Differentiating and Treating Gynecological Diseases based on the Theory of Collateral Diseases

XUE Bing (薛 冰), REN Jie (任 潔), YAN Ying (閆 穎), WU Lin-ling (吳林玲),HA Hong (哈 虹), ZHANG Han (張 晗)

Department of Gynecology, The First Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300381, China

ABSTRA CT The collateral disease theory is a unique component of the theoretical system of traditional Chinese medicine (TCM), which is currently applied to all kinds of diseases related to the collaterals. With the in-depth study of collaterals theory by many practitioners, its advantages in differentiating and treating gynecological diseases are gradually embodied. Based on the theory of collaterals disease, we discussed the pathogenesis, syndrome differentiation and treatment of gynecological diseases, concluded that the deficient collaterals under nourishment and the stagnant and blocked uterine collateral are the important pathogenesis of gynecological illness. Then we pointed out that invigorating the spleen and tonifying the kidney, and unblocking collateral and dissipating stasis are important treatment methods. We discussed the application of collateral disease theory in Tianjin HA's gynecology, and provided certain theoretical basis and clinical reference for the treatment of gynecologic diseases.

KEYWORDS Collateral disease theory; Gynecological diseases; Etiology and pathogenesis; Syndrome differentiation treatment; Tianjin HA's gynecology

The collaterals have four major characteristics of "shallow, deep, end, and network" in structure.They are the unity of micro-level structure and function[1]. It is not only the hub through which Qi (氣), blood and body fluids pass, but also a bridge between the body and the outside. The uterine collateral is an important branch. There are conditions when the deficient collaterals fail to nurture the uterus, or the uterine collaterals are stagnant and blocked to form coagulation, which results in a variety of gynecological diseases.Therefore, it is of great significance to explore the application and laws of collateral disease theory in gynecological diseases.

ORIGIN AND DEVELOPMENT OF COLLATERAL DISEASE THEORY

The formation and development of the collateral disease theory has gone through a long historical period. It started in theHuangdi's Internal Classic(《黃帝內(nèi)經(jīng)》), and became detailed in theSynopsis of the Golden Chamber(《金匱要略》),developed after the Han dynasty, matured in the Ming and Qing dynasties, and enriched in modern times. It is currently combined with the western medicine and vigorously used clinically[2].

Huangdi's Internal Classic(《黃帝內(nèi)經(jīng)》)first proposed the concept of "meridians" and"collaterals", and subdivided the collaterals into major collaterals, superficial collaterals and tertiary collaterals. In this classic, it put forward that the collaterals originate from meridians and run through the whole body, and they play the role in perfusion of blood and Qi, mutual infiltration of body fluid and blood, and unblocking the flow between the nutrient Qi and defensive Qi. The record of "For the chronic diseases, the pathogenic Qi deepens" first pointed out the development trend of chronic illness involving deeper inside. In terms of treatment,Huangdi's Internal Classicstates that the key of collateral diseases is "unblocking", such as "collateral pricking and bleeding" "contralateral collateral needling", and"collateral moxibustion" etc..

The first chapter ofSynopsis of the Golden Chamber,Diseases of the Zang-Fu Organs,Meridian and Collaterals-Sequence, Pulses and Patterns(《臟腑經(jīng)絡(luò)先后病脈篇》) focuses on the sequential pathological development "pathogenic factors attack meridians first and then affect the Zang-fu organs". The book has detailed descriptions of the pathogenesis of collateral diseases and their symptoms. For example, wind, cold, dampness,heat and other external pathogens entering the collaterals, and conflicting the Qi and blood in the collaterals, can cause the blockage of collaterals and then the arthropathy with pain in all joints, or the accumulation and retention of phlegm in the chest collaterals results in blockage of the chest collaterals, or the blocked Qi and blood flow in collaterals cause the stasis and stagnancy, in the form of distension due to the liver disorder and anemic asthenia etc.. The book correspondingly proposed the method of resolving phlegm and unblocking collaterals, unblocking collaterals with the pungent and dispersing, insects and ants removing stasis to unblock collateral, and Qi promoting and blood activating to unblock collateral et al. The representative formulas are Biejia Jian Pill(鱉甲煎丸), Dahuang Zhechong Pill (大黃蟄蟲丸),Xuanfuhua Decoction (旋覆花湯), Di Dang Decoction(抵當(dāng)湯), Xia Yuxue Decoction (下瘀血湯) and Tuguagen Powder (土瓜根散) etc.. ZHANG Zhongjing mostly used medicinal with pungent flavor, such asRamulus Cinnamomi, Bulbus Allii Macrostemonis,ginger, wine, etc., whichever has the effect of dispersing and unblocking the collaterals. When applying the potent prescription of insects and ants removing stasis to unblock collaterals, Zhongjing's prescription mostly used honey-made pills in order to weaken the effect, which aimed to activate the collateral without hurting the healthy Qi, and expel the pathogenic Qi without causing weakness.

