李东垣曰∶经闭不行有三，妇人脾胃久虚，形体羸弱。气血俱衰，以致经水断绝，或因劳心，心火上行。月
事不来，胞脉闭也。胞脉属心，络胞中，气上迫肺，心气不得下通，故不来。宜安心补血泻火。则经自行。（此
上焦心肺有热而经不行也。）或病中消。胃热善饥渐瘦，津液不生。夫经者，血脉津液所化。津液既绝，为热
所烁，肌肉渐瘦，时见燥渴。血海枯竭，名曰血枯经绝，宜泻胃之燥热，补益气血，则经自行。（此中焦胃有热结
而经不行也。）或心包络脉洪数，躁作时见，大便闭，小便难，而经水闭绝。此血海干枯，宜调血脉，除胞络
中火邪，则经自行。（此下焦胞脉热结而经不行也）
娄全善按∶洁古、东垣治妇人血枯经闭之法，皆主于补血泻火。补血用四物之属。泻火，东垣分上中下三
焦。如火在上，则得于劳心，治以芩、连及三和之类。火在中，则
善食消渴，治以调胃承气之类。火在下，则大小便难，治以玉烛之类。玉烛，四物与调胃承气是也。三和，四
物与凉膈是也。
《济阴纲目》按∶东垣之论，当有四证。如胃热、胞络热、劳心热三证，皆有余，宜泻火养血是矣。所言
脾胃久虚，致经水断绝一证，又当补脾胃为主，岂得舍而勿论。盖水入于经，其血乃生，谷入于胃，脉道乃行。
水去荣散，谷消卫亡，况脾统诸经之血，而以久虚之脾胃，致气血俱衰者，可不为之补益乎？即此以分虚实，明
是四证无疑。全善乃遗补虚之一证，何也？
慎斋按∶经闭主于泻心火，论本洁古。而东垣则以热结分上中下三焦，是月水不下，专以火热为病，药用玉
烛、三和为例。夫此方治劳心，心火上行，致胞脉闭塞，月事不来，是实热也。若心虚而热收于内，与心虚而
上衰者，二方又未可妄用也。大约妇人经闭，由于阴虚火旺，日渐煎熬，津液干涸，以致血枯经闭，当从赵养
葵滋水补肝之法，纯用三和、玉烛殊未尽善。若东垣三证，首言脾胃久虚一段，已见经水断流，俱从脾胃受病。
《济阴纲目》议全善之失，尤为有见。
慎斋按∶以上一条，序妇人经闭属火邪热结，而经不行也。夫经闭有寒有热，《金匮》三条，主于风冷积
寒，东垣、洁古主于火热实结，是皆指有余之客邪为病也。但寒热二证，宜分内伤外感处治。如心火不下降，
而三焦热结，此是血衰火旺，阴不足以配阳，故心气不通，热结三焦，而经不下，当益阴滋水，以培化源，若用
硝、黄、芩、连则失矣。如积冷血寒，凝结胞门，冲任脉寒，而血泣不下，是风冷客邪，乘虚袭入，宜温经
散寒，以大辛热之药，导血下行，后用养荣之剂为当也。
李东垣说：经闭不行有三种情况。一是妇人脾胃长期虚弱，身体消瘦羸弱，气血两亏，导致月经断绝；二是因为劳神过度，心火向上逆行，导致月经不来。胞脉归属于心，联络子宫，气机上迫于肺，使心气不能下行通达，所以月经不来。应当安心养血并清泻心火，月经自然就会来潮。（这是上焦心肺有热而导致经闭的情况。）
二是患有消渴病（以多饮、多食、多尿、身体消瘦为特征的疾病），胃中有热，容易饥饿且逐渐消瘦，津液无法生成。所谓月经，是由血脉和津液化生而成的。既然津液枯竭，又被热邪煎熬，肌肉逐渐消瘦，时常感到口干舌燥。血海枯竭，称为“血枯经绝”，应当清泻胃中的燥热，补益气血，月经自然就会来潮。（这是中焦胃中有热结而导致经闭的情况。）
三是心包络脉象洪大数急，烦躁发作时常见，大便闭塞，小便困难，从而导致月经闭绝。这也是血海干枯，应当调理血脉，清除胞络中的火邪，月经自然就会来潮。（这是下焦胞脉热结而导致经闭的情况。）
娄全善按语：洁古、东垣治疗妇人血枯经闭的方法，都主张补血并清泻火热。补血使用四物汤一类的方剂。清泻火热方面，东垣将其分为上、中、下三焦。如果火邪在上焦，多因劳心所致，治疗用黄芩、黄连及三和散之类的方剂；火邪在中焦，表现为善食易饥、消渴，治疗用调胃承气汤之类的方剂；火邪在下焦，表现为大小便困难，治疗用玉烛散之类的方剂。玉烛散，就是四物汤与调胃承气汤合方；三和散，就是四物汤与凉膈散合方。
《济阴纲目》按语：东垣的论述，应当包含四种证候。如胃热、胞络热、劳心热这三种证候，都属于实证有余，适宜泻火养血，这已经说清楚了。但所提到的脾胃长期虚弱导致经水断绝这一种证候，又应当以补益脾胃为主，怎么能舍弃而不讨论呢？大概水谷进入经脉，血液才能生成；食物进入胃中，脉道才能通畅运行。如果水谷精微流失，营气消散，谷气消亡，卫气也就亡失了。况且脾统摄各经之血，对于因脾胃长期虚弱而导致气血俱衰的情况，难道不应该进行补益吗？由此区分虚实，明确是四种证候无疑。娄全善却遗漏了补虚这一证候，为什么呢？
慎斋按语：经闭主要在于清泻心火，这个论点原本出自洁古。而东垣则根据热结的位置分为上、中、下三焦，认为月水不下，专门将火热作为病因，用药以玉烛散、三和散为例。这两个方子治疗的是劳心导致心火上炎，致使胞脉闭塞，月经不来的实热证。如果是心气虚弱而热邪内收，或者心气虚弱而上行无力，这两种情况又不可以妄用上述两个方子。大致来说，妇人经闭，多由于阴虚火旺，日渐煎熬，津液干涸，导致血枯经闭，应当遵循赵养葵滋水补肝的方法，单纯使用三和散、玉烛散并不完全妥当。至于东垣所说的三种证候中，首先提到的脾胃久虚一段，已经表明经水断流，都是源于脾胃受病。《济阴纲目》评议娄全善的失误，尤其是有见地。
