A 39-year-old woman with a history of recurrent endometriosis and acute abdominal pain was managed with a modified Si Ni San decoction and external therapies.

Case ID: CHC-0002

Case Summary

This case describes a 39-year-old woman who presented with severe, acute lower abdominal pain following a history of multiple surgeries for endometriosis. The original report documented a TCM assessment of Liver Qi stagnation combined with Blood stasis. The patient was managed through an integrated approach of internal herbal medicine, acupuncture, and targeted external therapies to break a vicious cycle of chronic pain and insomnia.

Patient Presentation

• Patient: 39-year-old female.
• Main Complaint: Acute, paroxysmal lower abdominal pain exacerbating at night, requiring pain medication.
• History: The patient had a long-standing history of endometriosis and chronic anxiety/insomnia. She had undergone two prior laparoscopic surgeries (in 2014 and most recently in December 2024) for extensive pelvic adhesion lysis and the resection of endometriotic lesions. Following intercourse in late March 2025, she developed progressive lower abdominal pain that became severe, fixed, and stabbing by mid-April. The pain severely impacted her sleep and work, necessitating the use of analgesic patches and oral painkillers.

Examination and Diagnosis

• Conventional Diagnosis: Laboratory tests, including sex hormones and infection markers, were largely within normal limits. An ultrasound revealed a right ovarian cyst (37x22x32mm). A gynecological examination noted a palpable, tender nodule behind the cervix, consistent with her history of deep infiltrating endometriosis.
• TCM Tongue and Pulse: The tongue was pale and dark with a thin white coating. The pulse was stringy and fine (弦细). Physical examination noted that her lower abdomen and extremities felt cool to the touch.

TCM Assessment

The original practitioner interpreted the presentation as Liver Qi stagnation and Blood stasis (肝郁气滞血瘀). In the TCM framework, emotional stress (evident in her chronic anxiety and insomnia) combined with the physical trauma of multiple surgeries creates a pathological cycle. The stagnant Liver Qi fails to move the Blood, leading to pooling and blockages in the pelvic region. Furthermore, based on the principles of Yin and Yang Chinese medicine associates nighttime with the Yin phase. The original report noted that as static blood settled deeper into the collaterals during this Yin phase, the localized stasis manifested as fixed, stabbing pain that predictably worsened at night.

Treatment Approach

The primary treatment principle was to soothe the Liver, regulate Qi, and transform stasis. Recognizing the severe and stubborn nature of post-surgical adhesions and endometriosis, the practitioner utilized a combined approach: internal herbal decoctions paired with external therapies (abdominal herbal poultices and enemas) to deliver medicinal effects directly to the pelvic region, alongside acupuncture.

Herbal Formulas and Modifications

• Base Formula (Initial Visit): The practitioner selected a modified version of Si Ni San (Frigid Extremities Powder). In TCM terminology, this classic formula is used not for true Yang deficiency, but for severe Qi stagnation that prevents vital energy from reaching the limbs (hence her cold hands and feet). Chai Hu and Zhi Shi were used to regulate the ascending and descending of Qi. Bai Shao and Zhi Gan Cao (which together form Shao Yao Gan Cao Tang) were employed to relieve smooth muscle spasm and alleviate acute abdominal pain.
• Stasis-Breaking Additions: Blood-moving herbs (Tao Ren, Hong Hua, Yi Mu Cao) were added to aggressively break down the pelvic stasis.
• Modifications (Subsequent Visits): As the patient approached her menstrual period (which often exacerbates endometriosis pain), heat-clearing and blood-cooling herbs (Mu Dan Pi, Huang Qin, Bai Jiang Cao) were added to address mild stagnant heat and prevent excessive bleeding. Niu Xi was included to direct the medicinal effects downward to the lower body.

Follow-Up

• April 17, 2025 (Second Visit): Pain frequency was reduced, though the intensity remained bothersome. Slight intermenstrual spotting was noted. Treatment continued with modifications for the approaching menses.
• April 22, 2025 (Third Visit): The source reported that abdominal pain was significantly improved. Nighttime pain flare-ups ceased, and her sleep quality improved. External therapies were paused to prepare for menstruation.
• April 26, 2025 (Fourth Visit): The patient experienced a relatively normal menstrual flow with clots, which indicates the clearing of stagnant blood. Her residual pain and dry mouth were resolved. The formula was adjusted for the post-menstrual phase to clear any remaining stasis without depleting her healthy energy.

Why This Case Is Interesting (Clinical Reasoning)

The notable feature of this case is the sophisticated application of Si Ni San, a classic formula originating from the ancient text Shanghan Lun (Treatise on Cold Damage). While commonly associated with treating cold extremities, the original practitioner recognized that the patient’s cold hands and lower abdomen were a result of severe Qi stagnation blocking circulation, not a lack of internal heat.

By mapping out the patient’s vicious cycle of “stagnation → stasis → pain → insomnia,” the treatment employed Si Ni San to unblock the Qi mechanism alongside specific spasmolytic herbs (Bai Shao and Gan Cao). This addressed the interconnected nature of her emotional stress and physical pelvic pain simultaneously, rather than merely relying on standard blood-invigorating herbs for endometriosis.

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What This Case Can — and Cannot — Tell Us

This is an individual case report, not a controlled clinical trial. It documents the reasoning, treatment, and outcome reported for one patient and should not be interpreted as evidence that the same approach will produce the same result in another person.

Source

• Original source: Guangdong Provincial Hospital of Chinese Medicine (广东省中医院) / Guangdong Provincial Administration of Traditional Chinese Medicine
• Original title: 以案说医丨经方疏郁通冲任，妙药化瘀止妇痛
• Practitioner: Dr. Huang Jinping (黄金平)
• Publication date: May 19, 2026
• Original language: Chinese
• Source link: View original page
• ChineseHerb.org version: English translation and editorial adaptation