Physicians in Sui and Tang dynasties discussed the pathogenesis of collateral diseases in more detail, and kept a large number of collateral disease formulas. There were many researches on medicinal for promoting blood circulation and dredging collaterals and prescriptions for warming and dredging collaterals. SUN Si-miao in the Tang dynasty retained a large number of empirical prescriptions for treating chest arthralgia,precordial pain, and stroke inEssential Recipes for Emergent Use Worth A Thousand Gold(《備急千金要方》), and most of the prescriptions used were with effects of unblocking collaterals by medicinal pungent in flavor and warm in nature. In the Tang Dynasty, WANG Tao'sArcane Essentials from the Imperial Library(《外臺秘要》) also developed the pathogenesis and treatment of collaterals and vessel illness. It not only continued using medicinal with warming in nature and pungent flavor includingRamulus Cinnamomi,Radix Aconiti Lateralis Preparata,Fructus Evodiae, etc., but also usedRadix Aucklandiae,Flos Caryophylli,Moschusand other aromatic medicine warm in nature with effect of unblocking. During the Song, Jin and Yuan dynasties, there were more abundant study and discussion in the syndrome differentiation and etiology of chest arthralgia and precordial pain. The extensive use of blood circulation to remove blood stasis and warming and unblocking with aromatic medicinal were the two characteristics of the therapy for chest arthralgia and precordial pain.

The Ming and Qing dynasties were a critical period for the maturity of the collateral disease theory. At the beginning of the Qing dynasty, YU Jia-yan further divided the collaterals on the basis of theHuangdi's Internal Classic, and advocated the use of stone needling to puncture the collaterals and orally take collateral-unblocking medicine to treat the evil settling in the collaterals. YE Tianshi pioneered the theory of "lingering sickness intruding into the collaterals" and "lingering pain intruding into the collaterals", made a master summary and development of the ancient theory of collateral diseases, and put forward the idea that the treatment of meridians and collaterals should be differentiated, i.e. potent method for the excess syndrome with difference in unblocking collaterals by medicine with pungent flavor combined with moistening, or combined with medicine in warm nature or aromatic medicine, or by using insects and ants; supplement the deficiency syndrome with difference in unblocking collaterals by nourishing Qi, or by medicine with pungent and sweet flavors and warm in nature, or by nourishing Yin (陰) and tonifying; if there is disharmony of collateral Qi,the treatment of harmonizing collaterals could be realized by directing Qi downwards or replenishing Qi and governing blood. Clinical treatments are often complemented with medicine supplementing liver and kidney, or blood and flesh products, which are intended to dredge the collaterals without hurting the healthy Qi, and provide treatment targeting its pathogenesis. WANG Qing-ren conducted in-depth research on human anatomy,further clarified the relationship between collateral diseases and blood stasis, elaborated on Qi deficiency leading to stasis, and established the method of invigorating Qi, activating blood and dredging collaterals, which is another breakthrough in collateral disease after ZHANG Zhong-jing and YE Tian-shi.

