, eyes or sides of head before or during menses | Throbbing headache in temples, eyes or sides of head before or during menses | Stabbing headache in temples, eyes or sides of head before menses |
| Other Signs | Dizziness, palpitations, insomnia, blurred vision, tiredness, dull pale complexion, pale and thin tongue, choppy fine pulse. | Heavy menses, dizziness, flashing in eyes, bitter taste, thirst, red face, dry stools, dark urine, irritability, red tongue with yellow coating, wiry rapid pulse | Irritability, dizziness, flashing lights in eyes, wiry or wiry-fine pulse | Dark menstrual blood with clots, painful menses, abdominal pain, purple tongue, wiry or choppy pulse |
| Acupuncture | LU 7, KI 6, RN 4, ST 36, SP 6, LV 8, UB 20, UB 18, UB 23, Tai Yang, DU 20, DU 23 | LV 2, SJ 5, GB 43, LV 3, LI 4, LI 11, SP 6, KI 3, Tai Yang, GB 5, GB 6, GB 9 | LU 7, KI 6, RN 4, SP 6, KI 3, LV 8, SJ 5, PC 6, GB 43, LV 3, Tai Yang, GB 5, GB 6, GB 9 | SP 4, PC 6, SP 10, UB 17, ST 29, SP 6, KI 14, LV 3, DU 20, GB 17 |
| Herbs | Modified Ba Zhen Tang | Long Dan Xie Gan Tang | Tian Ma Gou Teng Yin, Qi Ju Di Huang Wan | Tong Qiao Huo Xue Tang |
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Fever around Menses |
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| Differentiation |
Blood Heat |
Deficient Heat (LV & KI) |
Qi & Blood Deficiency |
Blood Stasis (with heat) |
| Fever Signs | Intense feeling of heat or fever during period | Fever or feeling of head during or after menses, worse in the evening | Fever or feeling of heat during or after period | Fever or feeling of heat before or during menses |
| Other Signs | Heavy menses, mental restlessness, agitation, headache, blood shot eyes, thirst, hot nose, red lips, rapid overflowing pulse, red tongue | 5 center heat, mental restlessness, night sweating, floating empty or fine rapid pulse, red tongue without coating | Scanty periods, pale complexion, dizziness, tiredness, pale thin tongue, choppy or fine pulse | Dark menstrual blood with clots, abdominal pain, purple tongue, wiry or choppy pulse |
| Acupuncture | LI 11, SP 10, DU 14, LV 2, KI 2, SP 1, SP 4, PC 6, LI 4, HT 6, PC 7 | LU 7, KI 6, RN 4, SP 6, KI 3, HT 6, KI 2 | ST 36, SP 6, RN 12, RN 4, UB 20, UB 21, SJ 5 | LI 11, SP 10, UB 17, SP 4, PC 6, SP 6, RN 6, DU 14 |
| Herbs | Qin Lian Si Wu Tang, Qing Jing San, Dan Zhi XiaoYaoSan | Di Gu Pi Wan, Liang Di Tang | Bu Zhong Yi Qi Tang | Tao Hong Si Wu Tang, Xue Fu Zhu Yu Tang, Yue Ju Wan |
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Body Aches during Menstruation |
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| Differentiation |
Blood Deficiency (Maybe with Yang Rising) |
Blood Stasis |
| Body Ache Signs | Aches and pains during or after period, mostly in limbs with numbness and tingling | Severe aches and pains during or before menses, mostly in the joints (not muscles) |
| Other Signs | Tiredness, dizziness, muscular weakness, insomnia, pale thin tongue, choppy fine pulse | Painful periods with dark and clotted blood, purple tongue, choppy pulse |
| Acupuncture | LU 7, KI 6, RN 4, ST 36, SP 6, LV 8, UB 17, UB 11, LI 10, SJ 5, GB 34, UB 18, UB 20, UB 23, UB 60, GB 21 | UB 17, SP 10, UB 11, SJ 5, PC 6, SP 6, Ba Xie, Ba Feng, ST 34, ST 41, ST 43, SP 5, LV 8, LV 3 |
| Herbs | Modified Sheng Yu Tang + Ji Xue Tang, Ba Zhen Tang, Qin Jiao Si Wu Tang, Qiang Gui Si Wu Tang | Modified Chen Tong San, Tao Hong Yin, Tao Hong Si Wu Tang |
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Edema during Menses |
