Treatment Principle: Nourish blood and soften the liver, clear heat and drain dampness. Prescription: Danggui Shaoyao San with modifications.

Symptoms: Before or during menstruation, pain or distension in the lower abdomen with a burning sensation, or pain radiating to the lumbosacral region, or persistent lower abdominal pain that worsens before menstruation, heavy menstrual flow or prolonged menstruation, dark red color, thick consistency or presence of clots; abundant vaginal discharge with yellow, thick, foul-smelling discharge, or accompanied by yellowish-red urine; red tongue, yellow and greasy coating, and slippery or moist pulse. Treatment Principle: Nourish blood and soften the liver, clear heat and drain dampness. Prescription: Danggui Shaoyao San with modifications. Angelica 10g, Peony 15g, Ligusticum 6g, Poria 12g, Alisma 10g, Atractylodes 10g, Moutan Bark 6g, Coptis 6g, Peach Kernel 10g, Safflower 6g. If the menstrual blood contains clots, consider adding Typha Pollen and Five Spirit Resin; for lower back pain, add Eucommia, Achyranthes, Dipsacus, and Taxillus; for excessive vaginal discharge, add Dioscorea, Chinese Yam, Phellodendron, and Plantago. 7. Analysis of Prescriptions Used by Professor Pei Zhengxue Shaofu Zhuyu Tang, recorded in “Yilin Gaicuo” compiled by the renowned late Qing physician Wang Qingren, is a classic prescription for treating cold-induced blood stasis-type dysmenorrhea. Professor Pei Zhengxue often uses this formula as a base, making adjustments according to the specific syndrome, to treat various gynecological diseases caused by cold invading the Chong and Ren channels and obstructing the flow of qi and blood, such as delayed menstruation, amenorrhea, and infertility due to cold in the uterus, among others. This formula is a derivative of Siwu Tang, composed of fennel, Five Spirit Resin, Angelica, Ligusticum, Red Peony, Cinnamon, Myrrh, Typha Pollen, Corydalis, and Dried Ginger. Among these ingredients, fennel is the mature fruit of the Umbelliferae plant anise, with a pungent-warm nature, entering the liver, kidney, spleen, and stomach meridians, classified as a warming herb, with effects of regulating qi and harmonizing the middle jiao, dispelling cold and relieving pain, used to treat cold invasion causing lower abdominal cold pain, dysmenorrhea, cold abdominal pain, and testicular discomfort; also applicable to cases of spleen-stomach deficiency-cold with qi stagnation in the middle jiao. Cinnamon is pungent-sweet and highly warming, entering the spleen, kidney, and liver meridians, with effects of tonifying fire and supporting yang, dispelling cold and relieving pain, warming the meridians and promoting blood circulation, guiding fire back to its origin, used to treat cold-damp stagnation-related amenorrhea and dysmenorrhea. Dried Ginger is also a warming herb, pungent and hot, entering the spleen, stomach, lung, and kidney meridians, warming the middle jiao and dispersing cold, while also retaining heat and promoting blood circulation, warming the lungs and transforming fluids, effective in treating cold-deficiency-related lower abdominal cold pain and vomiting. These three herbs, when used together, enter the liver and kidney meridians and also affect the spleen, enhancing the effect of warming the meridians and relieving pain, as well as facilitating the flow of qi to the lower jiao. Angelica is a sacred herb for replenishing blood, pungent-sweet-warm, entering the liver, heart, and spleen meridians, with a light and pungent nature, its function being to replenish blood, regulate menstruation, and activate blood circulation to relieve pain, thus serving as a key drug for activating blood and regulating qi, both regulating menstruation and relieving pain, commonly used in gynecological clinical practice. Ligusticum is a blood-activating and stasis-resolving drug, pungent-warm, entering the liver, gallbladder, and pericardium meridians, with effects of activating blood circulation, removing wind, and relieving pain, mainly treating blood stasis and qi stagnation, hence its nickname "blood-qi medicine." Corydalis is also a blood-activating and stasis-resolving drug, pungent-bitter-warm, entering the liver, spleen, and heart meridians, as stated in “Compendium of Materia Medica”: “It can resolve blood stasis… blood stasis in qi… therefore it specializes in treating all kinds of pain throughout the body.” It is the top-ranking drug for activating blood and resolving qi stagnation, treating various pains caused by qi stagnation and blood stasis. Myrrh enters the spleen meridians, pungent-bitter-neutral, with a fragrant and dispersing aroma, suitable for treating qi stagnation and blood stasis, especially for dispersing blood and resolving stasis, also having the effect of reducing swelling and promoting tissue regeneration, useful for treating injuries from falls and surgical wounds. Five Spirit