Modern practitioners combined the collateral disease theory with the understanding of vascular disease in modern medicine to explain cardiovascular and cerebrovascular diseases from a deeper level. ZHANG Xi-chun attached great importance to the role of Qi in the human body. He often treated collateral diseases by tonifying Qi and activating blood.Radix Astragali seu Hedysariwas his first choice to replenish Qi. He also used one or two fromRadix Codonopsis,Rhizoma Atractylodis MacrocephalaeandRhizoma Dioscoreae,etc. to assist the effect ofRadix Astragali seu Hedysari. He liked to useOlibanumandMyrrha,Rhizoma SparganiiandRhizoma Curcumaeetc.. Zhang also combined the rise and fall of the Qi movement in traditional Chinese medicine(TCM) with the understanding of cerebrovascular disease in modern medicine, which deepened the understanding of cerebrovascular disease in TCM, and also contributed to the study of collateral disease.

Contemporary physicians believe that collateral disease is not a simple disease, but a pathological state that is widespread in difficult and misuterineaneous internal injuries and severe exogenous diseases. Professor WU Yi-ling proposed a "three-dimensional network system" based on the collateral disease theory[3], introduced the concept of collateral spatial hierarchy and combined the three parts of the human body together, respectively the exterior, the middle and the interior. Wu used the theory of collateral disease to guide the research on the prevention and treatment of vascular disease, and proposed the network concepts of"vessel collateral-vascular system disease" and"Qi collateral-Nerve-Endocrine-Immunity (NEI)",which provided ideas for guiding the prevention and treatment of vascular disease. In addition,WU[4]believed that Liana medicinal for dredging collaterals, such asCaulis Trachelospermi,Caulis Spatholobi, etc. are entangled and spread like a network, in similar shape with collateral vessels,and could be used for the condition of pathogenic Qi intruding into the collaterals in obstinate diseases;insect medicine such asHirudo,Eupolyphaga Seu Steleophaga,ScorpioandScolopendraetc, are flowing in nature and they could expel evils and clear collaterals.

DISORDERS OF THE UTERINE COLLATERAL SYSTEM ARE THE KEY PATHOGENESIS OF GYNECOLOGICAL DISEASES

Uterine collaterals are subordinate to collaterals, which in a narrow sense refers to "the divergence on the uterus", that is, bilateral oviducts,and broadly refers to the collaterals distributed in the uterus, ovaries, and oviducts and their subdivided branches.Huangdi's Internal Classicstated that "If there is disorder in Chong meridian...women would have gynecologic abdominal lumps", which firstly clarified the correlation between collaterals and gynecological diseases.

The uterine collateral has the functions of circulating the meridian Qi throughout the body and permeating blood throughout the body. The uterus is also related to the "menstruation, leukorrhea, fetus,and birth" of women and is one of the important organs. The uterine collateral forms a circulation pathway network in the uterus, so that the Qi and blood generated from the Zang-fu organs enter the thoroughfare vessel, conception vessel, and governor vessel through the twelve meridians and then diffuse to the uterus from the collaterals. Qi and blood are the material basis for the uterine collateral to perform their functions. If the Qi and blood in the collaterals are vigorous and the transportation and perfusion is normal, the uterus is nourished. If the pathogenic Qi invades uterine collaterals, the abnormal flow, transportation and perfusion of Qi,blood and body fluid in the collaterals, and blockage in the collaterals or abnormal perfusion would occur, which results in uterine collateral stagnation,heat toxin stagnation, accumulation in collateral,stasis, blockage, dysfunction and damage in uterine collateral, deficient collaterals under nourishment and other different pathological changes. Therefore,the uterine collaterals as the hub of the Zangfu organs, meridians and uterus have special significance in the etiology and pathogenesis of gynecological diseases.

Deficient Collaterals Under Nourishment Is the Root of Disease

Qi and blood are the material basis for the physiological activities of the viscera and meridians.Probably due to congenital insufficiency, or overwork or disease overconsumption, women could suffer spleen and kidney dysfunction,imbalance of thoroughfare vessel and conception vessel, or insufficient Qi and blood generation and transformation, which can lead to collateral deficiency and undernourishment, and then trigger irregular menstruation, uterine bleeding,amenorrhea, leukorrhea diseases and infertility etc.YE Tian-shi said that "collateral deficiency causes pain", and collateral deficiency can also cause symptoms such as dysmenorrhea, dizziness during menstruation, abdominal pain during pregnancy,excessive fetal movement, and retarded growth of the fetus.

