Case study: Irregular menstruation
Female, 35 yrs
First consultation: 2017-12-4
Main complaint: Irregular menstruation for several years. Only 4 menstruation came this year until now which were 5/11, 30/8, 24/7, 30/5. In the past more than ten years, menstruation came every 3-4 months.
LMP:5/11, medium volume, clot(+), distending breast (++), was on “treatment” for more than 3 months, haven’t seen any improvement so far.
Currently: Irregular menstruation, cold fingers, constipation easily, sleep well, appetite normal. Pale tongue, thin white coating, slippery pulse.
Diagnosis: Delay menstruation due to Kidney Yang deficiency
Prescription: 1. Avoid raw or cold food/ drinks
Formula: Danggui10g Chishao10 Guizhi10 Wuzhuyu 10
Chuanxiong10 danpi10 Shudi15 Shanyao10
Xiangfu10 Ganjiang10 *28 days
Second consultation: 2018-1-18
Main complaint: LMP13/1,2018，until now (Today is the 6th day), medium volume, dark red, clot(++), distending breast (+-), still cold fingers, constipation better than before. Sleep well, normal appetite. Red tongue with teeth marks,thin white coating, slippery pulse.
Prescription: Nv zhen zi 10 Gouqi 10 were added to the previous formula *35 days.
Third consultation: 2018-3-4
Main complaint: 26/2,2018，until now (Today is the 6th day), medium volume, clot(+), distending breast (-), cold fingers better than before (not as cold as before), no constipation. The breasts didn’t feel distending at all.Red tongue with thin coating, slippery pulse.
Prescription: Same as 2018-1-18 *35 days.
In this case, the patient suffer from irregular menstruation, pale tongue with teeth marks, thin white coating. The diagnosis of Delay menstruation due to Kidney Yang deficiency can be made. The formula was focus on warming up the Kidney Yang. After the treatment, menstruation came in time for two cycles. The medicine was applied for another section.