Instructor: Dr. Daoshing Ni, Yo San University chair of Doctoral program in Women’s Health and Reproductive Medicine
Approved for CEU/PDA by:
NCCAOM Details: Core Competencies: AOM/Biomedicine: 1.5 PDA
California Acupuncture Board Details: California Category 1: 1.5 CEU
Treatment of Delayed and Irregular Menstruation
Welcome back to our integrative women’s health program and this course, today’s topic will be on Delayed Menstruation, again, delayed menstruation is one of the main conditions within the menstrual irregularities and there are many different reasons for it and
I’m going to start with a case, that is a typical case, that was presented by one of my master teacher dr. Wong . This is a 29 years old female, delayed menstruation for 14 years. she’s married and she’s been trying to get pregnant for two years. She menarched at 15 years old and in fact is basically since 15 years old her periods always been early and her period runs about three to five day flow. so it’s not too unusual and she has a 32-day to a 60-day cycle, fluctuating quite a bit. She also has used clomiphene citrate in the last three cycles, without being able to get pregnant. And the last period she had moderate amount of flow, the flow is bright red, there’s some clots, but not severely. There’s no pain, there’s really no significant breast tenderness, the tongue is dark red, the coating is somewhat yellow greasy in the middle, pulse is thin wiry, the pelvic exam is normal. Except the uterus is a little small. and so this is a kind of like a typical case in Asia, in China, where that a woman can have such delay cycles since menarche.
Now delayed menstruation refers to when menstruation is 7 or more days later than the usual periodical, and it occurs from two or more consecutive cycles. sometimes menstruation can be delayed up to six months, and if we look into our historical documentation in the classical tax such as Jin Gui Yao Lue, it says in the first definition it, defines the condition of delay menstruation in that, book and then Jing Yue Quan Shu, chapter treatment of heat in the blood causing delayed menstruation and later on in another textbook, the Nu Ke Qie Yao, it also talked about etiology of delayed menstruation as blood deficiency, coldness in the blood, and stasis conditions. So what are the known causes of delayed menstruation? well first of all you should always check for pregnancy. women can be pregnant, so that’s always the first thing you want to rule out. stress, strain, stress injury, trauma can all delay menstruation. major changes in weight, it could be weight-loss it could be even weight gain. a lot of time you could have delayed menstruation, or a sudden vigorous excessive exercise and activity can also cause weight change, and that in turn can cause changes in the menstrual cycle and cause delayed menstruation. thyroid irregularity. if there’s a thyroid dysfunction, that can cause a delayed menstruation. PCOS, polycystic ovarian syndrome patients can also have delayed menstruation. birth control pill usage – some people when you do a birth control pill usage could be that when you’re on the birth control pill you’re pretty normal but when you come off it you start to delay. so sometimes you can see that also chronic illness – people who have chronic illnesses Celiac disease can also delay menstruation, and some people who have premature menopause, their period starting to delay and delay and delay. and so those are kind of the possible risk factors for delayed menstruation in Chinese medicine.
There are basically five etiologies. basically, 3 deficiency etiology, and two excess type of etiology. First is kidney deficiency, second is blood deficiency, third is deficient cold, and then fourth is excessive Cold. And the fifth is Qi Stasis – Qi Stasis. if we look at closely into the situation of Kidney Qi deficiency we are looking at maybe over straining and excessive pregnancies such as miscarriages. this can all damage the kidney. when the kidney is damaged, kidney Qi is weakened, blood might be weakened, essence might be depleted. when they’re deficient this can actually delay the menstrual cycle. Or you could have spleen deficiency situation, where that there’s a lack of transformation of food essence and nutrients. and this name therefore is a nutritional disorder, this is where that if there are diseases or pregnancies, excessive pregnancy, or miscarriages, or abortions, this can cause quite a bit of loss of blood. and with that loss of blood the Yin blood is deficient ,therefore that periods going to be delayed, delayed. And then you might have emotional, emotional traumas, or emotional strain, that basically causes some Yang deficiency. And that the chronic deficiency can invite Cold congestions and that can also create this condition by causing delayed menstruation. so