Stasis and Blockage of Uterine Collaterals Is an Important Pathogenesis

All blood thickness, stickiness, or in poor flow due to coagulation are classified as "stasis". The etiology and pathogenesis of gynecological diseases are complex and diverse. Internal injury caused by excess of seven emotions can lead to depression of the Qi movement and blood stasis; careless health preservation during menstruation or postpartum,or unclean sexual intercourse could cause the invasion of cold, heat, dampness, turbidity, and uterine collateral stasis occur; or it congregate with the pathogenic Qi and form stasis, stay stagnant in the collaterals, and lead to the uterine circulatory disorder and then the blocked collaterals can cause pain, abdominal mass, bleeding, etc., the uterine vessel and collaterals could be directly damaged by surgery or trauma, and Qi and blood becomes imbalance and the stasis lingers, or blood overflows out of the vessels, and blood stasis causes blockage internally. Although there are many causes of blood stasis, it always coexists with "Qi stagnation".The movement of Qi leads to blood circulation,and stagnation of Qi leads to blood stasis. The two interact and act as cause and effect. The collateral stasis will build up for a long time, and it will block the collaterals, then Qi and blood will not run smoothly, and the thoroughfare vessel and conception vessel will be imbalanced, and therefore the blockage causes pain and menstrual disorders occur.

TONIFYING DEFICIENCY AND UNBLOCKING COLLATERALS, AND THERAPY AIMING AT BOTH UNBLOCKING AND TONIFYING ARE IMPORTANT TREATMENT PRINCIPLES

ZHANG Cong-zheng said: "In the book ofHuangdi's Internal Classic, the circulation of Qi and blood is the most important", and there are such expositions as "treatment should be focused on blood for collateral diseases" and "all diseases could be treated by unblocking method". YE Tian-shi inherited the spirit of theHuangdi's Internal Classicand proposed that "unblocking the blood vessel,attacking strongholds, and assisting with medicine in pungent flavor is the main method to treat collateral diseases." Since ancient times, "treating the collaterals by unblocking" has been the basic principle of treating collateral diseases. The uterine collateral stasis is an important pathogenesis of gynecological diseases. Therefore, the "collaterals unblocking method" should be used throughout its treatment. However, collateral deficiency and under nourishment, and uterine collateral stasis are the key to treating gynecological diseases from collateral disease theory. Therefore, in terms of treatment,tonifying deficiency and dredging collaterals should be combined with activating blood circulation to remove blood stasis as a more comprehensive treatment plan.

Fortify the Spleen and Tonify the Kidney to Strengthen the Uterine Collaterals

To fortify the kidney, the Yin and Yang should be emphasized simultaneously. The Yin and Yang in the kidney inter-dependent and interact with each other. Yang matched with adequate Yin makes living things freely growing and flourishing,and Yin matched with sufficient Yang makes living things fully vivid. The relative equilibrium of Yin-Yang will guarantee the kidneys' normal reproductive function.Radix Rehmanniae Preparatais commonly used to tonify the essence and blood,Rhizoma Drynariae,Radix Morindae OfficinalisandRadix Dipsaci Asperoidisare used to nourish the Yang in the kidney, andHerba TaxilliandRadix Cyathulaeto nourish the kidney Qi. Tonifying the kidney should also be synchronized between the congenital and the acquired. The essence of nutrient from foodstuff transported and transformed by the spleen and the stomach and the essence transformed and generated in the physical activity of viscera are stored in the kidney. The essence and blood are of the same origin. Therefore, products for strengthening the spleen, nourishing Qi, and nourishing blood should be added while invigorating the kidney, such asRadix Astragali seu Hedysari,Radix Pseudostellariae,Rhizoma Atractylodis Macrocephalae Poria,Radix Angelicae Sinensis,etc. in order to use the acquired essence to nourish the congenital essence.

