When most people think of a harmonizing formula for the treatment of qi stagnation painful menstruation, they usually think of Xiao Yao San (Rambling Powder), not Xiao Chai Hu Tang (Minor Bupleurum Decoction). However, when Xiao Chai Hu Tang is appropriately modified, it can be a very useful formula for many women with dysmenorrhea and is a base formula I commonly use for this purpose. In issue #7, 2003 of

Jiang Xi Zhong Yi Ya (Jiangxi Chinese Medicine & Medicinals), Xie Hui-ming and Liu Feng-lan published an article titled, "The Treatment of 38 Cases of Qi Stagnation & Blood Stasis Pattern Painful Menstruation with Xiao Chai Hu Tang Jia Jian (Minor Bupleurum Decoction with Additions & Subtractions)." This art i c l e appeared on page 36 of that journal. Because it exemplifies this often overlooked use of this famous formula, a summary of this article is presented below.

Among the 38 women in this group, 31 were unmarried and seven were married. The oldest was 30 and the youngest was 15 years old. The longest course of disease was five years and the shortest was three months. Criteria of pattern discrimination were based on Zhong Yi Bing Zheng Zhen Duan Liao Xiao Biao Sun (Criteria for the Chinese Medical Diagnosis, Treatment & Outcomes of Diseases & Patterns). The main symptoms were premenstrual or menstrual lower abdominal distention and pain refusing pressure possibly accompanied by breast and rib-side distention and pain and scanty menstruation which did not flow smoothly or easily and which was purple and black in color and contained clots. After these clots were precipitated, the pain diminished. The tongue was purple and dark or had static spots, while the pulse was deep and bowstring and/or choppy.

Xiao Chai Hu Tang Jia Jian consisted of: Radix Bupleuri (Chai Hu), 12g, Radix Scutellariae Baicalensis (Huang Qin), Radix Codonopsitis Pilosulae (Dang Shen), Rhizoma Pinelliae Ternatae (Ban Xia), Radix Ligustici Wallichii (Chuan Xiong), and Radix Angelicae Sinensis (Dang Gui), 10g each, blast-fried Rhizoma Zingiberis Officinalis (Pao Jiang), 3g, and Radix Glycyrrhizae Uralensis (Gan Cao), 6g. If pain was severe, Semen Pruni Persicae (Tao Ren), Radix Cyathulae Officinalis (Chuan Niu Xi), and possibly Shi Xiao San (Loose a Smile Powder) were added. If there was flank and rib-side distention and pain, Fructus Meliae Toosendam (Chuian Lian Zi) and Rhizoma Cory d a l i s Yanhusuo (Yan Hu Suo) were added. If there was l ower abdominal distention and pain, Radix Linderae Strychnifoliae (Wu Yao) and Rhizoma Cyperi Rotundi (Xiang Fu) were added. If there was also upper back distention and pain, Radix Linderae Strychnifoliae (Wu Yao) and Radix Et Rhizoma Notopterygii (Qiang Huo) were added. If there was breast distention, Fru c t u s G e rminatus Hordei Vu l garis (Mai Ya) , Pericarpium Citri Reticulatae Viride (Qign Pi), Fructus Liquidambaris Taiwaniae ( Lu Lu Tong), and Fructus Meliae Toosendam (Chuan Lian Zi) were added. If this was severe and accompanied by nodular, hard lumps and aching and pain, then Squama Mantidis Pentadactylis (Chuan Shan Jia) and Semen Vaccariae Segetalis (Wang Bu Liu Xing) were added. If there was accompanying lumbosacral pain, Cort ex Eucommiae Ulmoidis (Du Zhong) and Radix Achyranthis Bidentatae (Huai Niu Xi) were added. If there was insidious pain with a yellow facial complexion and lack of strength, the amounts of Dang Shen and Dang Gui were doubled and Caulis Milletiae Seu Spatholobi (Ji Xue Te n g) wa s added. If there was chilly pain, Ramulus Cinnamomi Cassiae (Gui Zhi), Fo l i u m Artemisiae Argyii (Ai Ye), and Radix ateralis Praeparatus Aconiti Carmichaeli (Fu Zi) were added and Huang Qin was reduced. If there was heat pain, Radix Salviae Miltiorrhizae (D a n S h e n), Cort ex Radicis Moutan (Dan Pi) , uncooked Radix Rehmanniae Glutinosae (Sheng Di), and Radix Rubrus Paeoniae Lactiflorae (Chi Shao) were added and Pao Jiang was deleted. These medicinals were started one week before the start of menstruation. Five packets were administered continuously, one packet per day decocted in water and administered in two divided doses. After this, the medicinals were stopped. This was done one time each menstrual cycle for three cycles.

Twenty-five women out of 38 in this study were judged cured. This meant that their pain disappeared and did not return within three menstrual cycles after stopping these medicinals. Another 11 patients were judged improved. This meant that there pain decreased or disappeared. However, if it disappeared, it returned within three menstrual cycles after stopping these medicinals. Only two patients got no eff e c t . Therefore, the total effectiveness rate was listed as 94.7%.

Xiao Chai Hu Tang is a harmonizing formula which harmonizes the liver and spleen as well as the liver and stomach. Because of its wide scope of application, it is one of the most commonly prescribed formulas in Chinese medicine. As Drs. Xie and Liu correctly point out, qi stagnation and blood stasis pattern of painful menstruation is closely related to the liver channel and has to do with the liver's governing coursing and discharge as well as its command over the regulation and easing of the qi mechanism. If the liver channel become depressed and stagnant, the qi mechanism will not flow easily or smoothly. This results in the movement of the qi and blood suffering obstruction. Hence the menstrual flow is not able to be smoothly and easily precipitated. Because the liver channel traverses the lower abdomen, this lack of free flow leads to pain. However, because of the close reciprocal relationship between the liver and spleen, when nthe liver becomes depressed and, therefore, replete, the spleen typically becomes vacuous and weak. Because the spleen is the latter heaven root of qi and blood engenderment and transformation, this results in insufficient blood to nourish the liver, especially during the premenstruum and menstrual period itself when blood is first sent downward to the uterus and then is precipitated. This leaves the liver malnourished and incapable of performing its duty of governing coursing and d i s c h a rge. Because the qi moves the bl o o d, enduring qi stagnation eventually evolves into blood stasis. Further, because the spleen governs the movement and transformation of water fluids, spleen vacuity often leads to damp accumulation. Because fluids and blood move together and either can obstruct and hinder the free flow of qi, damp accumulation leads to worsening of both qi stagnation and blood stasis. And finally, enduring liver depression often transforms heat.

When appropriately modified with additions and subtractions, Xiao Chai Hu Tang treats all of the above disease mechanisms and it can treat all the various evolved patterns of dysmenorrhea, such as cold congelation, heat stasis, and hot and cold, vacuity and repletion painful menstruation. I think Drs. Xie and Liu's modifications of this famous formula are quite good and merit close study by anyone thinking to use this formula for the treatment of dysmenorrhea. My own experience in clinic using this formula for this condition corroborates Dr. Xie and Liu's outcomes. If one thinks only or even primarily of this formula as a defensive and constructive harmonizing formula, they will have missed its much larger scope of application. Based on the prevalence of a liver-spleen-stomach disharmony in clinical practice, Xiao Chai Hu Tang is rightly one of the most commonly used formulas in Chinese medicine, and it is also one of the most effective.