if we look at etiology of excess type of etiology, we are looking at exogenous cold invasion, excessive intake of cold foods. these cold pathogens can cause stagnancy of the blood. and when the blood flow is not so smooth it’s going to be sluggish and that’s going to cause delayed menstruation. Or that if you have chronic depression, and excessive worrying, stagnant Chi can cause stagnant blood again. that stagnancy blood the flow of blood is gonna be sluggish therefore the menstruation it’s going to be delayed, now let’s take a look at pathology. we have Kidney deficiency, we have blood deficiency, these two deficiencies can all cause basically essence and weakness of the blood. with that weakness we cannot nourish the Chong and Ren properly and when you cannot do that the sea of blood becomes empty. or now full on time, and when that occurs you’re gonna have delayed menstruation. you can have Qi stasis with a coldness in the blood. these two especially coldness in the blood – whether it’s deficient cold or excess cold, both can cause a delayed blood flow. the Qi stasis also causes delayed blood flow. in that delayed flow Chong and Ren become blocked. when Chong and Ren channels become blocked the sea of blood is not filled in time. it’s empty or partially filled and so the period will be delayed – period will be delayed. so in summary you’re gonna have etiology, you’re going to be having cold pathogen issues, you’re gonna have some emotional factors, and you’re gonna have some nutritional factors. and you’re gonna add into constitutional factors which we’re looking at some Kidney deficiencies, blood deficiencies, deficient cold, excess cold as well as the Qi stasis situation. and these five things either they cause depletion or weakness in the in the filling of the the Chong-Ren channel. or that you have basically blockage or sluggish flow of the sea of blood – the Chong and Ren channel – therefore you have delayed menstruation.
so the major symptoms: usually menstruation that is seven or more days late from two or three consecutive cycles. and some of the minor symptoms there may be changes in menstrual flow, amount, there may be changes in clots or cramp when you have a delayed menstruation. otherwise if you look at how the exam a lot of time it’s a normal ovary, normal uterus size. may be the uterus will appear a little smaller. and looking at the basal temperature chart, you’re going to have three scenarios. you’re gonna have a situation where there is a delayed ovulation, there’s gonna be a scenario of a normal ovulation time, and there’s gonna be the scenario where that there’s no ovulation at all. it’s monophasic throughout. and so those are three scenario you might see you might see when we’re differentiating. there are differences between delayed menstruation, early pregnancy, and pregnancy bleeding. obviously pregnancy, you know beta HCG will be positive, so that’,s we don’t consider that as a condition of delayed menstruation. Delayed menstruation is just a symptom here. Or pregnancy are bleeding you know a lot of times someone’s pregnant, and it’s delaying and you can have some normal bleeding, so always when you have delayed menstruation, always make sure that the patient is not pregnant. And before you embark on treatment – and especially intervening treatment – if you have to activate the blood ,might be a good idea to double check to make sure the patient’s not pregnant during this time. so in kidney deficiency situation: the color of the flow is going to be darker and pale it’s gonna be thin, viscous, and there’s gonna be sore back and week knee situation. in a blood deficiency you’re going to be lightheaded, you’re going to have vertigo you’re gonna have some palpitation situations. and in the deficiency cold situation you’re going to have some desire of warmth and you’re gonna have aversion to cold. and there may be some intermittent abdominal pain, and discomfort. and a lot of time the color of a menstrual flow is much more pale, much more watery and light. and when you have the excess type of cold conditions now you’re gonna have more abdominal cold type of pain and it’s gonna be more aversion to pressure and usually this situation besides that delayed menstruation, you can have more scanty menstruation. In the Qi stasis situation you’re gonna have more breast distension, more bloating and more abdominal distension, morning pain. and that’s basically some of the differences among these five syndromes. so basically in the treatment principle we want to tonify what is deficient, we want to sedate what is excess. so therefore in deficiency syndrome such as Kidney situation we want to tonify kidney. blood situation we want to nourish blood. when you have deficient cold we want to warm up the channel and nourish the blood. and in an excess syndrome