Unblocking Collaterals and Resolving Stasis to Uninhibit the Uterine Collaterals

Unblocking collaterals is not limited to the application of activating blood and removing blood stasis drugs. The medications can be divided into unblocking collaterals by medicinal with pungent flavor, by insects and ants, by liana, and unblocking and tonifying for collateral deficiency. YE Tianshi emphasized that "the collaterals could be discharge by pungent flavor". The pungent medicine is spicy and flowing and can promote movement and disperse. The more commonly used methods are unblocking collaterals by pungent flavor and moistening and by pungent and salty flavor. In unblocking collaterals by pungent flavor and moistening, commonly used medicinal areSemen Persicae,Flos Carthami,Cortex Moutan Radicis,Radix Paeoniae Rubra,Herba Lycopi,Lignum Dalbergiae Odoriferae,Xinjiang,Rhizoma Corydalis,etc.. Unblocking collaterals by pungent and salty flavor mostly uses insect medicine, such asFaeces Togopteri,Carapax Trionycis,Concha Ostreaeand so on. At the same time, with the waning and waxing of Yin and Yang in the female menstrual cycle, the method of dredging collaterals also changes. During the premenstrual period, the sea of blood gradually fills up and the Yang Qi grows. The treatment focuses on regulating Qi, removing blood stasis and dredging the collaterals, so that the Yang grows and the Yin is filled, and the Yin and Yang are in balance.In the menstruation period, the focus is on promoting blood circulation and removing blood stasis,dredging collaterals and relieving pain to promote the transformation of Yin and Yang, dredging Qi and blood. In the later period of menstruation, the blood sea is empty, so the treatment for this period should emphasize nourishing Qi and tonifying the kidney,and activating blood to unblock collaterals.

APPLICATION OF COLLATERAL DISEASE THEORY TO GYNECOLOGICAL DISEASES

The pathogenesis of collateral diseases is generally divided into three aspects: "collateral vessel blockage" "collateral vessel emptiness" and"collateral vessel injury". The collateral body is narrow and easy to form stasis. In addition, collateral emptiness makes the movement of Qi and blood slow and the lingering causes stasis; or the blood overflow the collateral and stasis outside vessel forms. These are the basic pathological change of collateral diseases, and its syndrome characteristics are always inseparable from the "stasis". Women's uterine vessels and uterine collaterals are abundantly distributed in the lower abdomen. If the collateral vessels are stagnant, they are also accompanied by the accumulation of blood stasis,phlegm, dampness, toxic and other pathogens. Each of them could cause illness individually, or mixed with multiple kinds, and they usually cause chronic illness. That's why gynecological lower abdomen and pelvic diseases are mostly complicated and difficult diseases[5].

Premature Ovarian Failure

Premature ovarian failure (POF) is a serious stage in the development of menstrual disease.Also, in reference toHuangdi's Internal Classic,"Those whose period doesn't comes, the uterine vessels are closed", the pathogenesis can also be summarized as uterine vessel obstruction and blood stasis. Patients with POF go through a long course of onset, which develop from less frequent menstruation, oligomenorrhea, or even amenorrhea, to genital atrophy. However, reduced or even no blood flow for ovarian atrophy fit in with the description in Ye's "Guide to Clinical Practice with Medical Records" "accumulated damage invading the collaterals, and Qi and blood are both stagnant, then no blood flow comes out…" It indicates that the blood circulation in the vessel in the collateral disease theory is closely related to the small blood vessels and even the microcirculation in the modern medical circulatory system. Collateral diseases persist, deficiency of Qi cannot nourish the body, blood failure cannot nourish as well, and collaterals become stagnant and astringent due to Yin deficiency, collaterals could not be warmed and transported because of Yang deficiency. Thus, the pathological basis of collateral stasis is formed.

Professor ZHANG Yu-zhen believes that the essence of its pathogenesis is deficiency of the spleen and kidney, liver depression and blood stasis, so she created the "Zikui Yijing Decoction(滋癸益經(jīng)湯)" based on the treatment method of"tonifying the kidney and strengthening the spleen,soothing the liver and promoting blood circulation".In addition, Professor Zhang believes that the persistent disease will enter the collaterals, and the disease location has reached the deep part of the collaterals. In this condition, the attack towards the disease by herb medicine cannot be effective.Insects medicine to unblock collaterals drugs could be beneficial[6].Hirudois good at treating blood stasis and amenorrhea and promoting diuresis.Modern medical research has shown thatHirudohas a two-way regulating effect on the expression of new blood vessels. Therefore, a small amount ofHirudois often added in the prescription to "use the nature of insects and ants flying away quickly " to"loosen the root of diseases" and search and expel blood stasis and dried blood in the collaterals so as to clear the collaterals and so that the medicine to tonify the kidney, fortify the spleen, and sooth the liver can reach the focus.

Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is one of the most common gynecological endocrine diseases. TCM classifies it into categories such as late menstruation, amenorrhea, infertility,and abdominal mass. The blockage of uterine collaterals affects the circulation of Qi and blood in the collaterals and the transmission and transfusion of body fluids, resulting in disorders of the collateral system and the inability to maintain the normal function of the uterus. It then causes a series of pathological changes of collateral blockage,leading to oligomenorrhea or amenorrhea, obesity,polycystic ovarian changes, etc..

HONG Yin-wen et al.[7]started with obese PCOS and believed that it was mainly due to spleen deficiency and phlegm-dampness syndrome.Inactivation of spleen-Yang, abnormal movement and transformation of food essence, accumulation of dampness into phlegm, exuberant phlegm and salivation and then abundant fat lead to obesity;Heavy turbidity and greasiness of the phlegm could cause obstruction of blood vessels, stagnation of Qi and blood lead to stasis, and phlegm, stasis block thoroughfare vessel, conception vessel and uterine vessels and uterine collaterals, and Qi,blood and body fluid cannot nourish the uterus,causing menstrual disorders and infertility; in the long-term, the phlegm would combine with stasis and form masses, resulting in polycystic changes,fibrosis and endometrial hyperplasia in the ovaries.Therefore, the basic pathogenesis of PCOS is spleen deficiency and poor transportation, phlegm and blood stasis combination, which are closely related to liver and kidney dysfunction. Invigorating the spleen, resolving phlegm, nourishing the kidney and soothing the liver can better regulate the reproductive axis of kidney-reproduction-stimulating essence-thoroughfare and conception vesseluterus, and is also the foundation of treatment.At the same time, research in the use of "Jianpi Qutan Tongluo Decoction (健脾祛痰通絡(luò)方)" to treat obese PCOS and clinical confirming that it has achieved the same curative effect as metformin in promoting blood lipid metabolism and improving insulin resistance, which provides a theoretical basis for the treatment of PCOS by TCM.

Inflammatory Obstruction of Fallopian Tube

Fallopian tube inflammatory obstruction is the main factor of female infertility. It is mainly caused by repeated infections of chlamydia, gonococcus and other pathogens leading to fallopian tube mucosal damage, repeated and protracted local inflammation cause fallopian tube inflammatory exudation, edema, and hyperplasia, and gradually adhesion and narrowing of the fallopian tube lumen eventually led to obstruction. At present,the treatment of inflammatory obstruction of the fallopian tube in TCM focuses on promoting blood circulation and removing stasis. According to the hollow tubular structure of the fallopian tube and the long course of the disease and the symptoms of recurrent abdominal pain, some physicians believe that the pathogenesis of the disease is the visceral Qi and blood imbalance, Qi stagnation and blood obstruction, and blocked blood flow leading to stasis which will build up over a long period and it will block the uterine collaterals. The pathological changes have the characteristics of collateral diseases,"lingering sickness intruding into the collaterals" and"stagnation of Qi and blood may bring about pain".Therefore, suitable treatment should be dredging the fallopian tube, in which blood activating and stasis resolving therapy with the addition of collateral unblocking medicine could have good effects[8]. In this way, stasis and depression can be relieved by smooth flow of the Qi and blood in the fallopian tube, and also pain can be eliminated. Additionally,Qi and blood blockage in meridians and collaterals lead to the under nourishment of the fallopian tube,therefore the infertility and ectopic pregnancy occurs as a result of hypofunction of the egg transportation.The pathogenesis can also be considered to be the blockage of uterine vessels and collaterals, the stagnancy in the lower abdomen, and the egg failing to delivered to the uterus. Therefore, unblocking method can be used in both clinical treatment and prevention.