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| Differentiation |
Spleen Deficiency |
Kidney Deficiency |
Qi & Blood Stagnation |
| Edema Signs | Puffy face, limb edema, worse in the morning | Edema worse in lower limbs | Swelling and edema in the abdomen, hands or ankles before menses |
| Other Signs | Loose stools, heavy period, tired, pale swollen tongue, deep weak pulse | Frequent night urination, backache, fatigue, feeling of cold, pale swollen tongue, deep weak pulse | Abdominal distention, irritability, pre menstrual tension, red tongue sides, wiry (fine) pulse |
| Acupuncture | UB 20, UB 23, RN 12, ST 36, KI 7, RN 9, ST 28, SP 9, UB 22, RN 5, LU 7, LI 6 | UB 20, UB 23, RN 12, ST 36, KI 7, RN 9, ST 28, SP 9, UB 22, RN 5, LU 7, LI 6 | LV 3, GB 34, LV 14, UB 18, SJ 6, RN 5, RN 6, RN 9, PC 6, SP 8, LI 4, SP 10, SP 6 |
| Herbs | Ling Gui Zhu Gan Tang | Modified Zhen Wu Tang | Modified Ba Wu Tang, Dao Zhi Tong Jing Tang + Si Wu Tang |
| Quan Sheng Bai Zhu San, Ji Sheng Shen Qi Wan | |||
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Skin Rash or Eruption around Menses |
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| Differentiation |
Blood Deficiency |
Wind Heat in Blood |
| Skin Signs | Itchy, papular skin eruption during or after menses on limbs and body, worse at night | Itchy skin eruption during or before menses, worse with heat |
| Other Signs | Insomnia, dizziness, scanty periods, pale thin tongue, choppy or fine pulse | Irritability, dry mouth, red tongue with red spots, rapid pulse |
| Acupuncture | LU 7, KI 6, RN 4, SP 6, ST 36,LV8,LV11, SJ 6, GB 31, DU 14 | LI 11, DU 14, SJ 6, GB 31, UB 17, SP 10, LU 7, KI 6, SP 6, LV 8 |
| Herbs | Modified Dang Gui Yin Zi, Yang Xue Ding Feng Tang | Modified Fang Feng Tong Sheng San, Qin Jiao Niu Bang Wan |
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Emotional Changes around Menses |
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| Differentiation |
Heart Blood Deficiency |
Liver Qi Stagnation with Stagnant Fire |
Phlegm Obstruction |
| Emotional Signs | Sadness before, during or after menses | Anger or irritability before menstruation | Heavy sensation around head during menstruation, depression, irritability, moodiness |
| Other Signs | Palpitations, dizziness, insomnia, dream disturbed sleep, poor memory, anxiety, easily startled, dull pale complexion, pale lips, pale thin tongue, choppy or fine pulse | Tinnitus, deafness, temporal headache, dizziness, red face and eyes, thirst, bitter taste, dream disturbed sleep, constipation, dark yellow urine, nose bleeds, spitting blood, red tongue with redder sides, yellow dry coating, wiry rapid pulse | Chest oppression, lump in throat, difficulty swallowing, sighing, coughing phlegm, breast distention and pain, swollen tongue with a sticky coating, wiry and slippery pulse. |
| Acupuncture | UB 15, UB 18, UB 20, RN 17, RN 12, RN 6, RN 4 | PC 5, DU 26, SP 6,LV3, LI 4, KI 1 | DU 26, PC 6, DU 20, PC 5, SP 6, RN 12, ST 40 |
| Herbs | Modified Gan Mai Da Zao Tang + Bai Zi Yang Xin Tang | Modified Long Dan Xie Gan Tang | Modified Jia Wei Wen Dan Tang |
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Nose Bleeding or Spitting Blood around Menstruation |
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| Differentiation |
Liver Qi Stagnation with Fire |
Lung & Kidney Yin Deficiency |
| Bleeding Signs | Nose bleeding or spitting blood before or during period | Nose bleeding or spitting blood after menses |