we want to circulate Qi and relieve stagnancy. and if you have combination syndrome we want to try in a differentiate in the primary/secondary and treat both at the same time. and careful not to use very strong pungent and dry herbs and/or blood breaking herbs, especially for deficient cold conditions. so these five syndromes again: in summary. Kidney deficiency, blood deficiency, coldness in the blood basically deficient cold and excess cold and theses are the five major syndromes of delayed menstruation. So in Kidney deficiency we normally want to use Dan Gui Di Huang Yin. Which is a combination of Dan Gui, Shu Di, Shan Yao, Du Zhong, Niu Xi, Shan Zhu, Zhi Gan Cao. this formula is used for kidney deficiency and especially when you have lower back pains. and this comes out of complete work of Jing Yue, or what we call Jing Yue Quan Shu. and in particular this is what has been designed to be used for the kidney deficiency, lower back pain. and this herbal formula has been utilized in this particular condition of delayed menstruation due to kidney deficiency. so if there are combination symptoms of such as Lower Jiao deficiency, we can add some Ro Gui into the mix. if we are very strong deficient cold and we want to add some Fu Zi into the mix if we have a turbid leukorrhea then we should probably add Jin Ying Zi or Po Gu Zhi. if Qi is deficient we want to add Ren Shen and Gou Qi Zi into the mix. so now let’s go on to blood deficiency. Blood deficiency in delayed menstruation situation, usually can have more scanty pale red flow, thin flow, there might be pelvic intermittent ache, or vertigo palpitation, lack of sleep, pale face, sallow face, tongue is pale, pulse is thin weak in this situation. we want to tonify blood and Qi trying to regulate menstruation. so we want to try to use a formula called Da Bu Yuan Jian. Da Bu Yuan Jian is a combination of Ren Shen, Shan Yao, Shu Di, Du Zhong, Dang Gui, Shan Zhu Yu, Gou Qi Zi, Zhi Gan Cao. and so if this patient has a lack of appetite, or loose stools or, indigestion we can add some Bai Zhu, Bian Dou, as well as Sha Ren into the mix. now in a cold blood deficiency cold condition we’re going to have delayed menstruation, scanty flow, pale red or watery flow, thin flow. abdominal ache. liking warmth and pressure on the abdomen. sore back. fatigue. long clear urination. loose stool. usually tongue is going to be pale. coating is gonna be thin white and the pulse is gonna be delayed deep, or thin weak. so in this situation we want to assist yang, disperse cold and regulate menstruation. a perfect formula for this situation would be Wen Jing Tang coming out of Jin Kui Wen Jing Tang coming out of Jin Kui as you know the main herb in Jin Kui Wen Jing Tang is basically Wu Zhu Yu, an interior warming herb, a wonderful interior warming herb, So that’s Wu Zhu Yu, Dang Gui, Bai Shao, Chuan Xiong, Gui Zhi, Sheng Jiang, Dan Pi, Ban Xia, Mai Dong, Ren Shen, A Jiao, Gan Cao. Dan Pi, Ban Xia, Mai Dong, Ren Shen, A Jiao, Gan Cao. and if there’s a stronger coldness and aversion to cold we can add some Bu Gu Zhi, Ba Ji Tian, Xian Ling Pi into the mix. so let’s move forward to the blood excess type of cold condition. in this situation you’re going to have delayed menstruation, scanty flow, usually dark flow, they’re going to be some clots, there’s gonna be pelvic cold, pain aversion to pressure but better with warmth, aversion to cold cold extremities. we are going to have bluish white facial complexion, tongue is gonna be dark pale, coating is going to be white and pulse is going to be deep and tight. so we want to warm up the channel, disperse cold, and regulate menstruation in this situation. so the formula they use Wen Jing Tang again but this one coming from Liang Fang. basically it’s a combination of Dang Gui, Chuan Xiong, Bai Shao, Gui Zhi, Dan Pi, Er Zhu, Ren Shen, Gan Cao, Niu Xi. Very very different from Wen Jing Tang. So this is the Liang Fang Wen Jing Tang. if there is excessive menstrual flow, get rid of Er Zhu, Niu Xi, add Pao Jiang, and Ai Ye into the mix. next condition Qi stasis where you’re gonna have delayed menstruation, scanty or normal amount of flow, usually deep redh flow, with some moderate clots, there’s some pelvic, distending pain, depressive effect. there will be premenstrual breast tenderness and pain. tongue is pink or red, coating is thin white or a thin yellow, and pulse is wiry or wiry rapid. so in this situation we want to circulate Chi, relieve stasis and regular menstruation. so we will use Wu Yao Tang . it’s a very simple formula and there’s only a few herb basically ,Wu Yao, Xiang Fu, Mu Xiang, Dang Gui, Gan Cao. so if there’s a Scanty flow with clots, add Chuan Xiong, Dan Shen we can add some into the mix. now we’re going to be looking into acupuncture treatments with delayed menstruation. so in kidney deficiency