Resin is bitter-salty-sweet-warm, entering the liver meridians, classified as a blood-activating and stasis-resolving drug, clinically often used to treat various types of pain caused by stasis. Red Peony is bitter-mildly cold, entering the liver meridians, with effects of clearing heat and cooling blood, activating blood circulation and resolving stasis, classified as a heat-clearing and blood-cooling drug. Typha Pollen is sweet-neutral, entering the liver and pericardium meridians, classified as a stasis-resolving and hemostatic drug, entering the blood meridians, good at dealing with blood stasis, and when these herbs are combined in one formula, they have the effect of warming the meridians, dispersing cold, activating blood circulation, and relieving pain, eliminating cold and blood stasis, allowing the condition to resolve itself, representing a typical prescription for treating gynecological diseases caused by blood stasis obstruction. Danggui Shaoyao San was first recorded in “Jin Gui Yao Lue.” This formula uses Angelica, White Peony, and Ligusticum to nourish blood and regulate the liver, activating blood without being too aggressive, replenishing blood without causing stagnation; Atractylodes, Poria, and Alisma supplement the spleen and drain dampness, strengthening the spleen without hindering dampness, promoting water metabolism without harming the spleen, incorporating nourishment within drainage; Poria and Alisma are sweet and bland, draining dampness, preventing the spleen from being overwhelmed by damp evil; Angelica and Ligusticum activate blood circulation, keeping the blood flowing smoothly, collectively embodying the principles of nourishing blood and regulating the liver, supplementing the spleen and eliminating dampness. Professor Pei Zhengxue believes that the heavy use of White Peony in this formula is not only for nourishing blood but more importantly for calming the liver and relieving pain. The flavors of this formula are gentle, balancing supplementation and drainage, and with adjustments, it is suitable for both cold and heat, deficiency and excess. Modern pharmacological animal experiments have proven that Angelica has a dual effect on the uterus: its alcohol-soluble, non-volatile substances stimulate isolated uterine contractions, while its high-boiling-point volatile substances inhibit isolated uterine contractions, causing relaxation. White Peony relaxes and inhibits the movement of uterine smooth muscle; Ligusticum stimulates uterine smooth muscle contractions, strengthening them. When Angelica, White Peony, and Ligusticum work together, they can regulate uterine function, and with White Peony and Ligusticum having obvious sedative effects, Angelica also has some sedative efficacy, which may be the main reason why this formula can relieve dysmenorrhea. 8. Case Examples Example: A 27-year-old unmarried woman. On November 25, 2019, she presented with “lower abdominal pain during menstruation for more than ten years, worsening for half a year.” She had her first menstruation at age 15, with regular cycles of 29–31 days, lasting 7–8 days, with relatively heavy, dark red, thick menstrual flow. Every time before or during menstruation, she experienced burning pain in the lower abdomen, relieved by warmth, occasionally accompanied by nausea and low back pain. Her last menstrual period was from October 30 to November 5, 2019. Currently, she feels a burning sensation in the lower abdomen, with abundant, yellow, thick vaginal discharge, yellowish-red urine, decent sleep, a preference for spicy and stimulating foods, and sticky stools. Her tongue is red, with a yellow, greasy coating, and her pulse is slippery and rapid. She has no prior medical history. Gynecological ultrasound showed: uterus size 4.9 cm × 4.2 cm × 3.9 cm, uterus in horizontal position, no obvious abnormalities in bilateral adnexa. 【Western Medical Diagnosis】Dysmenorrhea (Damp-Heat Accumulation Type). [Treatment Principle] Clear heat and drain dampness, transform blood stasis to relieve pain. Angelica 10g, Peony 15g, Ligusticum 6g, Poria 12g, Alisma 10g, Atractylodes 10g, Moutan Bark 6g, Coptis 6g, Peach Kernel 10g, Safflower 6g. Decoction to be taken warm. Started medication on the day of consultation, continued until the fourth day of menstruation, and kept taking it after menstruation ended. Avoided spicy and stimulating foods, and refrained from strenuous exercise during menstruation. Second Consultation: December 14, 2014. Menstruation came on November 30, with heavy, dark, clotted menstrual flow, slight relief of lower abdominal pain, still experiencing low back pain, thirst and desire to drink, reduced vaginal discharge compared to before, paler yellow color, improved bowel movements, red tongue, yellow, greasy coating, and slippery pulse. Added Taxillus 10g, Dipsacus 10g, and Scutellaria 10g. Ten doses, decocted and taken warm. Started taking medication ten days before menstruation, continued until the second to fourth day of menstruation, advised to stop if menstrual flow becomes heavy, and resume after menstruation ends. Third Consultation: February 1, 2015. Menstruation came on January 27, with no abdominal pain during menstruation, normal menstrual flow and quality, occasional low back pain, rosy complexion. Tongue slightly red, coating thin and white, pulse slightly slippery. Continued taking the same prescription, ten doses, decocted and taken. Follow-up three months later, dysmenorrhea did not recur, and all symptoms resolved. 