| Other Signs | Heavy periods, red face, irritability, pre menstrual tension, feeling of heat, red eyes, thirst, red tongue sides, wiry rapid pulse | Scanty periods, dry throat, dry cough, night sweating, dizziness, tinnitus, 5 center heat, irregular periods, red tongue with no coating, fine rapid or floating empty pulse |
| Acupuncture | LV2, SP 4, PC 6, LI 11, SP 10, LU 6, LI 4, LU 5, LU 10 | LU 9, UB 13, LU 6, LI 4, RN 12, SP 6, KI 3, RN 4, KI 2, LI 11, SP 10 |
| Herbs | Qing Gan Yin Jing Tang, Shu Gan Jiang Ni Tang | Shun Jing Fang |
These symptoms may occur before, during or after periods and are generally associated with endometriosis according to Western Medicine. According to Chinese Medicine, this is generally due to a Chong Meridian pathology resulting in rebellious Qi.
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Mouth Ulcers around Menses |
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| Differentiation |
Kidney Yin Deficiency with Deficient Heat |
Stomach Fire or Stomach Damp Heat |
Stomach Damp Heat with Spleen Deficiency |
| Ulcer Signs | Tongue ulcers during or after menses | Mouth ulcers before or during period, foul breath | Mouth ulcers or cold sores around lips |
| Other Signs | 5 center heat, feeling of heat in the evening, night sweating, dizziness, tinnitus, dry mouth, red tongue with no coating, floating empty or fine rapid pulse | Thirst, dry stools, irritability, red tongue with yellow coating, over flowing pulse. | Abdominal distention, loose stools, tiredness, thirst, sticky taste, red tongue with sticky coating and teethmarks, slippery weak pulse |
| Acupuncture | KI 3, RN 4, LU 7, KI 6, HT 5, HT 6, KI 2, HT 8 | ST 44, LI 4, LI 11, RN 13, SP 4, PC 6, ST 25, SP 15 | SP 9, SP 6, UB 22, ST 44, ST 25, LI 11, ST 37, UB 20, RN 12 |
| Herbs | Yu Nu Jian + Dao Chi San | Lian Ge San | Gan Lu Xiao Du Yin |
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Dizziness around Menses |
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| Differentiation |
Blood Deficiency |
Kidney & Liver Yin Deficiency with Liver Yang Rising |
Phlegm with Spleen Qi Deficiency |
| Dizziness Signs | Dizziness during or after menses | Severe dizziness before or during menses | Severe dizziness before or during menses, feeling of fuzziness of heaviness of the head |
| Other Signs | Blurred vision, tingling limbs, poor memory, insomnia, scanty period, dull complexion, pale thin tongue, choppy pulse | Tinnitus, scanty menses, insomnia, mental restlessness, feeling of heat, malar flush, red tongue without coating, floating empty or fine rapid pulse | Excessive vaginal discharge, swelling of breasts before menses, sticky taste, swollen tongue with a sticky coating, slippery pulse |
| Acupuncture | LV8, ST 36, SP 6, RN 12, UB 20, UB 23, RN 4, DU 20 | RN 4, LU 7, KI 6, KI 3, SP 6, LV 8, GB 20, LI 4, LV 3, GB 13, DU 19 | RB 12, St 36, UB 20, ST 40, SP 9, SP 6, UB 22, RN 9, ST 8 |
| Herbs | Ba Zhen Tang | Qi Ju Di Huang Wan | Ban Xia Bai Zhu Tian Ma Tang |
This is a rather exhaustive list of premenstrual pathologies. When it comes to premenstrual syndromes, a Liver dysfunction is generally the root cause of the illness, often resulting in Liver Qi stagnation, Blood deficiency, Blood stasis, Spleen deficiency and/or Kidney deficiency. The most common formulas used include Xiao Yao San, Dan Zhi Xiao Yao San, Chai Hu Shu Gan San, Tong Xie Yao Fang, Qi Ju Di Huang Wan, Xiao Chai Hu Tang, Si Wu Tang, and Xue Fu Zhu Yu Tang. Herbs used include Chai Hu, Dang Gui, Shao Yao, Xiang Fu, Yu Jin, Qing Pi, Chen Pi, Mu Dan Pi, Zhi Zi, Sheng Di, Nu Zhen Zi, Tao Ren, Chuan Xiong, Bai Zhu and Fu Ling.