we can use points such as bladder 23, governing vessel 4, kidney 3, conception vessel 4, stomach 36, spleen or with moxibustion. with blood deficiency can use conception vessel 6, CV 4, as well stomach 29, conception vessel 3, spleen 6 and stomach 36. again we can do tonification all with moxibustion. now in the cold in the blood deficiency, deficiency cold type, we can use conception vessel 4, 6 stomach 29, can do spleen 8, we can do spleen be very helpful. and again we can use Tonification methods or with moxibustion. now cold in the blood of a excess type we want to break things up a little bit we can still use the same points but this time we can add bladder the mix but our methos is not going to be tonification. now we’re gonna do more sedation method and we can still use moxibustion. For Qi Stasis situation we will spleen 4 pericardium 6, liver 3, spleen sedation method. and usually we don’t use moxa in this situation. we can also utilize auricular points such as ovary, such as uterus, such as kidney and endocrine points. we can embed it or we can needle ,or we can do some natural stimulation. So going back to the case we talked about on doctor Wang Zi of a twenty nine-year-old who has a delayed menstruation for fourteen years ,married and trying to get pregnant for two years. this is a case of a kidney deficiency with a delayed menstruation. a primary infertility since she’s never been pregnant before. So what Dr. Wong has decided to do was to tonify kidney, nourish blood, to replenish the essence, to facilitate pregnancy using a modified Si Wu Tang type of formula. so he will use Dan Gui, Dang Gui 10, Sheng Di 15, Shu Di 15, Chi Shao 10, Bai Shao 10, Chuan Xiong 10, Xu Duan 15, Tu Si Zi 30, Ba Ji Tian 10, Zi He Che 10, Zi Shi Ying 15, Ai Ye 3, Shan Yao 15, Shou Wu 15, Rou Gui 10. so you can see it was actually quite a bit of very strong kidney tonis as well as blood tonic into the mix. seven bags one bag daily and come back for more visit to have a minor modification. so after about seven visits she actually had a regular cycle and she actually achieved pregnancy. Dr. Wong is older now. he was born in 1921. he is the chief TCM physician OBGYN gynecologist. Hi is ob/gyn department in Dong Zhi Men hospital which is an affiliate a teaching hospital of Beijing University of TCM. He is very reputable for his work in menopause, dysmenorrhea, and endometriosis. and I’m fortunate to be able to learn from him. thank you very much for your attention to this talk and I look forward to see you next time. Welcome back today our topic is on irregular menstrual cycle and this is part of the integrative woman’s health program. a typical case – dr. Wang, Mian Zhi, a professor in China had presented a case of 32 year old, heavy irregular menstrual cycle for several years and along with that she also exhibits dizziness, restlessness, poor sleep, pelvis is cold to the touch there’s leukorrhea, her back is sore, chest tightness, there’s some hypochondriac tightness. She has used Chinese herbs focused on pacifying the liver, activating the blood. But there seems to be no relief. And to further aggravate the symptoms, while the cycle is still irregular, pulse is wiry, the left Cun position is small, the right Chi position is deep, the the tongue is pale, and the coating is white. thin white. so that’s kind of like a typical case of irregular menstrual cycle. frequently besides menstrual cycle irregularity, a lot of time you can see a lot of liver Qi stasis, Qi stasis symptoms. but in this case it doesn’t seem like the herbs that help to relieve Qi stasis work in this situation. so we’ll take a look at what Dr. Wang does in this case at the end of our session here. so the definition is that of irregular menstrual cycles: menstruation occurs either earlier or later than 7 days for two to three consecutive cycles. And from the classics, of Complete Book of Jing Yue – Jing Yue Quan Shu – we originally called this a deranged menstruation. and later on Fu Qing Zhu – Doctor Fu Qing Zhu’s Gynecology, he basically said that irregular menstruation is really due to liver kidney disharmony and stagnation and should use a formula called Ding Jing Tang to soothe Liver and Kidney Qi, to tonify Liver and Kidney Essence to treat this condition. So what are the known causes of irregular menstruation? irregular menstrual cycles, well it is similar to early menstruation, as well delayed menstruation. such as adolescence, uncontrolled diabetes, eating disorders, hypothyroid, hyperprolactinemia, medications such as anti epileptic drugs or anti-psychotic drugs, perimenopause or premature ovarian insufficiency, polycystic ovarian syndrome, even pregnancy itself can start to create an irregularity in that particular time and finally stress and travel. so if we look at the etiology you know the Chinese medicine