慎斋按语：以上一条，叙述了妇人经闭属于火邪热结，导致经血不行的情况。经闭有寒证和热证，《金匮要略》中的三条条文，主论风冷积寒；东垣、洁古主论火热实结，这些都是指有余的客邪致病。但是寒证和热证，应当区分内伤和外感来进行治疗。例如心火不能下降，导致三焦热结，这是血衰火旺，阴不足以制约阳，所以心气不通，热结三焦，导致经血不下，应当滋阴补水，以培补化源，如果使用芒硝、大黄、黄芩、黄连就错了。如果是积冷血寒，凝结在胞门，冲任二脉寒冷，导致血液凝涩不下，这是风冷客邪乘虚侵袭，应当温经散寒，用大辛大热的药物引导血液下行，之后再用养荣的方剂才恰当。
Li Dongyuan stated: There are three types of amenorrhea (cessation of menstruation). First, if a woman's Spleen and Stomach have been deficient for a long time, her body becomes emaciated and weak, and both Qi and Blood decline, leading to the cessation of menses. Second, excessive mental labor may cause Heart Fire to ascend, resulting in the absence of menstruation because the Bao Mai (uterine vessels) are blocked. The Bao Mai belongs to the Heart and connects with the uterus; when Qi forces upward against the Lung, the Heart Qi cannot descend and communicate downward, hence menstruation does not occur. One should calm the mind, nourish Blood, and clear Heat to allow menstruation to resume naturally. (This refers to amenorrhea caused by Heat in the Upper Jiao involving the Heart and Lungs.)
Second, one may suffer from Xiao Ke (wasting-thirst syndrome), characterized by Stomach Heat, excessive hunger, gradual emaciation, and failure to generate fluids. Menstruation is transformed from blood vessels and body fluids. Once body fluids are exhausted and scorched by Heat, muscles gradually waste away, and dryness and thirst are frequently observed. When the Sea of Blood is depleted, it is called "Blood Depletion Amenorrhea." One should clear the dry Heat in the Stomach and tonify Qi and Blood to restore menstruation naturally. (This refers to amenorrhea caused by Heat accumulation in the Middle Jiao involving the Stomach.)
Third, if the Pericardium Collateral pulse is surging and rapid, accompanied by frequent irritability, constipation, and difficult urination, menstruation ceases completely. This is also due to the depletion of the Sea of Blood. One should regulate the blood vessels and eliminate Fire pathogens in the Bao Collaterals to restore menstruation naturally. (This refers to amenorrhea caused by Heat accumulation in the Lower Jiao involving the uterine vessels.)
