An Acupuncture Prescription Suggested for Treating Primary Dysmenorrhea

Primary dysmenorrhea (PM) is the issue that needs attention because most of the women during reproductive age are affected with it, causing discomfort in daily life. Acupuncture has been seen as an alternative therapy and been considered “essential health benefits” in the western countries with more and more popularity, which has confirmed TCM and acupuncture effective as Western medications for PM. However, all the TCM and acupuncture must follow pattern identification for the best results.


Introduction
"free flow" of Qi and Blood is disrupted. The relationship therefore between Qi and Blood can be determined to be interpromoting, interdependent, and intertransforming [7]. The circulation of Qi and Blood depends on the correct, interdependent functioning of Zang-Fu organs, involving in Lung, Heart, Liver, Spleen, Kidney, and San Jiao as shown in Table 1. The Liver Qi keeps Qi circulate in the all parts of the body, connecting to the Spleen and promoting the digestion functions to produce Blood [6]. Mechanisms in the disorder of Qi and Blood include external factors like Wind and Heat, emotional disturbance, bad diet and physic trauma, and improper exertion in activities, such as sex or excessive study [8]. In addition to the discussion about the relation between Qi and Blood, one of the important functions of Blood in TCM is moistening and nourishing the skin, muscles, sinews, bones and internal organs, which is closely related to pain when Qi malfunctions.

Treatments of Western Medicine for Pain in Dysmenorrhea
In the pathological perspective of Western medicine, the pathogenesis of primary dysmenorrhea may have much to do with elevated levels of prostaglandins in response to the rise and fall of progesterone, which can occur after ovulation. Lysosomes in the endometrial cells break down and release phospholipase A 2, which converts cell membrane fatty acids into arachidonic acid as progesterone production decreases by the corpus luteum.
The excessive elevation of prostaglandins leads to uterine hypercontractility, painful cramping and other nausea, vomiting, and diarrhea symptoms that are prostaglandin-related. Contractions Heat therapy is also reported to be beneficial to pain relief, particularly with NSAIDs, such as ibuprofen, ketoprofen, mefenamic acid, naproxen, and cyclooxygenase (COX) -2 inhibitor celecoxib3.
Laparoscopy is performed when conservative pharmacological management has failed. Pharmaceuticals used for relieving pain include nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, ibuprofen, and mefenamic acid. Cyclooxygenase (COX)-2 inhibitor is considered the first-line reactive treatment with the use of hormonal modulation; for example, oral contraceptive pills.
However, NSAIDSs can be associated with significant side effects, causing gastrointestinal symptoms like nausea and indigestion. It is also pointed out that NSAIDs are associated with higher risk of headache, dizziness, drowsiness, and dry mouth than placebo [11].
The result of relieving pain of a study shows that acupuncture therapy of the TCM can relieve pain in the patients with dysmenorrhea, promoting Qi and Blood circulation [12]. Whether or not the efficacy of acupuncture is better than other interventions is also confirmed with the conclusion that "Acupuncture was as effective as NSAID therapy for patients with primary dysmenorrhea." In this study, Group 1 received NSAIDs and group 2 received acupuncture care. The result shows that one month later the NSAID group showed a 52.2% decrease in dysmenorrhea related pain, but the acupuncture group demonstrated a 69.5% decrease in dysmenorrhea related pain [13]. In terms of the use of TCM herbs for dysmenorrhea, pattern identification plays a key role which can affect the treatments. It is presented in Table 2 that the most common patterns in Taiwan are Liver blood deficiency, Liver qi stagnation, and Blood stasis, highlighting the importance of Liver in this health issue [14]. In the TCM theories, Liver Qi is the key to the treatment of dysmenorrhea with the functions of regulating Blood and dispersing stagnated Qi. However, Liver Qi is easily stagnated with the emotional stimulation like anger, frustration, resentment, stress, etc. In addition to Liver, causative factors are Qi and Blood Deficiency, and Liver and Kidney Deficiency of Essence [5]. The general principle of treatment of dysmenorrhea is to regulate

Open Acc J Comp & Alt Med
Qi and Blood in the Penetrating and Directing Vessels. Acupoints suggested for the acupuncture treatment are shown in Table 3.

ST-36 & SP-9
To activate Spleen and Stomach to reinforce the Blood.

SP-6
To activate the Spleen and tonify the Blood.

KD-3 & CV-6
To tonify the Kidney to reinforce KD Qi and regulate menstruation.

SP-6
To tonify three Yin channels of the foot.

KD-10
To regulate the menstruation and clears Deficient-Heat.

Discussion
The Zang (臟)-Fu (腑) theory, the Five Elements theory and and analgesia in primary dysmenorrhea [14]. Acute pain can be mostly driven by central mechanisms while persistent pain is also largely driven by peripheral mechanisms. It is also suggested that there could not specific pathological factors in both primary and secondary dysmenorrhea. However, it is assumed contractions of the uterus that expel menstrual uterine constituents produce high-intensity stimuli. The sensitization or activation of uterine afferent neurons could be produced by the production of various  Blood circulation benefits the tissues to fight with inflammation.
Inflammation, to a certain extent, is viewed as obstruction which can gradually cause Qi in Liver and Kidney and Blood Deficiency from the aspect of the TCM [6]. It is confirmed and agreed the stimulation at the acupoints with acupuncture could increase blood flow velocity of the peripheral arterioles and oxygenated hemoglobin to modulate the blood circulation of the body surface. As blood circulation increased in the affected areas, proinflammatory response decreased with regulation of inflammation process and growth factors [15,16]. The role of acupuncture in stimulating immune function, including increasing blood cell count containing hemoglobin and enhancing lymphocyte and natural killer cell activity, has been confirmed [16].
Hemoglobin in blood cell binds to either oxygen or carbon dioxide. This binding allows oxygen to be transported around our body to our tissues and organs, and carbon dioxide to be taken away. However, the number of hemoglobin relies on the functions of Kidney in the TCM and the Western medicine [16]. The literature of oxygen metabolism, the theory of meridians, and Qi in the meridians highlights that both Qi and oxygen have informational, material, and functional features, and bear high similarity in physiological functions and pathological reactions [17]. One of the functions of the kidney is to set the hematocrit at a normal value of 45% to maximize oxygen delivery [18]. The rising formation of red blood cells, which are promoted by the hormone Erythropoietin (EPO) produced by the kidney, increases the oxygen-carrying capacity of the blood. However, it is stated that the production of Erythropoietin is determined by tissue oxygen pressure. In other words, the kidney is closely connected to the oxygen circulation [18,19]. This statement highlights the functions of Kidney in the TCM. Kidney qi, to some extent, can be viewed as blood oxygen [1]. Qi, a vague term, is one of the important concepts in the TCM that cannot be defined well and exactly in the Western medicine, but it can nourish the tissues and help digestion and absorption to produce Essence in the theory of the TCM as long as Qi can flow freely [20,21]. Blood circulation increases when Qi is circulating within the body smoothly, which is verified by the conclusion of a study that the blood circulation level increased with acupuncture treatment, which corresponds to the function of Qi in the TCM that Qi can move Blood to relieve the pain as shown in Figure 1 [17,18].
In terms of gynecologic complaints, including dysmenorrhea, Dong quai is the most popular herb with Chinese and has been used commonly in TCM formulas with the TCM diagnoses of "blood stasis" and "blood vacuity," associated with the diagnoses of amenorrhea, dysmenorrhea, uterine fibroids, and endometriosis