is really big on emotional stagnation a lot of times when there’s emotional trauma or emotional stagnation, especially anger can injure the liver and when the liver is injured the liver Qi is deranged in that particular stage the patency flow starts to become dysfunctional and that can cause see of the blood dysfunction. so the flow is kind of weird and unstable. so we get this irregular cycle. then the other etiology is the Kidney Qi insufficiency and this could be chronic this could be constitutional and this could be major illnesses that cause injury to the kidney. and this is where you have weakened the kidney qi and when you have we continue to you’re gonna have dysfunction of regulation of Chong and Ren channel so the filling of the sea of blood is not stable – sometimes fills nicely sometimes doesn’t fill nicely so you’re gonna cause sea of blood dysfunction so these are the two main etiology in this condition. so again: emotional factors, constitutional factors, can all cause this liver qi stasisas well as Kidney qi deficiency. and one affects the patency flow and one affects the dysfunction in storage and both ause Chong Ren irregularity, sea of blood irregularity, and this causes irregular menstrual cycle. so the diagnosis: a definition of irregular cycle is basically when it is early or delayed, greater than seven days, and three consecutive cycles, and menstrual flow can be normal in this situation and uterus can be normal size or may be slightly smaller. and there could be other symptoms and if this is something that’s been going on for a while, we need to take a look at whether or not there are causes that we are not seeing. now if you have your regular menstrual cycle that’s only a few days apart that may not be too much of an issue but when you start talking about seven days apart there is definitely some dysfunction here that we need to take a look at. so we need to differentiate between liver stasis and kidney deficiency, and a combination of liver stasis and kidney deficiency. in liver stasis, the blood flow quantity may be more or less dark flow, and frequently or with clots, there is usually a dominant distension, and bloating, there’s chest distension and the pulse is usually wiry. in kidney deficiency, the quantity is usually less, there’s pailful or minimal clots, lower lower back soreness, and the tongue is usually pale, the pulse is usually thin and weak . and in a combination syndrome, this is where the quantity can be more or less dark or pale flow or with clots there’s usually a dominant chest distension, hypochondria distension, lower back pain, pulse is wiry and thin. so the treatment: in liver Chi stasis, we want to circulate chi pacify liver and regulate menstruation. In kidney deficiency , we want to tonify kidney and regulate menstruation. in a combination syndrome liver stasis and kidney deficiency, we want to pacify liver, tonify kidney and regulate menstruation. so if we look at the herbal treatment for liver stasis usually we would use Xiao Yao San as a base. so you might want to use this particular formula or modify such to treat this condition. Xiao Yao San, as you know, is a combination of Chai Hu, Dang Gui, Bai Shao, Bai Zhu, Fu Ling, Bo He, Sheng Jiang. A very widely used formula. if you have menstrual clots, you may want to add add Dan Shen, Yi Mu Cao, Xiang Fu, and Yuan Hu into the mix in the kidney deficiency situation we may want to use a formula such as Gu Yin Jian. and Gu Yin Jian is a combination of Tu Si Zi, Shu Di Shan Zhu Yu, Ren Shen, Shan Yao, Zhi Gan Cao, Wu Wei Zi, Yuan Zhi. and you can add Du Zhong and Xu Duan if there is stronger or more severe lower back pain. now in a combination syndrome we usually would use doctor Fu Qingzhu’s very famous formula called Ding Jing Tang. this is a formula pacifying liver and any sometimes strengthens the liver and the kidney Yin essence. 8 herbs, a beautiful well composed formula to this day many physicians, TCM, OBGYN professionals love to Dr. Fu Qingzhu’s formula, and it is actually very important as professionals to really read his book. His formulas are small in quantity, and this formula does work very well. This formula, Ding Jing Tang, is composed of – Chai Du, Jing Jie, Dang Gui, Bai Shao, Shan Yao, Fu Ling, Tu Si Zi, Shu Di. so you have basically its – Chai Du, Jing Jie, Dang Gui, Bai Shao, pacifying the liver then you have the Shan Yao, Fu Ling, Tu Si Zi, Shu Di helping to strengthen the kidney, Fu Ling there kind of helps to strengthen the spleen – Tu Si Zi, Shu Di obviously for the kidney. so it’s a wonderful formula. put together for this combination syndrome of liver stasis and kidney deficiency. now it’s very important to focus on the other management guidance. focus on other things such as emotional management, a lot of times there’s some emotional component. so