Lou Quanshan commented: Jiegu and Dongyuan’s methods for treating blood-depletion amenorrhea in women both emphasize nourishing Blood and clearing Fire. For nourishing Blood, formulas such as Si Wu Tang (Four Substances Decoction) are used. For clearing Fire, Dongyuan categorized them into the Upper, Middle, and Lower Jiaos. If Fire is in the Upper Jiao, often caused by mental labor, treatment involves Huang Qin (Scutellaria Root) and Huang Lian (Coptis Rhizome), along with San He San (Three Harmonies Powder). If Fire is in the Middle Jiao, manifesting as excessive eating, thirst, and wasting, treatment involves Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction). If Fire is in the Lower Jiao, manifesting as difficulty in urination and defecation, treatment involves Yu Zhu San (Jade Candle Powder). Yu Zhu San combines Si Wu Tang and Tiao Wei Cheng Qi Tang. San He San combines Si Wu Tang and Liang Ge San (Cool the Diaphragm Powder).
The *Ji Yin Gang Mu* (Outline of Gynecology) commented: Dongyuan’s discussion should encompass four syndromes. The three syndromes of Stomach Heat, Pericardium Collateral Heat, and Mental Labor Heat are all excess conditions suitable for clearing Fire and nourishing Blood, which has been adequately explained. However, the syndrome of prolonged Spleen-Stomach deficiency leading to menstrual cessation should primarily be treated by tonifying the Spleen and Stomach; how can this be omitted? Generally, water entering the channels allows blood to be generated; food entering the Stomach allows the vessel pathways to function. If water is lost, Ying (Nutrient) Qi scatters; if grain is consumed without retention, Wei (Defensive) Qi perishes. Moreover, the Spleen governs the blood of all meridians. For cases where prolonged Spleen-Stomach deficiency leads to dual deficiency of Qi and Blood, is it not necessary to provide tonification? Distinguishing between deficiency and excess based on this, it is undoubtedly four syndromes. Why did Quanshan omit the deficiency-tonifying syndrome?
Shenzhai commented: The principle that amenorrhea is primarily managed by clearing Heart Fire originates from Jiegu. Dongyuan, however, divided heat accumulation into the Upper, Middle, and Lower Jiaos, attributing the failure of menses specifically to Fire-Heat pathology, using Yu Zhu San and San He San as examples. These formulas treat the excess Heat condition where mental labor causes Heart Fire to ascend, blocking the Bao Mai and preventing menstruation. If the condition involves Heart Deficiency with internalized Heat, or Heart Deficiency with failing ascending energy, these two formulas should not be used recklessly. Generally speaking, female amenorrhea often results from Yin Deficiency with Hyperactive Fire, which gradually consumes fluids until they are dried up, leading to blood depletion and amenorrhea. One should follow Zhao Yangkui’s method of nourishing Water and tonifying the Liver. Relying solely on San He San and Yu Zhu San is not entirely appropriate. Regarding Dongyuan’s three syndromes, the initial mention of prolonged Spleen-Stomach deficiency indicates that menstrual flow interruption stems from disease originating in the Spleen and Stomach. The critique of Quanshan’s omission in the *Ji Yin Gang Mu* is particularly insightful.
Shenzhai further commented: The above passage describes amenorrhea caused by Fire-Heat pathogens and heat accumulation. Amenorrhea can be either Cold or Heat. The three clauses in the *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet) focus on Wind-Cold accumulation; Dongyuan and Jiegu focus on Excess Fire-Heat accumulation. Both refer to pathogenic factors arising from excess conditions. However, Cold and Heat syndromes must be treated differently depending on whether they are internal injury or external contraction. For instance, if Heart Fire fails to descend, causing Heat accumulation in the Three Jiaos, this is Blood Deficiency with Fire Hyperactivity, where Yin is insufficient to control Yang, resulting in blocked Heart Qi and Heat accumulation in the Three Jiaos, preventing menstruation. In such cases, one should nourish Yin and tonify Water to cultivate the source of transformation; using Mang Xiao (Mirabilite), Da Huang (Rhubarb Root), Huang Qin (Scutellaria Root), or Huang Lian (Coptis Rhizome) would be erroneous. Conversely, if accumulated Cold and Blood-Cold coagulate at the Baomen (uterine gate), and the Chong and Ren meridians are cold, causing blood stagnation and failure to descend, this is Wind-Cold pathogenic factors invading due to deficiency. One should warm the meridians and dissipate Cold using pungent-hot herbs to guide blood downward, followed by the use of Ying-Rong (Nourishing) formulas.