The menstrual cycle in Chinese medicine is understood as a dynamic movement of Yin and Yang, Qi and Blood, unfolding through distinct physiological phases.
Rather than viewing menstruation as a single event, classical gynaecology recognizes the cycle as an evolving process in which treatment principles may shift according to timing, movement, nourishment and transformation.
In this article, Giovanni explores the four phases of the menstrual cycle and how patterns may be interpreted — and addressed — throughout each phase in clinical practice.
The Ebb and Flow of Yin and Yang
Menstrual blood is not like “ordinary” Blood in Chinese medicine. In other words, the “Blood” that nourishes the eyes and the sinews is not the same as menstrual blood. Menstrual blood is a direct manifestation of the Kidney-Essence equivalent to sperm in men. Menstrual Blood is called Tian Gui which could be translated as “Heavenly Dew” although the character Gui actually refers to the 10th Stem that pertains to Water.
The association with Water is not casual as menstrual Blood is part of Water and derives from the Yin part of the Kidneys. The great gynaecologist of the Qing dynasty Fu Qing Zhu often stressed this, saying that not by chance menstrual blood is called Jing Shui (“Period Water”).
The menstrual cycle is like a tide of Yin and Yang: the “water” of this tide is the substance of the Kidneys in their Yin and Yang aspects. Therefore, it is the ebb and flow of Kidney-Yin and Kidney-Yang that determines the menstrual cycle. The menstrual cycle goes through two moments of transformation of Yin to Yang and vice versa: the onset of the period marks the maximum of Yang and the transformation from Yang to Yin while the onset of ovulation marks the maximum of Yin and the transformation of Yin to Yang.
This transformation, together with the discharge of menstrual blood and the eggs, is under the control of the Heart whose Qi needs to go down to communicate with the Kidneys. See Figure 1.
Figure 1. The Uterus
The Four Phases of the Menstrual Cycle
The menstrual cycle may be divided into four phases as follows:
1. the period itself lasting approximately 5 days
2. the post-menstrual phase of about 1 week
3. the inter-menstrual phase of about 1 week
4. the pre-menstrual phase also lasting approximately 1 week.
The following is a description of the physiology of each phase with the relevant treatment principle.
Phase 1 – The Period
During the period, Blood moves and both Qi and Blood move downwards. During the period, expelling the “old” (i.e. old Blood) is important: if not enough “old” expelled, this could lead to “retention of menses”. Most people pay attention to excessive bleeding but scanty bleeding may lead to “retention of menses” and Blood Stasis.
Just before the beginning of the period, Yang is at its maximum and it rapidly decreases with the onset of the period. It is a moment of transformation from Yang to Yin.
Pre- menstrual symptoms are often due to Heat and the reason they rapidly disappear with the onset of the period is precisely because Yang decreases rapidly as soon as the period starts.
Treatment principle: invigorate Blood. If bleeding is heavy, invigorate Blood and stop bleeding.
Phase 2 – The Post-Menstrual Phase
This lasts for approximately 1 week starting from the end of the period. At this time, Blood and Yin are relatively empty but Yin is beginning to rise. The rapid decrease of Yang that takes place with the onset of the period ensures the growth of Yin (mutual consuming of Yin and Yang). This phase is therefore an important crossroads of Yin and Yang and it influences the whole menstrual cycle.
Growth of Yin also implies growth of fluids which are manifested by the clear, egg-white-like vaginal secretion that occurs before ovulation.
The post-menstrual phase is crucial to establish a regular cycle. It is therefore important to support during this phase to establish the foundations for a good menstrual cycle.
Treatment principle: nourish Blood, tonify the Kidneys.
Phase 3 – The Inter-Menstrual Phase (ovulation)
During the third phase, the Chong Mai and Ren Mai are in full activity and they promote ovulation. In this phase, Yin reaches its maximum and Yang starts to grow rapidly. It is a moment of transformation from Yin to Yang. Qi and Blood are active in this phase: this is similar to the activity of Qi and Blood during the period except that during the former phase there is an upward movement of Qi and Blood and during the latter a downward movement. This upward movement affects the Heart and Liver channels often with Heat.
During the third phase, physiological activity is concentrated on the lateral abdomen (Shao Fu) while during the period it is concentrated on the central abdomen (Xiao Fu).
During the third phase there is an increase in fluids and there should be a transparent, egg-white- like vaginal secretion immediately before ovulation. This should last at least 3 days. An absence of such secretion indicates a Kidney Deficiency even in the absence of any Kidney symptom.
Treatment principle: tonify the Kidneys, strengthen the Spleen, resolve Dampness.
Phase 4 – The Pre-Menstrual Phase
During the fourth phase, Yang reaches its maximum and Qi moves. Yin decreases to allow growth of Yang (mutual consumption of Yin and Yang). The decrease of Yin and growth of Yang during this phase is comparable to the increase of Yang and decrease of Yin during the second phase but it is more significant.
Growth of Yang implies that there is warmth in the Uterus at this time. Cold in the Uterus may interfere with fertilization. As this is a time of maximum Yang, Yin pathogenic factors affect the Uterus especially at this time as they rely on Yang to be dispersed.
Examples of Yin pathogenic factors are Blood Stasis, Phlegm, Cold and Dampness. Endometriosis and polycystic ovary are characterized by Yin pathogenic factors (Blood Stasis and Damp-Phlegm) and therefore emphasis may be placed on supporting Yang and facilitating the movement and transformation of these pathogenic influences.
Treatment principle: move Qi, stimulate the free flow of Liver-Qi, invigorate Blood, warm the Uterus.
See Figures 2 and 3.
Figure 2. The ebb and flow of Yin and Yang throughout the menstrual cycle.
Figure 3. The four phases of the menstrual cycle and their physiological characteristics.