Prevention & Self Treatment
Liver Qi Stagnation is one of the best known pathologies in Chinese Medicine. It is most often associated with stress and emotional instability and in this day and age, especially when living in the city it can be difficult to not be stressed, from traffic to work and family obligations, pollution, and social media pressure, it is so easy to become stagnant. Here are a few tips:
- Exercise: getting your Blood and Qi moving regularly will help to combat any stagnation due to poor posture at work, emotional changes or stress. Be sure to let your liver ‘breathe’ by stretching out the ribcage and allowing proper blood flow to the organs.
- Diet: generally we recommend staying away from dairy and greasy foods since they are more difficult to digest and result in accumulations and toxins in the body. Instead, eating lots of leafy green vegetables is good for the Liver. It is important to at least slightly cook or steam veggies until they become bright. When food is cold and raw the stomach needs to warm and cook the food itself, requiring more energy. By cooking your food, you are effectively beginning the digestive process and conserving your own energy. For those with heat signs: avoid red meat, and spicy and spiced foods which will exacerbate symptoms and instead eat cooling foods such as veggies. For those with cold signs, heavily spiced foods should still be avoided, instead add ginger and making sure your dishes are warm or hot before eating is best. For those with deficiency signs, it is imperative to cook your food first, making it easier to digest. Eating foods like rice, potato, sweet potato and Chinese yam are excellent foods for balancing and promoting digestion and giving your body the energy it needs.
- Down Time: TAKE SOME TIME TO BREATHE! Have you ever noticed that when you start thinking or focusing hard on something, you stop breathing? Breathing not only nourishes our body with oxygen, it helps to circulate the blood, thereby removing accumulations and toxins. The physical act – the movement of the lungs and diaphragm – helps to massage the organs and ensure proper blood and energy flow. By taking the time, obviously the more the better – to breathe, whether you count 3 breaths or set a timer for 5, 10, or 30 minutes a day to focus on breathing, you are helping your body rebalance and ward off the stagnations that accumulate because of every day life. Take deep breaths into your lower abdomen to help move the diaphragm, take deep breaths into the chest to separate your intercostals spaces, and visualize deep breaths into your head to clear out thoughts. Every little cell in our body respirates and by taking the time to breathe and focus only on our breath we can help to soothe and calm a stressful life. Practices such as yoga, qi gong and visualizations or meditation focus on breathing and can help with those who are restless and have difficulty sitting still.
For any questions, concerns or would like more information, please contact us. We’d love to hear from you.
Caroline Prodoehl, D.Ac.
References
Maciocia, Giovanni, 2011. Obstetrics and Gynecology in Chinese Medicine, 2nd Ed. Churchill Livingstone,Philadelphia,PA.
Wang, Yuxiang (2010). Integrated Gynecology Course Notes. TorontoSchoolof Traditional Chinese Medicine.