Pruritus vulvae
“Pruritus vulvae” means that the woman feels itching at the vulvae or inside the vagina; in severe cases, there may be intense itching around the anus and cause profound restlessness. It is also called “vulval itching”, “pruritus of the vaginal orifice” and is commonly seen in women before or after menopause, especially those having a fat body build.
There were may writings about the etiology, pathogenesis and treatment of vulval itching in TCM, particularly in the Ming dynasty when medicine was comparatively advance in development. The famous physician Zhang Jingyue (張景岳) and others commented in detail in the symptoms, principles and treatment of “vulval itching disease” and considered that there was “wetness-heat of liver”, so that they used drugs to clear and wash the liver, and prescribed drugs like “Longdan Xiegan Tang (“龍膽瀉肝湯”) and Xiaogao San (“消遙散”)”.
In the Ching dynasty, scholars raised the theory of “blood deficiency in the liver channel and exhaustion of body fluid” and proposed the treatment of “giving nutrients to the liver and blood, supplementing the spleen, nourishing yin and drying wetness”. Therefore, TCM considers that this disease is caused by the down flowing of wetness-heat and corrosion of vulva by worms or due to oldness or weakness of the body, yin deficiency of liver and kidney or deficiency of blood and energy or dryness due to wind produced by blood deficiency.
Therefore, it is usually classified into:
There is unbearable pruritus of vulva and leucorrhea is profuse and yellowish. The vulva is lubricated with wetness and local exudation. There is heaviness in the chest and the patient is anxious sleepless, having a poor appetite and the urine reddish yellow. The tongue proper is red and the coating yellowish and greasy; the pulse rapid and slippery or rapid and taut. Treatment should aim at clearance of heat, elimination of wetness, detoxication and abolishment of pruritus.
The vulva is dry and pruritus is unbearable, especially at night when the patient may experience a burning sensation. In severe cases, there may be anxiety, vertigo, pain in the loins, tinnitus, dryness of mouth and constipation. The tongue is red and the coating sparse; the pulse is small and rapid. Treatment should aim at nourishment of yin, supplement of kidney, softening of liver and dispersion of wind.
The vulva is dry and pruritic, especially at night so that the patient becomes restless, dizzy, anxious with also palpitation, having dreamful sleeping and waking easily. The skin is hypertrophic and desquamating after scratching. The stools are dry and hard. Treatment should aim at nourishment of blood, abolishment of dryness, elimination of wind and stoppage of pruritus.
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It is not difficult to find that there is internal relationship between the classification of this illness and liver disease, from the above etiological and pathogenetic classification. In fact, pruritus vulvae is not an isolate disease entity, but is caused by many systemic diseases (such as jaundice, anemia, vitamin deficiency, insufficient estrogenichormone, diabetes, allergic reactions, psychotic causes) or local causes, such as irritation by vaginal discharge, mycotic infection, trichomonas (滴虫), pinworms, vulvul eczema, herpes, psoriasis, neurodermatitis, drug dermatitis, vulval scleroderma or prodromal symptoms of vulval leukoderma. Symptoms may be severe sometimes and the patient may be painful pychologically and her health and work are affected. Scratching may cause local dermal changes like vulval keratosis and hypertrophy carrying a grayish color and scratch marks.
In fact, pruritus vulvae is usually the result of hepatophilic virus infection. The “wetness-heat of skin” in chronic hepatitis produces various common skin disease, some of which, like vulval eczema, herpes, psoriasis and neurodermatitis, are the chief local causes of pruritus, and following the decrease of immune function in chronic hepatitis, infections by fungus or trichomonas may exist and lead to “wetness-heat of lower-jiao”, so that pathologic secretions of the cervix and vagina may be produce and it may also cause vulval itching. Further more, the systemic causes leading to pruritus vulvae such as jaundice, anemia, endocrine disorders, estrogen deficiency, abnormal vitamin metabolism, diabetes, allergic constitution, are all results of hepatic dysfunction in chronic hepatitis patient. Therefore patients with pruritus vulvae should be examined carefully for liver disease and if abnormal margin of hepatic dullness or diagnosis of liver disease is present, effective systemic TCM therapy should be instituted.
Introduction of cases
Case 18
Yuen (code No. 2606), female, age 39 years.
Her first visit was in July 2001 with the chief complaint of pruritus vulvae for ten more years. She had repeated blood tinged leukorrhea, vaginal bleeding three days after menstruation, bright red or dark red in color, continuing without interruption until the next menstrual period. The menstrual blood was large in amount with clots, and there was also dysmenorrhea.
Five years ago, she was found to have palpitation, tremor of hands, exophthalmos (眼突) and hypertension, and was diagnosed as hyperthyroidism. Specific drugs were prescribed and were stopped afterwards because of hypothyroidism, but the disease relapsed half a moth later and the medication was therefore reapplied and continued up to the present. She was often attacked by common cold and had profuse amount of sputum, soreness of the loins and fatigue. Physical examination: thin, anemic hypochondriac anomaly, percussion tenderness over hepatic region, hepatomegaly of 3 cm.
After taking 3 parcels of TCM drugs, the liver returned to normal. She farted frequently and her vaginal bleeding ceased. Six days later, pruritus vulvae disappeared. During the course of treatment, she had repeated episodes of profuse yellowish leucorrhea, occasionally blood tinged. Her first menstrual period was still associated with pain, but the amount of blood and blood clots were less. The skin had been pruritic showing red macules and tenderness was felt on palpation over the fifth and sixth costosternal and right fifth costosternal joints. But all these were cured with the continuation of TCM therapy. The second period of menstruation came seven days earlier with bright red color, sparse clots, no pain and normal amount. She took 54 parcels of TCM drugs totally and medication was stopped at the attainment of clinical cure and then she was followed up. Drugs for hyperthyroidism was stopped during the sixth week of TCM treatment.
By WONG Kwok Hung
published on 15th January 2002
(translated by Professor ZHENG Hua En in 2004)