9. Ancient and Modern Physicians’ Discussions on Dysmenorrhea Ancient physicians’ understanding of dysmenorrhea first appeared in Zhang Zhongjing’s “Jin Gui Yao Lue · Discussion on Miscellaneous Diseases in Women and Their Pulse Diagnosis and Treatment” during the Eastern Han Dynasty: “If vaginal discharge is obstructed and there is fullness and pain in the lower abdomen, and menstruation recurs monthly, Tu Guagen Powder should be used.” This was the first time the pathogenesis of dysmenorrhea caused by blood stasis and the corresponding treatment prescription were proposed. By the Sui Dynasty, Chao Yuanfang’s “Discussions on the Causes and Symptoms of Various Diseases · Miscellaneous Diseases in Women · Symptoms of Abdominal Pain During Menstruation” argued: “When women experience abdominal pain during menstruation, it is due to exhaustion of qi and blood, leading to physical weakness, exposure to cold wind, which invades the uterine channels, damaging the Chong and Ren meridians... The menstrual blood becomes deficient and exposed to cold wind, so when menstruation approaches, qi and blood are stirred by the cold wind, and the cold wind collides with qi and blood, causing pain.” This was the first time the cause of dysmenorrhea was identified as cold wind invading the Chong and Ren meridians. During the Song Dynasty, Chen Ziming believed that cold pathogens could cause dysmenorrhea, as recorded in “Complete Collection of Good Remedies for Women · Chapter on Regulating Menstruation”: “Women experience abdominal pain during menstruation because cold wind invades the uterine channels and Chong and Ren...” Later, “General Record of Sacred Healing · Abdominal Pain During Menstruation in Virgins” also described: “When virgins experience abdominal pain during menstruation, it is because Tian Gui has just arrived, the Yingwei system is not yet balanced, the mind is restless, and cold wind occasionally invades, causing blood and qi to fail to flow smoothly, leading to menstrual blood getting stuck in the umbilical region, like a stabbing pain.” This indicated that dysmenorrhea was caused by cold invasion, and further analyzed that adolescent girls all lacked qi, and the poor circulation of qi and blood led to stagnation in the Chong and Ren channels, resulting in pain due to obstruction. “Danxi Xinfa · Chapter on Women” built upon previous summaries and further elaborated: “Pain caused by menstrual blood coming too early is due to heat within deficiency, hence the pain; pain caused by menstrual blood coming too late is due to blood being too real, sometimes qi stagnation. When the waist and abdomen ache before menstruation, it is due to stagnation...” This proposed the nature of dysmenorrhea, with pre-menstrual symptoms mostly being excess and post-menstrual symptoms mostly being deficiency. During the Ming Dynasty, Zhang Jingyue pointed out in “Complete Works of Jingyue · Regulations for Women · Abdominal Pain During Menstruation”: “Abdominal pain during menstruation has both deficiency and excess, with excess cases caused by cold stagnation, blood stagnation, qi stagnation, or heat stagnation; deficiency cases caused by blood deficiency, qi deficiency...” He pointed out that both external and internal factors could trigger dysmenorrhea. During the Qing Dynasty, “Fu Qingzhu’s Gynecology” provided an extremely detailed discussion on dysmenorrhea, stating in the text: “Three to five days before menstrual blood arrives, pain appears in the lower abdomen... this is due to the conflict between cold and dampness in the lower jiao.” “Menstrual blood comes and goes suddenly, sometimes painful, sometimes not... this is due to the liver qi not being comfortable.” “Abdominal pain several days before menstruation... this is due to extreme heat and the fire not being transformed! The liver belongs to wood, which contains fire; when it is relaxed, it flows smoothly, but when it is blocked, it doesn’t flow.” “Lower abdominal pain after menstruation is due to the kidney qi being hollow.” He believed that cold dampness, qi stagnation, and kidney deficiency were the causes of dysmenorrhea. Notably, “Medical Canon · Essential Principles of Gynecology” not only explained the causes and pathogenesis of dysmenorrhea,

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