Adapting the Treatment Principle to the Four Phases
Adapting the treatment principles to the four phases is crucial in addressing gynaecological problems.
By adapting the treatment principle to the four phases, the approach may be more effective when it follows the natural rhythm of women’s physiology and the ebb and flow of Yin and Yang in the menstrual cycle. Adapting the treatment principle to the four phases is particularly useful in complex gynaecological conditions when 2, 3 or even 4 different formulas are used.
In practice, treatment principles may shift throughout the cycle according to both the phase and the predominant pattern.
The following examples illustrate this principle with patterns of increasing complexity.
Clinical Formula Strategies
The following examples are provided to illustrate how treatment principles may be adapted according to the phase of the menstrual cycle and the underlying pattern. Formula selection should always be based on pattern differentiation and individual clinical assessment.
Liver-Qi Stagnation
Let us assume that a woman presents with the pattern of Liver-Qi Stagnation and no other pattern. Where Liver-Qi Stagnation has been identified as the predominant pattern, Freeing Constraint may be considered. The optimal time to administer this formula is during the pre-menstrual phase, approximately one week before the onset of the period, when Qi is moving and Yang is approaching its maximum.
There would be little point in administering this formula during the post-menstrual phase because, at that time, Blood is relatively empty. As Blood is the mother of Qi, moving Qi at this stage would have little effect.
Blood Stasis
Where Blood Stasis has been identified as the predominant pattern, Stir Field of Elixir may be considered during Phase 1. When this formula is selected, it is generally administered in Phase 1, i.e. during the period because at this time the Blood is already moving. However, the formula could be started a few days before the period. Again, there would be not much point in giving this formula after the period when Blood is relatively empty: at such a time, the formula would have little effect. If the period is heavy, we can still invigorate Blood in phase 1 but we may instead consider Invigorate Blood and Stem the Flow according to the individual’s presentation.
Liver-Qi Stagnation with Liver-Blood Deficiency
Let us assume a woman presents with Liver-Qi Stagnation occurring against a background of Liver-Blood Deficiency. Where these patterns have been identified, Freeing the Moon may be considered during the pre-menstrual phase and Precious Sea during the post-menstrual phase (possibly extending into Phase 3). This is a combination and timing that I use frequently in clinical practice.
Liver-Blood Stasis and Kidney Deficiency
Liver-Blood Stasis and Kidney Deficiency occur simultaneously very frequently: these patterns may present with painful and/or irregular periods.
Unicorn Pearl or Growing Jade may be considered, depending on whether the predominant pattern is Kidney-Yang or Kidney-Yin Deficiency, to be taken during phases 2 and 3, and Stir Field of Elixir may be considered during phases 4 and 1. If the period is heavy, we can still invigorate Blood in phase 1 but we may consider replacing Stir Field of Elixir with Invigorate Blood and Stem the Flow.
Liver-Qi Stagnation, Liver-Blood Stasis, Kidney Deficiency
For these three patterns we may consider Freeing the Moon (or Freeing Constraint) during phase 4, Stir Field of Elixir during phase 1 (or Invigorate Blood and Stem the Flow if the period is heavy), and Unicorn Pearl or Growing Jade (according to whether there is Kidney-Yang or Kidney-Yin Deficiency respectively) during phases 2 and 3.
Liver-Blood Stasis, Liver-Blood Deficiency
Stir Field of Elixir may be considered during phases 4 and 1 (or Invigorate Blood and Stem the Flow where heavy menstrual bleeding forms part of the presentation and the appropriate pattern has been identified) and Precious Sea may be considered during phase 2.
Liver-Blood Stasis, Kidney-Yang Deficiency, Dampness
Stir Field of Elixir may be considered during phases 4 and 1 (or Invigorate Blood and Stem the Flow where heavy menstrual bleeding forms part of the presentation), Unicorn Pearl may be considered during phases 2 and 3, and Clear the Palace may be considered during phases 3 and 4.
Liver-Blood Stasis, Kidney-Yang Deficiency, Dampness, Spleen-Qi Deficiency
Stir Field of Elixir during phases 4 and 1 (or Invigorate Blood and Stem the Flow if appropriate), Unicorn Pearl may be considered during phases 2 and 3 and Clear the Palace during phases 3 and 4 (tonify the Spleen with acupuncture).
Liver-Blood Deficiency, Dampness, Kidney Deficiency
Precious Sea may be considered during phase 2, Clear the Palace during phases 3 and 4, Unicorn Pearl or Growing Jade (according to whether there is Kidney-Yang or Kidney-Yin Deficiency respectively) during phases 2 and 3.
Understanding Patterns Across the Cycle
In clinical practice, patterns are rarely static throughout the month.
The timing of symptoms is often as important as the symptoms themselves.
Premenstrual symptoms may reflect constraint or Heat, while post-menstrual symptoms may reveal underlying Blood or Yin Deficiency.
Understanding when symptoms arise within the cycle often provides important insight into the underlying mechanism.
Clinical Reflections
Understanding the menstrual cycle through the four phases provides a more dynamic approach to gynaecology in Chinese medicine.
By recognizing how physiology and pathology evolve throughout the cycle, practitioners may develop a more precise and phase-specific clinical approach. As always, treatment principles and formula selection should be guided by pattern differentiation and tailored to the individual.
This framework becomes particularly valuable in complex or chronic presentations, where patterns shift over time and treatment principles must adapt accordingly.
Written by Giovanni Maciocia®
Further Study and Clinical Resources
For a deeper understanding of these patterns in clinical practice:
– Explore the Beng Lou presentation (70+ pages)
– Explore the Gynaecology in Chinese Medicine 1: Women’s Physiology course (15 CEUs)
– Explore the Gynaecology in Chinese Medicine 2: Women’s Pathology course (15 CEUs)