we need to counsel the patient and look at how we can help the patient to become more emotionally stable. second we need to also look at a stress level take a look at what we can do took guide and counsel our patients to manage their stress better, give them proper tools, give them proper techniques that they can learn to manage their own stress. and reduce stress. and also try to find the source of stress, and try to see if we can eliminate that. third is sleep. sleep really helps one to recover so we want to take a look at how the patient is sleeping and also look at a sleep hygiene and whether or not this patient has proper sleep on a regular basis. and we can also focus on eliminating or reducing time zone change in travel. I have a patient that has irregular menstrual cycle because she travels excessively, especially going across time zones. and that can throw your circadian rhythm off, and your endocrine system off, and that can cause a lot of irregularities. so in summary in Liver Qi stasis we want to use Xia Yao San, in Kidney Deficiency we want to use Gu Yin Jian, in combination syndrome of liver stasis/kidney deficiency you want to use Ding Jing Tang. So let’s look at the acupuncture treatments. in the liver stasis we can use bladder 18, liver 14, conception vessel 3, liver 3, spleen 6. and we will use a sedation method in this situation. now in kidney deficiency, we want to use conception 6, spleen 6, bladder 23, bladder 20, stomach 36, kidney 8. and we want to use tonification method or even with moxibustion. now if we have a combination syndrome we can mix and match some of these points. I personally like to use conception vessel 6, liver 3, conception vessel 3, spleen 6, stomach an even method in an acupuncture technique. so going back to this case of irregular menstrual cycle by Dr. Wang, a 32 year old, irregular menstrual cycle for several years, she exhibits dizziness, restlessness, poor sleep, pelvic cold to the touch leukorrhea, sore back, chest tightness, hypochondriac tightness. She has used Chinese herbs focused on pacifying liver, activating blood, with no relief except for the aggravation of these symptoms. , pulse wiry, left Cun small, right Chi deep, tongue is pale, coating white. obviously if you look at this, definitely this is not just a liver qi stasis. it’s probably a combination syndrome of the liver and the kidney issue, as well as a blood deficiency issue . so doctor Wang diagnosed this patient as a blood deficiency liver stasis. and he believed that in this situation blood deficiency is the cause and liver stasis is the manifestation. so while this patient has been using only liver circulating, pacifying herbs – this does not help because the cause was never treated. in fact these herbs make the condition worse. so what he wanted to do in this situation was to nourish blood as the primary treatment principle, and regulate liver would be kind of like in itself still under primary but mostly secondary under the main treatment. In the second treatment he wanted to also strengthen the spleen and warm up the kidney. so in his formulation he devised a formula of Sheng Di, Dang Gui, Chi Bai Shao, Chai Hu , Chuan Lian Zi, Bai Zhu , Fu Ling , Suan Zao Ren , Zhi Yuan Zhi , Chen Pi , Xian Ling Pi , Hong Hua , Du Zhong , Dan Pi. so you can see there are some kidney tonics there’s some stuff to strengthen spleen, there’s a lot of stuff that circulates Qi pacifying liver but also strengthen the blood. seven bags, one pack each daily. On the second visit patient comes back: the dizziness is decreased, sleep is better, there’s less chest and hypochondria distension, emotions are better, less leukorrhea, pulse is softer and less wiry, tongue coating root is peeled, and liver stasis is decreased, but the yin blood is still deficient. The mother of liver is kidney, therefore he decided , we call it Yi Gui Tong Yuan . he decided that that’s get rid of the Hong Hua, Yuan Zhi, Chen Pi, and Du Zhong. then add more Kidney tonic in there: Shu Di , Gou Qi Zi , Huai Niu Xi , Dang Shen , Zhi Xiang Fu, Sheng Jiang into the mix. so he prescribed ten packs of tea for her, one pack every day. And when she came back, her condition company recovered, her period became completely regular, and her symptoms were gone. Dr. Wang, Mian Zhi unfortunately is not not with us today. He was born in practitioner of TCM in his family. An extraordinary educator, in fact if you note our formula books in Chinese as well some is translated into English were written by this this particular professor Dr. Wang, Mian Zhi. Very reputable, especially his focus and his strength has been differentiation of syndrome, and and many kinds of writing in in formulations. so thank you very much for spending time with me today on the irregular menstrual cycle and I look forward to see you next time