Sequelae of Pelvic Inflammatory Disease

The sequelae of pelvic inflammatory disease are caused by improper health preservation during menstruation or improper nursing in postpartum care, and lax sterilization during the operation in the uterine cavity, etc. These behaviors result in weakness of healthy Qi, when the pathogenic wind,cold, dampness, heat, or insect toxins invade.They accumulate in the uterus, advance and retreat recurrently and exhaust the Qi and blood in thoroughfare vessel and conception vessel. ZHAN Jie[9]believes that its pathogenesis is analyzed from the perspective of collateral disease theory as follows. First, "lingering sickness intruding into the collaterals" refers to a long course of disease,and the sequelae of pelvic inflammatory diseases are mostly manifested as recurrent pain, protracted course, and difficult to cure afterwards. Second,chronic illnesses often have "stasis". The "stasis"can be blood stasis or body fluid coagulation,and damp heat, blood stasis, cold dampness and other excess pathogens are the pathological products of chronic disease and are also main causes of sequelae of pelvic inflammatory disease.Thirdly, because "stagnation of Qi and blood may bring about pain", and "under nourishment may bring about pain", damp heat, blood stasis and other tangible pathogens block the vessels and cause tingling pain or distending pain, etc., or exhaustion of Qi and blood and insufficient healthy Qi damages the vessels and cause bearing-down pain or dull pain, etc. Pain is also a common manifestation of chronic pelvic pain, a sequelae of pelvic inflammatory disease. The following different treatment should be adopted based on various syndromes, clearing heat and dispelling dampness,removing stasis and dredging collaterals, activating(benefitting) Qi and removing stasis, dredging collaterals and relieving pain, removing cold and dampness, warming the meridian and relieving pain, etc..

Thin Endometrium

The thickness of the endometrium is an important reference index for the receptivity of the endometrium. Thin endometrium refers to the thickness of the endometrium below the threshold thickness for successful pregnancy. In TCM, there is no name for thin endometrium. According to its symptoms, it can be classified into categories such as "menorrhagia" "childless", and "repeated pregnancy and abortion".

TCM believes that adequate kidney essence and blood to nourish the uterus is the material basis for endometrial proliferation. Kidney Yin is the material basis for endometrial proliferation, and kidney Yang is the power to promote endometrial proliferation. Modern pharmacological studies have found that Chinese medicinal for invigorating the kidney-Yang has such an estrogen-like effect that can significantly increase the thickness of the endometrium[10], which is the same as the treatment of thin endometrium with western medicine estrogen. In addition, the collaterals blockage, and the essence and blood cannot flowing downward into the uterus to nourish the endometrium but form stasis instead. It can also develop into thin endometrium. Western medicine believes that the occurrence of thin endometrium is related to the high resistance of uterine blood flow.Commonly used therapy includes antiplatelet and vasodilator. Modern pharmacology has confirmed that blood activating and stasis removing drugs and their compounds can regulate blood rheology,improve microcirculation, increase blood flow, and further promote endometrial growth[11]. Female pelvic vessels are clustered and distributed more abundantly. TCM believes that women have small and tortuous uterine collaterals. If the uterine collaterals are weak, damaged or blocked,the blood flow is slow and easy to form stasis.Therefore, the improvement of thin endometrium should be based on invigorating the kidney,activating blood and dredging collaterals, and Caulis Spatholobi, Fructus Liquidambaris are commonly used.

THEORY OF COLLATERAL DISEASES IN HA'S GYNECOLOGY

HA's Gynecology is one of the top ten schools of TCM gynecology in the country. Professor Ha Xiaolian is the son of the famous TCM gynecologist Professor HA Li-tian, and the fourth-generation inheritor of HA's gynecology in Tianjin. He is also the academic inheritor of the first batch of national TCM academic schools "Tianjin HA's Gynecology school inheritance studio". He has been practicing TCM for more than 50 years. He has studied under many famous practitioners. He is proficient in TCM theory. On the basis of HA's gynecological experience and his own unique insights, he takes "treatment of all diseases should focus on regulating Qi and blood" as the leading idea to diagnose and treat gynecological diseases in his unique style.

TCM believes that Qi and blood are the two basic substances in the human body. Qi and blood are constantly circulating and running, which are the most basic characteristics of life. The collaterals are the structural basis of collateral diseases.The terminal branches increase in levels, the collateral body becomes narrow and tortuous, and the movement of Qi and blood in the collaterals gradually slows down. From the perspective of HA's Gynecology, if the dysfunction of Qi transformation occurs, the collateral Qi will be stagnant, or the weak collateral Qi lacking the power to transport will lead to stagnation. The inhibited Qi transforming will cause the body fluid coagulating into phlegm, the unsmooth flow of Qi will make the astringent and stagnant blood flow, the phlegm stasis is blocked and the collateral becomes static from stagnant,which severely affects the function of the collaterals to run the blood and Qi, or even blocked. Stagnation of Qi and blood may bring about pain, and it will be painful for a long time. Phlegm and stasis blocking the collaterals further affect the ascending,descending, exiting and entering movement of Qi, and aggravate Qi stagnation. Therefore, the formation of a vicious circle leads to prolonged disease and difficult recovery.

Primary dysmenorrhea refers to lower abdomen pain, bearing down and swelling before and after menstruation or during menstruation, often accompanied by backache and other discomforts.The symptoms seriously affect women's normal life and work. The HA's gynecology team uses Chinese medicinal (Pericarpium Citri Reticulatae Viride,Radix Linderae,Herba Leonuri,Rhizoma Ligustici Chuanxiong,Radix Angelicae Sinensis,Radix Bupleuri,Rhizoma Cyperi,Rhizoma Corydalis,Fructus Meliae Toosendan,Sanguis Draconis) to apply to Guanyuan (CV4), Qihai (CV6), Diji (SP8),Shenshu (BL23) and Zusanli (ST36) to disperse the Qi of the three meridians of the liver, spleen and kidney, regulate Qi, promote blood and dredge the collaterals. In this way, the Qi and blood, Yin and Yang of the liver, spleen and kidney are in balance,and the Qi of the meridian is smooth, achieving the effect of no pain without stagnation, and no pain if nourished. It is clinically confirmed that the method can effectively improve the symptoms of patients with primary dysmenorrhea due to Qi stagnation and blood stasis[12]. In addition, HA's Gynecology also has unique insights into PCOS. Clinical observations have found that obese PCOS patients often have specific manifestations of "phlegm and dampness" such as distention and fullness in the chest and abdomen, phlegm in the throat, slippery pulse, and pale tongue with greasy coating. It is believed that phlegm-damp constitution has certain correlation with obese PCOS in terms of the etiology and pathogenesis[13]. It is concluded that the disease is caused by the deficiency of the spleen and kidney, and the pathological products such as phlegm and dampness block the uterus and uterine collaterals as the secondary syndrome.It is a syndrome of root vacuity and tip repletion.Radix Morindae Officinalis,Herba Epimedii,Cornu Cervi Degelatinatum,Semen Cuscutae,Placenta Hominis,Fluoritum,Poria,Rhizoma Atractylodis,Bulbus Fritillariae Thunbergii,Radix Angelicae Sinensis,Radix Salviae Miltiorrhizae,Spina Gleditsiae,Solanum nigrumL.,Semen Plantaginis,Folium Pyrrosiae, etc. could be used together to tonify the spleen and kidney and remove phlegm and stasis. The collaterals will be unblocked,Qi and blood flow smoothly, and menstruation can be on time. In addition, HA's Gynecology also conducted research on infertility, menstrual diseases, etc., and its treatment is based on regulating and harmonizing Qi and blood, and the whole theory is the guiding ideology throughout.

SUMMARY AND OUTLOOK

In summary, based on the study of collateral disease theory, collateral deficiency and under nourishment and stasis and blockage of uterine collateral are important pathogenesis of gynecological diseases. If there is insufficient Qi and blood, blood stasis and Qi stagnation.attention should be paid to invigorating the kidney and spleen, and adding blood circulation and stasis removing medicine properly to unblock the collaterals. It mainly relieves the primary cause of disease and also eliminates pathogens. With the indepth research and application of collateral disease theory in diseases in recent years, this not only provides theoretical guidance in the differentiation and treatment of gynecological diseases, but also becomes potential to open up new treatment paths for more diseases in the future.